Extent of non-adherence and non-persistence in asthma patients: analysis of a large claims data set

Medication nonadherence - definition, measurement, prevalence, and causes: reflecting on the past 20 years and looking forwards

In 2003, Sabate's World Health Organisation report defined medication nonadherence as a phenomenon where individuals' behaviour does not correspond to prescribed treatment recommendations from their healthcare provider. This concept of nonadherence evolved beyond a categorisation of patients as adherent or nonadherent. Rather, nonadherence varies within the same individual and treatment over time, and between treatments and individuals. The type and patterns of nonadherence are key determinants of outcome with individuals with the same percentage nonadherence having different outcomes depending on their pattern of nonadherence. Often the poorest clinical outcomes occur in individuals who do not initiate medication or discontinue early, but much of the nonadherence literature remains focused on implementation. This paper provides a nuanced discussion of nonadherence which has been enabled in part by the growing availability of technologies such as electronic nonadherence monitors, new biomarkers for adherence and greater access to 'big data' (e.g., on prescription refills). These allow granular assessment of nonadherence that can be linked with biophysical markers captured using technologies such as wearables. More validated self-report measures have also become available to profile nonadherence in research and practice. Together, in-depth data on dosing and clinical measures provide an opportunity to explore complex interactions between medications, therapeutic effects and clinical outcomes. This variation in measurement and definition means that there is a more fine-grained understanding of the prevalence of nonadherence and a greater recognition of the prevalence of nonadherence, with growing evidence suggesting that approximately a fifth of patients do not initiate treatment, of those initiating treatment approximately 30%-50% of patients do not implement their treatment as prescribed and that, over long follow-up periods in some conditions 80%-100% of patients discontinue. There is potential too to better understand causes of nonadherence. New behavioural models synthesise determinants of nonadherence previously considered separately. Frameworks like the COM-B (considering individual capability, opportunity, and motivation factors) and MACO (focusing on Medication Adherence Contexts and Outcomes) emphasize the multifaceted nature of nonadherence determinants. Greater focus on dynamic processes with interplay between individual, social, and environmental influences is needed. Addressing these complexities could lead to more effective and personalised support for patients.

Asthma prescribing trends, inhaler adherence and outcomes: a Real-World Data analysis of a multi-ethnic Asian Asthma population

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1-3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75-1.2: 0.73-0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59-0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61-0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01-1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08-1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84-0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47-1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05-1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.

Retrospective real-world analysis of adherence and persistence to lipid-lowering therapy in Germany

BACKGROUND

Cardiovascular disease is the leading cause of mortality in Germany. Cardiovascular risk can be mitigated with long-term lipid-lowering therapies (LLTs) that reduce levels of low-density lipoprotein cholesterol. Although effective, risk mitigation is hindered by poor persistence and adherence.

OBJECTIVE

To investigate real-world persistence and adherence to LLTs through 36 months post-initiation.

METHODS

This retrospective cohort study included patients with dyslipidemia who were newly prescribed LLTs between July and December 2017, using anonymized prescription data from the Insight Health™ Patient Insight Tool, and followed up until March 2021. Persistence and adherence to the therapies were stratified by age and sex. The proportion of days covered (PDC) was used to measure adherence.

RESULTS

Patients with dyslipidemia and newly prescribed statins (n = 865,732), ezetimibe (n = 34,490), or anti-proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (anti-PCSK9 mAbs; n = 1940) were included. Persistence to LLTs declined gradually across all treatment subgroups and was lower in women than men. Adherence, calculated as the mean PDC at the end of the analysis period (July 2017‒March 2021) was 0.84, 0.92, and 0.93 for statins, ezetimibe, and anti-PCSK9 mAbs, respectively. Among patients who discontinued treatment, mean treatment duration was 265, 255, and 387 days for statins, ezetimibe, and anti-PCSK9 mAbs, respectively. Only ~ 10% of patients persisted between 201 and 300 days. By Day 300, 71% of patients on statins had discontinued treatment. At 36 months, overall persistence rates were lowest with statins (20.6%), followed by ezetimibe (22.3%) and anti-PCSK9 mAbs (50.9%).

CONCLUSIONS

High non-persistence rates were observed across all LLT regimens analyzed, with the lowest persistence rates observed with statins.

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.