Healthcare provider targeted interventions to improve medication adherence: systematic review and meta-analysis

What is the quantity, quality and type of systematic review evidence available to inform the optimal prescribing of statins and antihypertensives? A systematic umbrella review and evidence and gap map

OBJECTIVES

We aimed to map the systematic review evidence available to inform the optimal prescribing of statins and antihypertensive medication.

DESIGN

Systematic umbrella review and evidence and gap map (EGM).

DATA SOURCES

Eight bibliographic databases (Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Health Management Information Consortium, MEDLINE ALL, PsycINFO, Conference Proceedings Citation Index-Science and Science Citation Index) were searched from 2010 to 11 August 2020. Update searches conducted in MEDLINE ALL 2 August 2022. We searched relevant websites and conducted backwards citation chasing.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We sought systematic reviews of quantitative or qualitative research where adults 16 years+ were currently receiving, or being considered for, a prescription of statin or antihypertensive medication. Eligibility criteria were applied to the title and abstract and full text of each article independently by two reviewers.

DATA EXTRACTION AND SYNTHESIS

Quality appraisal was completed by one reviewer and checked by a second. Review characteristics were tabulated and incorporated into an EGM based on a patient care pathway. Patients with lived experience provided feedback on our research questions and EGM.

RESULTS

Eighty reviews were included within the EGM. The highest quantity of evidence focused on evaluating interventions to promote patient adherence to antihypertensive medication. Key gaps included a lack of reviews synthesising evidence on experiences of specific interventions to promote patient adherence or improve prescribing practice. The evidence was predominantly of low quality, limiting confidence in the findings from individual reviews.

CONCLUSIONS

This EGM provides an interactive, accessible format for policy developers, service commissioners and clinicians to view the systematic review evidence available relevant to optimising the prescribing of statin and antihypertensive medication. To address the paucity of high-quality research, future reviews should be conducted and reported according to existing guidelines and address the evidence gaps identified above.

Nirmatrelvir/Ritonavir Utilization for the Treatment of Non-hospitalized Adults with COVID-19 in the National Veterans Affairs (VA) Healthcare System

INTRODUCTION

Limited data exist regarding real-world utilization of nirmatrelvir/ritonavir. We identified predictors of nirmatrelvir/ritonavir use among Veterans Affairs (VA) outpatients nationally.

METHODS

We conducted a retrospective cohort study among outpatients with coronavirus disease 2019 (COVID-19) who were eligible to receive nirmatrelvir/ritonavir between January and December of 2022, to identify factors associated with nirmatrelvir/ritonavir use (i.e., demographics, medical history, prior medication and healthcare exposures, frailty, and other clinical characteristics) using multivariable logistic regression.

RESULTS

We included 309,755 outpatients with COVID-19 who were eligible for nirmatrelvir/ritonavir, of whom 12.2% received nirmatrelvir/ritonavir. Nirmatrelvir/ritonavir uptake increased from 1.1% to 23.2% over the study period. Factors associated with nirmatrelvir/ritonavir receipt included receiving a COVID-19 booster vs. none (adjusted odds ratio [aOR] 2.19 [95% confidence interval [CI] 2.12-2.26]), age ≥ 50 vs. 18-49 years (aORs > 1.5 for all age groups ≥ 50 years), having HIV (aOR 1.36 [1.22-1.51]), being non-frail vs. severely frail (aOR 1.22 [1.13-1.33]), and having rheumatoid arthritis (aOR 1.12 [1.04-1.21). Those with concomitant use of potentially interacting antiarrhythmics (aOR 0.35 [0.28-0.45]), anticoagulants/antiplatelets (aOR 0.42 [0.40-0.45]), and/or psychiatric/sedatives (aOR 0.84 [0.81-0.87]) were less likely to receive nirmatrelvir/ritonavir.

CONCLUSIONS

Despite increases over time, overall utilization of nirmatrelvir/ritonavir was low. Predictors of nirmatrelvir/ritonavir utilization were consistent with known risk factors for progression to severe COVID-19, including older age and underlying medical conditions. Unvaccinated and undervaccinated patients and those receiving potentially interacting medications for cardiovascular or mental health conditions (antiarrhythmic, alpha-1 antagonist, anticoagulant/antiplatelet, sedative/hypnotic/psychiatric) were less likely to receive nirmatrelvir/ritonavir. Further education of prescribers and patients about nirmatrelvir/ritonavir treatment guidelines is needed to improve overall uptake and utilization in certain high-risk subpopulations.

The Role of Doctor's Authority in Patients' Treatment Decisions

OBJECTIVES

In this study, I aimed to find empirical support for the increasingly frequent assumption about the regulatory potential of legitimacy with regard to people's health behaviors. The research determined the effect of legitimacy on 3 crucial health behaviors. It also tested whether patients' perception of doctors as competent played a role in the recognition of doctors' legitimacy.

METHODS

The study included 210 participants, patients of independent primary healthcare facilities and specialist hospital outpatient clinics. The collected empirical data were analyzed using structural equation modeling (SEM). I tested 6 SEM models.

RESULTS

The study supported the main hypothesized relationship, showing that legitimacy was a factor increasing compliance with medical advice and regulating the treatment process. It also supported the relationship, postulated in the second hypothesis, between doctor's perceived competence and the perceived legitimacy of healthcare institutions.

CONCLUSIONS

The results of analyses indicate that the perception of a healthcare institution as trustworthy and patients' recognition of the legitimacy of doctors' authority increases their willingness to voluntarily comply with medical advice and continue treatment.

Impact of an Enhanced Patient Care Intervention on Viral Suppression Among Patients Living With HIV in Kenya

BACKGROUND

Effective patient-centered interventions are needed to promote patient engagement in HIV care. We assessed the impact of a patient-centered intervention referred to as enhanced patient care (EPC) on viral suppression among unsuppressed patients living with HIV in Kenya.

SETTING

Two rural HIV clinics within the Academic Model Providing Access to Health care.

METHODS

This was a 6-month pilot randomized control trial. The EPC intervention incorporated continuity of clinician-patient relationships, enhanced treatment dialog, and improved patients' clinic appointment scheduling. Provider-patient communication training was offered to all clinicians in the intervention site. We targeted 360 virally unsuppressed patients: (1) 240 in the intervention site with 120 randomly assigned to provider-patient communication (PPC) training + EPC and 120 to PPC training + standard of care (SOC) and (2) 120 in the control site receiving SOC. Logistic regression analysis was applied using R (version 3.6.3).

RESULTS

A total of 328 patients were enrolled: 110 (92%) PPC training + EPC, 110 (92%) PPC training + SOC, and 108 (90%) SOC. Participants' mean age at baseline was 48 years (SD: 12.05 years). Viral suppression 6 months postintervention was 84.4% among those in PPC training + EPC, 83.7% in PPC training + SOC, and 64.4% in SOC ( P ≤ 0.001). Compared with participants in PPC training + EPC, those in SOC had lower odds of being virally suppressed 6 months postintervention (odds ratio = 0.36, 95% confidence interval: 0.18 to 0.72).

CONCLUSIONS

PPC training may have had the greatest impact on patient viral suppression. Hence, adequate training and effective PPC implementation strategies are needed.

Effectiveness of interventions to improve medication adherence in adults with depressive disorders: a meta-analysis

BACKGROUND

Non-adherence to medication is a major obstacle in the treatment of depressive disorders. We systematically reviewed the literature to evaluate the effectiveness of interventions aimed at improving adherence to medication among adults with depressive disorders with emphasis on initiation and implementation phase.

METHODS

We searched Medline, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index and Science Citation Index for randomized or non-randomized controlled trials up to January 2022. Risk of bias was assessed using the criteria of the Cochrane Collaboration. Meta-analyses, cumulative and meta-regression analyses for adherence were conducted.

RESULTS

Forty-six trials (n = 24,324) were included. Pooled estimate indicates an increase in the probability of adherence to antidepressants at 6 months with the different types of interventions (OR 1.33; 95% CI: 1.09 to 1.62). The improvement in adherence is obtained from 3 months (OR 1.62, 95% CI: 1.25 to 2.10) but it is attenuated at 12 months (OR 1.25, 95% CI: 1.02 to 1.53). Selected articles show methodological differences, mainly the diversity of both the severity of the depressive disorder and intervention procedures. In the samples of these studies, patients with depression and anxiety seem to benefit most from intervention (OR 2.77, 95% CI: 1.74 to 4.42) and collaborative care is the most effective intervention to improve adherence (OR 1.88, 95% CI: 1.40 to 2.54).

CONCLUSIONS

Our findings indicate that interventions aimed at improving adherence to medication among adults with depressive disorders are effective up to six months. However, the evidence on the effectiveness of long-term adherence is insufficient and supports the need for further research efforts.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) number: CRD42017065723 .

Developing a medication adherence technologies repository: proposed structure and protocol for an online real-time Delphi study

INTRODUCTION

An online interactive repository of available medication adherence technologies may facilitate their selection and adoption by different stakeholders. Developing a repository is among the main objectives of the European Network to Advance Best practices and technoLogy on medication adherencE (ENABLE) COST Action (CA19132). However, meeting the needs of diverse stakeholders requires careful consideration of the repository structure.

METHODS AND ANALYSIS

A real-time online Delphi study by stakeholders from 39 countries with research, practice, policy, patient representation and technology development backgrounds will be conducted. Eleven ENABLE members from 9 European countries formed an interdisciplinary steering committee to develop the repository structure, prepare study protocol and perform it. Definitions of medication adherence technologies and their attributes were developed iteratively through literature review, discussions within the steering committee and ENABLE Action members, following ontology development recommendations. Three domains (product and provider information (D1), medication adherence descriptors (D2) and evaluation and implementation (D3)) branching in 13 attribute groups are proposed: product and provider information, target use scenarios, target health conditions, medication regimen, medication adherence management components, monitoring/measurement methods and targets, intervention modes of delivery, target behaviour determinants, behaviour change techniques, intervention providers, intervention settings, quality indicators and implementation indicators. Stakeholders will evaluate the proposed definition and attributes' relevance, clarity and completeness and have multiple opportunities to reconsider their evaluations based on aggregated feedback in real-time. Data collection will stop when the predetermined response rate will be achieved. We will quantify agreement and perform analyses of process indicators on the whole sample and per stakeholder group.

ETHICS AND DISSEMINATION

Ethical approval for the COST ENABLE activities was granted by the Malaga Regional Research Ethics Committee. The Delphi protocol was considered compliant regarding data protection and security by the Data Protection Officer from University of Basel. Findings from the Delphi study will form the basis for the ENABLE repository structure and related activities.

Healthcare professionals’ perceptions on barriers and facilitators to DMARD use in rheumatoid arthritis

Background

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) treatment. However, the full benefits of DMARDs are often not realized because many patients are sub-optimally adherent to their medication. In order to optimize adherence, it is essential that healthcare professionals (HCPs) understand patients’ barriers and facilitators for medication use. Insight in these barriers and facilitators may foster the dialogue about adequate medication use between HCPs and patients. What HCPs perceive as barriers and facilitators has, so far, scarcely been investigated. This study aimed to identify the perceptions of HCPs on patients’ barriers and facilitators that might influence their adherence.

Methods

This qualitative study was performed using semi structured in-depth interviews with HCPs. An interview guide was used, based on an adjusted version of the Theoretical Domains Framework (TDF). Thematic analysis was conducted to identify factors that influence barriers and facilitators to DMARD use according to HCPs.

Results

Fifteen HCPs (5 rheumatologists, 5 nurses and 5 pharmacists) were interviewed. They mentioned a variety of factors that, according to their perceptions, influence DMARD adherence in patients with RA. Besides therapy-related factors, such as (onset of) medication effectiveness and side-effects, most variation was found within patient-related factors and reflected patients’ beliefs, ways of coping, and (self-management) skills toward medication and their condition. In addition, factors related to the condition (e.g., level of disease activity), healthcare team and system (e.g., trust in HCP), and social and economic context (e.g. support, work shifts) were reported.

Conclusions

This study provided insights in HCPs’ perceptions of the barriers and facilitators to DMARD use patients with RA. Most factors that were mentioned were patient-related and potentially modifiable. When physicians understand patients’ perceptions on medication use, adherence to DMARDs can probably be optimized in patients with RA leading to more effectiveness of treatment outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07459-0.

Estimating proportion of days covered (PDC) using real-world online medicine suppliers' datasets

BACKGROUND

The proportion of days covered (PDC) is used to estimate medication adherence by looking at the proportion of days in which a person has access to the medication, over a given period of interest. This study aimed to adapt the PDC algorithm to allow for plausible assumptions about prescription refill behaviour when applied to data from online pharmacy suppliers.

METHODS

Three PDC algorithms, the conventional approach (PDC1) and two alternative approaches (PDC2 and PDC3), were used to estimate adherence in a real-world dataset from an online pharmacy. Each algorithm has different denominators and increasing levels of complexity. PDC1, the conventional approach, is the total number of days between first dispensation and a defined end date. PDC2 counts the days until the end of supply date. PDC3 removes from the denominator specifically defined large gaps between refills, which could indicate legitimate reasons for treatment discontinuation. The distribution of the three PDCs across four different follow-up lengths was compared.

RESULTS

The dataset included people taking ACE inhibitors (n = 65,905), statins (n = 100,362), and/or thyroid hormones (n = 30,637). The proportion of people taking ACE inhibitors with PDC ≥ 0.8 was 50-74% for PDC1, 81-91% for PDC2, and 86-100% for PDC3 with values depending on drug and length of follow-up. Similar ranges were identified in people taking statins and thyroid hormones.

CONCLUSION

These algorithms enable researchers and healthcare providers to assess pharmacy services and individual levels of adherence in real-world databases, particularly in settings where people may switch between different suppliers of medicines, meaning an individual supplier's data may show temporary but legitimate gaps in access to medication. Accurately identifying problems with adherence provides the foundation for opportunities to improve experience, adherence and outcomes and to reduce medicines wastage. Research with people taking medications and prescribers is required to validate the algorithms' assumptions.

Higher Clinician-Patient Communication Is Associated With Greater Satisfaction With HIV Care

Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.

Treatment Adherence in Integrative Medicine-Part One: Review of Literature

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Using the Medication Adherence Reasons Scale (MAR-Scale) in asthma and chronic obstructive pulmonary disease to determine the extent and identify the reasons for non-adherence

INTRODUCTION

Adherence to medications for asthma and COPD can reduce exacerbation rates, decrease healthcare costs, and improve health-related quality of life. In spite of the advantages to treatment adherence, individuals with asthma and COPD often fail to take medicines as prescribed. The objectives of this study were to determine the extent of non-adherence with asthma and COPD medicines and to describe the reasons for non-adherence in these conditions.

MATERIALS AND METHODS

Data from the National Health and Wellness Study (NHWS), a self-administered, annual, internet-based cross-sectional survey of US adults from 2018 was used. NHWS participants who self-reported taking daily prescription medication(s) to treat asthma and COPD responded to the 19 reasons for non-adherence and one global item in the Medication Adherence Reasons Scale (MAR-Scale). Frequencies were used to identify the reasons for non-adherence.

RESULTS

The non-adherence rate in asthma (N = 2810) was 38.4% and 28.4% in COPD (N = 1632). For both conditions, "simply missing the medicine" was the most common cause of non-adherence. Additionally, for both conditions, there was a difference between the non-adherence reason reported by more individuals and the reason for which the medicine was missed for the most number of days.

CONCLUSION

The MAR-Scale identified the most frequent reasons for non-adherence with asthma and COPD in a nationwide sample in the US. The MAR-Scale can be used as a tool in a clinic setting or at a population level to measure the extent and the reasons for non-adherence.

Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

OBJECTIVES

Newborns are often assigned temporary names at birth. Temporary newborn names-often a combination of the mother's last name and the newborn's gender-are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. We developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy.

METHODS

This study was conducted over a 14-month period in the newborn nursery and neonatal intensive care units of three hospitals that were part of the same health care system. We used a quasi-experimental study design using interrupted time series analysis to compare the differences in wrong-patient orders (an indicator of patient misidentification) before and after the implementation of the alternative distinct naming strategy.

RESULTS

Overall, there were 25 wrong-patient errors per 10,000 orders during entire study period (36.8 per 10,000 before and 19.6 per 10,000 after). However, there was no statistically significant change in the rate of wrong-patient ordering errors after the transition from the distinct to the alternative distinct naming strategy (β = 0.832, 95% confidence interval [CI] = -0.83 to 2.49, p = 0.326). We also found that, overall, 1.7% of the clinicians contributed to 62% of the wrong-patient errors.

CONCLUSION

Although we did not find statistically significant differences in wrong-patient errors, the alternative distinct naming approach provides pragmatic advantages over its predecessors. In addition, the localization of wrong-patient errors within a small set of clinicians highlights the potential for developing strategies for delivering training to clinicians.

The Evidence-Based Development of an Intervention to Improve Clinical Health Literacy Practice

Low health literacy is an issue with high prevalence in the UK and internationally. It has a social gradient with higher prevalence in lower social groups and is linked with higher rates of long-term health conditions, lower self-rated health, and greater difficulty self-managing long-term health conditions. Improved medical services and practitioner awareness of a patient's health literacy can help to address these issues. An intervention was developed to improve General Practitioner and Practice Nurse health literacy skills and practice. A feasibility study was undertaken to examine and improve the elements of the intervention. The intervention had two parts: educating primary care doctors and nurses about identifying and enhancing health literacy (patient capacity to get hold of, understand and apply information for health) to improve their health literacy practice, and implementation of on-screen 'pop-up' notifications that alerted General Practitioners (GPs) and nurses when seeing a patient at risk of low health literacy. Rapid reviews of the literature were undertaken to optimise the intervention. Four General Practices were recruited, and the intervention was then applied to doctors and nurses through training followed by alerts via the practice clinical IT system. After the intervention, focus groups were held with participating practitioners and a patient and carer group to further develop the intervention. The rapid literature reviews identified (i) key elements for effectiveness of doctors and nurse training including multi-component training, role-play, learner reflection, and identification of barriers to changing practice and (ii) key elements for effectiveness of alerts on clinical computer systems including 'stand-alone' notification, automatically generated and prominent display of advice, linkage with practitioner education, and use of notifications within a targeted environment. The findings from the post-hoc focus groups indicated that practitioner awareness and skills had improved as a result of the training and that the clinical alerts reminded them to incorporate this into their clinical practice. Suggested improvements to the training included more information on health literacy and how the clinical alerts were generated, and more practical role playing including initiating discussions on health literacy with patients. It was suggested that the wording of the clinical alert be improved to emphasise its purpose in improving practitioner skills. The feasibility study improved the intervention, increasing its potential usefulness and acceptability in clinical practice. Future studies will explore the impact on clinical care through a pilot and a randomised controlled trial.

Rheumatologists' insight into medication adherence in patients with rheumatoid arthritis: A qualitative study

BACKGROUND

Medication non-adherence is prevalent among patients with rheumatoid arthritis (RA). Rheumatologists are specialists in medication prescribing and counselling for RA, but their insights regarding medication adherence have not been studied.

OBJECTIVE

To explore rheumatologists' insights into medication adherence in patients with RA.

METHODS

A qualitative study using semi-structured interviews with 10 rheumatologists in Iran was undertaken. Thematic analysis was conducted to identify how rheumatologists assess medication adherence and their perceived determinants of adherence. The identified determinants of adherence were mapped according to the Andersen's Behavioral Model of Health Service Use.

RESULTS

Six participants were male, and the mean age was 47 years. The mean years of experience as a rheumatologist was 8.6 (SD = 7.1) years. Rheumatologists did not use a validated tool for medication adherence assessment. They assessed medication adherence either by asking their patients simple questions or using laboratory test results. The identified determinants of adherence were divided into 3 groups: patient-, rheumatologist- and healthcare organization-related determinants. The proposed suggestions to improve adherence were: (a) to understand a patient's financial situation before prescribing more expensive medications; (b) to employ a dose-reducing strategy; (c) to give hope to patients regarding remission; and (d) to arrange a session with the nurse educator.

CONCLUSION

The findings of this study provide insight into rheumatologists' perspectives on medication adherence of patients with RA. The identified determinants of adherence could be considered when developing initiatives to improve medication adherence in this group of patients.

Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol

OBJECTIVE

The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions.

INTRODUCTION

Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases.

INCLUSION CRITERIA

Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded.

METHODS

PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.

"You Want to Give the Best Care Possible, and You Know When They Leave Your Pharmacy, You Didn't Give the Best Care Possible Most of the Time": Pharmacist- and Community Health Worker-Identified Barriers and Facilitators to Medication Adherence in Marshallese Patients

BACKGROUND

The Marshallese experience high rates of chronic diseases including hypertension and diabetes. Medication adherence is crucial to successful disease management, and healthcare providers play a crucial role in assisting their patients with medication adherence.

METHODS

A qualitative study design was used with individual interviews and focus groups with pharmacists and community health workers (CHWs) serving the Marshallese community in Northwest Arkansas. Participants were asked about their experiences with and perceptions of barriers and facilitators to medication adherence among Marshallese adults in Northwest Arkansas.

RESULTS

Eight pharmacists and nine CHWs were interviewed. Five themes emerged regarding barriers to medication adherence: (1) financial, (2) transportation, (3) language, (4) health literacy and understanding of Western medicine, and (5) mistrust. Four themes emerged regarding facilitators to medication adherence: (1) in-depth patient education strategies, (2) efforts to address the language barrier, (3) family engagement, and (4) public transportation and prescription home delivery.

DISCUSSION

Pharmacists and CHWs identified the same barriers to medication adherence, which are consistent with those documented in previous studies. Pharmacists also reported distress over their inability to confirm Marshallese patient understanding in relation to the use of prescribed medications.

Identifying Brief Message Content for Interventions Delivered via Mobile Devices to Improve Medication Adherence in People With Type 2 Diabetes Mellitus: A Rapid Systematic Review

Background

Current interventions to support medication adherence in people with type 2 diabetes are generally resource-intensive and ineffective. Brief messages, such as those delivered via short message service (SMS) systems, are increasingly used in digital health interventions to support adherence because they can be delivered on a wide scale and at low cost. The content of SMS text messages is a crucial intervention feature for promoting behavior change, but it is often unclear what the rationale is for chosen wording or any underlying mechanisms targeted for behavioral change. There is little guidance for developing and optimizing brief message content for use in mobile device–delivered interventions.

Objective

This review aimed to (1) identify theoretical constructs (ie, the targets that interventions aim to change) and behavioral strategies (ie, features of intervention content) found to be associated with medication adherence in patients with type 2 diabetes and (2) map these onto a standard taxonomy for behavior change techniques (BCTs, that is, active ingredients of interventions used to promote behavioral change, to produce an evidence-based set of approaches that have shown promise of improving adherence in previous studies and which could be further tested in digital health interventions.

Methods

A rapid systematic review of existing relevant systematic reviews was conducted. MEDLINE and PsycINFO databases were searched from inception to April 10, 2017. Inclusion criteria were (1) systematic reviews of quantitative data if the studies reviewed identified predictors of or correlates with medication adherence or evaluated medication adherence–enhancing interventions and included adult participants taking medication to manage a chronic physical health condition, and (2) systematic reviews of qualitative studies of experiences of medication adherence for adult participants with type 2 diabetes. Data were extracted on review characteristics and BCTs, theoretical constructs, or behavioral strategies associated with improved adherence. Constructs and strategies were mapped onto the BCT version 1 taxonomy.

Results

A total of 1701 references were identified; 25 systematic reviews (19 quantitative reviews, 3 qualitative reviews, and 3 mixed-method reviews) were included. Moreover, 20 theoretical constructs (eg, self-efficacy) and 19 behavioral strategies (eg, habit analysis) were identified in the included reviews. In total, 46 BCTs were identified as being related to medication adherence in type 2 diabetes (eg, habit formation, prompts or cues, and information about health consequences).

Conclusions

We identified 46 promising BCTs related to medication adherence in type 2 diabetes on which the content of brief messages delivered through mobile devices to improve adherence could be based. By using explicit systematic review methods and linking our findings to a standardized taxonomy of BCTs, we have described a novel approach for the development of digital message content. Future brief message interventions that aim to support medication adherence could incorporate the identified BCTs.

What are the implications for practice that arise from studies of medication taking? A systematic review of qualitative research

Background

Despite several decades of evidence supporting the benefits of taking medications in various diseases and healthcare settings, a significant proportion of prescribed treatments are not taken. This review sought to synthesise qualitative research exploring experiences of medication taking around the world, and to determine whether there were consistent messages arising from these studies.

Methods and findings

5 databases (MEDLINE, PsycINFO, EMBASE, SCOPUS, CINAHL) were systematically searched to identify published research papers using qualitative methodologies, which explored medication-taking experiences in patients, citizens, carers, relatives and clinicians. Data were extracted independently by at least two clinician reviewers. Implications for practice from individual papers were charted and coded using thematic content analysis. These were then cross-tabulated with research paper categories to explore emergent patterns with particular implications for practice. 192 papers from 34 different countries were included in the review. Implications for practice fitted into 11 categories: increase family involvement, increase clinician involvement, promote personalised management, address practical barriers, provide ongoing support, promote self-management, adopt a patient-centred approach, improve patient education, address system barriers, increase access to non-prescribing clinicians and improve clinician training. These implications for practice were generally evenly spread across research paper categories.

Conclusions

Implications for practice from the published qualitative literature exploring medication-taking are notably consistent across research methods, disease categories and geographical settings. More recent clinical trials of interventions to improve adherence have started to draw on these findings by focussing on improving clinical interactions and involving patients in healthcare decisions. Promoting patient education and self-management have been widely advocated, and improvements at a system level have been frequently cited in studies from developing countries and those relating to communicable diseases. Regardless of the setting, clinicians and policymakers around the world can focus efforts to improve medication-taking by considering a number of consistently emerging findings.

Experiences and expectations of patients living with HIV on their engagement with care in Western Kenya

PURPOSE

In resource-limited HIV care settings, effective and innovative interventions that respond to the existing challenges along the HIV care continuum are urgently needed to realize the benefits of antiretroviral therapy (ART). Initiating effective ART adherence dialog in an environment that promotes patient engagement in care is key. It is therefore critical to enhance our understanding about how patients living with HIV in these regions conceptualize and experience patient engagement. This study explores HIV patients' perceptions, experiences and expectations of their engagement in care.

MATERIALS AND METHODS

We sampled 86 patients from three Academic Model for Providing Access to Healthcare (AMPATHplus) sites, one urban and two rural. We conducted 24 in-depth interviews and eight focus group discussions in either Swahili or English. Audio recordings of the interviews were transcribed, and then translated into English. We performed content analysis after thematic coding.

RESULTS

Patients living with HIV in Kenya desire active engagement with care. However, their engagement was inconsistent and varied depending on the provider. Patients had a sense of how provider's interpersonal behaviors influenced their level of engagement. These included various aspects of provider-patient communication and relationship dynamics. Patients also highlighted relational boundaries that influenced the level and kind of information they shared with their providers. Aspects of their psychological, social or economic wellbeing were often viewed as personal and not discussed with their clinicians. Patients identified factors that would promote or impede their engagement with care including those related to patients themselves, providers, and the healthcare system.

CONCLUSION

Patients living with HIV desired more active engagement in their care. In addition, they desired clinicians to engage in more social behaviors to promote patient engagement. To address existing patient engagement barriers, HIV care systems in the region should apply contextualized patient-centered interventions.

Evaluation of the chronic disease management program for appropriateness of medication adherence and persistence in hypertension and type-2 diabetes patients in Korea

The chronic disease management program (CDMP), a multilevel intervention including copayment reduction and physician incentives, was introduced in 2012 in Korea to improve blood pressure and glycemic control by strengthening the function of clinic as primary care institutions in managing hypertension and diabetes. This study, therefore, aimed to evaluate the effect of CDMP on the appropriateness of medication adherence and persistence in hypertension or type-2 diabetes patients.A pre-post retrospective study was conducted using claims cohort data from 2010 to 2013. Hypertension or type-2 diabetes patients were selected as the CDMP group, while dyslipidemia patients were the control group. Study groups were further categorized as clinic shifters or non-shifters on the basis of whether hospital use changed to clinic use during the study period. Pre-post changes in adherence and persistence were assessed. Adherence was measured by medication possession ratio (MPR) and categorized as under (<0.8), appropriate (0.8-1.1), and over-adherence (>1.1). Persistence was measured by 12-month cumulative persistence rate.The pre-post change was significantly improved for appropriate-adherence (hypertension, +6.0%p; diabetes, +6.1%p), 12-month cumulative persistence (hypertension, +6.5%p; diabetes, +10.8%p), and over-adherence (hypertension, -5.3%p; diabetes, -2.8%p) only among the shifters in the CDMP group. Among these, patients visiting the same, single clinic showed a significant increase in appropriate-adherence, whereas those who changed their clinics showed a nonsignificant increase. No significant improvement was verified among the non-shifters in the CDMP group.CDMP improved medication adherence and persistence by significantly increasing appropriate-adherence and 12-month cumulative persistence rate in hypertension and type-2 diabetes patients. Particularly, CDMP significantly improved over-adherence, which was associated with increasing healthcare costs and hospitalization risk.

A Systematic Review of Randomized Controlled Trials of Medication Adherence Interventions in Adult Stroke Survivors

BACKGROUND

Stroke survivors are at an increased risk for recurrent stroke. Despite recommendations to avoid recurrence from the American Heart Association/American Stroke Association, medication adherence (MA) in persons with chronic conditions such as stroke is only 50%.

PURPOSE

The aim of this study was to synthesize randomized controlled trial intervention studies designed to increase MA in adult stroke survivors.

SEARCH METHODS

The Cumulative Index of Nursing and Allied Health Literature, PsycINFO, PubMed, and Excerpta Medica database from January 1, 2009, to December 31, 2015, were searched.

STUDY SELECTION

This study reviewed randomized controlled trials evaluating MA interventions in stroke survivors.

DATA EXTRACTION

Two reviewers independently assessed all full-text articles, and those not meeting the inclusion criteria by both researchers were excluded.

RESULTS

This review included 18 studies involving 10 292 participants. Overall, the strength of the included studies was strong. Statistically significant results were reported in 5 of the 18 (28%) studies. Of these, 3 used cognitive/behavioral interventions to increase MA, whereas 2 studies used an educational-based intervention.

CONCLUSIONS

Despite some isolated success, most MA interventions in stroke survivors do not show statistically significant improvement. Future MA research must address the lack of consistent use of objective measurement tools and focus on the long-term benefits of MA interventions.

Systematic Review of Clinical Practice Guidelines for the Improvement of Medication Adherence

BACKGROUND

Poor adherence to medications is a significant problem that leads to increased morbidity, mortality, and health care costs. Recommended approaches to address medication adherence vary, and existing practice guidelines are unclear.

PURPOSE

This review evaluated clinical practice guidelines designed to help health care providers address patients' medication adherence.

METHOD

Multiple search methods were used to identify national or international guidelines addressing medication adherence. We included guidelines published in English, as well as guidelines with an English-language summary or translation.

RESULTS

We identified 23 guidelines of varying detail and quality. Recommendations were categorized as assessment strategies (n = 20 guidelines); educational strategies (n = 18); behavioral strategies (n = 17); therapeutic relationship, communication, and provider factors (n = 19); and addressing outside influences/co-morbidities (n = 10).

CONCLUSION

Future guidelines should be more clearly guided by research findings and comparative effectiveness methods. When implemented, guidelines will facilitate health care providers and health systems in supporting optimal adherence and improved health outcomes.

Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials

BACKGROUND

Poor adherence to medications is a common problem among heart failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function, and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown.

METHODS AND RESULTS

We conducted a comprehensive search and systematic review of intervention studies testing interventions to improve adherence to HF medications. Mortality and readmission outcome effect sizes (ESs) were calculated from the reported data. ESs were combined using random-effects model meta-analysis methods, because differences in true between-study effects were expected from variation in study populations and interventions. ES differences attributed to study design, sample, and intervention characteristics were assessed using moderator analyses when sufficient data were available. We assessed publication bias using funnel plots. Comprehensive searches yielded 6665 individual citations, which ultimately yielded 57 eligible studies. Overall, medication adherence interventions were found to significantly reduce mortality risk among HF patients (relative risk, 0.89; 95% CI, 0.81, 0.99), and decrease the odds for hospital readmission (odds ratio, 0.79; 95% CI, 0.71, 0.89). Heterogeneity was low. Moderator analyses did not detect differences in ES from common sources of potential study bias.

CONCLUSIONS

Interventions to improve medication adherence among HF patients have significant effects on reducing readmissions and decreasing mortality. Medication adherence should be addressed in regular follow-up visits with HF patients, and interventions to improve adherence should be a key part of HF self-care programs.

Meta-analyses of Theory Use in Medication Adherence Intervention Research

OBJECTIVE

This systematic review applied meta-analytic procedures to integrate primary research that examined theory- or model-linked medication adherence interventions.

METHODS

Extensive literature searching strategies were used to locate trials testing interventions with medication adherence behavior outcomes measured by electronic event monitoring, pharmacy refills, pill counts, and self-reports. Random-effects model analysis was used to calculate standardized mean difference effect sizes for medication adherence outcomes.

RESULTS

Codable data were extracted from 146 comparisons with 19,348 participants. The most common theories and models were social cognitive theory and motivational interviewing. The overall weighted effect size for all interventions comparing treatment and control participants was 0.294. The effect size for interventions based on single-theories was 0.323 and for multiple-theory interventions was 0.214. Effect sizes for individual theories and models ranged from 0.041 to 0.447. The largest effect sizes were for interventions based on the health belief model (0.477) and adult learning theory (0.443). The smallest effect sizes were for interventions based on PRECEDE (0.041) and self-regulation (0.118).

CONCLUSION

These findings suggest that theory- and model-linked interventions have a significant but modest effect on medication adherence outcomes.

Patient-Centered Outcomes of Medication Adherence Interventions: Systematic Review and Meta-Analysis

OBJECTIVE

Using meta-analytic procedures to synthesize changes in patient-centered outcomes after medication adherence interventions.

METHODS

Strategies to locate studies included online searches of 13 databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches of all eligible studies. Search terms included patient compliance, medication adherence, and related terms. Searches were conducted for all studies published since 1960. Eligible published or unpublished primary studies tested medication adherence interventions and reported medication knowledge, quality of life, physical function, and symptom outcomes. Primary study attributes and outcome data were reliably coded. Overall standardized mean differences (SMDs) were analyzed using random-effects models. Dichotomous and continuous moderator analyses and funnel plots were used to explore risks of bias.

RESULTS

Thorough searching located 141 eligible reports. The reports included 176 eligible comparisons between treatment and control subjects across 23,318 subjects. Synthesis across all comparisons yielded statistically significant SMDs for medication knowledge (d = 0.449), quality of life (d = 0.127), physical function (d = 0.142), and symptoms (d = 0.182). The overall SMDs for studies focusing on subsamples of patients with specific illnesses were more modest but also statistically significant. Of specific symptoms analyzed (depression, anxiety, pain, energy/vitality, cardiovascular, and respiratory), only anxiety failed to show a significant improvement after medication adherence interventions. Most SMDs were significantly heterogeneous, and risk of bias analyses suggested links between study quality and SMDs.

CONCLUSIONS

Modest but significant improvements in patient-centered outcomes were observed after medication adherence interventions.

Improving medication adherence among kidney transplant recipients: Findings from other industries, patient engagement, and behavioral economics-A scoping review

The immune system is a powerful barrier to successful organ transplantation, but one that has been routinely thwarted through modern pharmacotherapeutics. Despite the benefits of immunosuppressive therapy, medication non-adherence leads to an increased risk of graft rejection, higher hospital utilization and costs, and poor outcomes. We conduct a scoping review following Arksey and O'Malley's five-stage framework methodology to identify established or novel interventions that could be applied to kidney transplant recipients to improve medication adherence. As the desired outcome is a behavior (taking a pill), we assess three areas: behavioral-focused interventions in other industries, patient engagement theories, and behavioral economic principles. Search strategies included mining business, social sciences, and medical literature with additional guidance from six consultative interviews. Our review suggests that no intervention stands out as superior or likely to be more effective than any other intervention; yet promising strategies and interventions were identified across all three areas examined. Based on our findings, we believe there are five strategies that transplant centers and other organizations can implement to improve medication adherence: (1) Build a foundation of trust; (2) Employ multiple interventions; (3) Stratify the population; (4) Develop collaborative partnerships; and (5) Embed medication adherence into the organization's culture. The effectiveness of these interventions will need to be investigated further, but we believe they are a step in the right direction for organizations to consider in their efforts to improve medication adherence.

Peers as Facilitators of Medication Adherence Interventions: A Review

BACKGROUND

Difficulty taking essential medications as prescribed is a prevalent problem among people living with chronic diseases. Numerous interventions to enhance medication adherence have been developed; the majority facilitated by health care professionals.

OBJECTIVE

This review examined medication adherence interventions delivered by peers (ie, lay individuals living with the same chronic disease) and reports what is known about the impact of peer-facilitated interventions.

DATA SOURCES

PubMed, CINAHL, Google Scholar, Google, and PsychInfo, and ancestry searches.

STUDY SELECTION

Solely peers delivered the intervention and follow-up occurred for at least 24 weeks postintervention. Electronic databases were searched from their start date to December 31, 2014.

RESULTS

Eleven studies were located that reported 10 different interventions focused on 6 chronic disease conditions. Most interventions were delivered in clinical settings and grounded in a theoretical framework. Formats were evenly split between individual and group level, with one intervention using both. Length of training for the interventionists and the number of intervention sessions that subjects received varied across studies.

LIMITATIONS

Self-report was frequently used as a measure of adherence. Biomarkers were sometimes used to assess medication adherence; however, lifestyle modification may have also affected biomarker levels.

CONCLUSIONS

Overall, the interventions had positive effects and attrition was quite low. Peer-facilitated interventions appear to enhance medication adherence as well as other healthful behaviors, such as exercise.

Managing physician lipid management: a population wide, risk-based decision support approach

Successful implementation of clinical guidelines for preventing complications of dyslipidemias has been an ongoing challenge. The article by Vinker and colleagues in this journal investigates the results of implementing risk-based guidelines for LDL (Low Density Lipoprotein) management in comparison to the prior approach of using the same LDL cutoff for patients at all levels of risk. Results show LDL levels dropped across the primary care population using the new risk-based approach, suggesting that clinical decision aids that link to individual patient characteristics, rather than promoting a universal target for all, may provide a particularly strong stimulus for changing provider and patient behavior. Results also challenge healthcare organizations, providers and patients to learn more about the pathway from guidelines to clinical reminders and from reminders to lower LDL levels and better population health.