One-year adherence to oral antihyperglycemic medication and risk prediction of patient outcomes for adults with diabetes mellitus: An observational study

Overall Medication Adherence as an Indicator for Health Outcomes Among Elderly Patients With Hypertension and Diabetes

OBJECTIVES

The purpose of this research was to assess overall medication adherence as an indicator for emergency room (ER) visits, hospitalizations, and mortality among elderly patients.

METHODS

The study included individuals aged 75-90 years, diagnosed with diabetes or hypertension, who were treated with at least 1 antihypertensive, or antidiabetic medication in 2017. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. We retrieved information on all ER visits and hospitalizations in internal medicine and surgical wards from 2017 to 2019 and mortality in 2019.

RESULTS

Of the 171,097 individuals included in the study, 60% were women. The mean age was 81.2 years. 93% had hypertension, 46% had diabetes, and 39% had both diabetes and hypertension. In 2017, 61,668 (36.0%) patients visited the ER, 44,910 (26.2%) were hospitalized in internal medicine wards, and 13,305 (7.8%) were hospitalized in surgical wards. Comparing the highest adherence quintile to the lowest, ORs were 0.69 (0.63, 0.76) for ER visits, 0.40 (0.36, 0.45) for hospitalization in internal medicine wards, and 0.61 (0.52, 0.72) for hospitalization in surgery wards. ORs were similar for the 3 consecutive years 2017, 2018, and 2019. The adjusted OR for all-cause mortality in 2019 comparing the highest adherence quintile to the lowest was 0.60 (0.54, 0.66).

CONCLUSIONS

Better medication adherence was associated with fewer ER visits and hospitalizations among elderly patients with diabetes and hypertension and lower mortality rates. Overall medication adherence is an indicator for health outcomes unrelated to the patient's underlying health status.

Association of Medication Adherence With HbA1c Control Among American Indian Adults With Type 2 Diabetes Using Tribal Health Services

OBJECTIVE

To examine HbA1c levels and adherence to oral glucose-lowering medications and their association with future HbA1c levels among American Indian adults with type 2 diabetes (T2D) receiving medications at no cost from a tribal health care system.

RESEARCH DESIGN AND METHODS

Tribal citizens with T2D who used Choctaw Nation Health Services Authority (CNHSA) and Pharmacies and had HbA1c data during 2017-2018 were included in this study. Medication adherence (proportion of days covered [PDC] ≥0.80) was calculated using 2017 CNHSA electronic health record data.

RESULTS

Of the 74,000 tribal citizens living on tribal lands, 4,560 were eligible; 32% had HbA1c at or below target (≤7%), 36% were above target (>7 to ≤9%), and 32% were uncontrolled (>9%) in 2017. The percentage of patients with PDC ≥0.80 was 66% for those using biguanides, 72% for sulfonylureas, 75% for dipeptidyl peptidase 4 inhibitors, and 83% for sodium-glucose cotransporter 2 inhibitors. The proportion of patients with HbA1c at or below target increased slightly from 32% in 2017 to 42% in 2018. Higher average PDC in 2017 was associated with lower HbA1c levels in 2018 (β = -1.143; P < 0.001).

CONCLUSIONS

Medication adherence was higher than that found in previous studies using self-report methods in American Indian populations, although a smaller proportion of patients had HbA1c at or below target relative to U.S. adults with T2D. Medication adherence was associated with improved HbA1c levels for most oral glucose-lowering medication classes. Future studies of American Indians should use both longitudinal prescription data from both electronic health records and pharmacy refills.

Impact of prescription length supply policy on patient medication adherence in Thailand

BACKGROUND

Phramongkutklao Hospital is one of the largest military hospitals in Thailand. Beginning in 2016, an institutional policy was implemented in which medication prescription length was increased from 30 to 90 days. However, there have been no formal investigations into how this policy has impacted medication adherence among patients in hospitals. As such, this study evaluated how prescription length impacted medication adherence among dyslipidemia and type-2 diabetes patients who were treated at Phramongkutklao Hospital.

METHODS

This pre-post implementation study compared patients who received prescription lengths of 30 and 90 days based on information recorded in the hospital database between 2014 and 2017. Therein, we used the medication possession ratio (MPR) to estimate patient adherence. Focusing on patients with universal coverage insurance, we employed the difference-in-difference method to examine changes in adherence from before and after policy implementation, then conducted a logistic regression to test for associations between the predictors and adherence.

RESULTS

We analyzed data from a total of 2,046 patients, with equal amounts of 1,023 placed into the control group (no change to 90-day prescription length) and intervention group (change from 30 to 90-day prescription length). First, we found that increased prescription length was associated with 4% and 5% higher MPRs among dyslipidemia and diabetes patients in the intervention group, respectively. Second, we found that medication adherence was correlated with sex, comorbidities, history of hospitalization, and the number of prescribed medications.

CONCLUSION

Increasing the prescription length from 30 to 90 days improved medication adherence in both the dyslipidemia and type-2 diabetes patients. This shows that the policy change was successful for patients in the hospital considered for this study.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

Effectiveness of an Interprofessional Program (Siscare) for Supporting Patients With Type 2 Diabetes

OBJECTIVE

To assess the effectiveness of an interprofessional support program (Siscare) that includes motivational interviews (patient-pharmacist), electronic monitoring (EM) of medications, patient-reported and clinical outcomes monitoring, and interactions with physicians for patients with type 2 diabetes in French-speaking Switzerland.

METHODS

This was a prospective, multicenter, observational cohort study using a hybrid implementation-effectiveness design. Individual daily adherence to at least one oral antidiabetic medication was measured by EM. A global adherence score was estimated by the product of a model-estimated implementation and a nonparametric estimate of persistence over time. Clinical outcomes (A1C, blood glucose, BMI, blood pressure, heart rate, and cholesterol levels) and quality of life (QoL) were analyzed over time using linear mixed-effect models.

RESULTS

A total of 212 patients were included from 27 pharmacies; 120 patients (57%) were followed up for at least 15 months. In total, 140 patients (66%) were male, the mean age was 64 ± 11 years, and the mean number of chronic medications per patient at baseline was 5 ± 3. Of 178 patients who used EM, 95% (95% CI 92-99%) remained persistent at the end of the follow-up period. The percentage of persistent patients taking their medications appropriately (implementation) was stable during follow-up and was estimated to be 90% (95% CI 87-92%) at baseline and 88% (95% CI 84-91%) at month 15. At baseline, the mean A1C and BMI were 7.5% and 31 kg/m², respectively, which decreased by 0.5% (P = 0.012) and 0.6 kg/m² (P = 0.017), respectively, after 15 months. QoL remained stable during follow-up.

CONCLUSION

The program supports medication adherence and improves clinical outcomes, illustrating the overall preventive effect of coordinated care.

Medication non-adherence and therapeutic inertia independently contribute to poor disease control for cardiometabolic diseases

Poorly controlled cardiometabolic biometric health gap measures [e.g.,uncontrolled blood pressure (BP), HbA1c, and low-density lipoprotein cholesterol (LDL-C)] are mediated by medication adherence and clinician-level therapeutic inertia (TI). The study of comparing relative contribution of these two factors to disease control is lacking. We conducted a retrospective cohort study using 7 years of longitudinal electronic health records (EHR) from primary care cardiometabolic patients who were 35 years or older. Cox-regression modeling was applied to estimate how baseline proportion of days covered (PDC) and TI were associated with cardiometabolic related health gap closure. 92,766 patients were included in the analysis, among which 89.9%, 85.8%, and 73.3% closed a BP, HbA1c, or LDL-C gap, respectively, with median days to gap closure ranging from 223 to 408 days. Patients who did not retrieve a medication were the least likely to achieve biometric control, particularly for LDL-C (HR = 0.58, 95% CI: 0.55-0.60). TI or uncertainty of TI was associated with a high risk of health gap persistence, particularly for LDL-C (HR ranges 0.46-0.48). Both poor medication adherence and TI are independently associated with persistent health gaps, and TI has a much higher impact on disease control compared to medication adherence, implying disease management strategies should prioritize reducing TI.

Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review

We designed a systematic literature review to identify available evidence on adherence to and persistence with antidiabetic medication in people with type 2 diabetes (T2D). Electronic screening and congress searches identified real-world noninterventional studies (published between 2010 and October 2020) reporting estimates of adherence to and persistence with antidiabetic medication in adults with T2D, and associations with glycaemic control, microvascular and/or macrovascular complications, hospitalizations and healthcare costs. Ninety-two relevant studies were identified, the majority of which were retrospective and reported US data. The proportions of patients considered adherent (median [range] 51.2% [9.4%-84.3%]) or persistent (median [range] 47.7% [16.9%-94.0%]) varied widely across studies. Multiple studies reported an association between greater adherence/persistence and greater reductions in glycated haemoglobin levels. Better adherence/persistence was associated with fewer microvascular and/or macrovascular outcomes, although there was little consistency across studies in terms of which outcomes were improved. More adherent and more persistent patients were typically less likely to be hospitalized or to have emergency department visits/admissions and spent fewer days in hospital annually than less adherent/persistent patients. Greater adherence and persistence were generally associated with lower hospitalization costs, higher pharmacy costs and lower or budget-neutral total healthcare costs compared with lower adherence/persistence. In conclusion, better adherence and persistence in people with T2D is associated with lower rates of microvascular and/or macrovascular outcomes and inpatient hospitalization, and lower or budget-neutral total healthcare expenditure. Education and treatment strategies to address suboptimal adherence and persistence are needed to improve clinical and economic outcomes.

Adherence to treatment for hypothyroidism in pregnancy and relationship with thyrotropin control: a retrospective observational cohort study

Background

Hypothyroidism is the second most common endocrinological disease during pregnancy, with percentages that can range between 3.2 and 5.5%. A good maternal and foetal health outcome depends on thyroid hormone replacement therapy. The goal of such therapy is to maintain thyrotropin (TSH) in a range that is specific for pregnant women and varies between the trimesters of pregnancy. In our study, we wanted to analyse the adherence to hypothyroidism treatment among pregnant women and to evaluate the degree of control of the disease.

Methods

We performed a retrospective observational cohort study in pregnant women between 2012 and 2018 in the Lleida health region. Therapeutic adherence was analysed by the proportion of days covered (PDC). The relationship with other variables was assessed using the regression coefficients and their 95% confidence interval (CI).

Results

We examined a sample of 17,281 women, representing more than 92% of the pregnant women in the Lleida health region in the period analysed. Among this sample, the mean prevalence of hypothyroidism was 6.52% (0.07% clinical and 6.45% subclinical). 3.3% of the 17,281 pregnant women were treated. Among them, the mean adherence score was 79.6 ± 22.2. Of these, 54% presented high adherence. The latter had a higher mean age and better TSH control, in comparison to the ones showing low adherence.

Conclusions

Half of the treated patients had good adherence to treatment and a better TSH control, in comparison to the others. Most of them achieved a good control at the third trimester of pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04483-8.

Prescription drug coverage satisfaction, cost-reducing behavior, and medication nonadherence among Medicare beneficiaries with type 2 diabetes

BACKGROUND: Medication nonadherence in individuals with type 2 diabetes can lead to poor glycemic control, resulting in increased risk for diabetes-related complications. OBJECTIVE: To examine associations between factors (ie, drug coverage satisfaction and cost-reducing behavior) and medication nonadherence among Medicare beneficiaries with type 2 diabetes. METHODS: We analyzed the 2016 Medicare Current Beneficiary Survey Public Use File for beneficiaries aged 65 years and older with reported type 2 diabetes (n=1,430; weighted n=5,846,943). Medicare beneficiaries were considered to have medication nonadherence if they reported skipping doses or taking smaller doses than prescribed. A survey-weighted logistic model, adjusted for sociodemographics and comorbidities, was conducted to examine associations of drug coverage satisfaction and cost-reducing behavior with medication nonadherence. RESULTS: Among Medicare beneficiaries aged 65 years and older with type 2 diabetes, 10.3% reported medication nonadherence. In the adjusted analysis, the risk for medication nonadherence was higher among those who were dissatisfied with the amount paid for medications (OR = 2.43; P = 0.002) compared with those who were satisfied, and those who spent less on basic needs to save for medications were more likely to report medication nonadherence (OR = 2.23; P = 0.011) than those who did not. CONCLUSIONS: Our findings suggest that medication nonadherence among Medicare beneficiaries with type 2 diabetes is associated with dissatisfaction with the amount paid for medications and cost-reducing behavior. Interventions that lower medication costs for Medicare beneficiaries may help to improve medication adherence among this at-risk population. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to disclose.

[Treatment persistence with brand-name vs. generic metformin in monotherapy for type 2 diabetes: real-life retrospective study using the propensity matching score]

OBJECTIVE

To evaluate treatment persistence in patients with polymedicated type 2 diabetes (DM2) receiving new treatment with brand-name vs. generic metformin 850mg in usual clinical practice.

PATIENTS AND METHODS

Observational, retrospective study based on the medical records of patients aged ≥50 years who initiated metformin treatment (brand-name vs. generic) between 01/01/2016 and 31/12/2017. The follow up was two years.

MAIN MEASURES

treatment persistence and clinical consequences (metabolic control [HbA1c] and hospital admissions). Each patient in the brand-name group (reference) was paired with a patient from the generic group using propensity score matching. A Cox proportional risk model was constructed (p<0.05).

RESULTS

863 patients receiving brand-name metformin were matched (ratio 1:1) with patients receiving generic metformin. The median age was 60.8 years (SD: 8.8) years and 52.6% were female. Persistence at 24 months was 8.6% higher for brand-name vs. generic metformin (63.2% vs. 58.2%; p=0.034). The hazard ratio for brand-name metformin was 0.83 (95% CI: 0.71-0.96, p=0.013). During the follow-up there was a greater percentage reduction of HbA1c in the brand-name vs. generic group (-6.8% vs. -4.1%; p=0.013). There was a non-significant 19.1% reduction in hospital admissions in the brand-name vs. generic group (8.9% vs. 11.0%; p=0.148).

CONCLUSIONS

Polymedicated patients who initiated new brand-name metformin treatment for DM2 had greater treatment persistence than those who initiated it with generic metformin and had better metabolic control (percentage reduction in HbA1c).

Interest in and use of person-centred pharmacy services - a Swiss study of people with diabetes

Background

Diabetes is one of the most important chronic diseases and affects 9% of the world’s population. To support these people in the day-to-day management of their treatments, pharmacies can offer professional pharmacy services. These are defined as one or more actions organized or provided in a pharmacy to optimize the process of care, with the goal of improving health outcomes and the value of healthcare. Such services have to be tailored to the needs and interests of patients. This study aimed to evaluate interest in and use of pharmacy services among people with diabetes in the canton of Vaud, Switzerland.

Methods

This cross-sectional study analysed self-reported data from 790 people with diabetes included in the CoDiab-VD cohort. Questions focused on sociodemographic and economic characteristics, diabetes and its management, and interest in and use of pharmacy services related to (1) medication intake and adherence and (2) diabetes and general health. Descriptive analyses were first conducted. Logistic regression analyses were then performed for pharmacy services that were of interest to ≥50% of respondents.

Results

The mean age of participants was 66 years, and the sample included more males (59%) than females. The pharmacy services that interested the most respondents were individual interview, pill boxes or weekly pill boxes, treatment plans, checks of all medications, first medical opinions from pharmacists and counselling on devices. Factors significantly associated with interest in pharmacy services were being older, having a lower self-efficacy score, taking more than three medications and having a positive opinion about pharmacists.

Conclusions

This study provides key information on interest in and use of pharmacy services among patients with diabetes in Switzerland; it should help pharmacists individualize their services for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06217-6.

Association of Medication Adherence with Hospital Utilization and Costs Among Elderly with Diabetes Enrolled in a State Pharmaceutical Assistance Program

BACKGROUND

Medication adherence is crucial for the successful treatment among elderly patients with diabetes taking oral antidiabetic medications (OAMs). Cost of medications, lack of insurance coverage, and low income are major contributing factors towards medication nonadherence. State pharmaceutical assistance programs (SPAPs) provide medications at little or no cost to income-eligible patients and have potential to improve medication adherence among elderly patients. Despite this, limited research has focused on the association of medication adherence with health care utilization among elderly patients enrolled in SPAPs, and inclusion of health care costs as an outcome is even rarer.

OBJECTIVE

To evaluate the relationship between adherence to OAMs and hospital utilization and costs among elderly patients with diabetes who were enrolled in a SPAP.

METHODS

This retrospective observational study included elderly patients with diabetes enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program in 2015. Medication adherence was estimated as the proportion of days covered (PDC; adherent: PDC≥80%, nonadherent: PDC < 80%). Hospital utilization and costs were estimated using hospital discharge records from the Pennsylvania Health Care Cost Containment Council. Multiple adjusted regression analyses were used to examine the association of medication adherence with hospital utilization (all-cause and diabetes-related number of inpatient hospital visits and length of stay [LOS]) and costs.

RESULTS

Among 9,497 elderly PACE enrollees with diabetes, 81% were adherent, and 21% were hospitalized. Compared with adherent patients, patients who were nonadherent to OAMs had twice the odds of all-cause and diabetes-related hospitalization. Controlling for covariates, nonadherent patients had 27% more all-cause (95% CI = 9%-36%) and 21% more diabetes-related (95% CI = 5%-40%) hospital visits than adherent patients. Covariate-adjusted LOS for nonadherent patients was 24% longer than that of adherent patients for all-cause hospitalization (95% CI = 1.171-1.311) and 12.7% longer for diabetes-related hospitalization (95% CI = 1.036-1.227). Medication nonadherence was associated with significantly greater all-cause ($22,670 vs. $16,383; P < 0.0001) and diabetes-related ($13,518 vs. $12,634; P = 0.0003) hospitalization costs.

CONCLUSIONS

Among SPAP-enrolled elderly patients, nonadherence to OAMs was significantly associated with increased risk of hospitalization, longer hospital stays, and greater hospitalization costs. Attention is needed to improve medication adherence among elderly receiving financial assistance to pay their prescriptions to reduce economic burden on the health care system.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Use of selective serotonin reuptake inhibitors, other antidepressant medication, and risk of cataract: a case-control study based on Swiss claims data

PURPOSE

Three previous studies reported controversial results regarding selective serotonin reuptake inhibitor (SSRI) exposure and cataract development. We therefore aimed to assess risk of cataract associated with previous exposure to SSRI using data from a large health insurance in Switzerland.

METHODS

In a case-control study, we analyzed individuals insured by the Helsana Group, a large Swiss health insurance provider. We matched patients aged 40 years or older with cataract extraction (i.e., a proxy for a cataract diagnosis) in 2014 or 2015 to four control patients, on age, sex, date of cataract extraction, and area of residence. Exposure of interest was the number of SSRI claims prior to cataract extraction. We conducted conditional logistic regression analyses to calculate odds ratios (OR) with 95% confidence intervals (CI). We adjusted our analyses for the presence of hypertension, diabetes, glaucoma, systemic steroid use, and use of other antidepressant drugs.

RESULTS

We identified 13,773 cataract cases and 51,625 matched controls. Compared with non-use, long-term use of SSRI (≥ 20 claims) was not associated with an altered risk of cataract (adjusted OR 0.93, 95% CI 0.84-1.04). The analysis of the individual drug substances also yielded no statistically significant association between drug exposure and the risk of cataract.

CONCLUSIONS

According to our study, use of SSRI does not change the risk of cataract in the overall population.

Predictive models of medication non-adherence risks of patients with T2D based on multiple machine learning algorithms

OBJECTIVE

Medication adherence plays a key role in type 2 diabetes (T2D) care. Identifying patients with high risks of non-compliance helps individualized management, especially for China, where medical resources are relatively insufficient. However, models with good predictive capabilities have not been studied. This study aims to assess multiple machine learning algorithms and screen out a model that can be used to predict patients' non-adherence risks.

METHODS

A real-world registration study was conducted at Sichuan Provincial People's Hospital from 1 April 2018 to 30 March 2019. Data of patients with T2D on demographics, disease and treatment, diet and exercise, mental status, and treatment adherence were obtained by face-to-face questionnaires. The medication possession ratio was used to evaluate patients' medication adherence status. Fourteen machine learning algorithms were applied for modeling, including Bayesian network, Neural Net, support vector machine, and so on, and balanced sampling, data imputation, binning, and methods of feature selection were evaluated by the area under the receiver operating characteristic curve (AUC). We use two-way cross-validation to ensure the accuracy of model evaluation, and we performed a posteriori test on the sample size based on the trend of AUC as the sample size increase.

RESULTS

A total of 401 patients out of 630 candidates were investigated, of which 85 were evaluated as poor adherence (21.20%). A total of 16 variables were selected as potential variables for modeling, and 300 models were built based on 30 machine learning algorithms. Among these algorithms, the AUC of the best capable one was 0.866±0.082. Imputing, oversampling and larger sample size will help improve predictive ability.

CONCLUSIONS

An accurate and sensitive adherence prediction model based on real-world registration data was established after evaluating data filling, balanced sampling, and so on, which may provide a technical tool for individualized diabetes care.

Evaluating glycaemic control in patients poorly controlled on oral antidiabetic drugs in real-world setting: Results from assessing the Appropriate Timing of Type 2 diAbetes INtensification (ATTAIN)

INTRODUCTION

Many patients with type 2 diabetes mellitus (DM) fail to achieve glycaemic control despite recommended treatment strategies to reduce glycated haemoglobin (HbA1c). This real-world retrospective cohort study compared HbA1c change and treatment patterns between those intensifying and not intensifying therapy with oral antidiabetic drugs (OADs).

MATERIALS AND METHODS

Patients suboptimally controlled on OADs (>58 mmol/mol [>7.5%] or >64 mmol/mol [>8.0%] for high risk, index 1) were included from IQVIA Medical Research Data. Intensifiers within 12 months of index 1 were matched (1:1) to nonintensifiers. Primary outcomes were HbA1c change and proportion of participants achieving HbA1c targets 6 and 12 months post-index 2 (date of intensification [intensifiers] or pseudodate [nonintensifiers]). Therapy adherence was also assessed.

RESULTS

A total of 10 832 participants (5539 intensifiers and 5293 nonintensifiers) were included. Mean HbA1c decrease from baseline to 6 months was -1.13% (intensifiers) vs -0.75% (nonintensifiers), with no substantial further change at 12 months. Cox proportional hazards (PH) analysis suggested a nearly 20% greater chance of target achievement at 6 months for intensifiers vs nonintensifiers (hazard ratio [HR]: 0.79 [95% confidence interval [CI]: 0.73-0.86]), which was similar at 12 months (HR: 0.80 [95% CI: 0.74-0.86]). Intensifiers tended towards greater adherence to baseline therapy (90% [standard deviation (SD): 14.9] vs nonintensifiers 87% [SD: 16.0]), which decreased following intensification.

CONCLUSIONS

Significant reductions in HbA1c were evident at 6 months and were greater in intensifiers vs nonintensifiers. Little additional clinical benefit was seen 12 months postintensification. Despite good treatment adherence, many participants failed to achieve target HbA1c; actions beyond improved adherence are needed to improve suboptimal HbA1c.

Assessment of Non-Adherence to Oral Metformin and Atorvastatin Therapies: A Cross-Sectional Survey in Piedmont (Italy)

INTRODUCTION

It is not possible to recover from chronic diseases; however, a healthy lifestyle and correct adherence to therapy can avoid complications and co-morbidities. The aim of this study was the cross-sectional evaluation, by means of a questionnaire, of real-world data on the prevalence of non-adherence to metformin and atorvastatin oral therapies in a sample of patients that attend community pharmacies in the Piedmont Region. The secondary aim was to evaluate the presence of correlations between non-adherence and a number of variables detected by the questionnaire.

MATERIALS AND METHODS

Data were gathered from face-to-face interviews in six community pharmacies in Piedmont. The questionnaire was divided into two sections: the first included the Morisky, Green and Levine Medication Adherence Questionnaire (MAQ) (to assess therapy adherence); the second included questions on gender, age, level of education and the pharmacy in which the questionnaire was administered. Comparisons between proportions and mean values were performed using the χ2 test. Modified Poisson regression with robust standard errors was used for multivariate analysis. The level of significance was fixed at 0.05, CI at 95%.

RESULTS

The sample analysed was composed of 408 subjects (receiving either metformin or atorvastatin). According to MAQ, 62 patients were non-adherent (15% of the total cohort). Crude and multivariate analysis did not show any statistically significant correlation between gender, age, level of education and non-adherence. It emerged that there was a correlation between non-adherence and being a customer of two of the pharmacies involved [PR = 3.31 (p=0.028) and PR = 3.11 (p=0.027)].

CONCLUSIONS

Community pharmacies can be an appropriate setting to identify non-adherent patients. Therefore, healthcare professionals could realize an integrated and structured intervention to improve adherence. However, MAQ could underestimate the number of non-adherent patients. Further studies to test the association between non-adherence prevalence and being the customer of a specific pharmacy should be performed.

Adherence and Persistence with DPP-4 Inhibitors Versus Pioglitazone in Type 2 Diabetes Patients with Chronic Kidney Disease: A Retrospective Claims Database Analysis

BACKGROUND

Adherence and persistence with diabetes medication play an important role in glycemic control and may differ by medication class. However, there is a lack of research comparing diabetes medications in patients with renal impairment, despite the challenges and higher burden associated with managing this population.

OBJECTIVE

To compare adherence and persistence among patients with type 2 diabetes mellitus (T2DM) and nondialysis chronic kidney disease (CKD) treated with dipeptidyl peptidase-4 (DPP-4) inhibitors versus pioglitazone.

METHODS

This retrospective cohort study used Truven MarketScan administrative claims databases from 2009 to 2015. One-year adherence for patients with T2DM and nondialysis CKD who initiated therapy with either a DPP-4 inhibitor or pioglitazone was measured by proportion of days covered (PDC) following an initial dispensing, and PDC ≥ 0.80 was coded as adherent. Persistence was calculated as the days between the index date and last day with the index medication on hand, based on the end of the last days supply or the end of follow-up (i.e., 365 days), whichever occurred first. Multivariate logistic regression and Cox proportional hazards models were used to estimate confounder-adjusted differences between the groups for adherence and persistence.

RESULTS

The final cohort included 9,019 patients (DPP-4 inhibitors: 7,002; pioglitazone: 2,017). In the adjusted analysis, DPP-4 inhibitor users demonstrated a 1.41 (95% CI = 1.25-1.59) higher odds of being adherent compared with pioglitazone users. Overall adjusted HR for persistence was 0.74 (95% CI = 0.69-0.79), which favored DPP-4 inhibitors compared with pioglitazone. Relative to 2010, persistence with pioglitazone decreased in 2011-2012 and then increased in 2013-2014. In the subgroup analysis, DPP-4 inhibitors first had lower (2010: OR = 0.78, 95% CI = 0.70-0.87; 2011-2012: OR = 0.60, 95% CI = 0.54-0.66) and then similar (2013-2014: OR = 1.03, 95% CI = 0.88-1.19) hazards of nonpersistence compared with pioglitazone.

CONCLUSIONS

Among patients with T2DM and nondialysis CKD, the use of DPP-4 inhibitors was associated with better adherence compared with pioglitazone. However, following the approval of generic pioglitazone and associated lower cost sharing after 2012, the magnitude of difference in adherence between the medication classes reduced. Similarly, safety warnings in 2011 and approval of generic products in 2012 may have affected pioglitazone persistence, leading to first higher and then similar hazards for nonpersistence with pioglitazone as compared with DPP-4 inhibitors. These shifts in the results for pioglitazone warrant further investigation and close monitoring of the population initiating this medication.

DISCLOSURES

No funding was received for this study. The authors have no conflicts of interest to disclose. An abstract for this study was presented as a podium presentation at the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) 2019 Annual Meeting; May 18-22, 2019; New Orleans, LA.

Long-term Effects of Disasters on Seniors With Diabetes: Evidence From Hurricanes Katrina and Rita

OBJECTIVE

To estimate the long-run mortality effects of Hurricanes Katrina and Rita on seniors with diabetes.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort analysis of Medicare enrollment and claims data covering four states and ∼10 years. Affected individuals were identified by whether they lived in a county that suffered a high impact and were stratified by whether they moved to a different county following the storms. Propensity scores matched affected and comparison subjects based on demographic and socioeconomic characteristics and the presence of chronic conditions. Our sample consisted of 170,328 matched affected subjects.

RESULTS

The affected subjects had a nearly 40% higher all-cause mortality risk in the 1st month after the storms, but the difference fell to <6% by the end of the full observation period. The mortality risks of heart disease and nephritis also exhibited the largest differences immediately following the storms. Among the affected subjects, the all-cause mortality risk was higher for those who moved to a different county, with an especially large difference among those who moved to an affected county.

CONCLUSIONS

The propensity matching procedure resulted in the comparison and affected groups having similar observable characteristics. However, we only examined the extreme outcome of mortality, our definition of affected was somewhat crude, and our sample did not include individuals enrolled in Medicare Advantage. Our findings highlight the importance of the immediate response to disasters, yet also demonstrate the long-lasting impact disasters can have.

Adherence, persistence, glycaemic control and costs among patients with type 2 diabetes initiating dulaglutide compared with liraglutide or exenatide once weekly at 12-month follow-up in a real-world setting in the United States

AIMS

To evaluate adherence, persistence, glycaemic control and costs at 12-month follow-up for patients initiating dulaglutide versus liraglutide or exenatide once weekly.

MATERIALS AND METHODS

The present retrospective observational claims study included patients with type 2 diabetes (T2D) and ≥ 1 pharmacy claim for dulaglutide, liraglutide or exenatide once weekly from the HealthCore Integrated Research Database. Adherence was defined as proportion of days covered ≥80%, and persistence was measured by time to discontinuation of index therapy. Change from baseline in glycated haemoglobin (HbA1c) concentration was assessed in a subset with pre- and post-index HbA1c results. Propensity scores were used to match the cohorts.

RESULTS

The baseline characteristics were balanced for the matched cohorts, dulaglutide versus liraglutide (n = 2471) and dulaglutide versus exenatide once weekly (n = 1891). Among those initiating dulaglutide there was a significantly higher proportion of adherent patients compared with the groups initiating liraglutide (51.2% vs. 38.2%; P < 0.001) and exenatide once weekly (50.7% vs. 31.9%; P < 0.001). At 12 months, 55% of patients in the dulaglutide group versus 43.8% in the liraglutide group (P < 0.001), and 54.9% in the dulaglutide versus 34.4% in the exenatide once-weekly group (P < 0.001) were persistent. The dulaglutide group had a significantly greater reduction in HbA1c than the liraglutide group (-34.24 vs. -31.94 mmol/mol; P = 0.032), and a greater, but nonsignificant, reduction in HbA1c than the exenatide once-weekly group (-34.46 vs. -31.94 mmol/mol; P = 0.056). The diabetes-related total costs were not significantly different between the dulaglutide and the liraglutide group ($16,174 vs. $16,694; P = 0.184), and were significantly higher for dulaglutide than for exenatide once weekly ($15,768 vs. $14,615; P = 0.005).

CONCLUSIONS

Adherence and persistence are important considerations in patient-centric treatment selection for patients with T2D. Higher adherence and persistence for dulaglutide compared with liraglutide or exenatide once weekly are relevant criteria when choosing glucagon-like peptide-1 receptor agonist treatment for patients with T2D.

Differences in health outcomes associated with initial adherence to oral antidiabetes medications among veterans with uncomplicated Type 2 diabetes: a 5-year survival analysis

AIM

To determine the association of adherence to oral antidiabetes medication with macrovascular and microvascular complications, time to insulin therapy, revascularization, admissions, and death among veterans with uncomplicated diabetes.

METHODS

This was a retrospective cohort study using the Veterans Affairs Corporate Data Warehouse to examine 159 032 veterans diagnosed with uncomplicated diabetes during 2002-2014 and starting oral antidiabetes therapy for the first time. The first uncomplicated diabetes diagnosis was identified and confirmed by subsequent oral antidiabetes therapy initiation. Adherence was calculated from outpatient pharmacy records using the proportion of days covered over the first year of therapy. Health outcomes were observed up to 5 years beyond the first oral antidiabetes agent fill, and compared according to adherence status using Cox proportional hazards models adjusted for baseline demographic and clinical characteristics.

RESULTS

During the first 5 years of oral antidiabetes treatment, people initially non-adherent to oral antidiabetes therapy were more likely to experience myocardial infarction (hazard ratio 1.14, 95% CI 1.03-1.27) and ischaemic stroke (hazard ratio 1.22, 95% CI 1.05-0.1.42), or to die (hazard ratio 1.21; 95% CI 1.15-1.28). Veterans with <20% adherence to oral antidiabetes therapy in the first year had particularly high hazards for ischaemic stroke (hazard ratio 1.78, 95% CI 1.27-2.49) and all-cause death (hazard ratio 1.33, 95% CI 1.17-151). Adherent people were more likely to be diagnosed with a microvascular complication or chronic kidney disease.

CONCLUSIONS

People who are non-adherent to treatment were more likely to experience detrimental health outcomes within the first 5 years of antidiabetes therapy. Adherence is paramount to disease management and this should be stressed from the time at which treatment is initiated.

Evidence-based indicators for the measurement of quality of primary care using health insurance claims data in Switzerland: results of a pragmatic consensus process

BACKGROUND

The level of quality of care of ambulatory services in Switzerland is almost completely unknown. By adapting existing instruments to the Swiss national context, the present project aimed to define quality indicators (QI) for the measurement of quality of primary care for use on health insurance claims data. These data are pre-existing and available nationwide which provides an excellent opportunity for their use in the context of health care quality assurance.

METHODS

Pragmatic 6-step process based on informal consensus. Potential QI consisted of recommendations extracted from internationally accepted medical practice guidelines and pre-existing QI for primary care. An independent interdisciplinary group of experts rated potential QI based on explicit criteria related to evidence, relevance for Swiss public health, and controllability in the Swiss primary care context. Feasibility of a preliminary set of QI was tested using claims data of persons with basic mandatory health insurance with insurance at one of the largest Swiss health insurers. This test built the basis for expert consensus on the final set of QI.

RESULTS

Of 49 potential indicators, 23 were selected for feasibility testing based on claims data. The expert group consented a final set of 24 QI covering the domains general aspects/ efficiency (7 QI), drug safety (2), geriatric care (4), respiratory disease (2), diabetes (5) and cardiovascular disease (4).

CONCLUSIONS

The present project provides the first nationwide applicable explicit evidence-based criteria to measure quality of care of ambulatory primary care in Switzerland. The set intends to increase transparency related to quality and variance of care in Switzerland.

The association between adherence to levothyroxine and economic and clinical outcomes in patients with hypothyroidism in the US

OBJECTIVE

To evaluate outcomes associated with adherence to levothyroxine (LT4) in the US adult hypothyroidism population.

METHODS

We used data from Truven's MarketScan databases from 1 July 2011 through 31 December 2015. Patients aged 18 or older were diagnosed with hypothyroidism (confirmed at least twice) and prescribed LT4. Patients were excluded if they did not have continuous insurance coverage or if they received a diagnosis of thyroid cancer or pregnancy during the study period. Multivariable analyses on a matched cohort of adherent and nonadherent patients examined the relationships among patient outcomes and adherence, defined as the proportion of days covered ≥80%. Outcomes included all-cause and hypothyroidism-related medical costs and resource utilization and comorbid diagnoses measured over the 1 year post-period following the first prescription for LT4. The analyses controlled for patient age, sex, region of residence, type of insurance coverage, diagnosing physician and pre-period general health status as proxied by the Charlson Comorbidity Index.

RESULTS

Prior to matching, there were 168,457 patients identified as adherent and 198,443 patients identified as nonadherent. The matched cohort consisted of 318,628 individuals, with equal numbers of adherent and nonadherent patients (n = 159,314). Patients who were adherent used significantly fewer resources and had significantly lower all-cause ($14,136 vs. $14,926; p < .0001) and hypothyroidism-related ($1672 vs. $1709; p < .0001) total costs, although the costs of drugs were higher in the adherent group. Furthermore, adherent patients, compared to nonadherent patients, were significantly less likely to be diagnosed with comorbid Addison's disease, bipolar disorder, chronic kidney disease, depression, migraine, obesity, type 1 diabetes or type 2 diabetes during the follow-up period.

CONCLUSIONS

Compared to nonadherence, adherence to LT4 among patients with hypothyroidism was associated with a significant reduction in all-cause and hypothyroidism-related costs and resource utilization as well as significantly lower rates of many comorbid diagnoses.

Real-world effectiveness, adherence and persistence among patients with type 2 diabetes mellitus initiating dulaglutide treatment

OBJECTIVES

To assess glycemic effectiveness, adherence and persistence within 6 months of treatment initiation with dulaglutide, a once weekly GLP-1 receptor agonist, in a US real-world setting.

METHODS

This retrospective claims analysis included adults (≥18 years) with T2DM from the HealthCore Integrated Research Database, who had HbA1c laboratory results around initiation and within 6 months after initiation. Glycemic control was assessed by change in HbA1c from pre-initiation to post-initiation. Patients were considered adherent if their proportion of days covered (PDC) was ≥0.80; persistence was measured as days of continuous therapy from initiation to 6 months after initiation with no gaps >45 days between fills.

RESULTS

Of the 308 analyzed patients, the majority (n = 188; 61%) were adherent to dulaglutide (mean PDC 0.76; SD 0.26), with 115 patients (37%) discontinuing treatment. Mean persistence was 152 days/5 months. Mean HbA1c decreased from 8.49% (SD 1.70, median 8.20%) at baseline to 7.59% (SD 1.51, median 7.30%) at follow-up, corresponding to a mean HbA1c change of -0.90% (95% confidence interval [CI] -1.08 to -0.73; p < .01; median -0.70%). Patients who were adherent to or persistent with dulaglutide experienced larger reductions (-1.14% and -1.12% respectively), as did those without prior GLP-1 RA use (-1.03%). The proportion of patients with HbA1c <7% increased from 18% to 40%.

CONCLUSIONS

Dulaglutide was associated with a significant decrease in HbA1c levels 6 months after treatment initiation. Patients who adhered to or persisted with dulaglutide therapy, or were naïve to GLP-1 RA use, experienced greater decreases in HbA1c levels.

Women are less likely than men to achieve optimal glycemic control after 1 year of treatment: A multi-level analysis of a Korean primary care cohort

We investigated differences in the achievement of glycemic control among newly diagnosed type-2 diabetes patients according to gender using a multi-clinic retrospective cohort study. Optimal glycemic control was defined as hemoglobin A1c (HbA1c) of less than 6.5% after 1 year of diabetes management. A generalized linear mixed model, which controlled for the fixed effects of baseline characteristics and prescribed oral hypoglycemic agent (OHA), was used to calculate the probability of achieving the target HbA1c. The study included 2,253 newly diagnosed type-2 diabetes patients who completed 1 year of diabetic management, including OHA, in the 36 participating primary clinics. Within the study population, the women had an older average age, were less likely to smoke or drink alcohol, and showed lower levels of fasting blood glucose and HbA1c at the time of diagnosis. There were no significant differences by sex in prescribed OHA or median number of visits. After 1 year of diabetes management, 38.9% of women and 40.6% of men achieved the target HbA1c-a small but significant difference. This suggests that type-2 diabetes is managed less well in women than in men.

Factors Associated With Medication Engagement Among Older Adults With Diabetes: Systematic Review and Meta-Analysis

Purpose

The purpose of this systematic review and meta-analysis is to explore the factors associated with medication engagement among older adults (≥60 years) with diabetes.

Methods

Five databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Scopus) were systematically searched to identify studies examining the association between factors and medication engagement among older diabetes patients. A study met inclusion for meta-analysis if the prevalence of medication engagement or factor was reported in ≥2 studies and the frequency or strength of association was either reported or able to be computed. Quality appraisal was performed with the Downs and Black tool.

Results

Of 538 retrieved studies, 33 (20 cohort and 13 cross-sectional) were included for systematic review; of these, 22 met criteria for meta-analysis. Findings from meta-analysis show that women (odds ratio [OR], 0.92; 95% CI, 0.86-0.97), those with depression (OR, 0.73; 95% CI, 0.62-0.87), and those with higher out-of-pocket spending for prescription drugs (OR, 0.87; 95% CI, 0.80-0.94) were less likely to take diabetes medication when compared with men, those without depression, and those with lower out-of-pocket costs, respectively. Older age (OR, 1.13; 95% CI, 1.00-1.27) was associated with better engagement to diabetes medication.

Conclusions

Of 4 identified factors, 2 are modifiable. Recent policy efforts to decrease the cost burden of prescribed medication for older adults, such as Medicare Part D, may remove this barrier to medication engagement. Routine screening for depression among older adults with diabetes should be included as part of usual care to facilitate an integrated treatment approach.

Association Between Metformin Adherence and All-Cause Mortality Among New Users of Metformin: A Nested Case-Control Study

BACKGROUND

Metformin presents better survival rates than other oral antidiabetics in the treatment of type 2 diabetes. However, these benefits may be dampened by inadequate treatment adherence.

OBJECTIVE

We aimed to investigate the relationship between adherence level to metformin therapy and all-cause mortality over 10 years in incident metformin users.

METHODS

A nested case-control study was conducted using a large cohort of beneficiaries of the Quebec public drug insurance plan, aged 45 to 85 years, who initiated metformin between 2000 and 2009. Each case of all-cause death during follow-up was matched with up to 10 controls. Adherence to metformin was measured using the medication possession ratio (MPR). Conditional logistic regression models were used to estimate rate ratios (RRs) for mortality between adherent (MPR ≥ 80%) and nonadherent patients (MPR < 80%). Subgroup analyses were conducted according to age (45-64 and 65-85 years) and comedication use (antihypertensive/cardiovascular drugs and statins).

RESULTS

The cohort included 82 720 incident metformin users, followed up for 2.4 [0.8-4.4] years (median [interquartile range]) and 4747 cases of all-cause deaths. Analyses revealed decreased mortality risks after long-term adherence to metformin. Specifically, RRs were 0.84 (95% CI = [0.71-0.98]) and 0.69 [0.57-0.85] after 4 to 6 and ≥6 years of adherence to metformin, respectively. Survival benefits of long-term adherence (≥4 years) were also observed across most subgroups and particularly in patients using neither antihypertensive/cardiovascular drugs nor statins (0.57 [0.41-0.77]).

CONCLUSIONS

Long-term adherence to metformin is associated with decreased risks of all-cause mortality in incident metformin users. Further research should investigate whether survival benefits vary according to the comorbidity burden of patients.

Retrospective interrupted time series examining hypertension and diabetes medicines usage following changes in patient cost sharing in the 'Farmácia Popular' programme in Brazil

OBJECTIVES

'Farmácia Popular' (FP) programme was launched in 2004, expanded in 2006 and changed the cost sharing for oral hypoglycaemic (OH) and antihypertensive (AH) medicines in 2009 and in 2011. This paper describes patterns of usage and continuity of coverage for OH and AH medicines following changes in patient cost sharing in the FP.

STUDY DESIGN

Interrupted time series study using retrospective administrative data.

METHODS

Monthly programme participation (PP) and proportion of days covered (PDC) were the two outcome measures. The open cohort included all patients with two or more dispensings for a given study medicine in 2008-2012. The interventions were an increase in patient cost sharing in 2009 and zero patient cost sharing for key medicines in 2011.

RESULTS

A total of 3.6 and 9.5 million patients receiving treatment for diabetes and hypertension, respectively, qualified for the study. Before the interventions, PP was growing by 7.3% per month; median PDC varied by medicine from 50% to 75%. After patient cost sharing increased in 2009, PP reduced by 56.5% and PDC decreased for most medicines (median 60.3%). After the 2011 free medicine programme, PP surged by 121 000 new dispensings per month and PDC increased for all covered medicines (80.7%).

CONCLUSION

Cost sharing was found to be a barrier to continuity of treatment in Brazil's private sector FP programme. Making essential medicines free to patients appear to increase participation and continuity of treatment to clinically beneficial levels (PDC >80%).

Medication adherence and glycemic control among newly diagnosed diabetes patients

BACKGROUND

Poor medication adherence can have negative consequences for the patients, the provider, the physician, and the sustainability of the healthcare system. To our knowledge, the association between medication adherence and glycemic control among newly diagnosed diabetes patients has not been studied. This study aims to bridge the gap.

METHOD

This is a retrospective cohort study of 2463 patients managed in the National Healthcare Group in Singapore with newly diagnosed diabetes. Patients were followed up for the first two years from their first medication dispensed for measuring medication adherence, proportion of days covered (PDC); and for another three years for investigating outcomes of glycemic control, emergency department visit, and hospitalization. Multivariable regressions were performed to study the association between medication adherence and the outcomes as well as the risk factors of poor adherence.

RESULTS

The prevalence of medication adherence (PDC≥80%) was 65.0% (95% CI 63.1% to 66.9%) among newly diagnosed diabetes patients in Singapore. Male, Indian, or patients without hypertension or dyslipidemia were associated with poorer medication adherence. The HbA1c level of poor adherent patients (PDC <40%) increased by 0.4 (95% CI 0.2 to 0.5) over the two years, and they were also more likely to have hospitalization (OR 2.6,95% CI 1.7 to 3.8) or emergency department visit (OR 2.4,95% CI 1.7 to 3.4) compared with the fully adherent patients (PDC=100%).

CONCLUSIONS

The medication adherence in the early stage of diabetes is important for maximizing the effectiveness of pharmaceutical therapy. Health policies or interventions targeting the improvement of medication adherence among newly diagnosed diabetes patients are in need.

Medication adherence in patients with diabetes mellitus: does physician drug dispensing enhance quality of care? Evidence from a large health claims database in Switzerland

BACKGROUND

The drug-dispensing channel is a scarcely explored determinant of medication adherence, which is considered as a key indicator for the quality of care among patients with diabetes mellitus. In this study, we investigated the difference in adherence between diabetes patients who obtained their medication directly from a prescribing physician (physician dispensing [PD]) or via a pharmacy.

METHODS

A retrospective cohort study was conducted using a large health care claims database from 2011 to 2014. Patients with diabetes of all ages and receiving at least one oral antidiabetic drug (OAD) prescription were included. We calculated patients' individual adherence to OADs defined as the proportion of days covered (PDC), which was measured over 1 year after patient identification. Good adherence was defined as PDC ≥80%. Multivariate logistic regression analysis was performed to assess the relationship between the PDC and the dispensing channel (PD, pharmacy).

RESULTS

We identified a total of 10,430 patients prescribed drugs by a dispensing physician and 16,292 patients receiving drugs from a pharmacy. Medication adherence was poor in both patient groups: ~40% of the study population attained good adherence to OADs. We found no significant impact of PD on the adherence level in diabetes patients. Covariates associated significantly with good adherence were older age groups, male sex, occurrence of comorbidity and combined diabetes drug therapy.

CONCLUSION

In conclusion, adherence to antihyperglycemic medication is suboptimal among patients with diabetes. The results of this study provide evidence that the dispensing channel does not have an impact on adherence in Switzerland. Certainly, medication adherence needs to be improved in both supply settings. Physicians as well as pharmacists are encouraged to develop and implement useful tools to increase patients' adherence behavior.