Primary non-adherence in Portugal: findings and implications

Adherence to pharmacological therapy for hypertension in Portugal: a health professionals focus groups study

INTRODUCTION

The perspectives of local healthcare professionals for developing effective strategies to enhance medication adherence in arterial Hypertension as well as its barriers have not yet been explored through qualitative research in Portugal.

OBJECTIVES

This study aimed to assess the views of healthcare professionals including general practitioners/family physicians, nurses, and community pharmacists, from Portugal on effective strategies to improve medication adherence in Hypertension, and to identify factors hindering pharmacological adherence.

METHODS AND ANALYSES

This was a qualitative study with synchronous online focus groups, in which, the participants were general practitioners/family physicians, family nurses, or community pharmacists in Portugal with experience managing patients with Hypertension. They were selected based on age, sex, and geographical region with the number of focus groups determined by theoretical saturation. Recruitment was facilitated through specific mailing lists. Purposive and snowball sampling techniques were employed. Focus group discussions were recorded and transcribed. Two researchers conducted content analyses via MAXQDA®2023, applying comparative analysis and reaching consensus. The results are described narratively.

RESULTS

Three focus group discussions revealed a multifaceted approach to improving medication adherence for Hypertension. Key strategies to enhance coordination and communication among healthcare professionals, patients, and caregivers were identified. These included shared informatics software among healthcare professionals; using mobile applications and wearables; health literacy initiatives and patient empowerment; preprepared medication in pillboxes; involving family and the concept of a "family pharmacist". Participants highlighted barriers to medication adherence such as the lack of communication with patients concerning issues like medication adherence.

CONCLUSIONS

This qualitative study outlines strategies to improve medication adherence among patients with Hypertension in Portugal. These involve improving healthcare coordination and communication, patient empowerment, and involving family and "family pharmacists" in supporting adherence. These strategies are based on the insights of healthcare professionals and could be implemented following robust intervention studies.

CLINICAL TRIAL NUMBER

Not applicable.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Using the national electronic prescription system to determine the primary non-adherence to medication in the Czech Republic

The primary medication non-adherence occurs when a patient does not collect his or her newly prescribed medication. Various studies give estimates that this occurs between 0.2 percent and 74 percent. Recently, this topic has been researched by analyzing data in national electronic prescription systems. The database of the Czech electronic prescription system was used to obtain the number of all prescriptions issued and collected in 2021 for fifty particular substances (associated with six medication groups). Additionally, a similar query was performed with an additional criterion that the same substance had not been prescribed within the last 365 days. The data were obtained separately in five age categories. The total number of prescriptions analyzed in this study was over 21 million, which represents almost 30 percent of all prescriptions issued in the Czech Republic in 2021. The primary medication non-adherence in the selected substances was 4.56 percent, which negatively correlates (rxy = 0.707) with the age of a patient. There is a higher primary non-adherence in the Psychoanaleptics and Lipid modifying medication groups than in the whole studied sample (p < 0.05). Lipid-modifying medication group and several other particular substances showed a larger difference between primary non-adherence and overall non-adherence, indicating issues in the initiation of these drugs. The results of our study are following earlier studies with similar methodologies from other countries. However, the difference between primary non-adherence and overall non-adherence had not been observed in other studies before. The electronic prescription system proved to be a valuable tool for conducting this type of research.

Exploring Muslims' Health-Related Behaviours in Portugal: Any Impact on Quotidian Community Pharmacy Practice?

Muslims are a growing community in European countries. General health habits, including therapy-related behaviours, have been described, though implications to pharmacy practice might vary with the local dominant culture and setting. This exploratory study aimed to describe Muslims’ prevalent health and medication-related practices and possible implications for culturally competent community pharmacy practice. A descriptive cross-sectional survey was administered to a convenient sample of 100 participants at Lisbon Central Mosque, Portugal. Demographics, dietary, Traditional Arabic and Islamic Medicine (TAIM) and religious practices were examined, including health conditions and conventional biomedical treatments. Participant reported ailments (26%) were aligned with prevalent conditions in the general population. Ill participants were significantly associated with TAIM and Islamic dictates (p < 0.05), particularly Zam-Zam water and milk thistle usage. Participants’ orientation to dietary options and Qur’an restrictions were observed regarding forbidden substances in medication, raising issues on medication adherence for some oral dosage forms. TAIM and religious beliefs supplement illness recovery and health improvement instead of replacing conventional healthcare in a religious minority well integrated within the dominant culture. Portuguese community pharmacists should not neglect religious specificities if seamless care is delivered, enhancing professionals’ collaboration skills with multicultural patients.

Quality of Life, Sexual Functioning and Chronic Disease: A Comparative Study with Portuguese Women without Chronic Disease, and Women with Diabetes Type 1 and 2, and Arterial Hypertension

Aims: Previous research has focused on the impact of chronic diseases on men's sexual functioning and quality of life; however, little is known about the association between chronic disease and women's sexual functioning and quality of life. Current study aimed at exploring the differences in quality of life and sexual functioning between women without chronic disease, and women with type 1 diabetes, with type 2 diabetes, and with arterial hypertension. Methods: A web-survey was completed by 313 Portuguese women (167 without chronic disease, 48 with type 1 diabetes, 48 with type 2 diabetes, and 50 with arterial hypertension). Results: Women without chronic disease scored significantly higher than women with chronic disease in quality of life and sexual functioning, adjusting for age. Conclusions: Quality of life and sexual functioning in women with chronic diseases is impaired.

Factors Associated with HIV and Vulnerability Contexts for Women in Brazil

The purpose of this study was to identify factors associated with HIV and vulnerability contexts for women in Porto Alegre, Brazil. The participants were 1326 women recruited by complex sampling design, divided into two groups: 640 women with HIV (WLH) and 686 women who did not have HIV (WNLH). Gross and weighted statistical analyses were performed. Logistic regression models were used to estimate the odds ratio (OR) for 12 variables. The main results demonstrated that WLH had lower income (p < .001) and poorer education (p = .038), and few used condoms during their first sexual intercourse (p < .001). The occurrence of HIV was higher among the black population (p < .001). Sex in exchange for money (p < .001) and sexually transmitted infections (p < .001) were more frequent among WLH than among WNLH. The age of sexual debut and age difference from the partner at first sexual intercourse (FSI) were not associated with the outcome. The high percentage of non-use of condoms during the FSI shows how vulnerable individuals are right at the beginning of their sexual lives. More effective prevention strategies can be developed by nurses in view of the contexts of vulnerability surrounding women.

Development of medicines consumption in Portugal before and during the financial crisis

BACKGROUND

In May 2011, the Portuguese Government signed a Memorandum of Understanding with the European Commission, the European Central Bank and the International Monetary Fund, including detailed measures to control health costs, allowing Portugal to receive a financial rescue package. This study aims to investigate medicines utilization in the outpatient sector during Troika's financial rescue.

METHODS

Using Defined Daily Dose per million inhabitants per year as a measurement unit, we compared medicines utilization with other relevant indicators over 5-year intervals for a total period of 20 years, based on a built-in inventory of national outpatient drug use using the Intercontinental Medical Statistics Health and Anatomical Therapeutic Chemical index of the World Health Organization databases. The calculation was made on the basis of both compound and year-on-year growth rates.

RESULTS

With the exception of the interval 2009-11, an absolute rise in consumption was observed over the 20-year period. The downturn occurred prior to financial rescue, when expenditure management mechanisms were already in place, and coincided with an increase in out-of-pocket spending. With the decline of cost for patients, the access trend returned to being positive, but at a slower pace.

CONCLUSION

The rise in out-of-pocket and austerity measures may have led to decreased access to medicines. The findings of this study suggest that this impact was influenced by public cost-saving policies implemented even before the financial rescue. The results show that price reduction attenuated the repercussion of the measures.

Medication adherence and related determinants in older people with multimorbidity: A cross-sectional study

AIM

Identify the medication adherence determinants in older adults with multimorbidity and polypharmacy.

MATERIALS AND METHODS

A cross-sectional study was conducted in a non-probabilistic sample of 245 adults ≥65 years recruited in a general medical ward of one teaching hospital. Data were collected during hospital stay using a face-to-face interview based on a set of validated questionnaires, such as the measure treatment adherence, the beliefs about medicines questionnaire-specific and the geriatric depression scale. Descriptive and multiple linear regression analysis were performed.

RESULTS

Participants' mean age was 78.32 (SD: 6.95) years and 50.6% were women. Older adults lived with an average of 7.51 (SD: 1.95) chronic conditions and had a mean of 7.95 (min. 4; max. 18) medications prescribed. The proportion of older adults adherent to medication was 43.7%. Depression ( β  = -0.142; p = 0.031), beliefs about treatment necessity ( β  = 0.306; p = 0.001) and concerns about the medication ( β  = -0.204; p = 0.001) were found as independent determinants of adherence.

CONCLUSION

Self-reported medication non-adherence appears to be common in older adults with multimorbidity and polypharmacy. Depression, necessity and concerns should be considered when assessing medication non-adherence in practice. This study will also contribute to develop an intervention to manage adherence in older people, as part of a doctoral research project.

Is Prescription Nonredemption a Source of Poor Health Among the Roma? Cross-Sectional Analysis of Drug Consumption Data From the National Health Insurance Fund of Hungary

Background: The health status of the Roma is inferior to that of the general population. The causes of poor health among this population are still ambiguous, but they include low utilization of healthcare services. Our study aimed to investigate prescription redemptions in segregated Roma colonies (SRC) where the most disadvantaged quartile of Roma people are living.

Methods: A cross-sectional study was carried out with data obtained from the National Institute of Health Insurance Fund Management in the settlements belonging to the study area of the “Public Health-Focused Model Program for Organizing Primary Care Services.” The study included 4,943 residents of SRC and 62,074 residents of the complementary area (CA) of the settlements where SRC were located. Crude and age- and sex-standardized redemption ratios for SRC and CA were calculated for each Anatomic Therapeutic Chemical (ATC) group and for the total practice by ATC group. Standardized relative redemptions (RR) with 95% confidence intervals were calculated for SRC, with CA as a reference.

Results: The crude redemption ratios were 73.13% in the SRC and 71.15% in the CA. RRs were higher in the SRC than in the CA for cardiovascular, musculoskeletal system, and alimentary tract and metabolism drugs (11.5, 3.7, and 3.5%, respectively). In contrast, RRs were lower in the SRC than in the CA for anti-infective agents (22.9%) due to the poor redemption of medicines prescribed for children or young adults. Despite the overall modest differences in redemption ratios, some ATC groups showed remarkable differences. Those include cardiovascular, alimentary and musculoskeletal drugs.

Conclusion: Redemption of prescriptions was significantly higher among Roma people living in SRC than among those living in CA. The better redemption of cardiovascular and alimentary tract drugs was mainly responsible for this effect. These findings contradict the stereotype that the Roma do not use health services properly and that prescription non-redemption is responsible for their poor health.

A Nationwide Cross-Sectional Study of Self-Reported Adherence and Factors Associated with Analgesic Treatment in People with Chronic Pain

This study aims to shed light on the frequency and associated factors of self-reported adherence to analgesic treatment among chronic pain (CP) patients in the Spanish population. A nationwide cross-sectional study was performed of 1066 Spanish adults, of whom 251 suffered from CP and 168 had been prescribed analgesic treatment. Adherence was assessed using a self-reported direct questionnaire and related factors were collected. Descriptive and bivariate analyses were conducted. Among the 23.5% (95% CI: 21.0–26.2%) of the sample with CP, 66.9% (95% CI: 60.7–72.7%) were taking analgesic treatment prescribed by a doctor, and 81.0% (95% CI: 74.2–86.6%) said they took the treatment as the doctor indicated. However, 17.6% forgot to take the medication, 11% overused them when in great pain, 46.3% stopped the treatment when feeling better and 33.3% when feeling worse, and 7.3% stopped taking them for financial reasons. Higher intensity of pain, polymedication, administration route (injection/patches) and some patient-related factors were associated with self-perceived adherence to treatment. Most Spanish people with CP consider that they are adherent to their analgesic treatment. However, their behavior presents contradictions. It would be advisable for professionals to inform patients about appropriate behavior regarding their therapy recommendations, and to explore potential factors related to non-adherence. This could contribute to improving pain control.

Awareness about barriers to medication adherence in cardiovascular patients and strategies used in clinical practice by Portuguese clinicians: a nationwide study

BACKGROUND

Although much is known about cardiovascular patients' medication adherence, the extent to which clinicians perceive non-adherence as a barrier in clinical practice is little explored. Objective To evaluate knowledge and awareness about potential barriers to medication adherence, and to evaluate strategies used in clinical practice by Portuguese clinicians on how to foster medication adherence of patients undergoing secondary cardiovascular prevention. Setting Nominal Group Technique (NGT) at the University of Lisbon; online survey addressed to physicians working in primary and secondary care in Portugal. Method A narrative literature review was conducted in Pubmed to identify studies describing interventions targeted at physicians to manage medication adherence. The NGT included 12 allied healthcare professionals with recognized expertise in medication adherence and was organised in four phases, resulting in survey development. The survey was used in a cross-sectional national study where clinicians reported their knowledge and perceptions about patients' medication adherence and their daily practice. Main outcome measures Knowledge and awareness about barriers to medication adherence; and practice patterns. Results A total of 296 papers were identified, 26 of which were included. Four main topics were selected to be used in the NGT: adherence determinants, detecting non-adherence, fostering adherence, and educating physicians. NGT resulted in a survey, reaching 451 physicians, mostly practicing in primary care. Most had specific education on medication adherence and considered patient interviews and prescription records the most useful assessment methods. Nonetheless, many recognised often using clinical judgement to evaluate adherence in practice. Barriers to medication adherence were perceived to occur often during implementation. Most perceived reasons for uncontrolled hypertension were non-adherence to lifestyle recommendations and to medication. Less than half the physicians asked their patients if medication was taken. More useful enabling strategies included reducing daily doses, reviewing therapeutic options and motivational interventions. Conclusions Clinicians seem well informed about the importance of medication adherence and aware of problems encountered in practice. Limited time during medical appointment may be a barrier for better patient support.

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

BACKGROUND

This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration.

METHODS

It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide.

RESULTS

Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self-management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals.

CONCLUSION

On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

Medication Adherence In Patients With Arterial Hypertension: The Relationship With Healthcare Systems' Organizational Factors

PURPOSE

Arterial hypertension is one of the most common diseases in the world, presenting a great impact on global mortality. Despite having good medication, the best control depends on patient's adherence. Our aim is to characterize the relationship of adherence to medication in hypertensive patients with consultation length and other organizational factors of healthcare systems.

PATIENTS AND METHODS

We performed a comprehensive review of literature using the MeSH terms "hypertension" and "medication adherence". 61 articles were selected for inclusion and adherence parameters were extracted, allowing us to estimate the mean adherence for each country. The adherence was then correlated with organizational aspects of healthcare systems: consultation length, number of health providers (doctors, nurses and pharmacists), number of hospital beds, health expenditure and general government expenditure.

RESULTS

Adherence to medication ranged between 11.8% in Indonesia and 85.0% in Australia. There is much heterogeneity in methodology, but the Morisky Medication Adherence Scale was the preferred method, used in 63.6% of the cases. We found no relation with consultation length, but a significant one with the greater number of health professionals available. Some differences were observed when considering European countries or Morisky Medication Adherence Scale alone.

CONCLUSION

The better the drugs, the better the control of blood pressure, if patients take them. Rather than investing in the prescription of more drugs, it is important to address non-adherence and reduce it to promote better blood pressure control. Organizational factors are relevant constraints and depend on administrative and political decisions. Although they are not always considered, they greatly impact the adherence to medication.

Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol

OBJECTIVE

The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions.

INTRODUCTION

Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases.

INCLUSION CRITERIA

Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded.

METHODS

PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.

The Great Recession and inequalities in access to health care: a study of unemployment and unmet medical need in Europe in the economic crisis

Background

Unmet medical need (UMN) had been declining steadily across Europe until the 2008 Recession, a period characterized by rising unemployment. We examined whether becoming unemployed increased the risk of UMN during the Great Recession and whether the extent of out-of-pocket payments (OOP) for health care and income replacement for the unemployed (IRU) moderated this relationship.

Methods

We used the European Survey on Income and Living Conditions (EU-SILC) to construct a pseudo-panel (n = 135 529) across 25 countries to estimate the relationship between unemployment and UMN. We estimated linear probability models, using a baseline of employed people with no UMN, to test whether this relationship is mediated by financial hardship and moderated by levels of OOP and IRU.

Results

Job loss increased the risk of UMN [β = 0.027, 95% confidence interval (CI) 0.022–0.033] and financial hardship exacerbated this effect. Fewer people experiencing job loss lost access to health care in countries where OOPs were low or in countries where IRU is high. The results are robust to different model specifications.

Conclusions

Unemployment does not necessarily compromise access to health care. Rather, access is jeopardized by diminishing financial resources that accompany job loss. Lower OOPs or higher IRU protect against loss of access, but they cannot guarantee it. Policy solutions should secure financial protection for the unemployed so that resources do not have to be diverted from health.

Reasons for Primary Medication Nonadherence: A Systematic Review and Metric Analysis

BACKGROUND

The behavior of medication nonadherence is distinguished into primary and secondary nonadherence. Primary nonadherence (PNA) is not as thoroughly studied as secondary nonadherence.

OBJECTIVE

To explore and synthesize contributing factors to PNA based on the existing body of literature.

METHODS

A search was performed on the PubMed, PsycINFO, CINAHL, and ScienceDirect databases to identify previously published scholarly articles that described the "factors," "reasons," "determinants" or "facilitators" of PNA. The alternate spelling of "nonadherence" was used as well. The effect that the articles had in the research community, as well as across social media, was also explored.

RESULTS

22 studies met the inclusion criteria for this review. The PNA factors that the studies identified were diverse, spanning economic, social, and medical dimensions. A multilevel classification method was applied to categorize the factors into 5 broad groups-patient, medication, health care provider, health care system, and socioeconomic factors. Patient factors were reported the most. Some groups overlapped and shared a dynamic causal relationship where one group influenced the outcome of the other.

CONCLUSIONS

Like all nonadherence behaviors, PNA is multifaceted with highly varied contributing factors that are closely associated with one another. Given the multidimensional nature of PNA, future intervention studies should focus on the dynamic relationship between these factor groups for more efficient outcomes.

DISCLOSURES

This research was supported by the National Research Foundation Singapore under its National Innovation Challenge on Active and Confident Ageing (Award No. MOH/NIC/CAHIG03/2016) and administered by the Singapore Ministry of Health's National Medical Research Council. This research was also supported by the National Research Foundation within the Prime Minister's Office of Singapore, under its Science of Research, Innovation and Enterprise Programme (SRIE Award No. NRF2014-NRF-SRIE001-019). The authors have no relevant conflicts of interest to disclose.

Cross-cultural adaptation and validation of a European Portuguese version of the 8-item Morisky medication adherence scale

INTRODUCTION AND OBJECTIVE

The 8-Item Morisky Medication Adherence Scale (MMAS-8) is one of the most widely used instruments to assess medication adherence, but a validated European Portuguese version of MMAS-8 does not exist. Our aim was to develop and validate a European Portuguese version of the MMAS-8.

METHODS

A process of translation and back-translation of the original MMAS-8 was performed. The questionnaire was administered in nine community pharmacies and one public hospital between March 2014 and September 2015. Adult patients taking at least one antihypertensive drug were invited to participate. A confirmatory factor analysis was performed and internal consistency, convergent validity and concurrent validity were examined.

RESULTS

A total of 472 patients were enrolled in the study. The mean MMAS-8 score obtained was 6.74±1.39. One hundred and thirty-two patients were classified as low adherers (28%), 181 (38.3%) as medium adherers and 159 (33.7%) as high adherers. For the factorial structure of the Portuguese version of the MMAS-8, the fit indices of the final model (chi-square [18] 48.465, p<0.001) are suggestive of very good fit, with comparative fit index 0.95, root mean square error of approximation 0.06 (90% confidence interval 0.04-0.08), and standardized root mean square residual 0.04, confirming that the construct tested was unidimensional. The Cronbach's alpha for all items was 0.60, and the translated version presents convergent validity and concurrent validity.

CONCLUSION

A European Portuguese version of the MMAS-8 was created that maintained a similar structure to the original MMAS-8 and good psychometric properties.

Effect of different methods for estimating persistence and adherence to new glucose-lowering drugs: results of an observational, inception cohort study in Portugal

PURPOSE

Several methods have been developed for assessing medication-taking behavior; understanding the determinants and variability in estimates obtained is crucial in interpreting results. We estimated persistence and adherence levels to new glucose-lowering drugs (GLDs) in type 2 diabetes mellitus (T2DM) patients using different methods: through the collection of pharmacy records and combining pharmacy records with self-reported data.

METHODS

We conducted a prospective observational cohort study of T2DM patients initiating a new GLD. Data were collected at baseline through interviews (demographic and clinical data). Follow-up data included pharmacy records (refill dates and medication possession) and telephone questionnaires (self-declared monitored GLD refill in another pharmacy, reasons for drug withdrawal). The cohort was divided into incident and prevalent new users. Persistence and adherence (proportion of days covered) were estimated for patients using pharmacy records exclusively (Method 1) and ≥1 self-declared statement of being persistent (Method 2). Log-rank tests were used to compare Kaplan-Meier curves of time to nonpersistence.

RESULTS

A total of 1,328 patients were recruited. When considering Method 1, 38.7% (95% confidence interval [95% CI]: 36.0-41.5) of patients were persistent, whereas combining with self-reported information, this estimate increased to 65.6% (95% CI: 62.9-68.2). Using Method 1, the risk of persistence failure was associated with using an oral GLD, living alone and living in a suburban/urban setting. Three hundred and twenty-seven (24.8%) patients stopped to use the inception GLD.

CONCLUSION

Regardless of the method used, results indicated low levels of persistence and adherence to a new GLD; however, when combining self-reported information, higher estimates were obtained. Considering pharmacy records exclusively, prevalent new users, who were more complex patients in terms of T2DM disease but more likely to be pharmacy-loyal patients, were significantly more adherent than the incident new users. Barriers and reasons leading to GLD withdrawal, namely adverse drug event management, should be addressed, since they represent half of the reasons for treatment switching or discontinuation.

Initial medication non-adherence: prevalence and predictive factors in a cohort of 1.6 million primary care patients

AIMS

Adherence to medicines is vital in treating diseases. Initial medication non-adherence (IMNA) - defined as not obtaining a medication the first time it is prescribed - has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system.

METHODS

This is a retrospective, register-based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non-initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013-June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation.

RESULTS

Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin-converting-enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain-related or mental disorder and being treated by a substitute/resident general practitioner in a resident-training centre.

CONCLUSIONS

The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.

Effects of economic recession on elderly patients' perceptions of access to health care and medicines in Portugal

Background In view of the current financial and demographic situation in Portugal, accessibility to health care may be affected, including the ability to adhere to medication. Objective To evaluate the perceived effects of the crisis on elderly patient's access to medicines and medical care, and its implications on medicine-taking behaviour. Setting Community pharmacy. Method A cross-sectional study was undertaken during April 2013, where elderly patients answered a self-administered questionnaire based on their health-related experiences in the current and previous year. Binary logistic regression was used to ascertain the effects of potential predictors on the likelihood of adherence. Main outcome measures self-reported adherence. Results A total of 1231 questionnaires were collected. 27.3% of patients had stopped using treatments or health services in the previous year for financial motives; mostly private medical appointments, followed by dentist appointments. Almost 30% of patients stopped purchasing prescribed medicines. Over 20% of patients reduced their use of public services. Out-of-pocket expenses with medicines were considered higher in the current year by 40.1% of patients. The most common strategy developed to cope with increasing costs of medicines was generic substitution, but around 15% of patients also stopped taking their medication or started saving by increasing the interdose interval. Conclusion Reports of decreasing costs with medicines was associated with a decreased likelihood of adherence (OR 0.42; 95% CI 0.27-0.65). Lower perceived health status and having 3 or more co-morbidities were associated with lower odds of adhering, whilst less frequent medical appointments was associated with a higher likelihood of exhibiting adherence.

Effects of the financial crisis and Troika austerity measures on health and health care access in Portugal

Although Portugal has been deeply affected by the global financial crisis, the impact of the recession and subsequent austerity on health and to health care has attracted relatively little attention. We used several sources of data including the European Union Statistics for Income and Living Conditions (EU-SILC) which tracks unmet medical need during the recession and before and after the Troika's austerity package. Our results show that the odds of respondents reporting having an unmet medical need more than doubled between 2010 and 2012 (OR=2.41, 95% CI 2.01-2.89), with the greatest impact on those in employment, followed by the unemployed, retired, and other economically inactive groups. The reasons for not seeking care involved a combination of factors, with a 68% higher odds of citing financial barriers (OR=1.68, 95% CI 1.32-2.12), more than twice the odds of citing waiting times and inability to take time off work or family responsibilities (OR 2.18, 95% CI 1.20-3.98), and a large increase of reporting delaying care in the hope that the problem would resolve on its own (OR=13.98, 95% CI 6.51-30.02). Individual-level studies from Portugal also suggest that co-payments at primary and hospital level are having a negative effect on the most vulnerable living in disadvantaged areas, and that health care professionals have concerns about the impact of recession and subsequent austerity measures on the quality of care provided. The Portuguese government no longer needs external assistance, but these findings suggest that measures are now needed to mitigate the damage incurred by the crisis and austerity.