Non-adherence to antidiabetic and cardiovascular drugs in type 2 diabetes mellitus and its association with renal and cardiovascular outcomes: A narrative review

Evaluation of diabetes mellitus medication-taking behavior among first- and second-generation Australians of Chinese heritage: A nationwide cross-sectional study

Aim

To investigate the association of health literacy, illness perceptions, and beliefs about medications on medication-taking behavior among first- and second-generation Australians of Chinese heritage living with type 2 diabetes mellitus (T2DM).

Method

A nationwide cross-sectional online survey of (N = 455) of whom 196 responded, was conducted among adults (≥18 years) with T2DM of Chinese heritage residing in Australia. Participants were recruited via direct invitation (national registry and specialist clinic). Data collection utilized four validated questionnaires: The Brief Medication Questionnaire, Beliefs about Medicines Questionnaire Specific (BMQ-Specific), Brief Illness Perception 9 Questionnaire (BIPQ), and a 12-item short-form health literacy (HL) questionnaire (HLS-SF12). Bivariate and multivariate analyses were conducted to explore the factors associated with medication-taking.

Results

Overall, 27 % of participants reported missing diabetes medication(s) in the past week, with access barriers most cited (38 %), followed by belief (27 %) and recall (24 %) barriers. Median scores for health literacy, illness perception and beliefs about medications showed problems with health literacy (General Health Literacy Index, median [IQR] =31.94 [26.39ꟷ38.89], a moderate threat to illness perception (BIPQ:= 38.56 ± 10.52) and higher perceived necessity of taking diabetes medications relative to concern (BMQ-Specific Necessity: = 3.80 [3.20-4.20]; BMQ-Specific Concern: = 3.00 [2.50-3.67]). Better medication-taking was seen in people with high necessity beliefs and with low concerns in the use of medications. Health literacy and illness perceptions were not significantly associated with medication-taking behavior.

Conclusion

Medication beliefs play a role in sub-optimal medication-taking behavior among Chinese adults with T2DM. Increased attention needs to be placed on examining and enhancing understanding of diabetes medications while addressing concerns among individuals of Chinese backgrounds to better understand the complexities of medication-taking behavior. Culturally relevant clinical discussion and structured diabetes education may support the development of health promoting medication beliefs potentially supporting optimal medication-taking behavior.

A qualitative study of type 2 diabetes mellitus outpatients' perspectives on readiness, acceptance and barriers of mobile apps for medication adherence

OBJECTIVES

This qualitative phenomenological study explored the perspectives of type 2 diabetes mellitus (T2DM) outpatients in adopting mobile apps for medication adherence management.

METHODS

Through 25 semi-structured in-depth interviews, themes were identified using thematic analysis, guided by the Technology Readiness and Acceptance Model (TRAM).

RESULTS

Anticipated convenience and benefits, openness to new technologies acted as drivers, while limited digital literacy and concerns about data privacy and security served as inhibitors of readiness to adopt health apps. Acceptance was influenced by elements related to medication, patient, healthcare professional, family and app aspects. The identified barriers were related to patient, smartphone and monetary factors. Patients perceived the need to adopt digital apps were for those with poor adherence, complex medication regimen and forgetfulness issues. However, concerns about effectively implementing this approach were noted as T2DM patients were predominantly late middle-aged adults who faced technical challenges, leading to combination approach between digital technology and conventional patient education and counselling.

CONCLUSION

The findings highlighted the factors influencing patient's readiness, acceptance, and barriers on effective utilisation of digital health solutions in managing adherence issues.

PRACTICAL IMPLICATIONS

The elements of TRAM provide guidance for strategic actions to enhance digital health technology adoption among T2DM patients.

Enhancing Therapy Adherence: Impact on Clinical Outcomes, Healthcare Costs, and Patient Quality of Life

Adherence to therapy, defined as the extent to which a patient follows prescribed therapeutic recommendations, is a pivotal factor in the effective management of chronic diseases such as diabetes, hypertension, and cardiovascular conditions. This review highlights the profound influence of adherence on clinical outcomes, healthcare costs, and patient quality of life. Despite its critical importance, non-adherence remains a pervasive challenge globally, contributing to suboptimal treatment results, higher rates of complications, increased hospitalizations, and substantial healthcare expenditures. This narrative review examines the multifaceted impact of adherence, focusing on its role in achieving clinical efficacy, mitigating economic burdens, and enhancing patient well-being. The findings reveal that poor adherence exacerbates the risk of disease progression, complications, and higher healthcare costs. Conversely, improved adherence promotes better disease control, fewer complications, and enhanced patient quality of life. Interventions such as patient education, streamlined treatment regimens, and the integration of digital health tools have shown promise in addressing adherence barriers. Furthermore, the role of healthcare professionals is underscored as fundamental, with their continuous support, effective communication, and efforts to build patient trust being essential to fostering better adherence. In conclusion, adherence significantly affects clinical outcomes, healthcare costs, and patient quality of life. Addressing barriers to adherence requires a comprehensive and personalized approach, considering individual patient needs and circumstances. Future research should prioritize the long-term evaluation of emerging technologies and the development of tailored strategies to improve adherence across diverse patient populations. Strengthening adherence is not only crucial for individual patient outcomes, but also for enhancing the sustainability and efficiency of healthcare systems.

Stakeholder perspectives on facilitators and barriers to implementing a zero-dollar copay program for chronic conditions study

BACKGROUND

Type 2 diabetes mellitus (T2D) remains a pressing public health concern. Despite advancements in antidiabetic medications, suboptimal medication adherence persists among many individuals with T2D, often due to the high cost of medications. To combat this issue, Blue Cross and Blue Shield of Louisiana (Blue Cross) introduced the $0 Drug Copay (ZDC) program, providing $0 copays for select drugs. This study sought to explore barriers and facilitators to the successful implementation of Blue Cross's ZDC program (updated version).

METHODS

Focus group discussions and interviews were conducted with health plan leadership, health coaches and providers who participate in the health plan organization's healthcare quality improvement program. Focus group discussions and semi-structured interviews were conducted between October 2022 and July 2023. Discussion guides were developed collaboratively and tailored to each participant group. Interviews were recorded, transcribed and analysed using NVivo® qualitative analysis software. A descriptive, qualitative analysis was conducted, resulting in the identification of seven codes and subsequent candidate themes.

RESULTS

In total, 15 participants were interviewed: 6 were Blue Cross administrators, 5 were health coaches and 4 were Quality Blue providers. Overall, participants had positive feedback on the ZDC program and perceived that it has significant benefits for patients and the health system but could be improved, and four themes related to implementation barriers and facilitators, effectiveness and potential areas of improvement were identified: (1) the ZDC program reduces friction for patients, prescribers and the health system; (2) the program is aligned with the values of health systems, insurers and providers, facilitating implementation success; (3) expanding coverage (drug classes and conditions) and education (for providers and patients) could maximize program benefits; and (4) coronavirus disease 2019 (COVID-19) did not negatively impact program administration because the $0 copay was programmed at the benefit level.

CONCLUSIONS

The ZDC program aligns goals and can benefit patients, providers and patients. The program can have the largest potential if it is expanded to include new medications and new conditions, and if there is more education for patients and providers. Regardless of challenges, reduced-copay programs have the potential to improve medication adherence, improve HbA1C control and improve overall health outcomes. Trial Registration This study was approved by the Tulane University Institutional Review Board, IRB #2020-1986.

Survey of fear and compliance of Insulin Degludec and Insulin Aspart injection in type 2 diabetes mellitus patients and analysis of influencing factors

This study aims to investigate the fear and compliance of Insulin Degludec and Insulin Aspart (IDegAsp) injection in type 2 diabetes mellitus (T2DM) patients and study the factors influencing patient compliance. A total of 120 patients with T2DM treated from February 2019 to March 2022 were investigated and analyzed for fear and compliance on the Diabetes Fear of Injecting and Self-testing Questionnaire of diabetic patients and were divided into compliance and noncompliance groups according to the results to analyze the factors affecting patient compliance. The study found a high level of fear of IDegAsp injection among the 120 T2DM patients, with an average Diabetes Fear of Injecting and Self-testing Questionnaire score of (39.19 ± 4.59) points. Scores for medication compliance, dietary compliance, blood sugar monitoring, and lifestyle changes were (10.48 ± 1.52) points, (12.18 ± 2.27) points, (0.84 ± 0.12) points, and (9.13 ± 2.21) points, respectively. There was no significant difference between the compliance and noncompliance groups in terms of gender, age, lifestyle, educational level, occupation, current treatment method, family monthly income per capita, and medical payment method (P > .05). However, there were significant differences influenced by disease duration, complications, cognitive level, self-efficacy level, comorbidity count, and living status (P < .05). Multifactorial analysis showed that educational level, disease duration, complications, cognitive level, self-efficacy level, comorbidity count, and living status all affected patient compliance (P < .05). Educational level, disease duration, complications, cognitive level, self-efficacy level, comorbidity count, and living status are important factors affecting the fear and treatment compliance of IDegAsp injection in T2DM patients. These findings have implications for improving patient compliance and alleviating treatment fear.

Non-adherence to cardiometabolic medication as assessed by LC-MS/MS in urine and its association with kidney and cardiovascular outcomes in type 2 diabetes mellitus

AIMS/HYPOTHESIS

Non-adherence to medication is a frequent barrier in the treatment of patients with type 2 diabetes mellitus, potentially limiting the effectiveness of evidence-based treatments. Previous studies have mostly relied on indirect adherence measures to analyse outcomes based on adherence. The aim of this study was to use LC-MS/MS in urine-a non-invasive, direct and objective measure-to assess non-adherence to cardiometabolic drugs and analyse its association with kidney and cardiovascular outcomes.

METHODS

This cohort study includes 1125 participants from the PROVALID study, which follows patients with type 2 diabetes mellitus at the primary care level. Baseline urine samples were tested for 79 cardiometabolic drugs and metabolites thereof via LC-MS/MS. An individual was classified as totally adherent if markers for all drugs were detected, partially non-adherent when at least one marker for one drug was detected, and totally non-adherent if no markers for any drugs were detected. Non-adherence was then analysed in the context of cardiovascular (composite of myocardial infarction, stroke and cardiovascular death) and kidney (composite of sustained 40% decline in eGFR, sustained progression of albuminuria, kidney replacement therapy and death from kidney failure) outcomes.

RESULTS

Of the participants, 56.3% were totally adherent, 42.0% were partially non-adherent, and 1.7% were totally non-adherent to screened cardiometabolic drugs. Adherence was highest to antiplatelet and glucose-lowering agents and lowest to lipid-lowering agents. Over a median (IQR) follow-up time of 5.10 (4.12-6.12) years, worse cardiovascular outcomes were observed with non-adherence to antiplatelet drugs (HR 10.13 [95% CI 3.06, 33.56]) and worse kidney outcomes were observed with non-adherence to antihypertensive drugs (HR 1.98 [95% CI 1.37, 2.86]).

CONCLUSIONS/INTERPRETATION

This analysis shows that non-adherence to cardiometabolic drug regimens is common in type 2 diabetes mellitus and negatively affects kidney and cardiovascular outcomes.

Estimating the effect of realistic improvements of metformin adherence on COVID-19 mortality using targeted machine learning

Background

Type 2 diabetes elevates the risk of severe outcomes in COVID-19 patients, with multiple studies reporting higher case fatality rates. Metformin is a widely used medication for glycemic management. We hypothesize that improved adherence to metformin may lower COVID-19 post-infection mortality risk in this group. Utilizing data from the Mexican Social Security Institute (IMSS), we investigate the relationship between metformin adherence and mortality following COVID-19 infection in patients with chronic metformin prescriptions.

Methods

This is a retrospective cohort study consisting of 61,180 IMSS beneficiaries who received a positive polymerase chain reaction (PCR) or rapid test for SARS-CoV-2 and had at least two consecutive months of metformin prescriptions prior to the positive test. The hypothetical intervention is improved adherence to metformin, measured by proportion of days covered (PDC), with the comparison being the observed metformin adherence values. The primary outcome is all-cause mortality following COVID-19 infection. We defined the causal parameter using shift intervention, an example of modified treatment policies. We used the targeted learning framework for estimation of the target estimand.

Findings

Among COVID-19 positive patients with chronic metformin prescriptions, we found that a 5% and 10% absolute increase in metformin adherence is associated with a respective 0.26% (95% CI: -0.28%, 0.79%) and 1.26% (95% CI: 0.72%, 1.80%) absolute decrease in mortality risk.

Interpretation

Subject to the limitations of a real-world data study, our results indicate a causal association between improved metformin adherence and reduced COVID-19 post-infection mortality risk.

Predictors of microvascular complications in patients with type 2 diabetes mellitus at regional referral hospitals in the central zone, Tanzania: a cross-sectional study

Microvascular complications encompass a group of diseases which result from long-standing chronic effect of diabetes mellitus (DM). We aimed to determine the prevalence of microvascular complications and associated risk factors among patients with type 2 diabetes mellitus (T2DM). A cross-sectional analytical hospital-based study was conducted at Singida and Dodoma regional referral hospitals in Tanzania from December 2021 to September 2022. A total of 422 patients with T2DM were included in the analysis by determining the prevalence of microvascular complications and their predictors using multivariable logistic regression analysis. A two-tailed p value less than 0.05 was considered statistically significant. The prevalence of microvascular complications was 57.6% (n = 243) and diabetic retinopathy was the most common microvascular complication which accounted for 21.1% (n = 89). Having irregular physical activity (AOR = 7.27, 95% CI = 2.98-17.71, p < 0.001), never having physical activity (AOR = 2.38, 95% CI = 1.4-4.01, p = 0.013), being hypertensive (AOR = 5.0, 95% CI = 2.14-11.68, p = 0.030), having T2DM for more than 5 years (AOR = 2.74, 95% CI = 1.42-5.26, p = 0.025), being obese (AOR = 2.63, 95% CI = 1.22-5.68, p = 0.010), and taking anti-diabetic drugs irregularly (AOR = 1.94, 95% CI = 0.15-0.77, p < 0.001) were the predictors of microvascular complications. This study has revealed a significant proportion of microvascular complications in a cohort of patients with T2DM. Lack of regular physical activity, being obese, taking anti-diabetic drugs irregularly, presence of hypertension, and long-standing duration of the disease, were significantly associated with microvascular complications.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

Chronic kidney disease (CKD) imposes a significant medication burden on patients due to the necessity of multiple treatments to slow disease progression, manage coexisting conditions, and address complications. The complex medication regimen, in turn, has implications for clinical and patient-centered outcomes. This umbrella review provides comprehensive evidence on extent of medication nonadherence among adults with CKD, as well as associated risk factors, outcomes, and the effectiveness of interventions by synthesizing evidence from published systematic reviews and/or meta-analyses. We identified 37 works that met our inclusion criteria. These reviews covered various aspects of treatment adherence in people with CKD, which can be categorized into four main themes: (i) prevalence of treatment nonadherence; (ii) factors associated with (non)adherent behaviors; (iii) outcomes associated with treatment (non)adherence; and (iv) interventions to improve treatment adherence or overall self-management practices. Approximately half of the included studies (15/34) focused on interventions aimed at improving medication adherence or overall CKD management, while outcomes associated with medication (non)adherence were relatively underexplored in the literature. The reported prevalence rates of medication nonadherence varied widely among reviews and stages of CKD. The determinants of adherence identified included socioeconomic variables, disease or clinical conditions, and psychosocial factors. Common interventions to improve adherence included nurse-led interventions, pharmaceutical services, and eHealth technologies, which had varying effects on medication adherence or dialysis sessions.

Self-management practices for preventing complications of type II diabetes mellitus in low and middle-income countries: A scoping review

Introduction

The projected increase in the prevalence of diabetes mellitus globally is expected to hit the low and middle income countries the hardest. The majority of the day to day disease management activities needed to achieve glycaemic control and improve the quality of life among patients with diabetes mellitus falls on the patient and/or their families. Determining the self-management practices by patients with diabetes mellitus can help develop interventions that can enhance these practices and help prevent complications.

Objective

The current study aimed to explore the self-management practices of patients with type II diabetes mellitus in low and middle-income countries to prevent complications.

Design

A scoping review was conducted using the Joanna Briggs Institute approach to conducting scoping reviews. The context of the review was low and middle income countries with the core concept being self-management practices for prevention of complications.

Methods

Articles in Scopus databases and on the EBSCOHost platform were searched, as were their reference lists. If abstracts met inclusion criteria, full articles were downloaded and data extracted. The review included original research studies, published in the English language. The research studies included in the review were conducted between the year 2000 to 2022 among patients diagnosed with type II diabetes mellitus.

Results

This search yielded 823 articles; after deduplication, twelve studies were included in the final list. Four categories of self-management practices for preventing complications of type II diabetes mellitus were identified. The categories are i) acquisition of diabetes-related knowledge, ii) essential skills to manage diabetes mellitus, iii) lifestyle modification, and iv) availability of psychological support and follow-up.

Conclusions

Most diabetes care is dependent on patients' self-management levels. The studies reviewed in this article show that patients are capable of adequate self-management when practices are tailored to their needs.

Registration

The scoping review protocol was registered in the Fig Share platform on 17th January 2022 under the digital object identifier https://doi.org/10.38140/ufs.17206751.

Chronic kidney outcomes associated with GLP-1 receptor agonists versus long-acting insulins among type 2 diabetes patients requiring intensive glycemic control: a nationwide cohort study

BACKGROUND

Effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) versus long-acting insulins (LAIs) on preventing progressive chronic kidney outcomes is uncertain for type 2 diabetes (T2D) patients requiring intensive glycemic control. This study aimed to evaluate comparative effectiveness of GLP-1RA versus LAI therapies on progressive chronic kidney outcomes among patients having poor glycemic control and requiring these injectable glucose-lowering agents (GLAs).

METHODS

7279 propensity-score-matched pairs of newly stable GLP-1RA and LAI users in 2013-2018 were identified from Taiwan's National Health Insurance Research Database and followed until death or 12/31/2019 (intention-to-treat). Subdistributional hazard model was utilized to assess the comparative effectiveness on a composite renal outcome (i.e., renal insufficiency [eGFR < 15 mL/min/1.73 m2], dialysis-dependent end-stage renal disease [ESRD], or renal death) and its individual components. Sensitivity analyses with the as-treated scenario, PS weighting, high-dimensional PS techniques, using cardiovascular diseases (CVDs) as positive control outcomes, and interaction testing were performed.

RESULTS

In primary analyses, subdistribution hazard ratios (95% CIs) for initiating GLP-1RAs versus LAIs for the composite renal outcome, renal insufficiency, dialysis-dependent ESRD, and renal death were 0.39 (0.30-0.51), 0.43 (0.32-0.57), 0.29 (0.20-0.43), and 0.28 (0.15-0.51), respectively. Sensitivity analysis results were consistent with the primary findings. CVD history and the medication possession ratio of prior oral GLAs possessed modification effects on GLP-1RA-associated kidney outcomes.

CONCLUSION

Using GLP-1RAs versus LAIs was associated with kidney benefits in T2D patients requiring intensive glycemic control and potentially at high risk of kidney progression. GLP-1RAs should be prioritized to patients with CVDs or adherence to prior oral GLAs to maximize kidney benefits.

Medication Adherence among Patients with Diabetes Mellitus and Its Related Factors-A Real-World Pilot Study in Bulgaria

Background and Objectives: The objective is to evaluate medication adherence level (MA) and the relevant determinants of MA among patients with type 2 diabetes mellitus (T2DM) monitored in ambulatory settings by general practitioners. Materials and Methods: A cross-sectional study was conducted among patients with T2DM monitored in a GP practice in Sofia, Bulgaria (September-December 2022). All patients were interviewed according to a predesigned questionnaire after granting informed consent. MA level was evaluated through the Morisky-Green four-item questionnaire, and health-related quality of life was evaluated by EQ-5D-5L and VAS (visual analogue scale). Data were aggregated and statistically evaluated. Results: The total number of observed patients was 93. Around 48.4% of patients were female, and 90.3% of patients were between 50 and 80 years of age. Multimorbidity was identified among 70% (n = 65) of the respondents. High and medium levels of MA were revealed in 64.51% and 33.3% of respondents, respectively. Patients treated with insulin secretagogues were most adherent to the therapy (n = 83.3%) in comparison with the other treatment groups. The onset of the disease, professional status, age, gender, number of therapies, and quality of life did not affect the level of MA (p > 0.05). VAS scores among nonsmokers (VAS = 63.16 ± 20.45 vs. 72.77 ± 14.3) and non-consumers of alcohol (VAS = 63.91 ± 19.34 vs. VAS = 72.54 ± 15.98) were statistically significant lower (p < 0.05). A significant related factor for MA was years lived with diabetes (OR = 3.039, 95% CI 1.1436-8.0759, p = 0.0258). The longer the disease duration, the more the odds for a high MA level increased. Conclusions: The number of nonadherent diabetic patients in Bulgaria is low, which might be evidence of patients' concern about their own health and understanding about the importance of prescribed therapy. Further comprehensive study with additional patients is required to confirm the results and investigate the predicting factors for a high level of MA.

Predictors of Long-Term Mortality in Patients with Stable Angina Pectoris and Coronary Slow Flow

Background and Objectives: Coronary slow flow (CSF) is an angiographic phenomenon characterized by the slow progression of an injected contrast agent during diagnostic coronary angiography in the absence of significant stenosis. Although CSF is a common angiographic finding, the long-term outcomes and mortality rates are still unknown. This study aimed to investigate the underlying causes of mortality over a 10-year period in patients diagnosed with stable angina pectoris (SAP) and CSF. Materials and Methods: This study included patients with SAP who underwent coronary angiography from 1 January 2012 to 31 December 2012. All patients displayed CSF despite having angiographically normal coronary arteries. Hypertension (HT), diabetes mellitus (DM), hyperlipidaemia, medication compliance, comorbidities, and laboratory data were recorded at the time of angiography. Thrombolysis in myocardial infarction (TIMI) frame count (TFC) was calculated for each patient. The cardiovascular (CV) and non-CV causes of long-term mortality were assessed. Results: A total of 137 patients with CSF (93 males; mean age: 52.2 ± 9.36 years) were included in this study. Twenty-one patients (15.3%) died within 10 years of follow-up. Nine (7.2%) and 12 (9.4%) patients died of non-CV and CV causes, respectively. Total mortality in patients with CSF was associated with age, HT, discontinuation of medications, and high-density lipoprotein cholesterol (HDL-C) levels. The mean TFC was associated with CV mortality. Conclusion: Patients with CSF exhibited a notable increase in cardiovascular-related and overall mortality rates after 10 years of follow-up. HT, discontinuation of medications, HDL-C levels, and mean TFC were associated with mortality in patients with CSF.

Adherence to Medication in Older Adults with Type 2 Diabetes Living in Lubuskie Voivodeship in Poland: Association with Frailty Syndrome

Purpose: Diabetic patients aged 65 years or older are more likely to be frail than non-diabetic older adults. Adherence to therapeutic recommendations in the elderly suffering from diabetes and co-existent frailty syndrome may prevent complications such as micro- or macroangiopathy, as well as significantly affect prevention and reversibility of frailty. The study aimed at assessing the impact of frailty syndrome (FS) on the level of adherence to medication in elderly patients with type 2 diabetes (DM2). Patients and Methods: The research was carried out among 175 DM2 patients (87; 49.71% women and 88; 50.29% men) whose average age amounted to 70.25 ± 6.7. Standardized research instruments included Tilburg frailty indicator (TFI) to assess FS and adherence in chronic disease scale questionnaire (ACDS) to measure adherence to medications. Results: The group of 101 (57.71%) patients displayed medium, 39 (22.29%)—low, and 35 (20.00%)—high adherence. As many as 140 of them (80.00%) were diagnosed with frailty syndrome. The median of the average result of TFI was significantly higher in the low adherence group (p ˂ 0.001) (Mdn = 9, Q1–Q3; 7–10 pt.) than in the medium (Mdn = 6, Q1–Q3; 5–9 pt.) or high adherence (Mdn = 6.00, Q1–Q3; 4.5–8 pt.) ones. The independent predictors of the chance to be qualified to the non-adherence group included three indicators: TFI (OR 1.558, 95% CI 1.245–1.95), male gender (OR 2.954, 95% CI 1.044–8.353), and the number of all medications taken daily (each extra pill decreased the chance of being qualified to the non-adherence group by 15.3% (95% CI 0.728–0.954). Conclusion: Frailty syndrome in elderly DM2 patients influenced medical adherence in this group. The low adhesion group had higher overall TFI scores and separately higher scores in the physical and psychological domains compared to the medium and high adhesion groups.