Predictors of self-reported adherence to antihypertensive medicines: a multinational, cross-sectional survey

Unravelling the Belgian cascade of hypertension care and its determinants: insights from a cross-sectional analysis

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease and all-cause mortality worldwide. Despite the widespread availability of effective antihypertensives, blood pressure (BP) control rates remain suboptimal, even in high-income countries such as Belgium. In this study, we used a cascade of care approach to identify where most patients are lost along the continuum of hypertension care in Belgium, and to assess the main risk factors for attrition at various stages of hypertension management.

METHODS

Using cross-sectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Survey, we estimated hypertension prevalence among the Belgian population aged 40-79 years, and the proportion that was (1) screened, (2) diagnosed, (3) linked to care, (4) in treatment, (5) followed up and (6) well-controlled. Cox regression models were estimated to identify individual risk factors for being unlinked to hypertension care, untreated and not followed up appropriately.

RESULTS

The prevalence of hypertension based on self-reported and measured high BP was 43.3%. While 98% of the hypertensive population had their BP measured in the past 5 years, only 56.7% were diagnosed. Furthermore, 53.4% were linked to care, 49.8% were in treatment and 43.4% received adequate follow-up. Less than a quarter (23.5%) achieved BP control. Among those diagnosed with hypertension, males, those of younger age, without comorbidities, and smokers, were more likely to be unlinked to care. Once in care, younger age, lower BMI, financial hardship, and psychological distress were associated with a higher risk of being untreated. Finally, among those treated for hypertension, females, those of younger age, and without comorbidities were more likely to receive no adequate follow-up.

CONCLUSION

Our results show that undiagnosed hypertension is the most significant barrier to BP control in Belgium. Health interventions are thus needed to improve the accurate and timely diagnosis of hypertension. Once diagnosed, the Belgian health system retains patients fairly well along the continuum of hypertension care, yet targeted health interventions to improve hypertension management for high-risk groups remain necessary, especially with regard to improving treatment rates.

Structural Equation Modelling to Identify Psychometric Determinants of Medication Adherence in a Survey of Kidney Dialysis Patients

Purpose

Medication non-adherence in dialysis patients is associated with increased mortality and higher healthcare costs. We assessed whether medication adherence is influenced by specific psychometric constructs measuring beliefs about the necessity for medication and concerns about them. We also tested whether medication knowledge, health literacy, and illness perceptions influenced this relationship.

Patients and Methods

This study is based on data from a cross-sectional in-person questionnaire, administered to a random sample of all adult dialysis patients at a teaching hospital. The main outcome was self-assessed medication adherence (8-Item Morisky Medication Adherence Scale). The predictors were: concerns about medications and necessity for medication (Beliefs About Medication Questionnaire); health literacy; medication knowledge (Medication Knowledge Evaluation Tool); cognitive, emotional, and comprehensibility Illness perceptions (Brief Illness Perception Questionnaire). Path analysis was performed using structural equations in both covariance and variance-based models.

Results

Necessity for medication increased (standardized path coefficient [β] 0.30 [95% CI 0.05, 0.54]) and concerns about medication decreased (standardized β -0.33 [-0.57, -0.09]) medication adherence, explaining most of the variance in outcome (r2=0.95). Medication knowledge and cognitive illness perceptions had no effects on medication adherence, either directly or indirectly. Higher health literacy, greater illness comprehension, and a more positive emotional view of their illness had medium-to-large sized effects in increasing medication adherence. These were indirect rather and direct effects mediated by decreases in concerns about medications (standardized β respectively -0.40 [-0.63,-0.16], -0.60 [-0.85, -0.34], -0.33 [-0.52, -0.13]).

Conclusion

Interventions that reduce patients' concerns about their medications are likely to improve adherence, rather than interventions that increase patients' perceived necessity for medication. Improving patients' general health literacy and facilitating a better understanding and more positive perception of the illness can probably achieve this. Our study is potentially limited by a lack of generalizability outside of the population and setting in which it was conducted.

The Association between Deductibles and Cardiovascular Medication Adherence: A Retrospective Inception Cohort Study

OBJECTIVE

Drug non-adherence in primary preventive cardiovascular therapy is one of the most important modifiable drivers of cardiovascular events. The effect of deductibles in healthcare cost-sharing plans (the amount that has to be paid for healthcare services before the insurance company starts to pay) on such non-adherence in a European setting is unknown. Therefore, we estimated the association between deductibles and the adherence to primary preventive antihypertensive and antihyperlipidemic medication.

METHODS

Using the claims database of Menzis Health Insurer in the Netherlands, we applied ordered beta regression mixed modelling to estimate the association between deductibles and adherence taking several demographic and social-economic factors, repeated measurements and within-patient variation into account.

RESULTS

All in all, 106,316 patients starting primary preventive antihypertensive or antihyperlipidemic monotherapy were eligible for analysis. At index date, mean age of the study population was 58 years and 52% were male. Reaching the deductible limit and no need to pay for medication anymore increased the adherence [relative adherence ratio (RAR) 1.03, 95% confidence interval (95% CI): 1.00-1.05] for antihyperlipidemic therapy and 1.02 (95% CI: 1.00-1.04) for antihypertensive therapy. A larger deductible amount decreases the adherence of antihyperlipidemic and antihypertensive therapy (RAR 0.83; 95% CI: 0.69-1.00 and RAR 0.85, 95% CI: 0.74-0.98, respectively).

CONCLUSION

Independent of other risk factors for non-adherence, presence of deductibles in health insurance is associated with a small negative effect on the adherence to both primary preventive antihypertensive as well as antihyperlipidemic therapy. Further study is needed on the potential health-economic consequences.

Association between medication adherence and health-related quality of life of patients with hypertension and dyslipidemia

PURPOSE

Τo evaluate the association between medication adherence and health-related quality of life (HRQoL) of patients with hypertension and dyslipidemia in Greece.

METHODS

In a multicenter, cross-sectional, non-interventional study, a total of 721 hypertensive and 463 dyslipidemic adult outpatient patients were recruited during the COVID-19 pandemic using consecutive sampling. The EQ-5D-5L instrument was used to measure HRQoL, and medication adherence was assessed with the Adherence Starts with Knowledge 20 questionnaire. Multiple linear stepwise regressions using robust standard errors were employed.

RESULTS

Approximately 28% of hypertensive and 16% of dyslipidemic patients had not been fully adherent during the previous week, while the estimates were 49 and 34%, respectively when the previous month was considered. The HRQoL domain with the highest prevalence of problems was anxiety/depression, followed by mobility and usual activities for both conditions; HRQoL was lower in dyslipidemic patients. Higher medication non-adherence was independently associated with lower EQ-VAS in hypertension and a lower EQ-5D index in dyslipidemia. Other significant risk factors of impaired HRQoL and general health were lack of exercise, longer duration of disease, and multimorbidity, while a curvilinear effect of BMI and age was observed. Also, female gender, employment, and marriage worked as protective factors for hypertensive patients and education for dyslipidemic participants.

CONCLUSION

Medication adherence is suboptimal in patients with hypertension and, in particular, with dyslipidemia in Greece. Moreover, poor medication adherence has a detrimental impact on patients' HRQoL. Therefore, improving treatment outcomes and patients' HRQoL in a sustainable way requires a better understanding of the factors influencing medication adherence.

Association Between Illness Perception and Adherence to Treatment in Slovak Patients With Hypertension: A Cross-sectional Study

BACKGROUND

Lack of adherence to treatment in patients with arterial hypertension leads to poor blood pressure control, increased morbidity and mortality, and increased costs to health and social care. Regular assessment of treatment adherence as well as factors influencing it is important to improve patient adherence and consequently increase treatment efficacy. Personal beliefs, particularly illness representations, are significant factors that influence adherence.

OBJECTIVE

The aim of this study was to assess the associations between adherence to treatment, illness perception, and selected sociodemographic and clinical characteristics in patients with arterial hypertension.

METHODS

In this cross-sectional observational study, 235 patients with arterial hypertension completed the Hill-Bone Compliance to High Blood Pressure Therapy Scale and the Brief Illness Perception Questionnaire. Associations between variables were assessed by Spearman ρ and multiple linear regression analysis.

RESULTS

Younger age, male gender, overall number of drugs used, and poorer beliefs related to the timeline, treatment control, and understanding were associated with higher levels of nonadherence. The final regression model significantly ( P ≤ .05) explained 19.4% of the variance in diet adherence, 5.0% in appointment keeping, and 17.8% in medication adherence.

CONCLUSION

Comprehensive care aimed at regular evaluation of illness perceptions with an emphasis on increasing understanding of the disease and its treatment and reducing patient worries and negative emotions seems to be a relevant strategy for improving adherence to antihypertensive treatment in everyday clinical practice.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

Excessive daytime sleepiness, but not sleep apnea, sleep duration or insomnia, was associated with poor adherence to anti-hypertensive treatment: The ELSA-Brasil study

Hypertension is the leading risk factor for cardiovascular mortality. Poor adherence may partially explain this scenario. Beyond traditional factors, it is conceivable that sleep conditions such as Obstructive Sleep Apnea (OSA), Sleep Duration (SDUR), sleepiness and insomnia may contribute to impair adherence but the evidence is scanty. Consecutive participants with hypertension from the ELSA-Brasil study performed a home sleep monitoring and 7-days actigraphy to determine OSA (apnea-hypopnea index ≥15 events/hour) and SDUR, respectively. Excessive daytime sleepiness (EDS) and insomnia were evaluated by Epworth Sleepiness Scale (ESS) and Clinical Interview Scheduled Revised (CIS-R), respectively. The 4-itens Morisky questionnaire was used to evaluate adherence to anti-hypertensive therapy. A total of 411 patients were including in the analysis (mean age: 54 ± 8 years, 47% men). Medium/low adherence to anti-hypertensive therapy was observed in 62%. Compared to the high adherence group, the participants with medium/low adherence had lower frequencies of Whites (64.1 vs. 47.8%), high-degree education (50.6 vs. 40%), and monthly per-capita income ($1021.90 vs. $805.20). In contrast, we observed higher frequency of EDS (35.9 vs. 46.1%). No differences were observed for OSA, short SDUR (<6 h) and insomnia. Logistic regression analysis showed that race other than White (OR: 1.80; 95% IC:1.15-2.82), lower monthly income (OR: 1.74; 95% IC:1.01-3.0) and EDS (OR: 1.63; 95% IC:1.05-2.53) were independently associated with medium/low adherence to the anti-hypertensive treatment. Interestingly, EDS mediated the abdominal obesity-adherence outcome. In conclusion, among sleep-related parameters, EDS, but not OSA, short SDUR or insomnia, were associated to impaired adherence to anti-hypertensive therapy.

Global Burden, Regional Differences, Trends, and Health Consequences of Medication Nonadherence for Hypertension During 2010 to 2020: A Meta-Analysis Involving 27 Million Patients

Background

Nonadherence to antihypertensive medications is the leading cause of poor blood pressure control and thereby cardiovascular diseases and mortality worldwide.

Methods and Results

We investigated the global epidemiology, regional differences, and trend of antihypertensive medication nonadherence via a systematic review and meta‐analyses of data from 2010 to 2020. Multiple medical databases and clinicaltrials.gov were searched for articles. Observational studies reporting the proportion of patients with anti‐hypertensive medication nonadherence were included. The proportion of nonadherence, publication year, year of first recruitment, country, and health outcomes attributable to antihypertensive medication nonadherence were extracted. Two reviewers screened abstracts and full texts, classified countries according to levels of income and locations, and extracted data. The Joanna Briggs Institute prevalence critical appraisal tool was used to rate the included studies. Prevalence meta‐analyses were conducted using a fixed‐effects model, and trends in prevalence were analyzed using meta‐regression. The certainty of evidence concerning the effect of health consequences of nonadherence was rated according to Grading of Recommendations, Assessment, Development and Evaluations. A total of 161 studies were included. Subject to different detection methods, the global prevalence of anti‐hypertensive medication nonadherence was 27% to 40%. Nonadherence was more prevalent in low‐ to middle‐income countries than in high‐income countries, and in non‐Western countries than in Western countries. No significant trend in prevalence was detected between 2010 and 2020. Patients with antihypertensive medication nonadherence had suboptimal blood pressure control, complications from hypertension, all‐cause hospitalization, and all‐cause mortality.

Conclusions

While high prevalence of anti‐hypertensive medication nonadherence was detected worldwide, higher prevalence was detected in low‐ to middle‐income and non‐Western countries. Interventions are urgently required, especially in these regions. Current evidence is limited by high heterogeneity.

Registration

URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021259860.

Health Facts Medication Adherence in Transplantation (H-MAT) Study: A Secondary Analysis of Determinants and Outcomes of Medication Nonadherence in Adult Kidney Transplant Recipients

Aims

To explore the relationship between determinants and posttransplant medication nonadherence (MNA) in adult kidney transplant recipients, and to examine the relationship between posttransplant MNA and clinical outcomes.

Methods

Using the World Health Organization's model, this retrospective, multicenter, correlational study examined the relationship between determinants, posttransplant MNA, and clinical outcomes in 16,671 adult kidney transplant recipients from the Cerner Health Facts national data warehouse.

Results

With 12% MNA, those who were nonadherent were more likely to have the social/economic factors of being younger, single, Caucasian versus Hispanic race, have the condition-related factor of mental health/substance use disorder, and have the healthcare system-related factor of government/health maintenance organization/managed care insurance (p′s < 0.05). Bivariate correlations indicated both age (OR = 1.006, p=0.01) and mental health or substance use disorder diagnosis (OR = 1.26, p=0.04) were significant predictors of MNA. Patients were 0.6% more likely to be medication adherent for each year they increased in age and 26% more likely to be MNA if they were diagnosed with a mental health/substance use disorder. Nonadherent patients were less likely to be readmitted, but more likely to have complications after transplant and medication side effects (p′s < 0.01).

Conclusions

Using one of the largest samples of adult kidney transplant patients, our findings support the WHO model and move the body of medication adherence intervention research forward by clarifying the importance of focusing interventions not only on the patient but on multilevel determinants. Consistent with previous studies, MNA negatively impacts transplant outcomes.

Medication Adherence and Perceived Social Support of Hypertensive Patients in China: A Community-Based Survey Study

PURPOSE

Previous studies suggested perceived social support has impact on medication adherence among hypertensive patients, but did not simultaneously elucidate the different contents or key providers of social support that patients perceived. This study was to identify the contents and providers of perceived social support beneficial for improving medication adherence among hypertensive patients in China, which could prove important for targeted interventions.

PATIENTS AND METHODS

Following a multi-stage stratified sampling framework, a total of 903 hypertensive patients from 12 primary health institutions across a middle-income city were recruited from April to June 2021. Medication adherence was measured using the Chinese version of the Morisky, Green and Levine scale; perceived social support was determined using the name generator method. A binary logistic regression model was performed to identify the association between medication adherence and perceived social support. The contents of support included informational, emotional, and instrumental support (finances and caregiving). The support providers included spouse/partner, children, parents, siblings, other relatives, and friends.

RESULTS

A total of 506 (56.04%) patients optimally adhered to their antihypertensive medication. Female, older, urban patients, patients with shorter duration of hypertension and antihypertensive medications used showed better adherence (P<0.05). Optimal medication adherence was positively associated with the overall score of caregiving support (adjusted odds ratio [AOR] = 1.128; 95% confidence interval [CI] = [1.013-1.257]), informational support from the spouse/partner (AOR = 1.574; 95% CI = [1.112-2.227]), emotional support from the spouse/partner (AOR = 1.430; 95% CI = [1.032-1.981]), financial support from the spouse/partner (AOR = 1.439; 95% CI = [1.069-1.937]) and caregiving support from the spouse/partner (AOR = 1.652; 95% CI = [1.130-2.414]), whereas optimal medication adherence was negatively associated with caregiving support from friends (AOR = 0.499; 95% CI = [0.286-0.872]).

CONCLUSION

Informational, emotional, financial and caregiving support from spouses/partners have positive impacts on optimal medication adherence of hypertensive patients of community-level. Community-based interventions designed to improve medication adherence of hypertensive patients should target both patients and their spouses/partners; spouses/partners could be encouraged to provide various support to improve the medication adherence of hypertensive patients.

Medication Adherence and Blood Pressure Control: A Scientific Statement From the American Heart Association

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

The Potential to Reduce Patient Co-Payment and the Public Payer Spending in Poland through an Optimised Implementation of the Generic Substitution: The Win-Win Scenario Suggested by the Real-World Big Data Analysis

High medication costs are one of the major barriers to patient adherence. Medication affordability might be improved by generic substitution. The aim of this study was to assess the effectiveness of the implementation of generic substitution mechanisms in Poland. This was a retrospective analysis of nationwide real-world big data corresponding to dispensation of metformin preparations in 2019 in Poland. Relevant prescription and dispensation data were compared to assess the prevalence of generic substitution and its economic consequences. Among the 1,135,863 e-prescriptions analysed, a generic substitution was found in only 4.81% of the packs dispensed, based on e-prescriptions issued for metformin under its originator version and 2.73% under generic drugs. It is estimated that if these values were applied to the total Polish drug market, patients could lose the opportunity to lower their co-payment by 15.91% and the national payer to reduce its reimbursement expenditures by 8.31%. Our results point at the suboptimal implementation of generic substitution in Poland. Therefore, relevant actions need to be taken in order to maximise the benefits provided by this mechanism. It could not only lead to the win-win scenario in which both patients and the national payer are secured substantial savings, but it could also have a positive impact on patient adherence.

Assessing forgetfulness and polypharmacy and their impact on health-related quality of life among patients with hypertension and dyslipidemia in Greece during the COVID-19 pandemic

Purpose

We estimate the association between forgetfulness to take medications as prescribed and polypharmacy and health-related quality of life (HRQoL) among a cohort of patients with hypertension, dyslipidemia or both in Greece during the COVID-19 pandemic.

Methods

A telephone survey of 1018 randomly selected adults was conducted in Greece in June 2020. Participants were included in the survey, if they (a) had a diagnosis of hypertension, dyslipidemia or both and (b) were on prescription treatment for these conditions. HRQoL was calculated using the short form (SF) -12 Patient Questionnaire. A multivariable generalized linear regression model (GLM) was used to estimate the association between forgetfulness and polypharmacy and HRQoL, controlling for sociodemographic and health-related covariates.

Results

Overall, 351 respondents met the inclusion criteria, of whom 28 did not fully complete the questionnaire (response rate: 92%, n = 323). Of those, 37% were diagnosed with hypertension only, 28% with dyslipidemia only, and 35% with both. Most reported good to average physical (64.1%) and mental health (48.6%). Overall, 25% indicated that they sometimes forget to take their prescribed medications, and 12% took two or more pills multiple times daily. Total HRQoL score was 68.9% (s.d. = 18.0%). About 10% of participants reported paying less attention to their healthcare condition during the pandemic. Estimates of multivariable analyses indicated a negative association between forgetfulness (− 9%, adjusted β: − 0.047, 95% confidence interval − 0.089 to − 0.005, p = 0.029), taking two or more pills multiple times daily compared to one pill once a day (− 16%, adjusted β: − 0.068, 95% confidence interval − 0.129 to − 0.008, p = 0.028) and total HRQoL.

Conclusion

Our results suggest that among adult patients with hypertension, dyslipidemia or both in Greece, those who forget to take their medications and those with more complex treatment regimens had lower HRQoL. Such patients merit special attention and require targeted approaches by healthcare providers to improve treatment compliance and health outcomes.

Nonadherence to antihypertensive medications amongst patients with uncontrolled hypertension: A retrospective study

ABSTRACT

Medication nonadherence represents a modifiable risk factor for patients with hypertension. Identification of nonadherent patients could have significant clinical and economic implications in the management of uncontrolled hypertension.We analysed the results of 174 urinary adherence screens from patients referred to Addenbrooke's Hospital, Cambridge, for uncontrolled hypertension. Cases were identified for evaluation by results of liquid chromatography-tandem mass spectrometry of urine samples (males: 91; females: 83; age range: 17-87). We performed a binary logistic regression analysis for nonadherence using age, sex, and number of medications prescribed (both antihypertensives and non-antihypertensives separately) as independent predictors. Rates of nonadherence for individual antihypertensive drugs were calculated if prescribed to ≥10 patients.The overall rate of nonadherence to one or more prescribed antihypertensive medications was 40.3%. 14.4% of all patients were nonadherent to all prescribed antihypertensive medications (complete nonadherence), whereas 25.9% of all patients were nonadherent to at least 1, (but not all) prescribed antihypertensive medications (partial nonadherence). 72% of patients were prescribed ≥3 antihypertensives And for every increase in the number of antihypertensive medications prescribed, nonadherence increased with adjusted odds ratios of 2.9 (P < .001). Logistic regression showed that women were 3.3 times more likely to be nonadherent (P = .004). Polypharmacy (≥6 medications prescribed for hypertension and/or concomitant comorbidities) was prevalent in 52%. Bendroflumethiazide and chlortalidone demonstrated the highest and lowest nonadherences respectively (45.5% and 11.8%).Rate of nonadherence in patients with hypertension was significantly impacted by sex and number of antihypertensive medications prescribed. Understanding these factors is crucial in identifying and managing nonadherence.

Instrument to evaluate the behavioral intention of hypertensive people when taking anti-hypertensives

OBJECTIVES

to build and analyze the validity of an instrument to assess the behavioral intention of individuals with hypertension to take antihypertensive pills.

METHODS

methodological study based on the theory of planned behavior, developed in three stages: preparation of the instrument, validation of content and pre-test with the target audience. The content has been validated by six experts. The Content Validity Index was applied.

RESULTS

five nurses and one psychologist participated, with experiences in systemic arterial hypertension and/or planned behavior theory. The first version of the instrument contained 40 items. After analysis, the second version originated, with 36 items. 100% agreement was obtained for the scope of the constructions. The pre-test showed clarity and understanding of the items by the target audience.

CONCLUSIONS

the instrument is a reliable and innovative technological product for use in populations with systemic arterial hypertension and beliefs similar to those identified in the surveyed group.

Adherence to antihypertensive medication after referral to secondary healthcare: A prospective cohort study

BACKGROUND

Nonadherence (NAd) to antihypertensive medication is associated with lack of blood pressure control and worsened long-term outcomes. Increased access to a programme for high-risk cardiovascular patients has the potential to reduce NAd and improve clinical outcomes. We evaluated implementation NAd prevalence and risk factors among severely hypertensive patients after 12-month-long access to secondary healthcare centres.

METHODS

The Morisky Green Levine Scale (MGLS) was used to analyse antihypertensive medication NAd in a prospective cohort of 485 patients. Logistic regression models evaluated the influence of ecological model factors on NAd.

RESULTS

The majority of patients were female, had low health literacy, a low family income and a mean age of 61.8 ± 12.5 years. Prevalence of NAd fell from 57.1% at programme entry to 28.3% (P < .001) at the end of the study. After access to a secondary healthcare centre, we observed better blood pressure control, an increase in the number of pills/day and a higher number of antihypertensive medications. Predictive variables of NAd were age (OR 1.027; CI 1.003-1.051; P = .023), low health literacy (OR 1.987; CI 1.009-3.913; P = .047), systolic blood pressure (OR 1.010; CI 1.003-1.021; P = .049), dosages ≥ 2 times/day (OR 1.941; CI 1.091-3.451; P = .024) and patient satisfaction with the healthcare team (OR 0.711; IC 0.516-0.980; P = .037).

CONCLUSIONS

Greater access to health services is associated with a reduction in NAd to antihypertensive medication and better blood pressure control. NAd was correlated with modifiable variables such as treatment complexity and, for the first time, team satisfaction, suggesting that implementation of similar programmes may limit NAd in similar patient groups.

The association between self-efficacy and self-care in essential hypertension: a systematic review

BACKGROUND

The successful management of hypertension requires sustained engagement in self-care behaviour such as adhering to medication regimens and diet. Bandura's Social Cognitive Theory suggests that self-efficacy is a major determinant of engagement in self-care behaviour. Self-efficacy refers to an individual's belief in their capacity to execute behaviours necessary to produce specific performance attainments. This systematic review of observational studies aims to summarise and evaluate the quality of evidence available to support the association between self-efficacy and engagement in self-care behaviour in hypertension.

METHODS

Searches were performed of the Pubmed, MEDLINE, CINAHL and OpenSIGLE databases from database inception to January 2020. Reference lists and individual journals were also hand searched. Observational studies in English quantifying self-efficacy and self-care behaviour in hypertensive adults were included. The quality of included articles was assessed with the National Institute of Health Quality Assessment Tool for observational studies.

RESULTS

The literature search identified 102 studies, of which 22 met the inclusion criteria for full-text review. There were 21 studies which reported that higher self-efficacy was associated with engagement in self-care behaviours including medication adherence (n = 9), physical activity (n = 2) and dietary changes (n = 1). Of these, 12 studies were rated as 'good' on the quality assessment tool and 10 were 'fair'. A common limitation in these studies was a lack of objectivity due to their reliance on self-reporting of engagement in self-care behaviour.

CONCLUSION

Our review suggests an association between self-efficacy and self-care. However, the evidence supporting this association is of low to medium quality and is limited by heterogeneity. Our findings suggest the need for further well-designed interventional studies to investigate this association.

The prevalence and associated factors of nonadherence to antihypertensive medication in secondary healthcare

PURPOSE

Non-adherence (NA) to medication is a major contributor to treatment failure in hypertensive patients. Factors of the ecological model, at family/healthcare professional, service, and system levels, are rarely evaluated as correlates of NA in hypertensive patients.

METHODS

This crossectional study assessed the prevalence of and associated factors of NA to antihypertensive medication among 485 hypertensive patients upon receiving secondary healthcare. The Morisky Green Levine Scale (MGLS) measured the implementation phase of adherence, and the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA) instrument, health literacy. Multivariate analysis to NA included variables according to the levels of the ecological model.

RESULTS

Most patients were female (56.3%), white (53.2%), mean age of 62.0 ± 12.6 years, illiterate (61.6%), with low health literacy (70.9%), and low income (65.4%). Uncontrolled BP was frequent (75.2%); 57.1% of patients were nonadherent. In multivariate analysis based on the ecological model, adjusted for micro, meso- and macro-level correlates, NA was associated only with variables of patient-level: low health literacy (OR 1.62, CI 1.07-2.44, p = 0.020), income ≥ two reference wages (OR 0.46, CI 0.22-0.93, p = 0.031), lack of homeownership (OR 1.99, CI 1.13-3.51, p = 0.017), sedentarism (OR 1.78, CI 1.12-2.83, p = 0.014), and complexity of treatment (number of medications taken ≥ two times/day) (OR 1.56, CI 1.01-2.41, p = 0.042).

CONCLUSION

In this group of severely hypertensive patients with high cardiovascular risk, only patient-related characteristics were associated with NA. Our findings highlight the need for effective actions to optimize clinical outcomes in similar healthcare programs.

Adherence to treatment in paediatric patients - results of the nationwide survey in Poland

Background

Due to high prevalence, non-adherence to prescribed treatment seriously undermines the effectiveness of evidence-based therapies in paediatric patients. In order to change this negative scenario, physicians need to be aware of adherence problem, as well as of possible solutions. Unfortunately, full potential of adherence-targeting interventions is still underused in Poland. Therefore, the aim of this study was to assess the knowledge, attitudes and behaviours toward non-adherence in Polish paediatricians.

Methods

An anonymous cross-sectional nationwide survey was conducted in the convenience sample of Polish doctors providing care to paediatric patients. The survey focused on the prevalence of non-adherence, its causes, and interventions employed. Primary studied parameter was perceived prevalence of non-adherence in paediatric patients. Reporting of this study adheres to STROBE guidelines.

Results

One thousand and thirty-three responses were eligible for analysis. Vast majority of respondents were female (85.9%), most of them worked in primary care (90.6%). The respondents represented all 16 Polish Voivodeships, with the biggest number coming from the Mazowieckie Voivodeship (n = 144, 13.9%). Survey participants believed that on average 28.9% of paediatric patients were non-adherent to medication. More than half of the respondents (n = 548, 53.0%) were convinced that their own patients were more adherent than average. Duration of the professional practice strongly correlated with a lower perceived prevalence of non-adherence. Professionals with more than 40 years of practice believed that the percentage of non-adherent patients was <=20% particularly often (OR = 3.82 (95% CI 2.11–6.93) versus those up to 10 years in practice). Out of all respondents, they were also most often convinced that their own patients were more adherent than the general population (P < 0.01). Consequently, they underestimated the need for training in this area.

Conclusions

Physicians taking care of Polish paediatric patients underestimated the prevalence of medication non-adherence and believed that this was a problem of other doctors. This optimistic bias was particularly pronounced in older doctors. These results identify important barriers toward improving patient adherence that are worth addressing in the pre- and post-graduate education of Polish physicians. They also put some light over the challenges that educational activities in this area may face.

Psychometric Properties of the Polish Version of the Self-care of Hypertension Inventory

BACKGROUND

According to evidence-based guidelines, adherence to blood pressure-lowering medication and lifestyle modifications is a crucial part of hypertension management. Self-care is an effective method for secondary prevention. However, patients continue to exhibit major deficits in terms of adherence, self-control, and self-care. Standardized instruments for the effective monitoring of patients' self-care abilities are still lacking.

OBJECTIVE

The objectives of this study were to produce a translation and cross-cultural adaptation of the Self-care of Hypertension Inventory (SC-HI) and to evaluate the psychometric properties of its Polish version.

METHODS

The scale underwent translation and psychometric assessment using the standard methodology (forward-backward translation, review, psychometric analysis, criterion validity). The study included 250 patients, with a mean age of 61.23 ± 14.34 years, treated in a hypertension clinic.

RESULTS

Mean self-care levels were evaluated in 3 domains: self-care maintenance (56.73 ± 18.57), self-care management (64.17 ± 21.18), and self-care confidence (62.47 ± 24.39). The Cronbach α for each domain showed satisfactory parameters: 0.755 for maintenance, 0.746 for management, and 0.892 for confidence. In the Polish version, the 3-factor structure of the SC-HI was not directly confirmed. Therefore, so-called modification indices were applied to obtain a standardized root mean square residual value less than 0.09 and a root mean square error of approximation value less than 0.06.

CONCLUSIONS

The SC-HI has been successfully translated and adapted for Polish settings, and is suitable for application among patients with hypertension.

Multilevel Correlates of Immunosuppressive Nonadherence in Kidney Transplant Patients: The Multicenter ADHERE BRAZIL Study

BACKGROUND

Immunosuppressive nonadherence is a risk factor for worse outcomes after kidney transplantation (KT). Brazil, having the world's largest public, fully covered transplantation system and the second-highest KT volume worldwide, provides a unique setting for studying multilevel correlates of nonadherence (patient, healthcare provider, transplant center, and healthcare system levels) independent of patients' financial burden.

METHODS

By applying a multistage sampling approach, we included 1105 patients from 20 KT centers. Nonadherence to immunosuppressives (implementation phase) was defined as any deviation in taking or timing adherence and dose reduction assessed by the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Based on Bronfenbrenner's ecological model, we assessed multilevel factors using established instruments and measures specifically developed for this study and analyzed their independent contribution to nonadherence by performing sequential logistic regression analysis.

RESULTS

The nonadherence prevalence rate was 39.7%. The following factors were independently associated with nonadherence: Patient level-having a stable partner (odds ratio [OR]: 0.75; confidence interval [CI]: 0.58-0.97), nonadherence to appointments (OR: 2.98; CI: 2.03-4.39), and nonadherence to physical activity recommendations (OR: 1.84; CI: 1.38-2.46); and transplant center level-satisfaction with the waiting room structure (OR: 0.54; CI: 0.42-0.71), consultation >30 minutes (OR: 1.60; CI: 1.19-2.14), adequacy of the consultation frequency (OR: 0.62; CI: 0.43-0.90), and centers with >500 beds (OR: 0.58; CI: 0.46-0.73).

CONCLUSIONS

As the first multicenter study assessing multilevel correlates of nonadherence in KT, our findings point to the need for multilevel interventions beyond the patient level, targeting transplant center practice patterns as an approach to tackle nonadherence.

Erectile dysfunction and adherence to antihypertensive therapy: Focus on β-blockers

The management of arterial hypertension is very challenging in everyday clinical practice. Blood pressure control rates remain disappointingly low, despite intense efforts. Poor adherence to antihypertensive treatment is among the main causes of inadequate blood pressure control. Among the various parameters leading to poor adherence, medication adverse events seem to be the prevailing cause of treatment discontinuation. Β-blockers are a class of drugs commonly used in the management of hypertension. However, β-blockers use has been associated with various adverse events, among which, erectile dysfunction is a prevalent one. Accumulating evidence supports the detrimental role of β-blockers on erectile function. Older studies have shown contradictory findings, which however may be attributed to methodological errors related with the assessment of erectile function. More recent studies, however, unveiled the negative impact of this drug category on erectile function. Nevertheless, β-blockers represent a class of drugs with substantial within class heterogeneity. Nebivolol presents a unique mode of action through enhanced nitric oxide bioavailability that may be associated with benefits on erectile function. Indeed, studies of nebivolol have shown improvement in erectile function, suggesting that nebivolol represents the only exception in this class of drugs in terms of erectile function.

Sex differences in the adherence of antihypertensive drugs: a systematic review with meta-analyses

OBJECTIVES

Poor worldwide rate of blood pressure control is largely due to poor adherence to antihypertensive (AHT) drug treatment. The question of whether sex affects adherence has long been debated but conflicting findings have been reported on this issue. Our objective was to evaluate sex differences in the adherence to AHT therapy.

RESEARCH DESIGN AND METHODS

Studies were identified through a systematic search of PubMed, CINAHL, PsycINFO, Web of Science and Google Scholar (through January 2020) and manual handsearching of relevant articles. Observational studies reporting adherence to AHT drugs measured by self-report or pharmacy refill prescription-based methods among men and women were included. Summarised estimates of OR_s with 95% CIs were calculated using random-effects model and meta-regression models.

RESULTS

From 12 849 potentially relevant publications, 82 studies (15 517 457 men and 18 537 599 women) were included. No significant between-sex differences in adherence to AHT were observed, whether all study-specific estimates were summarised (OR_s 1.04, 95% CI 1.00 to 1.09, p=0.07), nor estimates were pooled according to the method for measuring adherence. Among patients aged 65 years or older, lower self-reported adherence was observed in women (OR_s 0.84, 95% CI 0.72 to 0.97, p=0.02), while the main result remained unchanged according to other subgroup analyses.

CONCLUSIONS

Definitive evidence of sex differences in adherence to AHT therapy cannot be drawn. Our little knowledge about factors affecting adherence, in particular of sex effect among elderly, urgently requires high-quality studies investigating these issues.

Primary Non-Adherence to Antihistamines-Conclusions From E-Prescription Pilot Data in Poland

Background

In allergic conditions such as allergic rhinitis and urticaria, orally administered H₁-antihistamines belong to first-line therapy and therefore, are widely prescribed. Due to the frequent, and often chronic, course of allergic diseases, adherence is of great importance. In 2018 a novel, nationwide e-prescription system was piloted in Poland, which allowed to analyze primary non-adherence to orally administered H₁ antihistamines.

Objectives

To assess the primary non-adherence to orally administered H₁-antihistamines in Poland, defined as not redeeming the drug issued on a particular e-prescription within its validity period.

Methods

The study was based on all e-prescriptions issued in Poland in 2018, issued for 119.880 drugs. The analysis included nine major orally administered H₁ antihistamines available in Poland.

Results

Out of 2280 analyzed e-prescriptions on orally administered antihistamines, 1803 (79.1%) of them were redeemed. Therefore, the level of primary non-adherence reached 21%. Among women it reached 19.9%, but it was not significantly lower than among men (23.4%, p=0.064). The highest non-adherence (31.3%) was observed in the age group 19-39, whilst the highest adherence rate (84.6%) was observed in those 75 years or older. The most frequently prescribed second-generation antihistamine was bilastine—596 e-prescriptions with 23.7% primary non-adherence.

Conclusions

More than 1 out of 5 e-prescriptions on orally administered H₁-antihistamines were not redeemed in Poland in 2018. Age, but not gender, significantly influenced the degree of primary non-adherence to these drugs. To authors knowledge, this is the first real-life study on primary non-adherence to H₁-antihistamines in Poland and one of the very few on this subject worldwide.

Adaptation and validation of the Polish version of the Beliefs about Medicines Questionnaire among cardiovascular patients and medical students

Background

The Beliefs about Medicines Questionnaire (BMQ) is the leading tool intended to assess the cognitive representation of medication, however, the validated Polish version of the questionnaire is lacking.

Aims

To adapt the original BMQ tool to the Polish language (BMQ-PL) and to validate it.

Materials and methods

The BMQ was adapted to Polish according to widely accepted guidelines. A total of 311 cardiovascular in- and outpatients as well as medical students taking chronic medication were surveyed to assess data-to-model fit and internal consistency of the measure. The criterion-related validity was determined with the use of Polish version of the Adherence to Refills and Medications Scale. Confirmatory and exploratory factor analyses were used, as well as general linear modeling.

Results

The BMQ-PL exhibited the same factorial structure as the original questionnaire and all the items loaded on their expected factors. Internal consistency of the questionnaire was satisfactory in the group of cardiovascular patients (Cronbach’s alpha ranging from 0.64 to 0.82 and McDonald’s omega from 0.90 to 0.91). There were significant correlations in the predicted directions between all BMQ-PL subscales and the measure of drug adherence in cardiovascular outpatients, but not in inpatients. Medical students may conceptualize the beliefs about medicines in a different way; as a result, a modified version of the BMQ-PL-General, suitable for medically-educated people, was proposed.

Conclusion

The BMQ-PL exhibits satisfactory proof of validity to be used among cardiovascular patients.

Patients' Preferences and Willingness to Pay for Solid Forms of Oral Medications-Results of the Discrete Choice Experiment in Polish Outpatients

Purpose: Personal preferences play an important role in the patients’ decision process whether to adhere to treatment, or not. The purpose of this study is to assess Polish outpatients’ preferences for solid forms of oral medications across various scenarios. Methods: The convenience sample of 200 outpatients took part in this study. According to the discrete choice experiment (DCE) design, participants were provided with selection of tablets and capsules, in different shapes, sizes, colors, and copayment levels and were asked to state their preferences. DCE results were analyzed using mixed logit (MXL) models. Results: MXL models revealed patients’ willingness to pay for various solid forms of medications. The most preferred combination of drug parameters were: small yellow capsule for chronic treatment, and small yellow long tablet for short-term treatment. Study participants were happy to pay extra 6.52 PLN (≈1.63 EUR) for this drug formulation per month of antihypertensive treatment, and 14.44 PLN (≈3.61 EUR) for this drug formulation per 7-days’ long course of antibiotic treatment, respectively. Conclusion: Results suggest that color, shape, and size of solid form of oral medications are important predictors of patients’ acceptance. It can not only be expressed in monetary value, but also may serve as an important hint for companies designing new drugs, or policymakers who are happy to improve patient adherence with better prescribing, or dispensing. However, our findings are probably country-specific, and further research is necessary to better understand the relationship between solid drug characteristics, and patient’s preferences across countries.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Psychosocial Predictors of Self-Efficacy Related to Self-Reported Adherence in Older Chronic Patients Dealing with Hypertension: A European Study

PURPOSE

Non-adherence to clinical prescriptions is widely recognized as the most common cause of uncontrolled hypertension, contributing to develop acute and chronic cardiovascular diseases. Specifically, patients' unintentional non-adherence is related to psychosocial factors as beliefs about medications, perceived physician's communication effectiveness and medication-specific social support. The aim of this study was to observe the impact of these factors on self-efficacy in relation to pharmacological and non-pharmacological self-reported adherence among older chronic patients with hypertension.

PATIENTS AND METHODS

This research had a cross-sectional, observational and multicentre study design. Italian inpatients under rehabilitation, and Polish inpatients/outpatients were recruited. Following a cognitive screening, socio-demographic and clinical characteristics were obtained. Data on clinical and behavioral adherence (i.e., pharmacological adherence, adherence to refill medicines, intentional non-adherence) and psychosocial factors related to treatment adherence (i.e., beliefs about medicines, physician's communication skills, medication-specific social support, psychological antecedents and self-efficacy) were collected with self-report questionnaires.

RESULTS

A total of 458 patients were recruited. Fischer's LSD post hoc test revealed significant differences between Italian and Polish samples in all measures (p<0.001). Multiple linear regression analysis showed low self-reported intentional non-adherence (β = -.02, p=0.031), high self-reported adherence to refill medications (β=-.05, p=0.017), high levels of perceived physician's communication effectiveness (β=0.11, p<0.001), positive beliefs about medications (β=0.13, p<0.001), and high perceived medication-specific social support (β=0.05, p<0.001) to predict significantly high patients' self-efficacy in relation to pharmacological and non-pharmacological self-reported adherence.

CONCLUSION

The observed psychosocial and behavioral factors revealed to positively impact on self-efficacy in relation to treatment adherence among older chronic patients dealing with hypertension. In a prevention framework, future studies and clinical practice may consider these factors in order to improve assessment and intervention on adherence in this population.

Knowledge about Disease, Medication Therapy, and Related Medication Adherence Levels among Patients with Hypertension

Background and Objectives: A particular problem in cardiology is poor adherence to pharmacological treatment among patients with hypertension. It is known that approximately half of these patients do not use their medications as prescribed by their doctor. Patients may choose not to follow the doctor's recommendations and regularly do not control their blood pressure, owing to many factors. A convenient method for measuring the level of adherence is the Morisky Medication Adherence Scale, which also provides insight into possible remedies for low adherence. We investigated their therapy, knowledge about the disease and its control, and demographic differences to assess the adherence of patients with hypertension. Materials and Methods: This was a cross-sectional observational study. Data were collected through a survey of 12 pharmacies in Latvia. The study involved 187 participants with hypertension. Results: The prevalence of non-adherence was 46.20% in Latvia. The oldest patients were the most adherent (p = 0.001, β = 0.27). The higher the self-rated extent from 0 to 10, to which the patient takes their antihypertensives exactly as instructed by their physician, the higher the level of adherence (p < 0.0001, β = 0.38), where at "0", the patient does not follow physician instructions at all, and at "10", the patient completely follows the physician's instructions. Non-adherent patients tend to assess their medication-taking behavior more critically than adherent patients. The longer the patient is known to suffer from hypertension, the more adherent he or she is (p = 0.014, β = 0.19). Conclusions: Medication non-adherence among patients with hypertension is high in Latvia. Further investigations are needed to better understand the reasons for this and to establish interventions for improving patient outcomes.

Retrospective Claims Analysis Indirectly Comparing Medication Adherence and Persistence Between Intravenous Biologics and Oral Small-Molecule Therapies in Inflammatory Bowel Diseases

Introduction

Patients’ adherence to and persistence on treatment for inflammatory bowel disease (IBD) can vary, depending on type and distribution of disease and treatment modality. We aim to identify differences in adherence and persistence with treatments with different administration routes (intravenous vs oral) in IBD.

Methods

A retrospective cohort analysis of a claims database of adult patients diagnosed with IBD or rheumatoid arthritis (RA) who began treatment with vedolizumab, tofacitinib, or infliximab from January 2015 through December 2015. Adherence evaluated by proportion of days covered (PDC) and cumulative days with gaps at least 20% beyond expected interval (CG20) using multivariable generalized linear equation models. Persistence assessed as time to treatment discontinuation over 12 months of follow-up using Kaplan–Meier estimates and Cox proportional hazards models; proportion of persistent patients determined via multivariable logistic regression. Indirect comparisons across disease states adjusted using infliximab data.

Results

After indirect adjustment by disease, mean PDC difference was significantly higher (difference of 4.7%; P = 0.0376) and mean CG20 was lower (difference of 15 days; P = 0.0646) but not statistically significant in vedolizumab/IBD than tofacitinib/RA.

Conclusion

We describe a novel adjustment method for interdisease treatment differences using infliximab treatment patterns to bridge differences between IBD and RA. After adjustment, adherence was higher with infusions than oral medications, which may affect outcomes. Indirect comparisons between vedolizumab and tofacitinib are not generalizable and should be confirmed in tofacitinib-treated IBD patients.

Funding

Takeda Pharmaceuticals U.S.A., Inc.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01037-x) contains supplementary material, which is available to authorized users.

Effects of transitional health management on adherence and prognosis in elderly patients with acute myocardial infarction in percutaneous coronary intervention: A cluster randomized controlled trial

Purpose

This study aimed to assess the effects of transitional health management on adherence and prognosis in elderly patients with acute myocardial infarction undergoing percutaneous coronary intervention.

Methods

We conducted the trial from June 2016 to December 2016. A total of one hundred and fifty patients with acute myocardial infarction after PCI who met the inclusion criteria were randomly divided into an experimental (n = 75) group and a control (n = 75) group. The participants in the experimental group received transitional health management for three months. The two groups of patients were evaluated for treatment adherence, quality of life, clinical indicators, adverse cardiovascular events and statistics regarding readmission rates at baseline and 6 months after discharge.

Results

Compared with the controls, patients in the intervention group demonstrated better medication adherence, reexamination adherence, healthy lifestyle and clinical indicators (all P<0.05) and lower rates of adverse cardiovascular events and readmission (all P<0.05).

Conclusion

Transitional health management effectively improved adherence in elderly patients with acute myocardial infarction after PCI, ameliorated clinical indicators, and effectively reduced the incidence of adverse cardiovascular events and readmission rates. Transitional health management was an effective intervention for PCI patients after discharge.

Better understanding the influence and complexity of beliefs on medication adherence in asthma

OBJECTIVE

The aim was to better understand how beliefs influence medication adherence in asthma.

METHODS

All participants were prescribed an inhaled corticosteroid for a diagnosis of asthma. Each participant completed a survey consisting of: Beliefs about Medicines Questionnaire (BMQ), Brief-Illness Perception Questionnaire (B-IPQ) and Multi-dimensional Health Locus of Control Scale (MHLCS). Adherence to inhaled corticosteroids was elicited using the Medication Adherence Report Scale (MARS). Multiple linear regression with interaction effects was used to identify significant predictors of medication adherence and interactions between beliefs.

RESULTS

A total of 198 participants completed the survey. The mean(±SD) MARS score was 19.2(±4.5). A multivariable model (adjusted R² = 0.39) predicted adherence using: age, asthma hospitalisation, timeline (B-IPQ) subscale, necessity and concern (BMQ) subscales, doctor (MHLCS) subscale and the two interaction effects (concerns [BMQ] moderated by chance [MHLCS] and treatment control [B-IPQ] moderated by understanding [B-IPQ]).

CONCLUSION

The findings of this study contribute to a better understanding of the role of beliefs in medication adherence in asthma. Certain beliefs meaningfully interrelate and change the relationship they have with medication adherence.

PRACTICE IMPLICATIONS

If these beliefs are causally related to medication adherence and can be intervened upon, the findings are useful for providing targets to personalise adherence support.

The relationship between patients' perception of type 2 diabetes and medication adherence: a cross-sectional study in Japan

BACKGROUND

The self-management of type 2 diabetes mellitus (T2DM), which involves adherence to medical instructions on diet and nutritional advice, physical activity, medication regimen, and weight and stress management, is necessary for the treatment of T2DM.In this study, we investigated the relationship between patients' perceptions of their disease and their adherence to their medications. And we attempted to determine whether distinct subphenotypes of behavioral change of medication adherence can be discerned based on a patients' perceptions.

METHOD

A cross-sectional study using a questionnaire was conducted among 157 patients with T2DM from October 2015 to September 2017. Questionnaires were administered to assess the participants' demographic and clinical characteristics, medication adherence, diabetes knowledge, and perception of being diabetic. Principal component analysis (PCA) and cluster analyses were performed to classify medication adherence patterns in the total cohort. Multiple regression analyses were performed to identify the determinant factors of medication adherence.

RESULTS

PCA showed the interpretable medication adherence of patients with diabetes by using component 1 ("accessibility to medical treatment") and component 2 ("status of taking medicines"). We identified four groups that show significantly different medication adherence by using cluster analysis on the basis of the two components. Multiple regression analysis showed that body mass index (BMI), family history of diabetes, one factor of patient's perception (living an orderly life), and diabetes knowledge were found to be significant predictors of medication adherence in patients with T2DM.

CONCLUSIONS

In patients with T2DM, the patient's diabetes perception of "living an orderly life" is associated with medication adherence. A poor adherence group may be able to change their adherence to diabetes treatment by developing the perception of "living an orderly life."

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.

Moving from the Trial to the Real World: Improving Medication Adherence Using Insights of Implementation Science

Medication nonadherence is a serious public health concern. Although there are promising interventions that improve medication adherence, most interventions are developed and tested in tightly controlled research environments that are dissimilar from the real-world settings where the majority of patients receive health care. Implementation science methods have the potential to facilitate and accelerate the translation shift from the trial world to the real world. We demonstrate their potential by reviewing published, high-quality medication adherence studies that could potentially be translated into clinical practice yet lack essential implementation science building blocks. We further illustrate this point by describing an adherence study that demonstrates how implementation science creates a junction between research and real-world settings. This article is a call to action for researchers, clinicians, policy makers, pharmaceutical companies, and others involved in the delivery of care to adopt the implementation science paradigm in the scale-up of adherence (research) programs.

Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale^© (BAASIS^© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

Factors affecting medication adherence in community-managed patients with hypertension based on the principal component analysis: evidence from Xinjiang, China

PURPOSE

The analysis of factors affecting the nonadherence to antihypertensive medications is important in the control of blood pressure among patients with hypertension. The purpose of this study was to assess the relationship between factors and medication adherence in Xinjiang community-managed patients with hypertension based on the principal component analysis.

PATIENTS AND METHODS

A total of 1,916 community-managed patients with hypertension, selected randomly through a multi-stage sampling, participated in the survey. Self-designed questionnaires were used to classify the participants as either adherent or nonadherent to their medication regimen. A principal component analysis was used in order to eliminate the correlation between factors. Factors related to nonadherence were analyzed by using a χ2-test and a binary logistic regression model.

RESULTS

This study extracted nine common factors, with a cumulative variance contribution rate of 63.6%. Further analysis revealed that the following variables were significantly related to nonadherence: severity of disease, community management, diabetes, and taking traditional medications.

CONCLUSION

Community management plays an important role in improving the patients' medication-taking behavior. Regular medication regimen instruction and better community management services through community-level have the potential to reduce nonadherence. Mild hypertensive patients should be monitored by community health care providers.

Effect of characteristics of pharmacotherapy on non-adherence in chronic cardiovascular disease: A systematic review and meta-analysis of observational studies

INTRODUCTION

Cardiovascular medications are effective in prevention of cardiovascular diseases (CVD); however, medication non-adherence contributes to morbidity and mortality.

OBJECTIVE

This systematic review and meta-analysis aims to summarise the evidence regarding the relationship between characteristics of drug therapy (pharmacotherapy) and medication non-adherence in the CVD population.

METHODS

Systematic searches in PubMed, LILACS, Academic Search and CINAHL databases for observational studies that enrolled adults with CVD were performed, from January 1960 to December 2015. The meta-analysis tested the association between characteristics of pharmacotherapy and self-reported medication non-adherence outcome, using a random effects model. To investigate heterogeneity, we performed subgroup analysis and sensitivity analysis.

RESULTS

Twenty-four cross-sectional studies and 7 cohort studies were included in this review. Based on 31 studies including 27 441 participants, we performed meta-analyses for all the characteristics of drug therapy that at least 2 studies evaluated, with a total of fourteen meta-analyses. The pooled results showed that studies which evaluate whether participants have insurance or another program that assists with medication costs, but not full coverage (OR = 0.63; 95% CI: 0.53-0.74; P < .001; I²  = 0%, P = .938), and a dosing frequency of twice or more daily (OR = 1.38; 95% CI: 1.13-1.69; P < .001) were associated with non-adherence.

CONCLUSIONS AND RELEVANCE

The results of this review suggest that access to insurance or another program that assists with medication costs was a protection factor for non-adherence. On the other hand, a high frequency of dosing was a risk factor for non-adherence. Therefore, these characteristics of pharmacotherapy must be considered to improve medication adherence among CVD patients.

Factors associated with antihypertensive medication non-adherence: a systematic review

Non-adherence to antihypertensive medication is the most important cause of uncontrolled blood pressure and is influenced by multiple interrelating factors. Understanding the complexity of medication non-adherence and its associated factors is important to determine intervention strategies. Therefore, a systematic review was performed aimed to identify factors associated with antihypertensive medication non-adherence. Different databases were searched for observational studies reporting on factors associated with non-adherence to antihypertensive medication. Titles, abstracts and full texts were reviewed by three researchers. Subsequently, the methodological quality of each study was assessed. Factors that were extracted from the included studies were categorised as factors with consistent or inconsistent evidence to put their potential importance into perspective. Forty-four studies were included. Higher co-payment, side effects and a poor patient-provider relationship were identified as factors with consistent evidence since consistent significant relationships were found for these factors whenever studied. The relationships between non-adherence and multiple other factors were inconsistent among the reviewed studies. However, some of these factors deserve some consideration. Since multiple potentially relevant factors were identified, patient-tailored interventions focussing on identifying and addressing patients' specific barriers to adherence are needed. Further research should clarify the influence of inconsistent factors on adherence and their potential to be addressed in interventions.

The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

BACKGROUND

Despite a variety of efficient and cost-effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients.

METHODS

The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale (MMAS-8) and objective pill count rate. Secondary outcomes include: change in the MMAS-8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out.

DISCUSSION

The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence-based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03105687 . Registered on 07 March 2017.

Understanding barriers to medication, dietary, and lifestyle treatments prescribed in polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (PKD) is the most common genetic renal disease and the fourth leading cause of end-stage renal disease in the United States. Although there is no cure for PKD, several treatments are considered to be beneficial, including blood pressure control, exercise, low-salt diet, and high volume water intake. However, levels of understanding of the importance of these treatments and adherence to these recommendations vary among patients. This study explores illness perception models of patients with PKD to reveal barriers in adherence to prescribed therapies; satisfaction with medical care; and sources of medical information.

METHODS

We designed a phenomenological interview study to evaluate illness perception models of individuals with PKD. Patients were identified from the national PKD Foundation e-mail distribution list (N = 190) and responded voluntarily to an introductory survey (N = 50). Seventeen PKD patients in the Bay Area were scheduled for one-on-one in-depth interviews with one trained interviewer (W-CT). Open-ended questions administered with an interview guide were used to evaluate patients' beliefs.

RESULTS

Mean age was 56.6 +/- 12 years (range 29-78); 65% were female. Many of the PKD patients in this study were highly motivated and willing to incorporate blood pressure, exercise, low-salt diet, and high volume water intake into their daily routines. Barriers to adherence to these therapies include personal beliefs and confusion due to unclear recommendations.

CONCLUSIONS

These findings suggest there is variability between what patients understand about their disease and treatments and what they believe their doctors have told them. Not all physicians focus on lifestyle-based treatments, but the majority of PKD patients in our study are motivated and willing to incorporate blood pressure control, exercise, low-salt diet, and high volume water intake into their daily routines and would like specific recommendations on how to implement these. These findings support a role for further exploring patient beliefs about the disease and its necessary treatments in order to design strategies to improve communication and meet the needs of these patients.

Risk Factors for Nonadherence to Antihypertensive Treatment

Nonadherence to antihypertensive treatment is a critical contributor to suboptimal blood pressure control. There are limited and heterogeneous data on the risk factors for nonadherence because few studies used objective-direct diagnostic methods. We used high-performance liquid chromatography-tandem mass spectrometry of urine and serum to detect nonadherence and explored its association with the main demographic- and therapy-related factors in 1348 patients with hypertension from 2 European countries. The rates of nonadherence to antihypertensive treatment were 41.6% and 31.5% in the UK and Czech populations, respectively. Nonadherence was inversely related to age and male sex. Each increase in the number of antihypertensive medications led to 85% and 77% increase in nonadherence ( P <0.001) in the UK and Czech populations, respectively. The odds of nonadherence to diuretics were the highest among 5 classes of antihypertensive medications ( P ≤0.005 in both populations). The predictive model for nonadherence, including age, sex, diuretics, and the number of prescribed antihypertensives, showed area under the curves of 0.758 and 0.710 in the UK and Czech populations, respectively. The area under the curves for the UK model tested on the Czech data and for the Czech model tested on UK data were calculated at 0.708 and 0.756, respectively. We demonstrate that the number and class of prescribed antihypertensives are modifiable risk factors for biochemically confirmed nonadherence to blood pressure–lowering therapy. Further development of discriminatory models incorporating these parameters might prove clinically useful in assessment of nonadherence in countries where biochemical analysis is unavailable.

Depression and medication adherence among older Korean patients with hypertension: Mediating role of self-efficacy

Many studies have reported the negative effects of depression on adherence to antihypertensive medication. However, little is known about the mechanism underlying this relationship in elderly patients with hypertension. The aim of this cross-sectional study is to examine the mediating role of self-efficacy in the relationship between depression and medication adherence among older patients with hypertension. The data were collected from October to December 2014. A total of 255 older patients with hypertension were assessed using the Geriatric Depression Scale, the Self-efficacy for Appropriate Medication Use Scale, and the Morisky Medication Adherence Scale. Hierarchical linear regression analysis and the Sobel test were used to examine the mediating role of self-efficacy in the relationship between depression and medication adherence. Depression and self-efficacy were statistically significant predictors of medication adherence in older patients with hypertension. Self-efficacy partially mediated the relationship between depression and medication adherence. Interventions targeting self-efficacy could increase the confidence of patients in their ability to actively take their medicines. Moreover, health care providers should be aware of the importance of early detection of depression in older patients with hypertension. Future studies with longitudinal data are warranted to clarify the multidirectional relationships between depression, self-efficacy, and medication adherence.

Validated adherence scales used in a measurement-guided medication management approach to target and tailor a medication adherence intervention: a randomised controlled trial

OBJECTIVE

To determine if a targeted and tailored intervention based on a discussion informed by validated adherence scales will improve medication adherence.

DESIGN

Prospective randomised trial.

SETTING

2 community pharmacies in Brisbane, Australia.

METHODS

Patients recently initiated on a cardiovascular or oral hypoglycaemic medication within the past 4-12 weeks were recruited from two community pharmacies. Participants identified as non-adherent using the Medication Adherence Questionnaire (MAQ) were randomised into the intervention or control group. The intervention group received a tailored intervention based on a discussion informed by responses to the MAQ, Beliefs about Medicines Questionnaire-Specific and Brief Illness Perception Questionnaire. Adherence was measured using the MAQ at 3 and 6 months following the intervention.

RESULTS

A total of 408 patients were assessed for eligibility, from which 152 participants were enrolled into the study. 120 participants were identified as non-adherent using the MAQ and randomised to the 'intervention' or 'control' group. The mean MAQ score at baseline in the intervention and control were similar (1.58: 95% CI (1.38 to 1.78) and 1.60: 95% CI (1.43 to 1.77), respectively). There was a statistically significant improvement in adherence in the intervention group compared to control at 3 months (mean MAQ score 0.42: 95% CI (0.27 to 0.57) vs 1.58: 95% CI (1.42 to 1.75); p<0.001). The significant improvement in MAQ score in the intervention group compared to control was sustained at 6 months (0.48: 95% CI (0.31 to 0.65) vs 1.48: 95% CI (1.27 to 1.69); p<0.001).

CONCLUSIONS

An intervention that targeted non-adherent participants and tailored to participant-specific reasons for non-adherence was successful at improving medication adherence.

TRIAL REGISTRATION NUMBER

ACTRN12613000162718; Results.

Effects of interactive patient smartphone support app on drug adherence and lifestyle changes in myocardial infarction patients: A randomized study

BACKGROUND

Patients with myocardial infarction (MI) seldom reach recommended targets for secondary prevention. This study evaluated a smartphone application ("app") aimed at improving treatment adherence and cardiovascular lifestyle in MI patients.

DESIGN

Multicenter, randomized trial.

METHODS

A total of 174 ticagrelor-treated MI patients were randomized to either an interactive patient support tool (active group) or a simplified tool (control group) in addition to usual post-MI care. Primary end point was a composite nonadherence score measuring patient-registered ticagrelor adherence, defined as a combination of adherence failure events (2 missed doses registered in 7-day cycles) and treatment gaps (4 consecutive missed doses). Secondary end points included change in cardiovascular risk factors, quality of life (European Quality of Life-5 Dimensions), and patient device satisfaction (System Usability Scale).

RESULTS

Patient mean age was 58 years, 81% were men, and 21% were current smokers. At 6 months, greater patient-registered drug adherence was achieved in the active vs the control group (nonadherence score: 16.6 vs 22.8 [P = .025]). Numerically, the active group was associated with higher degree of smoking cessation, increased physical activity, and change in quality of life; however, this did not reach statistical significance. Patient satisfaction was significantly higher in the active vs the control group (system usability score: 87.3 vs 78.1 [P = .001]).

CONCLUSIONS

In MI patients, use of an interactive patient support tool improved patient self-reported drug adherence and may be associated with a trend toward improved cardiovascular lifestyle changes and quality of life. Use of a disease-specific interactive patient support tool may be an appreciated, simple, and promising complement to standard secondary prevention.

What influences persistence with medicines? A multinational discrete choice experiment of 2549 patients

AIM

The aim was to examine patients' stated preferences to persist with medicines and to explore the influence of psychosocial and sociocognitive factors.

METHODS

Community-dwelling, hypertensive patients recruited from nine European countries were invited to complete a discrete choice experiment (DCE) with attributes for treatment benefits, mild yet common adverse drug reactions (ADRs), rare but potentially life-threatening ADRs and dosing frequency. Patients responded to the binary choice of which medicine would they be most likely to continue taking. Data were analyzed using a random effects logit model.

RESULTS

Two thousand five hundred and forty-nine patients from Austria (n = 321), Belgium (n = 175), England (n = 315), Germany (n = 266), Greece (n = 288), Hungary (n = 322), the Netherlands (n = 231), Poland (n = 312) and Wales (n = 319) completed the DCE. All attributes significantly influenced patients' stated preference to persist with medications (P < 0.05). Patients were willing to accept decreases in treatment benefits of 50.6 percentage points (95% CI 46.1, 57.9) for a very rare (as opposed to rare) risk of severe ADR, 28.3 percentage points (95% CI 25.2, 33.1) for a once daily instead of twice daily dosing and 0.74 percentage points (95% CI 0.67, 0.85) for a 1% point reduction in mild ADRs. Models accounting for psychosocial and sociocognitive characteristics were significantly different from the base case.

CONCLUSION

Patients' intention to persist with treatment was associated with their willingness to trade potential benefits, harms and dosing frequency. Psychosocial and sociocognitive factors influenced the extent of trading. The utility model may have value in assessing patients' likelihood of persisting with medicines and to tailor treatment to maximize persistence.