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

Non-dispensed prescriptions - A nationwide descriptive study

Background

Medication non-adherence is associated with suboptimal health outcomes, higher mortality, and increased healthcare costs.

Objective

The aim of this study was to estimate the number and share of non-dispensed prescriptions at a national level and in specific patient and medicine subgroups.

Methods

The study was a nationwide retrospective register-based study. The data consisted of prescriptions prescribed in Finland in 2020 and dispensed between 2020 and 2022. A prescription was considered non-dispensed if it had not been dispensed within the two-year validity period. For each prescription, information on the patient's birth date, sex, and income as well as details of the prescribed medicine and physician's employment sector (public/private) were collected. Distributions and odds ratios (ORs) with corresponding 95 % confidence intervals (CI) were used in the analyses.

Results

Of the 26 million prescriptions, 13.3 % were never filled. Over 1.7 million people (43.3 % of all people with prescriptions issued in 2020) had at least one non-dispensed prescription. The share of non-dispensed prescriptions was lower in men than women (12.9 % vs. 13.5 %; OR:0.95; CI:0.95-0.95). Compared to the youngest age group, the share of non-dispensed prescriptions was lower in the older age groups. The lowest share of non-dispensed medicines was in antineoplastic and immunomodulating agents (7.8 %) and in cardiovascular system medicines (8.1 %), whereas the highest was in dermatologicals (20.2 %). The proportion of non-dispensed prescriptions varied between medicine groups, from 5 % for thyroid therapy to 38 % for other nervous system drugs. The most frequently non-dispensed medications were paracetamol, ibuprofen, and salbutamol.

Conclusion

The share and number of non-dispensed prescriptions varied across therapeutic areas, medicine groups, active pharmaceutical ingredients, and patient groups. Healthcare professionals should avoid unnecessary prescribing and improve medication adherence to ensure safer and more effective care.

Network analysis of psychotic symptoms in schizophrenia

BACKGROUND

Schizophrenia with a wide range of psychotic symptoms which indicate the severity of disorders, risk of relapse, frequency and duration of hospitalization, and decreases social and occupational function. In clinical practice, Positive and Negative Systems Scale always used for assessment the severity of psychotic symptoms of patients with schizophrenia. This network analysis explores the inter-relationship of psychotic symptoms of patients with based on Positive and Negative Systems Scale (PANSS).

METHODS

The psychotic symptoms of the patients with schizophrenia were assessed by psychiatrist using PANSS when the first day in hospitalization. The network structure of psychotic symptoms was modelled with a graph and characterized using "Expected Influence" and "Bridge Expected Influence" as influential indices in the symptom network. Network stability was tested using a case-dropping bootstrap procedure. Network Comparison Test (NCT) was conducted to examine whether network characteristics differed on the basis of gender.

RESULTS

A total of 799 patients with schizophrenia were included. The mean age of the included participants was 39.51(standard deviation (SD)13.93). The main finding of the study was Preoccupation, Emotional instability and Anxiety were the most influential psychotic symptoms, while Active social avoidance, Emotional instability and Preoccupation were the most bridge influential psychotic symptoms within the interpret-able level of influential in the network. Gender did not significantly affect the overall network structure.

CONCLUSION

This influential (Preoccupation, Emotional instability and Anxiety) and bridge influential symptoms (Active social avoidance, Emotional instability and Preoccupation) dimension could be addressed in treatment target and treatment response for the patients with schizophrenia.

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

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

Prevalence and Associated Factors of Medication Non-Adherence in CRS Patients following Endoscopic Sinus Surgery

This study aimed to evaluate factors that may predispose patients to not adhere to prescribed medication after endoscopic sinus surgery (ESS) and to compare SNOT-22 scores at 0-12 months post-operatively between adherent and non-adherent patients. CRS patients who underwent ESS between 2012 and 2016 were recruited to this retrospective cohort study. Adherence was assessed through a questionnaire and review of medical notes. Ninety-four participants were included (61% male, mean age 60). Of those, 66% did not adhere to their prescribed post-operative CRS medication timing or dosage. The most common reason for non-adherence was improvement of symptoms (17%), followed by deterioration of symptoms (11%) and side effects (10%). Post-operative SNOT-22 scores were lowest for non-intentionally non-adherent (NINA) participants with a mean of 10.5 [95% CI: 7.47-13.5], compared to 25.0 for intentionally non-adherent (INA) [95% CI: 17.6-32.4] and 17.7 for adherent patients [95% CI: 13.7-21.7], p = 0.01. This study identifies that almost two-thirds of patients are not compliant with CRS medications after ESS. NINA participants reported lower post-operative SNOT-22 scores compared to INA and adherent participants. Future studies should focus on educating patients to continue with medications post-operatively despite an initial improvement in symptoms.

Prevalence and predictors of primary nonadherence to medications prescribed in primary care

BACKGROUND

Most research on medication adherence has focused on secondary nonadherence and persistence to therapy. Medication prescriptions that are never filled by patients (primary nonadherence) remain understudied in the general population.

METHODS

We linked prescribing data from primary care electronic medical records to comprehensive pharmacy dispensing claims between January 2013 and April 2019 in British Columbia (BC) to estimate primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date. We used hierarchical multivariable logistic regression to determine prescriber, patient and medication factors associated with primary nonadherence among community-dwelling patients in primary care.

RESULTS

Among 150 565 new prescriptions to 34 243 patients, 17% of prescriptions were never filled. Primary nonadherence was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). In multivariable analysis, primary nonadherence was lower for prescriptions issued by male prescribers (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.88). Primary nonadherence decreased with patient age (OR 0.91, 95% CI 0.90-0.92 for each additional 10 years) but increased with polypharmacy among patients aged 65 years or older. Patients filled more than 82% of their medication prescriptions within 2 weeks after their primary care provider visit.

INTERPRETATION

The prevalence of primary nonadherence to new prescriptions was 17%. Interventions to address primary nonadherence could target older patients with multiple medication use and within the first 2 weeks of the prescription issue date.

Utilization of remote e-prescription (Anat) in Saudi Arabia during COVID-19: Factors associated with primary adherence and antibiotic prescription

Background

The COVID-19 pandemic has affected healthcare systems globally. Various health care technologies have been used to mitigate the risk of disease transmission. Telemedicine is one such technology, and remote consulting and prescribing comprise one of its key aspects. In Saudi Arabia, telephone health services have been widely used through the free Medical Consultation Call Center (937). This platform facilitates medical consultations for all citizens, residents, and visitors. After consultations, healthcare providers are able to issue authenticated e-prescriptions using the Anat platform.

Objectives

To explore the utilization of the Anat remote prescription system in Saudi Arabia during the COVID-19 pandemic and to identify the factors associated with antibiotic prescription and primary medication adherence.

Methods

This retrospective analysis included data from the Anat e‑prescription system using a stratified random sample of 25000 prescriptions issued in Saudi Arabia in 2020. Predictive factors related to the patients, practitioners, and prescriptions were identified through bivariate and multivariate logistic regression analyses.

Results

Out of 25,000 e-prescriptions, 8885 were dispensed, resulting in a 35.5% primary medication adherence rate. The significant predictors of primary adherence were children, respiratory diseases, and antibacterial drugs. In addition, antibiotics made up 32.1% of the e-prescriptions. The prescription of antibiotics was significantly associated with male sex, children, genitourinary system diseases, and being treated by radiologists.

Conclusions

Almost two thirds 62.2% of e-prescriptions were undispensed, with antibiotic eprescriptions at 32.1%. Findings emphasize the need to enhance primary medication adherence and antibiotic prescription interventions. These findings could aid decision-makers in improving patient-centered e-prescribing practices.

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

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

Improving Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care: Pilot trial of a complex intervention

Introduction

The Initial Medication Adherence (IMA) intervention is a multidisciplinary and shared decision-making intervention to improve initial medication adherence addressed to patients in need of new treatments for cardiovascular diseases and diabetes in primary care (PC). This pilot study aims to evaluate the feasibility and acceptability of the IMA intervention and the feasibility of a cluster-RCT to assess the effectiveness and cost-effectiveness of the intervention.

Methods

A 3-month pilot trial with an embedded process evaluation was conducted in five PC centers in Catalonia (Spain). Electronic health data were descriptively analyzed to test the availability and quality of records of the trial outcomes (initiation, implementation, clinical parameters and use of services). Recruitment and retention rates of professionals were analyzed. Twenty-nine semi-structured interviews with professionals (general practitioners, nurses, and community pharmacists) and patients were conducted to assess the feasibility and acceptability of the intervention. Three discussion groups with a total of fifteen patients were performed to review and redesign the intervention decision aids. Qualitative data were thematically analyzed.

Results

A total of 901 new treatments were prescribed to 604 patients. The proportion of missing data in the electronic health records was up to 30% for use of services and around 70% for clinical parameters 5 months before and after a new prescription. Primary and secondary outcomes were within plausible ranges and outliers were barely detected. The IMA intervention and its implementation strategy were considered feasible and acceptable by pilot-study participants. Low recruitment and retention rates, understanding of shared decision-making by professionals, and format and content of decision aids were the main barriers to the feasibility of the IMA intervention.

Discussion

Involving patients in the decision-making process is crucial to achieving better clinical outcomes. The IMA intervention is feasible and showed good acceptability among professionals and patients. However, we identified barriers and facilitators to implementing the intervention and adapting it to a context affected by the COVID-19 pandemic that should be considered before launching a cluster-RCT. This pilot study identified opportunities for refining the intervention and improving the design of the definitive cluster-RCT to evaluate its effectiveness and cost-effectiveness.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05094986.

Complex multidisciplinary intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): mixed-methods process evaluation protocol

INTRODUCTION

Medication non-initiation, or primary non-adherence, is a persistent public health problem that increases the risk of adverse clinical outcomes. The initial medication adherence (IMA) intervention is a complex multidisciplinary intervention to improve adherence to cardiovascular and diabetes treatments in primary care by empowering the patient and promoting informed prescriptions based on shared decision-making. This paper presents the development and implementation strategy of the IMA intervention and the process evaluation protocol embedded in a cluster randomised controlled trial (the IMA-cRCT) to understand and interpret the outcomes of the trial and comprehend the extent of implementation and fidelity, the active mechanisms of the IMA intervention and in what context the intervention is implemented and works.

METHODS AND ANALYSIS

We present the protocol for a mixed-methods process evaluation including quantitative and qualitative methods to measure implementation and fidelity and to explore the active mechanisms and the interactions between the intervention, participants and its context. The process evaluation will be conducted in primary care centres and community pharmacies from the IMA-cRCT, and participants include healthcare professionals (general practitioners, nurses and community pharmacists) as well as patients. Quantitative data collection methods include data extraction from the intervention operative records, patient clinical records and participant feedback questionnaires, whereas qualitative data collection involves semistructured interviews, focus groups and field diaries. Quantitative and qualitative data will be analysed separately and triangulated to produce deeper insights and robust results.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Research Ethics Comittee (CEIm) at IDIAP Jordi Gol (codeCEIm 21/051 P). Findings will be disseminated through publications and conferences, as well as presentations to healthcare professionals and stakeholders from healthcare organisations.

TRIAL REGISTRATION NUMBER

NCT05026775.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BACKGROUND

Between 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.

METHODS

The IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.

DISCUSSION

The IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05026775 . Registered 30th August 2021.

Pediatric Medication Noninitiation in Spain

OBJECTIVES

To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior.

METHODS

Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported.

RESULTS

Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician).

CONCLUSIONS

The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

Non-initiation of prescribed medication from a Spanish health professionals' perspective: A qualitative exploration based on Grounded Theory

We explore, from the perspective of primary care health professionals, the motivations that lead patients to not initiate prescribed treatments, by developing a qualitative study in Spanish primary care. Six focus groups (N = 46) were conducted with general practitioners, nurse practitioners, social workers and community pharmacists and carried out in primary care (PC) of Barcelona Province, from April to July of 2018. The 46 participants were identified by three general practitioners and two pharmacists. In the interviews, the reasons for non-initiation of PC patients' medication were explored. Triangulated content analysis was performed. Patients' perspective, analysed in a previous study, and professionals' perspective agree on most of the factors that affect non-initiation. New factors were categorized into existent categories, confirming, and supplementing the model developed with patients. Health professionals identified some new factors which were not present in the patients' discourse, such as stigma related to the drug, hidden reasons for consultation, the role of nurses in prescription and support, the role of the pharmacy technician, illiteracy and lack of social support. The professionals confirm and expand on the Theoretical Model of Medication Non-Initiation. Primary care professionals should consider the factors described when prescribing a new medication. Knowledge contributed by the model should guide the design of interventions to improve initiation.

Machine Learning and Medication Adherence: Scoping Review

BACKGROUND

This is the first scoping review to focus broadly on the topics of machine learning and medication adherence.

OBJECTIVE

This review aims to categorize, summarize, and analyze literature focused on using machine learning for actions related to medication adherence.

METHODS

PubMed, Scopus, ACM Digital Library, IEEE, and Web of Science were searched to find works that meet the inclusion criteria. After full-text review, 43 works were included in the final analysis. Information of interest was systematically charted before inclusion in the final draft. Studies were placed into natural categories for additional analysis dependent upon the combination of actions related to medication adherence. The protocol for this scoping review was created using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.

RESULTS

Publications focused on predicting medication adherence have uncovered 20 strong predictors that were significant in two or more studies. A total of 13 studies that predicted medication adherence used either self-reported questionnaires or pharmacy claims data to determine medication adherence status. In addition, 13 studies that predicted medication adherence did so using either logistic regression, artificial neural networks, random forest, or support vector machines. Of the 15 studies that predicted medication adherence, 6 reported predictor accuracy, the lowest of which was 77.6%. Of 13 monitoring systems, 12 determined medication administration using medication container sensors or sensors in consumer electronics, like smartwatches or smartphones. A total of 11 monitoring systems used logistic regression, artificial neural networks, support vector machines, or random forest algorithms to determine medication administration. The 4 systems that monitored inhaler administration reported a classification accuracy of 93.75% or higher. The 2 systems that monitored medication status in patients with Parkinson disease reported a classification accuracy of 78% or higher. A total of 3 studies monitored medication administration using only smartwatch sensors and reported a classification accuracy of 78.6% or higher. Two systems that provided context-aware medication reminders helped patients to achieve an adherence level of 92% or higher. Two conversational artificial intelligence reminder systems significantly improved adherence rates when compared against traditional reminder systems.

CONCLUSIONS

Creation of systems that accurately predict medication adherence across multiple data sets may be possible due to predictors remaining strong across multiple studies. Higher quality measures of adherence should be adopted when possible so that prediction algorithms are based on accurate information. Currently, medication adherence can be predicted with a good level of accuracy, potentially allowing for the development of interventions aimed at preventing nonadherence. Monitoring systems that track inhaler use currently classify inhaler-related actions with an excellent level of accuracy, allowing for tracking of adherence and potentially proper inhaler technique. Systems that monitor medication states in patients with Parkinson disease can currently achieve a good level of classification accuracy and have the potential to inform medication therapy changes in the future. Medication administration monitoring systems that only use motion sensors in smartwatches can currently achieve a good level of classification accuracy but only when differentiating between a small number of possible activities. Context-aware reminder systems can help patients achieve high levels of medication adherence but are also intrusive, which may not be acceptable to users. Conversational artificial intelligence reminder systems can significantly improve adherence.

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

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

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

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

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

Primary non-adherence to inhaled medications measured with e-prescription data from Poland

BACKGROUND

Treatment adherence greatly influences the clinical outcomes in various fields of medicine, including management of asthma and COPD. With the recent implementation of a nationwide e-Health solutions in Poland, new and unique opportunities for studying primary non-adherence in asthma and COPD emerged. The aim was to study primary non-adherence to inhaled medications available in Poland indicated in asthma and/or COPD and analyse the impact of patients' demographics and inhalers' characteristics (dry powder inhalers (DPIs) vs metered dose inhalers (MDIs) and presence of a dosage counter) on primary non-adherence.

METHODS

A retrospective analysis of all e-prescriptions issued in Poland in 2018 (n = 119,880) from the national e-prescription pilot framework.

RESULTS

Primary non-adherence for inhalable medications reached 15.3%. It significantly differed among age groups-the lowest (10.8%) was in 75 + years-old patients, highest (18%) in 65-74 years-old patients. No gender differences in primary non-adherence were found. The highest non-adherence was observed for ICS + LABA combinations (18.86%). A significant difference was found between MDI and DPI inhalers and between inhalers with/without a dosage counter.

CONCLUSIONS

Out of e-prescriptions for inhaled medications issued in 2018 in Poland, 15.3% were not redeemed. The degree of primary non-adherence was influenced by age, but not gender. Significant differences between MDIs and DPIs and between inhalers with/without a dosage counter were observed.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Health Outcomes and Primary Adherence to Secondary Prevention Treatment after St-Elevation Myocardial Infarction: a Spanish Cohort Study

This retrospective observational study aimed to establish the first prescription and its dispensation (primary adherence) in the first 30 days of the four pharmacotherapeutic classes recommended after a type 1 STEMI episode, determine the potential risk factors for lack of primary adherence, and evaluate the potential impact of primary adherence on cardiovascular outcomes. Of the 613 patients analyzed, 576 were included (64.7 ± 13.8 years, 73.8% men) between January 2008 and December 2013. Primary adherence exceeded 90% in all groups. Complete primary adherence was higher in high-drug coverage patients and was lower in patients with cardiovascular or neuropsychiatric diseases. According to competing risk analysis, 1-year cardiovascular mortality was significantly lower in patients with complete primary adherence than in those without complete prescription or adherence, 1.8% versus 5.6% (HR = 0.286; p = 0.012). Complete primary adherence did not prevent a 1-year cardiovascular event, 5.6% versus 5.5% (p = 0.904).

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.

Initiation and Single Dispensing in Cardiovascular and Insulin Medications: Prevalence and Explanatory Factors

BACKGROUND

Adherence problems have negative effects on health, but there is little information on the magnitude of non-initiation and single dispensing.

OBJECTIVE

The aim of this study was to estimate the prevalence of non-initiation and single dispensation and identify associated predictive factors for the main treatments prescribed in Primary Care (PC) for cardiovascular disease (CVD) and diabetes.

METHODS

Cohort study with real-world data. Patients who received a first prescription (2013-2014) for insulins, platelet aggregation inhibitors, angiotensin-converting enzyme inhibitors (ACEI) or statins in Catalan PC were included. The prevalence of non-initiation and single dispensation was calculated. Factors that explained these behaviours were explored.

RESULTS

At three months, between 5.7% (ACEI) and 9.1% (antiplatelets) of patients did not initiate their treatment and between 10.6% (statins) and 18.4% (ACEI) filled a single prescription. Body mass index, previous CVD, place of origin and having a substitute prescriber, among others, influenced the risk of non-initiation and single dispensation.

CONCLUSIONS

The prevalence of non-initiation and single dispensation of CVD medications and insulin prescribed in PC in is high. Patient and health-system factors, such as place of origin and type of prescriber, should be taken into consideration when prescribing new medications for CVD and diabetes.

Pain drawings, interpreter support and clinical findings among immigrant patients on sick leave in Swedish primary health care

Aim:

To evaluate the spread of pain and its correlates among immigrant patients on sick leave.

Background:

Backache, outspread pain and sick-leave questions are problematic to handle primary health care, especially in multicultural settings.

Methods:

Two hundred and thirty-five patients 20–45 years on paid sick leave (59% women, 93% foreign-born, mostly non-Europeans). Many had little formal education. One-third had professional interpreter support. The patients pointed out on their bodies where they felt pain. This information was transferred on a pain drawing [pain drawing fields (PDFs) 0–18] by a doctor. Major depression and psychosocial stressors were assessed using Diagnostic and Statistical Manual of Mental Disorders. Nociceptive locations for pain were established (pain-sites 0–18). Dependent variable was the number of PDFs. Independent variables were social data, sick leave, interpreter, depression, stress levels and number of pain sites. Calculations were done using descriptive methods and multi-variable linear regression in full models, by gender.

Findings:

Many patients had depression (51% women versus 32% men). A majority were exposed to psychosocial stressors. Women had more PDFs, in median 5 [inter-quartile ranges (IQR) 4–8] versus men 3 (IQR 2–5), and also more pain sites, in median 3 (IQR 2–5) versus men in median 2 (IQR 1–3). For men, the regression calculations revealed that numbers of PDFs associated only with increasing numbers of pain sites (B 0.871 P < 0.001). For women, this association was weaker (B 0.364, P < 0.001), with significant values also for age (B 0.103) and sick leave > one year (B 0.767, P = 0.010), and a negative predicting value for interpreter support (B −1.198, P < 0.043). To conclude, PDFs associated often with somatic findings but varied much among the women. This implies potential problems regarding cause, function and sick leave questions. However, support by professional interpreters may facilitate a shared understanding with immigrant women having long-standing pain.

Exposure measurement error when assessing current glucocorticoid use using UK primary care electronic prescription data

Purpose

To quantify misclassification in glucocorticoid (GC) exposure defined using UK primary care prescription data.

Methods

A cross‐sectional study including patients with rheumatoid arthritis prescribed oral GCs in the past 2 years. Glucocorticoid exposure based on electronic prescription records was compared with participant‐reported GC use captured using a paper diary. Prescription data (containing information about prescriptions issued but no dispensing information) was provided by the Clinical Practice Research Datalink. The following variables were defined: current use and dose of oral GCs and if (and when) participants had received a GC injection. For oral GCs, self‐reported use was taken to represent “true” exposure. A dataset representing a hypothetical population was generated to assess the impact of the misclassification found for current use.

Results

A total of 67 of 78 study participants (86%) were correctly classified as currently on/off oral GCs; 32/38 (84.2%) participants reporting current GC use and 35/40 (87.5%) participants not reporting current use were correctly classified. Estimated values of current dose were imprecise (correlation coefficient 0.46). Concordance between reported and prescribed GC injections was poor (kappa statistic 0.14). Misclassification bias was demonstrated in the hypothetical population: For “true” relative risks of 1.5, 4, and 9, the “observed” relative risks were 1.33, 2.48, and 3.58, respectively.

Conclusions

Misclassification of current use of oral GCs was low but sufficient to lead to significant bias. Researchers should take care to assess the likely impact of exposure misclassification on their analyses.

Development of a Strategic Tool for Shared Decision-Making in the Use of Antidepressants among Patients with Major Depressive Disorder: A Focus Group Study

Shared decision-making (SDM) has been recognized as an important tool in the mental health field and considered as a crucial component of patient-centered care. Therefore, the purpose of this study was to develop a strategic tool towards the promotion and implementation of SDM in the use of antidepressants among patients with major depressive disorder. Nineteen doctors and 11 major depressive disorder patients who are involved in psychiatric outpatient clinic appointments were purposively selected and recruited to participate in one of six focus groups in a large teaching hospital in Malaysia. Focus groups were transcribed verbatim and analyzed using a thematic approach to identify current views on providing information needed for SDM practice towards its implementation in near future. Patients&rsquo; and doctors&rsquo; views were organized into six major themes, which are; summary of treatment options, correct ways of taking medication, potential side effects of treatments related to patients, sharing of case study related to the treatment options, cost of treatment options, and input from pharmacist. The information may be included in the SDM tool which can be useful to inform further research efforts and developments that contribute towards the successful implementation of SDM into clinical practice.

Effect of copayment policies on initial medication non-adherence according to income: a population-based study

Objective

Copayment policies aim to reduce the burden of medication expenditure but may affect adherence and generate inequities in access to healthcare. The objective was to evaluate the impact of two copayment measures on initial medication non-adherence (IMNA) in several medication groups and by income level.

Design

A population-based study was conducted using real-world evidence.

Setting

Primary care in Catalonia (Spain) where two separate copayment measures (fixed copayment and coinsurance) were introduced between 2011 and 2013.

Participant

Every patient with a new prescription issued between 2011 and 2014 (3 million patients and 10 million prescriptions).

Outcomes

IMNA was estimated throughout dispensing and invoicing information. Changes in IMNA prevalence after the introduction of copayment policies (immediate level change and trend changes) were estimated through segmented logistic regression. The regression models were stratified by economic status and medication groups.

Results

Before changes to copayment policies, IMNA prevalence remained stable. The introduction of a fixed copayment was followed by a statistically significant increase in IMNA in poor population, low/middle-income pensioners and low-income non-pensioners (OR from 1.047 to 1.370). In high-income populations, there was a large statistically non-significant increase. IMNA decreased in the low-income population after suspension of the fixed copayment and the introduction of a coinsurance policy that granted this population free access to medications (OR=0.676). Penicillins were least affected while analgesics were affected to the greatest extent. IMNA to medications for chronic conditions increased in low/middle-income pensioners.

Conclusion

Even nominal charge fixed copayment may generate inequities in access to health services. An anticipation effect and expenses associated with IMNA may have generated short-term costs. A reduction in copayment can protect from non-adherence and have positive, long-term effects. Copayment scenarios could have considerable long-term consequences for health and costs due to increased IMNA in medication for chronic physical conditions.

Impact of initial medication non-adherence to SSRIs on medical visits and sick leaves

BACKGROUND

Initial medication non-adherence (IMNA) to antidepressants, which are commonly used to treat depression in primary care (PC), is around 6-12%. Although it is well known that post-initial non-adherence to antidepressants increases the cost of depression, the impact of IMNA on cost is unknown. The aim of this study is to assess the impact of IMNA to Selective Serotonin Reuptake Inhibitors (SSRI) on medical visits and sick leave in patients with depression treated in PC in Catalonia (Spain).

METHODS

This was a four-year retrospective register-based study (2011-2014). All PC patients of working age who received a new SSRI prescription and had a diagnosis of depression were included (N = 79,642). Treatment initiation, number of visits and days on sick leave were gathered from the database. We assessed the impact of IMNA on costs with ordered logistic regressions.

RESULTS

The 3-year incidence of IMNA was 15%. Initially non-adherent patients made a lesser number of GP visits (OR = 0.82; 95% CI = 0.79-0.84) but had more days on sick leave (OR = 1.25; 95% CI = 1.20-1.31). There were no differences in the number of specialist visits (OR = 1.04; 95% CI = 0.99-1.08).

LIMITATIONS

Differences between adherent and non-adherent patients could be explained by non-observed variables. GP recognition and documentation of depression might be inaccurate. Costs of unpaid work and use of hospital services were not considered.

CONCLUSIONS

Although IMNA decreases the use of medical PC services, it increases the number of days on sick leave. This could also indicate worse health status. These consequences are currently overlooked when considering post-initial medication non-adherence.

Primary nonadherence to chronic disease medications: a meta-analysis

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence.

OBJECTIVES

The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications.

MATERIALS AND METHODS

We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model.

RESULTS

Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence.

CONCLUSION

Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

Self-efficacy for medication management: a systematic review of instruments

BACKGROUND

Medication self-efficacy is a potentially important construct in research around optimal use of prescription medications. A number of medication self-efficacy measures are available; however, there is no systematic review of existing instruments and cataloguing of their theoretical underpinnings or psychometric properties, strengths, and weaknesses. The aim of the study was to identify instruments that measure self-efficacy for medication management. The study also aimed to examine the quality, theoretical grounding, and psychometric evaluation of existing measures of self-efficacy for medication management. The study was a systematic review.

METHODS

Data were extracted from PubMed, OVID, and MEDLINE using a predefined search strategy. Citations were included if they reported the development and/or psychometric evaluation of an instrument to measure self-efficacy for medication management and were in English. Abstracts were screened for studies potentially meeting eligibility criteria. Full articles of these studies were then reviewed in depth. The review was carried out independently by two members of the research team.

RESULTS

The search identified 158 citations of which 12 were included after screening. Full review identified 3 articles fitting inclusion criteria for the review. Generally, development was theoretically grounded and included patients and experts in the field. Psychometric testing showed evidence of internal consistency (2/3 instruments) and test-retest reliability (1/3 instruments). All instruments showed some validity; however, assessment of all forms of validity for each instrument was lacking.

CONCLUSION

Although our analysis would recommend the use of the Self-Efficacy for Appropriate Medication Use Scale because of the current evidence of validity and reliability, more psychometric evaluation is required, particularly in terms of responsiveness to change as self-efficacy is a malleable patient-level factor. Three measures of self-efficacy for medication management were identified. Overall, some evidence of reliability and/or validity was demonstrated for all instruments; however, other forms of validity were not tested (ie, responsiveness to change). Use of a well-validated measure of self-efficacy medication management is essential in order to understand relationships between medication self-efficacy and other patient-reported outcomes such as patient-centeredness, patient enablement, and burden of treatment, an important area of research that is currently lacking.

Impact of initial medication non-adherence on use of healthcare services and sick leave: a longitudinal study in a large primary care cohort in Spain

BACKGROUND

Initial medication non-adherence is highly prevalent in primary care but no previous studies have evaluated its impact on the use of healthcare services and/or days on sick leave.

AIM

To estimate the impact of initial medication non-adherence on the use of healthcare services, days of sick leave, and costs overall and in specific medication groups.

DESIGN AND SETTING

A 3-year longitudinal register-based study of all primary care patients (a cohort of 1.7 million) who were prescribed a new medication in Catalonia (Spain) in 2012.

METHOD

Thirteen of the most prescribed and/or costly medication subgroups were considered. All medication and medication subgroups (chronic, analgesics, and penicillin) were analysed. The number of healthcare services used and days on sick leave were considered. Multilevel multivariate linear regression was used. Three levels were included: patient, GP, and primary care centre.

RESULTS

Initially adherent patients made more use of medicines and some healthcare services than non-adherent and partially adherent patients. They had lower productivity losses, producing a net economic return, especially when drugs for acute diseases (such as penicillins) were considered. Initial medication non-adherence resulted in a higher economic burden to the system in the short term.

CONCLUSION

Initial medication non-adherence seems to have a short-term impact on productivity losses and costs. The clinical consequences and long-term economic consequences of initial medication non-adherence need to be assessed. Interventions to promote initial medication adherence in primary care may reduce costs and improve health outcomes.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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