Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists

Clinical pharmacist role in improving the knowledge and outcomes in patients using isotretinoin: A randomized, controlled study

Objective

To evaluate the role of a clinical pharmacist in improving knowledge and outcomes among isotretinoin users.

Methods

Patients were randomly assigned to an intervention group (received education about isotretinoin by a clinical pharmacist in addition to the physician) and a control group (received routine education by the physician), then followed for three months. Patients' knowledge about isotretinoin optimal use, and side effects and their management and other outcomes were measured in both groups at baseline and at follow up after three months using a validated questionnaire.

Results

Two-hundred and three patients completed the study; 103 were in the intervention group and 100 in the control group. The knowledge improvement between baseline score and follow-up score was greater in the intervention group (mean = 2.835 ± 1.329) compared to the control group (mean = 0.530 ± 0.784) with mean differences = -2.30495, P < 0.001.

Conclusion

Implementing clinical pharmacy services in dermatology clinics can positively increase patients' level of knowledge about isotretinoin, which could reduce the severity of its side effects. Therefore, improving patients' quality of life, and improvement in acne.

Practice implications

Implementing clinical pharmacist services to patients using isotretinoin is feasible in an outpatient setting. Clinical pharmacist counseling and education improve the medication knowledge among patients who use isotretinoin.

Impact of Pharmacist-Led Interventions to Improve Clinical Outcomes for Adults With Type 2 Diabetes at Risk of Developing Cardiovascular Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis of randomised controlled trials is to evaluate the impact of pharmacist-led interventions on cardiovascular disease (CVD) risk factors among patients with type 2 diabetes.

METHOD

A literature review was conducted according to PRISMA guidelines using 4 electronic databases: Embase, MEDLINE, CINHAL and the Cochrane Central Register of Controlled Trials. We searched for pharmacist interventions among adults with type 2 diabetes and cardiovascular disease in randomised controlled trials from inception to May 2021 in primary care, diabetes clinics and hospitals. The clinical outcomes measured glycosylated haemoglobin (HbA1c), blood pressure (BP) and lipid profile. The non-clinical outcomes included medication adherence, smoking, health-related quality of life and the cost of the intervention. For the meta-analysis, clinical outcomes were pooled with the random effect model in RevMan 5.3. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We retrieved 223 studies,141 of which were included in the review. Ten published articles met the inclusion criteria and were included in the meta-analysis. The pharmacists delivered the interventions alone or collaboratively with other healthcare professionals in hospitals or similar settings. The overall result showed a significant reduction in HbA1c (n = 10; standard deviation in mean value [SDM]: -.53%, 95% CI: -.84, -.23) and systolic BP (n = 10; [SDM]: -.35 mmHg, 95% CI: -.51, -.20) in pharmacist intervention groups. For the non-clinical outcomes, the review revealed variable results from pharmacist intervention compared with those standard care.

CONCLUSION

Pharmacy interventions provide evidence for pharmacists' decisive role in diabetes care management and reducing cardiovascular risk factors among adults with type 2 diabetes.

Impact of a Clinical Pharmacist Intervention Program on the Follow-up of Type-2 Diabetic Patients

Aims

The primary aim of this current study was to investigate the impact of the clinical pharmacist interventions on glycemic control and other health-related clinical outcomes in patients with type 2 diabetes in Egypt.

Methods

A prospective trial was conducted on 100 patients with uncontrolled type 2 diabetes admitted in the diabetes outpatient's clinics. Patients were randomly allocated into the clinical pharmacist intervention group and usual care group. In the intervention group, the clinical pharmacist, in collaboration with the physician had their patients receive pharmaceutical care interventions. In contrast, the usual care group patients received routine care without clinical pharmacist's interference.

Results

After 6-month of follow-up, of the average HbA1c and FBG values of the patients in the clinical pharmacist intervention group (HbA1c % from 8.6 to 7.0; FBG (mg/dL) from 167.5 to 121.5) decreased significantly compared to the usual care group patients (HbA1c % from 8.1 to 7.8; FBG (mg/dL) from 157.3 to 155.9) (P < .05). Additionally, the results indicated that mean scores of patients 'diabetes knowledge, medication adherence, and diabetes self-care activities of the patients in the clinical pharmacist group increased significantly compared to the control group (P < .05).

Conclusions

The study demonstrated an improvement in HbA1c, FBG, and lipid profile, in addition to self-reported medication adherence, diabetes knowledge, and diabetes self-care activities in patients with type 2 diabetes who received pharmaceutical care interventions. The study outcomes support the benefits and the need to integrate clinical pharmacist interventions in the multidisciplinary healthcare team in Egypt.

Anti-Hyperglycemic Medication Adherence and Health Services Utilization in People with Diabetes: A Longitudinal Study of Alberta's Tomorrow Project

BACKGROUND

Little is known about the long-term (>2 years) relationship between the time-varying drug adherence and healthcare utilization for patients with diabetes.

OBJECTIVE

To characterize the relationship between time-varying anti-hyperglycemic medication adherence and healthcare utilization in patients with diabetes, using data from Alberta's Tomorrow Project, a population-based cohort study in Alberta, Canada.

METHODS

Incident cases of diabetes with at least 24 months of follow-up were included in the study. Anti-hyperglycemic drug adherence was measured by proportion of days covered (PDC) in the past 12 months for each year after diagnosis. The rate of healthcare utilization was assessed for the subsequent 12 months, 36 months and 60 months. A time-varying, negative binomial generalized estimating equation model was used to examine the association between medication adherence and healthcare utilization.

RESULTS

Among 2155 incident cases of diabetes, average age at diagnosis was 59.6±9.3, 51.0% were female and average duration of follow-up was 7.3±3.7 (range, 2.0-16.2) years. The proportion of patients taking anti-hyperglycemic medications was 47.6% during the first year of diagnosis, which increased to 77.3% by the end of follow-up. Compared to adherent patients (PDC≥0.8), non-adherent patients (PDC<0.8) had substantially higher rate of all-cause hospitalization [incident rate ratio, IRR=1.48 (1.22-1.79), ED visits [1.30 (1.15-1.47)] and GP visits [1.17 (1.08-1.27)] in the subsequent 12 months. However, these associations became weaker with longer follow-up [eg, IRR=1.18 (0.98-1.39) and 1.05 (0.94-1.18) for all-cause hospitalization in the subsequent 36 and 60 months, respectively].

CONCLUSION

Poor adherence among diabetic patients was associated with substantially higher rate of healthcare utilization in the short term (eg, 12 months); however, this association weakened over a longer period (eg, 36-60 months).

Public health interventions on prescription redemptions and secondary medication adherence among type 2 diabetes patients: systematic review and meta-analysis of randomized controlled trials

Background

Despite the inadequate filling of prescriptions among chronic care patients has been a problem, little is known about the intervention effect on it.

Objective

The aim of this systematic review and meta-analysis (SRMA) was to investigate the effectiveness of various public health interventions on primary and secondary medication adherence among T2DM patients.

Methods

Searching was done from the major databases; Cochrane Library, Medline/PubMed, EBSCOhost, and SCOPUS. A hand search was made to find grey works of literature. Articles focused on interventions to enhance primary and secondary medication among type 2 diabetes mellitus patients were included. After screening and checking eligibility, the methodological quality was assessed. Secondary medication adherence was synthesized descriptively due to measurement and definition variations across studies. Finally, a meta-analysis was made using the fixed effects model for primary medication adherence.

Results

3992 studies were screened for both primary and secondary medication adherences. Among these, 24 studies were included in the analysis for primary (5) and secondary (19) medication adherence. Pooled relative medication redemption difference was RD = 8% (95% CI: 6-11%) among the intervention groups. Age, intervention, provider setting, and IDF region were determinant factors of primary medication adherence. About two-thirds of the studies revealed that interventions were effective in improving secondary medication adherence.

Conclusion

Both primary and secondary medications were enhanced by a variety of public health interventions for patients worldwide. However, there is a scarcity of studies on primary medication adherence globally, and in resource-limited settings for the type of adherences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-021-00878-0.

Adherence to antidiabetic treatment and impaired hypoglycemia awareness in type 2 diabetes mellitus assessed in Spanish community pharmacies: the ADHIFAC study

INTRODUCTION

Adherence to treatment and hypoglycemia awareness are strongly linked to glycemic control and hypoglycemia risk in people with type 2 diabetes mellitus (T2DM). Community pharmacies are suitable facilities to detect these conditions, and should be involved in the strategies to minimize the associated risks and burden.

RESEARCH DESIGN AND METHODS

This cross-sectional study conducted at community pharmacies across Spain assessed the prevalence of low adherence to antidiabetic treatments, the frequency of impaired hypoglycemia awareness, and their predictive factors. Adherence was measured with the 8-item Morisky Medication Adherence Scale (MMAS-8) and electronic records of dispensed treatments. The Clarke questionnaire was used to assess impaired hypoglycemia awareness. Healthcare counseling provided in the pharmacy was collected.

RESULTS

Seventy-nine pharmacists and 618 subjects with T2DM participated in the study. Mean age in the overall T2DM population was 67 years, being the majority (69%) pensioners. Adherence was high in 41% of participants, medium in 35%, and low in 24% according to the MMAS-8. Impaired hypoglycemia awareness was observed in 25% of participants. Main determinants of low adherence were the level of education, the number of treatments per patient, hypoglycemia awareness, and the type of pharmacy. Predictive factors of impaired hypoglycemia awareness were the level of education, information on diabetes-related complications, adherence levels, and the type of pharmacy. The proportion of participants who had healthcare counseling was 71% in the overall population and 100% in subjects with impaired hypoglycemia awareness and low adherence. Healthcare counseling comprised diabetes education (69%), pharmacotherapeutic assessment (20%), and physician referrals (11%).

CONCLUSION

Lack of adherence to antidiabetic treatments and impaired hypoglycemia awareness are frequent and correlate in T2DM. Community pharmacies can detect these conditions and should have an active role in the design of strategies to minimize them.

Impact of pharmacist insulin injection re-education on glycemic control among type II diabetic patients in primary health clinics

Background

Insulin injection technique re-education and diabetes knowledge empowerment has led to improved glycemic control.

Objectives

To evaluate the impact of pharmacist's monthly re-education on insulin injection technique (IT), lipohypertrophy, patients' perception on insulin therapy and its effect on glycaemic control.

Methods

This randomized controlled, multi-centered study was conducted among type 2 diabetics from 15 government health clinics. 160 diabetics with baseline HbA1_C ≥ 8% and unsatisfactory IT technique were randomized into control or intervention group. Control group received standard pharmacist counselling during initiation and at 4th month. Intervention group received monthly counselling and IT re-education for 4 months. Assessment of diabetes, IT knowledge, adherence and perception towards diabetes were conducted using validated study tools Insulin Treatment Appraisal Scale (ITAS) and Medication Compliance Questionnaire (MCQ)).

Results

139 patients completed the study; control group (69), intervention group (70). In control group, all outcomes shown improvement except for patient's perception. Mean HbA1_C decreased 0.79% ± 0.24 (p = 0.001). In intervention group, all outcomes improved significantly. HbA1c reduces significantly by 1.19% ± 0.10 (p < 0.001). Monthly re-education improved patient's perception towards insulin therapy (ITAS score reduced 1.44 ± 2.36; p = 0.021). Between groups, interventional arm shown significantly better improvement in all outcomes. Improvement was shown in IT technique (+2.02 score; p < 0.001), medication adherence (+1.48 score; p < 0.001) and ITAS (-1.99 score; p = 0.037). Mean HbA1_C reduced an additional of 0.63% (p = 0.008) compared to control arm.

Conclusion

Re-education is more effective in increasing adherence, reducing lipohypertrophy, improving injection technique and patient's perception on insulin therapy, thereby providing better glycaemic control.

Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic

INTRODUCTION

The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy specialists (CPS) in patient-aligned care teams (PACT) to improve patient care outcomes and create access for veterans. With the unfortunate arrival of Coronavirus disease 2019 (COVID19), PACT CPS were duty-bound to expand telehealth services at an accelerated rate. The purpose of this quality improvement analysis is to compare CPS efficiency as well as some objective patient metrics to assess for a change in the quality of care. This is the first study to compare the efficiency and quality of care by CPS in the VA pre-COVID19 and during the COVID19 pandemic.

METHODS

This is a retrospective review of PACT CPS comprehensive medication management from 3/10/19 to 11/30/19 and 3/10/20 to 11/30/20. Data points focused on clinic encounters, patient accountability to appointments, disease state expansion, and markers of disease-state management. Given diabetes and hypertension are the main disease states managed by most PACT CPS', the study evaluated changes in hemoglobin A1c (HbA1c) and blood pressure (BP) between the two cohorts as well. Data were analyzed using GraphPad Software or Microsoft Excel. A student T-test was used for continuous data and Chi-squared or Fishers Exact for nominal data.

RESULTS

The total number of PACT CPS encounters increased 32% in 2020, and the number of unique patients increased by 12%. There were a statistically significant increase in telephone and direct-to-consumer (DCT) video visits. The rates of no shows and cancellations significantly decreased between 2019 and 2020. There was no difference in the average change in HbA1c or average blood pressure between the two study groups.

CONCLUSIONS

When PACT CPS services transitioned from primarily face-to-face visits to all virtual care, the consistency of care improved, and the quality of care was not compromised.

Determinants of Satisfaction with Services, and Trust in the Information Received in Community Pharmacies: A Comparative Analysis to Foster Pharmaceutical Care Adoption

Patient’s satisfaction with community pharmacy services, and patients’ trust in the information received in community pharmacies are important drivers of pharmaceutical care adoption. An online questionnaire assessing patient satisfaction with the services received in pharmacies and trust in the pharmacist’s advice, along with their determinants, was administered to 343 Romanian chronic and non-chronic patients. Using various statistical tests, exploratory factor analysis, and robust regression we explored determinants of satisfaction and trust. We found that satisfaction with services is predicted by pharmacists’ attitude (β = 631, p < 0.001), low waiting time (β = 0.180, p < 0.001), affordable cost of the drugs (β = 0.09, p = 0.009), and drug availability (β = 0.157, p < 0.001). At the same time, trust in the information received is driven by pharmacists’ attention (β = 0.610, p < 0.001), whether the patient received precautionary information (β = 0.425, p < 0.001), low waiting time (β = 0.287, p < 0.001), and whether the respondent is a chronic patient or not (non-chronic patients express more trust, β = 0.328, p = 0.04). Our study expands the existing paradigm that sees trust as a simple predictor of satisfaction by showing that trust and satisfaction are predicted by different variables, and thus they should be addressed using different strategies. In fact, we found that they share only one predictor—waiting time, highly significant in both cases. Our findings show that, without prioritizing trust in the information received in community pharmacies to reduce information asymmetry between patient and pharmacist, the focus only on patient satisfaction may lead to a scenario in which community pharmacies will end up to be better integrated in the business sector and not in the public health system.

Poor adherence and persistence to sodium glucose co-transporter 2 inhibitors in real-world settings: Evidence from a systematic review and meta-analysis

AIMS

Despite increasing prescription of sodium glucose co-transporter 2 (SGLT2) inhibitors, there is limited insight of the patterns of use among patients with diabetes prescribed these drugs. This study aimed to summarize available real-world data on the adherence and persistence to SGLT2 inhibitors.

MATERIALS AND METHODS

A systematic review for observational studies reporting the adherence and persistence to SGLT2 inhibitors was performed in Medline, Embase, and Web of Science from their inception to October 2019. Data were analysed via random-effects meta-analysis.

RESULTS

A total of 22 studies (31 cohorts) comprising 123 854 individuals prescribed SGLT2 inhibitors from eight countries were included. The pooled mean proportions of days covered [PDC] at six months and one year were 0.77 (95% confidence interval [CI] 0.72-0.82) and 0.72 (95% CI 0.66-0.77), respectively. The pooled proportions adherent (PDC ≥0.80) at six months and one year were 59.5% (95% CI 52.9-65.9) and 49.0% (95% CI 42.3-55.8), respectively. The pooled proportions of people persistent at six months, one year, and two years were 80.1% (95% CI 75.8-84.0), 61.8% (95% CI 57.8-65.7), and 45.9% (95% CI 35.5-56.5), respectively. When persistence was defined as the absence of ≥90-days gap, the equivalent pooled proportions persistent were 81.5% (95% CI 73.1-88.6), 58.9% (95% CI 53.1-64.6), and 34.7% (95% CI 33.6-35.8). Adherence and persistence appeared to vary across different SGLT2 inhibitors.

CONCLUSIONS

Real-world adherence and persistence to SGLT2 inhibitors is poor. Hence, targets for improving treatment adherence and persistence need to be identified and appropriate interventions implemented.

Real-world adherence, persistence, and in-class switching during use of dipeptidyl peptidase-4 inhibitors: a systematic review and meta-analysis involving 594,138 patients with type 2 diabetes

AIMS

Medication adherence and persistence are important determinants of treatment success in type 2 diabetes mellitus (T2DM). This systematic review and meta-analysis evaluated the real-world adherence, persistence, and in-class switching among patients with T2DM prescribed dipeptidyl peptidase-4 (DPP4) inhibitors.

METHODS

MEDLINE, EMBASE, Cochrane Library, PsychINFO, and CINAHL were searched for relevant observational studies published in the English language up to 20 December 2019. This was supplemented by manual screening of the references of included papers. Random-effects meta-analysis was performed.

RESULTS

Thirty-four cohort studies involving 594,138 patients with T2DM prescribed DPP4 inhibitors from ten countries were included. The pooled proportion adherent (proportion of days covered (PDC) or medication possession ratio (MPR) ≥ 0.80) was 56.9% (95% confidence interval [CI] 49.3-64.4) at one year and 44.2% (95% CI 36.4-52.1) at two years. The proportion persistent with treatment decreased from 75.6% (95% CI 71.5-79.5) at six months to 52.8% (95% CI 51.6-59.8) at two years. No significant differences in adherence and persistence were observed between individual DPP4 inhibitors. At one year, just 3.2% (95% CI 3.1-3.3) of patients switched from one DPP4 inhibitor to another. Switching from saxagliptin and alogliptin to others was commonest.

CONCLUSIONS

Adherence to and persistence with DPP4 inhibitors is suboptimal but similar across all medications within the class. While in-class switching is uncommon, saxagliptin and alogliptin are the DPP4 inhibitors most commonly switched. Interventions to improve treatment adherence and persistence among patients with T2DM prescribed DPP4 inhibitors may be warranted.

Pharmacists' roles in supporting people living with severe and persistent mental illness: a systematic review protocol

INTRODUCTION

Severe and persistent mental illness (SPMI) can significantly impact a person's social, personal and professional life. Previous studies have demonstrated pharmacists' roles in mental healthcare; however, limited studies to date have focused on pharmacists' roles in providing healthcare services, specifically, to people living with SPMI. The aim of this systematic review is to explore the pharmacists' roles in providing support to people living with SPMI.

METHODS AND ANALYSIS

A systematic search will be conducted in Medline, Embase (Ovid), PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses to identify potentially relevant primary research for inclusion. This will be guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist for systematic reviews. All primary research publications regardless of study design exploring or reporting on pharmacists' involvement in supporting people living with SPMI will be considered for inclusion. A tabular summary will be completed using data extracted from each included publication. Data synthesis and quality assessment methods will be chosen based on included study designs.

ETHICS AND DISSEMINATION

The results will be published in a peer-reviewed journal and used to inform the development of a pharmacist-specific training package to support people living with SPMI.

PROSPERO REGISTRATION NUMBER

CRD42020170711.

How does the general public balance convenience and cognitive pharmaceutical services in community pharmacy practice

BACKGROUND

Community pharmacy is shifting its focus from traditional, product-focused roles to the provision of cognitive pharmaceutical services (CPS). Previous research has indicated that community pharmacists predominantly want to devote their capacity to CPS. Ideally, services provided also address users' needs. The general public's preferences regarding the services provided by community pharmacists are currently less understood.

AIM

This study investigates the general public's preferences and perceived importance of CPS versus convenience in community pharmacy practice.

METHOD

An online survey of 1.500 members of the Dutch Health Care Consumer Panel containing questions regarding preferences for CPS and convenience was distributed. Descriptive statistics and linear regression analysis were performed to investigate the relationship between preferences and participant characteristics.

RESULTS

516 panel members completed all questions regarding preferences and importance of the availability of services. The majority preferred convenience (68.2%) and a smaller proportion preferred CPS (27.7%). However, participants considered it important from a societal viewpoint that CPS is provided (45.0%). Participants who preferred CPS over convenience were generally older (p < 0.001) and used more medicines (p < 0.001).

CONCLUSION

Convenience of community pharmacy services is most preferred by the general public. However, CPS is perceived as important, especially for elderly who use more medicines. Elderly patients who use more medicines more often rate CPS as more important than convenience. These findings suggest that community pharmacists should ensure that pharmacy logistics are organized efficiently before focusing on the provision of CPS.

Mobile Phone Text Messages and Effect on Treatment Adherence in Patients Taking Methotrexate for Rheumatoid Arthritis: A Randomized Pilot Study

OBJECTIVE

To assess the impact of weekly text messages on adherence in patients taking methotrexate (MTX) for rheumatoid arthritis (RA).

METHODS

This prospective, randomized pilot, single-site study included patients with RA stabilized using MTX alone or combined with biologics. Participants were randomized to 3 interventions: a standard consultation (controls), a 15-minute pharmacist-led counseling session, or the receipt of text message reminders. The change over time in the Compliance Questionnaire Rheumatology (CQR-19) score between baseline and 6 months was defined as the primary outcome for adherence. Multivariable analyses and final adherence (as a composite outcome of the CQR-19 score, the Girerd score, and the medication possession ratio) were probed in sensitivity tests. Rheumatologic scales, inflammation, and patient satisfaction were also analyzed.

RESULTS

A total of 96 patients (mean ± SD Disease Activity Score in 28 joints 2.42 ± 1.03) were monitored. The change over time in the CQR-19 score was significantly higher in the text message group (mean ± SD 3.32 ± 5.66; P = 0.02) than in the control group (mean ± SD 0.22 ± 6.56) and the pharmacist-led counseling group (mean ± SD -0.14 ± 7.56). Multivariable logistic regression showed that text messages remained associated with an increase in the CQR-19 score, independently of the baseline CQR-19 score (odds ratio 3.63 [95% confidence interval 1.26-10.49]; P = 0.017). In the text message group, the increase in the CQR-19 score was correlated with the Health Assessment Questionnaire score (r = -0.405, P = 0.021), and patient satisfaction was significantly higher (P < 0.01) than in the control group.

CONCLUSION

Our results showed evidence of a positive impact of text messages on adherence to MTX treatment for RA. The clinical benefit and the ideal target patient remain to be determined.

Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say?

OBJECTIVE

Clinical pharmacist support for patients with type 2 diabetes mellitus (T2DM) can optimize patient outcomes and medication adherence. However, there is limited understanding of what pharmacist roles patients perceive as most helpful in T2DM management interventions. This study describes experiences of minority patients with uncontrolled T2DM in terms of perceived pharmacist helpfulness and specific roles found to be most helpful within diabetes management.

DESIGN

A secondary analysis of a 2-year randomized, crossover trial was conducted.

SETTING AND PARTICIPANTS

This study included 244 African American and Hispanic adults with uncontrolled T2DM who received clinical pharmacist support within a team-based model.

OUTCOME MEASURES

The patients completed a mixed-methods survey regarding their experience with the intervention that included a general helpfulness rating on a 10-point unipolar Likert scale and described the support qualitatively, including their perception of the pharmacist roles. Thematic analysis guided coding of the responses.

RESULTS

One hundred forty-seven (60%) patients completed the survey and had at least 1 encounter with a clinical pharmacist. Of these, 108 (74%) were African American, 39 (27%) were Hispanic, and 101 (69%) were women. The median rating of clinical pharmacist helpfulness was 10 (very helpful). Only 10 (7%) participants rated pharmacist helpfulness as 1 (not at all helpful). "Medication education and management" was the most frequently perceived supportive role of the clinical pharmacists, followed by "non-medication-related patient education," "social support," and "care coordination." Miscommunication related to scheduling was the most common reason cited for not meeting with the clinical pharmacist.

CONCLUSION

This sample of minority patients with uncontrolled T2DM recognized many roles outlined within the American Pharmacists Association Medication Therapy Management framework. Patient experiences with clinical pharmacist T2DM support are crucial for developing effective programs, maximizing patient engagement, satisfying patient needs, and ensuring that a program's intended purpose aligns with the patient perspective.

Innovations in Providing Diabetes Care for Individuals Experiencing Homelessness: An Environmental Scan

OBJECTIVES

For a variety of reasons, homelessness creates major challenges for the management of diabetes, resulting in excess morbidity and mortality in this population. The objective of this study was to document innovations in providing diabetes care for individuals experiencing homelessness.

METHODS

Using directed snowball sampling, we recruited a sample of service providers (family physicians, nurses, social workers, endocrinologists, diabetes educators, shelter workers) in 5 Canadian cities (Vancouver, Calgary, Edmonton, Toronto, Ottawa). Data were collected using detailed, open-ended interviews. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

We interviewed 96 program managers and providers representing 38 organizations. Although many of the same challenges were faced by care providers in different jurisdictions, there was little communication or sharing of experiences across providers and organizations. However, we identified 5 unique and innovative approaches to providing diabetes care to individuals experiencing homelessness. These include: 1) provision of in-shelter care, 2) peer outreach/support workers, 3) diabetes specialty outreach clinics, 4) diabetes group care specific for this population and 5) community-based pharmacy interventions.

CONCLUSIONS

Providers and organizations in different cities face similar challenges in providing diabetes care to individuals who are experiencing homelessness, yet they tend to address these difficulties in isolation. Despite this, numerous organizations have created innovative solutions to improve diabetes care. Sharing experiences across organizations and jurisdictions can facilitate development and implementation of successful program models.

Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians

OBJECTIVE

To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures.

DATA SOURCES AND STUDY SETTING

The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness.

STUDY DESIGN

In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist.

DATA COLLECTION

Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims.

PRINCIPAL FINDINGS

We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default.

CONCLUSIONS

Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia's flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants' backgrounds, and contextual factors, estimated the intervention's effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics -the appointment card and counseling job aid-effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Adherence, Persistence, and Switching Among People Prescribed Sodium Glucose Co-transporter 2 Inhibitors: A Nationwide Retrospective Cohort Study

INTRODUCTION

Non-adherence and non-persistence to diabetes medications are associated with worse clinical outcomes. In this study, we aimed to characterise the 1-year switching, adherence, and persistence patterns among people with diabetes aged 18 years and older prescribed sodium-glucose co-transporter 2 inhibitors (SGLT2is) in Australia.

METHODS

Using data from Australia's national Pharmaceutical Benefits Scheme (PBS), we identified 11,981 adults (mean age 60.9 years; 40.5% female) newly initiated on SGLT2is (5993 dapagliflozin; 5988 empagliflozin) from September 2015 to August 2017. Adherence was assessed via the proportion of days covered (PDC), persistence was defined as the continuous use of SGLT2i without a gap of ≥ 90 days, and switching was defined as the first change from dapagliflozin to empagliflozin or vice versa. Generalised linear models (GLMs) were used to compare the adherence (PDC = continuous), logistic regression models were used to compare the likelihoods of being adherent (PDC ≥ 0.80), and Cox proportional hazard models were used to compare the likelihoods of persistence and switching between people prescribed empagliflozin and dapagliflozin.

RESULTS

Overall, 65.8% (7879/11,981) of people dispensed SGLT2is were adherent (PDC ≥ 0.80) and 72.1% (8644/11,981) were persistent at 12 months. The mean PDC was 0.79 ± 0.27. The use of empagliflozin was associated with higher adherence (PDC = continuous) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.03-1.05], being adherent (OR 1.39, 95% CI 1.29-1.51), and persisting for 12 months [hazard ratio (HR) 1.14, 95% CI 1.06-1.22] compared with dapagliflozin. Only 4.3% (509/11,981) of people switched between the SGLT2i. Compared with dapagliflozin, people initiated on empagliflozin were less likely to switch [HR 0.46, 95% CI 0.38-0.55].

CONCLUSIONS

A considerable proportion of Australians prescribed SGLT2is were non-adherent or non-persistent. However, empagliflozin was associated with better adherence and persistence rates and a lower likelihood of switching compared with dapagliflozin.

Effect of dose administration aids on adherence to self-administered medications: a systematic review protocol

INTRODUCTION

Forgetting to take a medication is the most common reason for non-adherence to self-administered medication. Dose administration aids (DAAs) are a simple and common solution to improve unintentional non-adherence for oral tablets. DAAs can be in the form of compartmentalised pill boxes, automated medication dispensing devices, blister packs and sachets packets. This protocol aims to outline the methods that will be used in a systematic review of the current literature to assess the impact of DAAs on adherence to medications and health outcomes.

METHODS AND ANALYSIS

Randomised controlled trials will be identified through electronic searches in databases including EMBASE, MEDLINE, CINAHL and the Cochrane Library, from the beginning of each database until January 2020. Two reviewers will independently screen studies and extract data using the standardised forms. Data extracted will include general study information, characteristics of the study, participant characteristics, intervention characteristics and outcomes. Primary outcome is to assess the effects of DAAs on medication adherence. Secondary outcome is to evaluate the changes in health outcomes. The risk of bias will be ascertained by two reviewers in parallel using The Cochrane Risk of Bias Tool. A meta-analysis will be performed if data are homogenous.

ETHICS AND DISSEMINATION

Ethics approval will not be required for this study. The results of the review described within this protocol will be disseminated through publication in a peer-reviewed journal and relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018096087.

Perceptions of Integration of the Clinical Pharmacist into the Patient Care Medical Home Model

INTRODUCTION

The patient-centered medical home (PCMH) model is a multidisciplinary, team-based approach to healthcare that focuses on actively involving the patient in clinical decision making. The Veterans Health Administration (VA), while desiring to be a national leader in the delivery of primary care services, used the principles of the PCMH model to design the patient-aligned care team (PACT). The purpose of this study, was to explore the perception of the PACT members after integration of a clinical pharmacist to the PACT.

METHODS

This was a single-center cross-sectional study conducted at an integrated Veterans Health Administration system. We electronically surveyed PACT staff practicing within VA-Tennessee Valley Health Care System as of October 1, 2016 using a modified version of the Medicine Medication Use Processes Matrix (MUPM) containing 19 items on five theoretical grouping of processes (evaluation and management, monitoring, medication review, documentation, and education) and two groupings(clinician satisfaction and access).

RESULTS

Ninety-one complete responses were received. Perceptions were positive, with 79% rated as either 4 ("moderate contribution") or 5 ("major contribution"). Individual responses based on discipline, with the exception of the medical support assistant were rated positive, specifically job satisfaction.

CONCLUSIONS

This study evaluated the perceptions of clinical pharmacist integration into the PACT model. Respondents perceived clinical pharmacist beneficial.

Evaluation of the clinical pharmacist role in improving clinical outcomes in patients with lower urinary tract symptoms due to benign prostatic hyperplasia

Background Lower urinary tract symptoms due to benign prostatic hyperplasia set restriction to patients' daily life activities and decrease their quality of life. Adherence to medications is considered a core element to improve patients' clinical outcomes. Objective To evaluate the role of clinical pharmacist in improving adherence to medication, reducing severity of symptoms, and improving quality of life in this group of patients. Setting The study was conducted in urology outpatients' clinics in Amman, Jordan. Methods This was a prospective randomized controlled trial, patients were randomly allocated into intervention group or control group. Patients in the intervention group were offered a pharmaceutical care service and patients in the control group received regular healthcare provided by urologist and then followed for 1 month. Main outcome measures Morisky Medication Adherence Score and International Prostate Symptom Score. Results Among 209 patients completed the study, 105 were in the intervention group and 104 in the control group. By the end of the study, 91.4% of the intervention group patients became adherent to their medication compared to 72.1% in the control group (p < 0.0001). At follow up, the severity of the symptoms to calculated score was lower in the intervention group (mean 15.6 ± 5.69) compared to control group (mean 13.9 ± 5.43) (p < 0.0001). The quality of life score were better in the intervention group compared to the control group at follow-up (p < 0.0001). Conclusion The current findings indicate that implementing clinical pharmacy services can positively increase the level of adherence to medications. This was accompanied by modest improvement in the severity of urinary symptoms in benign prostatic hyperplasia and in quality of life for patients. Hence, clinical pharmacy services could provide beneficence in outpatient setting.

Evaluation of the clinical pharmacist role in improving clinical outcomes in patients with lower urinary tract symptoms due to benign prostatic hyperplasia

Background Lower urinary tract symptoms due to benign prostatic hyperplasia set restriction to patients' daily life activities and decrease their quality of life. Adherence to medications is considered a core element to improve patients' clinical outcomes. Objective To evaluate the role of clinical pharmacist in improving adherence to medication, reducing severity of symptoms, and improving quality of life in this group of patients. Setting The study was conducted in urology outpatients' clinics in Amman, Jordan. Methods This was a prospective randomized controlled trial, patients were randomly allocated into intervention group or control group. Patients in the intervention group were offered a pharmaceutical care service and patients in the control group received regular healthcare provided by urologist and then followed for 1 month. Main outcome measures Morisky Medication Adherence Score and International Prostate Symptom Score. Results Among 209 patients completed the study, 105 were in the intervention group and 104 in the control group. By the end of the study, 91.4% of the intervention group patients became adherent to their medication compared to 72.1% in the control group (p < 0.0001). At follow up, the severity of the symptoms to calculated score was lower in the intervention group (mean 15.6 ± 5.69) compared to control group (mean 13.9 ± 5.43) (p < 0.0001). The quality of life score were better in the intervention group compared to the control group at follow-up (p < 0.0001). Conclusion The current findings indicate that implementing clinical pharmacy services can positively increase the level of adherence to medications. This was accompanied by modest improvement in the severity of urinary symptoms in benign prostatic hyperplasia and in quality of life for patients. Hence, clinical pharmacy services could provide beneficence in outpatient setting.

Evaluation of pharmacy-based telephone interventions on medication pick-up rates: a retrospective, quality improvement study at charity outpatient clinics

OBJECTIVES

To evaluate a live telephonic outreach intervention made by clinical pharmacists and clinical pharmacy technicians on medication pick-up rates.

METHODS

A retrospective, quality improvement study conducted at six outpatient charity clinics in Dallas-Fort Worth area between 1 January 2017 and 31 July 2017. A live telephonic call was made by a pharmacy team member if the patient did not pick-up at least one prescription item. Patients may receive more than one call if they did not pick-up medication(s) more than once during the study period. A live telephonic call resulted in three categories: contacted, left a voice message and unable to contact. Medication pick-up rates were obtained from a pharmacy claims database.

KEY FINDINGS

The study population included 1726 individual patients who failed to pick-up at least one medication from Baylor Scott & White Health pharmacy. A total of 2551 live telephonic calls were made for the study population. A total of 1175 live telephonic calls (46.1%, n = 2551) resulted in a patient picking up medication(s). Results from the generalized estimating equation logistic regression models showed that patients who received a voice message (OR: 1.37; 95% CI: 1.05 to 1.80; P < 0.021) or was contacted (OR: 1.99; 95% CI: 1.54 to 2.60; P < 0.001) were more likely to pick-up their medications as compared to the 'unable to contact' group.

CONCLUSIONS

Telephonic interventions from the pharmacy team can serve as a successful means to increase medication pick-up rates among charity clinic patients.

Promoting Patient Care Through Communication Training in a Pre-clerkship Pharmacy Education Course in Japan

Objective. The purpose of this study was to teach communication skills for patient care to pre-clerkship students and observe changes in student perspectives towards communication from pre- to post-training. Methods. Two cohorts of fourth-year pharmacy students completed an eight-week pre-clerkship training course designed to improve their communication skills. The course involved class discussions and in-class research of medications, practicing communication skills, learning to give science-based responses, and developing an awareness of patient education for lifestyle, self-medication, quality of life, and medication adherence. A comparison of students' pre- and post-training responses to a questionnaire were used to assess changes in students' ability and confidence in communicating with patients. An exploratory factor analysis was used to analyze and compare the data results. Results. Students' mean post-training scores for perceived ability to make small talk and confidence to communicate with patients increased compared to pre-training scores. Based on the results of the exploratory factor analysis, the greatest increase in students' scores was in the area of patient education skills. Conclusion. The pre-clerkship communication training improved student understanding of the pharmacy communication skills needed to conduct effective patient education and pharmacist-patient interaction beyond dispensing, affirming the theory that specialized communication training before students' begin a clerkship may be essential.

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.

Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya

Background

Short birth intervals are a major risk factor for poor maternal and newborn outcomes. Utilisation of modern contraceptive methods during the postpartum period can reduce risky birth intervals but contraceptive coverage during this critical period remains low.

Methods

We conducted a randomised controlled experiment to test whether vouchers for free contraception, provided with and without behavioural ‘nudges’, could increase modern contraceptive use in the postpartum period. 686 pregnant women attending antenatal care in two private maternity hospitals in Nairobi, Kenya, were enrolled in the study. The primary outcomes were the use of modern contraceptive methods at nearly 3 months and 6 months after expected delivery date (EDD). We tested the impact of a standard voucher that could be redeemed for free modern contraception, a deadline voucher that expired 2 months after delivery and both types of vouchers with and without a short message service (SMS) reminder, relative to a control group that received no voucher and no SMS reminder.

Results

By nearly 6 months after EDD, we find that the combination of the standard voucher with an SMS reminder increased the probability of reporting utilisation of a modern contraceptive method by 25 percentage points (pp) (95% CI 6 pp to 44 pp) compared with the control group. Estimated impacts in other treatment arms were not statistically significantly different from the control group.

Conclusions

Reducing financial barriers to postpartum contraception alone may not be enough to encourage take-up. Programmes targeting the postpartum period should consider addressing behavioural barriers to take-up.

Challenges and innovations of delivering medicines to older adults

Older adults with multimorbidity, polypharmacy, and complex health needs are the major consumer of health care. Ensuring that medicines are used safely, effectively, and delivered efficiently in this population is challenging. In this context, the approach to medicines delivery should seek to overcome some of the difficulties of delivering medicines to older people, and ensure each medication is delivered by the optimal and most convenient route for the patient in question. However, this poses significant obstacles, as the development of medicines suitable for use in older populations does not often account for complex health needs, potential challenges in relation to drug disposition, safety of excipients and limitations with practical usability of dosage forms. The objective of this review is to summarise and discuss current challenges and novel approaches to delivering medications to older adults.

Development and evaluation of an algorithm-based tool for Medication Management in nursing homes: the AMBER study protocol

BACKGROUND

Residents of nursing homes are susceptible to risks from medication. Medication Reviews (MR) can increase clinical outcomes and the quality of medication therapy. Limited resources and barriers between healthcare practitioners are potential obstructions to performing MR in nursing homes. Focusing on frequent and relevant problems can support pharmacists in the provision of pharmaceutical care services. This study aims to develop and evaluate an algorithm-based tool that facilitates the provision of Medication Management in clinical practice.

METHODS AND ANALYSIS

This study is subdivided into three phases. In phase I, semistructured interviews with healthcare practitioners and patients will be performed, and a mixed methods approach will be chosen. Qualitative content analysis and the rating of the aspects concerning the frequency and relevance of problems in the medication process in nursing homes will be performed. In phase II, a systematic review of the current literature on problems and interventions will be conducted. The findings will be narratively presented. The results of both phases will be combined to develop an algorithm for MRs. For further refinement of the aspects detected, a Delphi survey will be conducted. In conclusion, a tool for clinical practice will be created. In phase III, the tool will be tested on MRs in nursing homes. In addition, effectiveness, acceptance, feasibility and reproducibility will be assessed. The primary outcome of phase III will be the reduction of drug-related problems (DRPs), which will be detected using the tool. The secondary outcomes will be the proportion of DRPs, the acceptance of pharmaceutical recommendations and the expenditure of time using the tool and inter-rater reliability.

ETHICS AND DISSEMINATION

This study intervention is approved by the local Ethics Committee. The findings of the study will be presented at national and international scientific conferences and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00010995.

Effect of a Pharmacist-Led Program on Improving Outcomes in Patients with Type 2 Diabetes Mellitus from Northern Cyprus: A Randomized Controlled Trial

BACKGROUND

The management of type 2 diabetes mellitus is complex, requiring continuous medical care by health care professionals and considerable self-care efforts by patients. Pharmacist-led care programs have been shown to help patients with diabetes succeed in achieving treatment goals and improving outcomes. Pharmacist-led care is a new health care concept in Northern Cyprus.

OBJECTIVE

To evaluate the effect of a pharmacist-led care program on glycemic control, determined by hemoglobin A1c (A1c), and secondarily on blood pressure, lipid profile, body mass index (BMI), waist circumference, medication adherence, and self-care activities, for patients with type 2 diabetes over a 12-month period.

METHODS

This was a prospective, randomized controlled study conducted in a public hospital's outpatient diabetes clinic, with 152 patients who had been diagnosed with type 2 diabetes. Of these, 75 patients were in the intervention group, and 77 patients were in the usual care group. The intervention group participated in a pharmacist-led care program with a clinical pharmacist who provided 5 face-to-face educational sessions over a period of 12 months. The main outcome measure was change in A1c, and secondary outcome measures were changes in fasting blood glucose, systolic and diastolic blood pressure, lipid values (total cholesterol, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and serum levels of triglycerides [TGs]), BMI, waist circumference, self-reported medication adherence (Morisky-Green test), and self-care activities. Changes in outcome measures from baseline to the end of the study were assessed using the Mann-Whitney U-test and Wilcoxon test.

RESULTS

At the end of the 12-month study period, the intervention patients showed a greater reduction in A1c values than the usual care patients (-0.74% vs. -0.04%; P < 0.001). Both groups showed significant reductions in fasting blood glucose levels between baseline and the end of 12 months; the difference between the groups was statistically nonsignificant (P = 0.410). When comparing the intervention and usual care groups, there was a significant decrease in systolic (P = 0.01) and diastolic blood pressure (P = 0.04) at the end of the trial. No significant differences were found between the groups in LDL-C, HDL-C, or TG values; however, total cholesterol levels did decrease significantly (P = 0.063, 0.331, 0.896, and 0.04, respectively). Significant reductions occurred in BMI (P < 0.001) and waist circumference (P < 0.001), and improvements were observed in self-reported medication adherence and self-care activities in the intervention group.

CONCLUSIONS

A clinical pharmacist-led care program in a public hospital's outpatient diabetes clinic was associated with significant improvements in reducing A1c and other secondary outcomes in a 12-month randomized controlled study.

DISCLOSURES

This study was conducted as a PhD thesis by Korcegez under the supervision of Sancar for the clinical pharmacy program at Near East University, Health Sciences Institute, Northern Cyprus, and received no external funding. The authors have no potential conflicts of interest to report. Study concept and design were contributed by Korcegez, with assistance from Sancar and Demirkan. Korcegez took the lead in data collection, and data interpretation was performed by Korcegez, along with Sancar and Korcegez. The manuscript was written and revised by Korcegez, along with Sancar, and with assistance from Demirkan.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence

BACKGROUND

Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence.

OBJECTIVE

To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN.

METHODS

A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score.

RESULTS

A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence.

CONCLUSIONS

Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes.

DISCLOSURES

This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers

PURPOSE

To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives.

PARTICIPANTS AND METHODS

A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives.

CONCLUSION

Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.

Improved treatment satisfaction and medication adherence after readjusting oral medication regimens with the cooperation of health insurance pharmacy in type 2 diabetic patients in Japan

Background

Treatment satisfaction and medication adherence can be improved if physicians carefully monitor the situations, check the level of difficulties patients experience when taking medications at specific times, and readjust medication regimens based on this information. However, physicians in Japan encounter difficulties in taking enough time to collect this information in clinical practice. The aim of the current study was to investigate improvements in satisfaction and adherence with the cooperation of a health insurance pharmacy in clinical practice.

Methods

We retrospectively analyzed 29 type 2 diabetic outpatients who were receiving their prescriptions at a medical clinic and filling prescriptions at a nearby pharmacy. The pharmacy collected information regarding satisfaction, adherence, and preferred time of taking medications, and provided these data to the clinic. The oral medication regimens for these 29 patients were readjusted based on the information obtained.

Results

After readjustments, the dosing frequency was decreased from 3.4 ± 1.2 to 1.8 ± 0.5 times/day, and the number of pills was reduced from 5.7 ± 2.0 to 4.5 ± 1.7 (both p < 0.001). Increases in treatment satisfaction from 33 ± 12 to 44 ± 10 points (n = 29, p < 0.001) were observed when assessed using a questionnaire (60-point maximum). Medication adherence based on pill counts increased from 75% ± 22% to 91% ± 14% (n = 24, p < 0.001) (5 patients were excluded due to missing data).

Conclusions

Treatment satisfaction and medication adherence were improved after readjustments of oral medication regimens with the cooperation of a health insurance pharmacy in clinical practice in Japan.

Patient and public perspectives of community pharmacies in the United Kingdom: A systematic review

Background

The United Kingdom has been at the forefront of enhancing pharmacist roles and community pharmacy services, particularly over the past decade. However, patient and public awareness of community pharmacy services has been limited.

Objective

To identify and synthesize the research literature pertaining to patient and public perspectives on: existing community pharmacy services, extended pharmacist roles and strategies to raise awareness of community pharmacy services.

Search strategy

Systematic search of 8 electronic databases; hand searching of relevant journals, reference lists and conference proceedings.

Inclusion criteria

UK studies investigating patient or public views on community pharmacy services or pharmacist roles from 2005 to 2016.

Data extraction and synthesis

Data were extracted into a grid and subjected to narrative synthesis following thematic analysis.

Main results

From the 3260 unique papers identified, 30 studies were included. Manual searching identified 4 additional studies. Designs using questionnaires (n = 14, 41%), semi‐structured interviews (n = 8, 24%) and focus groups (n = 6, 18%) made up the greatest proportion of studies. Most of the studies (n = 28, 82%) were published from 2010 onwards and covered perceptions of specific community pharmacy services (n = 31). Using a critical appraisal checklist, the overall quality of studies was deemed acceptable. Findings were grouped into 2 main themes “public cognizance” and “attitudes towards services” each with 4 subthemes.

Discussion and conclusions

Patients and the public appeared to view services as beneficial. Successful integration of extended pharmacy services requires pharmacists’ clinical skills to be recognized by patients and physicians. Future research should explore different approaches to increase awareness.

Synthesizing and Appraising the Quality of the Evidence on Factors Associated with Medication Adherence in Diabetes: A Systematic Review of Systematic Reviews

BACKGROUND

Nonadherence to medications is a common phenomenon in patients with diabetes. Several studies and systematic reviews have investigated the barriers to medication adherence in diabetes. However, no study has evaluated the quality of the existing literature and synthesized the plethora of evidence with a goal to design holistic conceptual frameworks and interventions.

OBJECTIVES

The aims of this review were to systematically evaluate existing systematic reviews focusing on factors associated with medication adherence in diabetes in an effort to synthesize the evidence, determine their methodological quality, and identify the gaps in the current literature.

METHODS

Fourteen databases and gray literature sources were systematically searched through June 2016. Systematic reviews reporting factors associated with medication adherence (barriers and facilitators) in patients with diabetes were selected on the basis of predetermined criteria. Studies were appraised for quality using AMSTAR (A Measurement Tool to Assess Systematic Reviews).

RESULTS

Seventeen systematic reviews including 542 primary studies, most of which were cross-sectional quantitative studies, were included. All the reviews were rated as moderate to low quality and exhibited common methodological pitfalls. Factors influencing medication adherence identified were categorized as patient-, medication-, disease-, health care provider-, health care system-, and social-related factors.

CONCLUSIONS

Factors influencing medication adherence are multifactorial with remarkably consistent findings across the existing reviews; yet, most reviews were judged to be of low to moderate quality. Further comprehensive and well-conducted original studies and systematic reviews on this topic shall be conducted taking into consideration the drawbacks of existing ones.

The impact of pharmacist-led medication therapy management on medication adherence in patients with type 2 diabetes mellitus: a randomized controlled study

Background:

Poor adherence to antidiabetic medications leads to a higher rate of hospital admissions and adverse health outcomes in type 2 diabetes mellitus patients.

Objective:

This study aims to evaluate whether a pharmacist-led medication therapy management, compared to the usual care, could enhance medication adherence and reduce hospital admission in patients with type 2 diabetes mellitus.

Methods:

A prospective randomized controlled study was conducted in patients with type 2 diabetes mellitus from February 1 to July 30, 2016. Patients in the control group (n=65) received the usual care while patients in the intervention group (n=62) received a personalized pharmacotherapeutic care plan and diabetes education. The two groups were compared by repeated measure ANOVA at 3 and 6-months with medication adherence (using Morisky medication adherence scale) and number of hospital admissions as the main outcome variables.

Results:

A total of 127 patients were included in the study. A marked and statistically significant increase in medication adherence from baseline to 3 and 6 months were noted in the intervention group (increased from 9.2% at baseline to 61% at 6 month) compared with the control group (increased from 13.2% at baseline (to 30.2% at 6 month; p-value<0.01). Furthermore, at the 6-month follow-up, only 23 patients in MTM group with poorly controlled blood glucose levels resulted in hospital admissions compared to 48 patients in non-MTM group, resulting in a 52.1% fewer hospital admissions (p< 0.001).

Conclusions:

The findings of this study implied that pharmacist-led medication therapy management might improve medication adherence and reduce number of hospitalizations in patients with type 2 diabetes mellitus. Hence, policies and guidelines should be in place in order for clinical pharmacists to fully engage in patient care and improve the medication therapy outcomes.

Detection of people at risk of diabetes in community pharmacies of Pontevedra (Spain) (DEDIPO)

OBJECTIVE

The aim of this study was to detect people at risk of suffering diabetes or changes in carbohydrate metabolism and to refer them for possible diagnosis to health care centres. The number of diagnoses and costs for the pharmacy were recorded.

METHODS

A cross-sectional, observational study was conducted in community pharmacies in Pontevedra in September-October of 2014. The Findrisc questionnaire was completed by pharmacy users over 18 years old. If Findrisc score was ≥ 15, capillary blood glucose was measured, and the participant was referred to a physician if the value was ≥110mg/dL. The main variables included score in the Findrisc questionnaire, number of diabetes diagnosed, and cost of the service. Differences between the groups were calculated using a Chi-squared test, a Student's t test, and/or a Wilcoxon test.

RESULTS

This study was conducted in 180 pharmacies on a sample of 4,222 users, including 992 (23.5%) with a high or very high risk of diabetes (F≥15). In the 1,060 basal capillary blood glucose tests performed, mean glucose level was 110.2 (SD=20.4)mg/dL (56-254). The Galician Health Service sent information about 83 of the 384 (9.1%) subjects referred to a physician: 28 (33.7%) of them were diagnosed with diabetes (3.1% of the sample), and 26 (31.3%) were diagnosed with prediabetes (2.8% of the sample). Cost per diagnosed subject was € 184.22 per subject with diabetes and € 96.86 per subject with prediabetes.

CONCLUSIONS

The proportion of subjects with new diagnosis of diabetes (3.1%) shows the high efficiency of a screening program for hidden diabetics implemented at community pharmacies as the one presented here.

Self-care of long-term conditions: patients' perspectives and their (limited) use of community pharmacies

Background Self-care support is an 'inseparable' component of quality healthcare for long-term conditions (LTCs). Evidence of how patients view and use community pharmacy (CP) to engage in self-care of LTCs is limited. Objective To explore patients' perspectives of engaging in self-care and use of CP for self-care support. Setting England and Scotland. Method Qualitative design employing semi-structured interviews. LTCs patients were recruited via general practitioners (GPs) and CPs. Interviews were conducted between May 2013 and June 2014; they were audio-recorded, transcribed verbatim and analysed thematically. Results Twenty-four participants were interviewed. Three main themes emerged: engaging in self-care, resources for self-care support and (limited) use of community pharmacy. Participants' LTC 'lived experience' showed that self-care was integral to daily living from being diagnosed to long-term maintenance of health/wellbeing; self-care engagement was very personal and diverse and was based on beliefs and experiences. Healthcare professionals were viewed as providing information which was considered passive and insufficient in helping behavioural change. Non-healthcare sources (family, carers, friends, internet) were important in filling active support gaps, particularly lifestyle management. Participants' use of, and identified need for, community pharmacy as a resource for self-care support of LTCs was limited and primarily focussed on medicines supply. There was low awareness and visibility of CPs' potential roles and capability. Conclusion CP needs to reflect on patients' low awareness of its expertise and services to contribute to self-care support of LTCs. Rethinking how interventions are designed and 'marketed'; incorporation of patients' perspectives and collaboration with others, particularly GPs, could prove beneficial.

A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan

BACKGROUND

Patients with comorbid hypertension (HTN) and diabetes mellitus (DM) are at a high risk of developing macrovascular and microvascular complications of DM. Controlling high blood pressure can greatly reduce these complications. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with both DM and HTN by the American Diabetes Association guidelines, and their benefit and efficacy in reducing macrovascular and microvascular complications of DM have been well documented. Poor adherence, however, remains a significant barrier to achieving full effectiveness and optimal outcomes.

OBJECTIVE

To examine the effect of a brief pharmacist telephone intervention in identifying adherence barriers and improving adherence to ACEI/ARB medications among nonadherent patients with comorbid HTN and DM who are enrolled in a Medicare Advantage plan.

METHODS

Cigna-HealthSpring's medical claims data was used to identify patients with HTN and DM diagnoses by using ICD-9-CM codes 401 and 250, and at least 2 fills for ACEIs or ARBs between January 2013 and October 2013. Patients who failed to refill their medication for more than 1 day and had a proportion of days covered (PDC) < 0.8 were considered nonadherent and were contacted by a pharmacist by phone to identify adherence barriers. Two outcome variables were evaluated: The first was adherence to ACEIs/ARBs, defined as PDC during the 6 months following the phone call intervention. The second outcome variable was a categorical outcome of discontinuation versus continuation. Discontinuation was defined as not using ACEIs/ARBs during the 6-month post-intervention period. Patients who disenrolled from the plan in 2014 or were switched to another medication commonly used for treating DM and HTN were excluded from further analysis. Descriptive statistics were conducted to assess the frequency distribution of sample demographic characteristics at baseline. Multiple linear regression was conducted to assess the intervention effect on adherence during the 6 months post-intervention using the first outcome of post-intervention PDC, adjusting for baseline PDC and other covariates. Logistic regression was performed to assess the association between medication discontinuation and other baseline characteristics using the second outcome of discontinuation. Other control variables in the models included demographics (age, sex, language), physician specialty (primary care vs. specialist), health plan (low-income subsidy vs. other), Centers for Medicare & Medicaid risk score, Charlson Comorbidity Index, and number of distinct medications.

RESULTS

In total, 186 hypertensive diabetic patients, nonadherent to ACEIs/ARBs (PDC < 0.8), were included in the study. Of the 186 patients, 87 received the pharmacist phone call intervention. Among these patients, forgetfulness (25.29%) and doctor issues, such as having difficulty scheduling appointments (16.79%), were the most commonly reported barriers. After excluding those who switched from ACEIs/ARBs to another medication, 157 patients were included in the logistic regression model. Of those, 131 had continued using ACEIs/ARBs and were included in the linear regression model. The mean (±SD) post-intervention PDC for the intervention group was 0.58 (±0.26) and for the control group 0.29 (±0.17). Intervention was a significant predictor of better adherence in the linear regression model after adjusting all the other baseline covariates (β = 0.3182, 95% CI = 0.19-0.38, P < 0.001). Other covariates were not significantly associated with better adherence. In the logistic regression model (discontinuation: 26 [yes]/131 [no]) for predicting medication discontinuation, patients who received intervention were more likely to continue using ACEIs/ARBs (OR = 3.56, 95% CI = 1.06-11.86), and those with a higher comorbidity index were less likely to continue using them (OR = 0.72, 95% CI = 0.53-0.99).

CONCLUSIONS

The brief pharmacist telephone intervention resulted in significantly better PDCs during the 6 months following the intervention as well as lower discontinuation rates among a group of nonadherent patients with comorbid HTN and DM. The overall PDC rates in both the intervention and control groups were still lower than the recommended 80%. Improving adherence to clinically meaningful values may require more than a brief pharmacist phone call. Incorporating motivational interviewing techniques with follow-up calls to address adherence barriers may be more influential in forming sustainable behavioral change and enhancing medication adherence.

Effects of interventions promoting monitoring of medication use and brief messaging on medication adherence for people with Type 2 diabetes: a systematic review of randomized trials

AIMS

To assess the impact of interventions promoting the monitoring of medication use and brief messaging to support medication adherence in patients with Type 2 diabetes mellitus, and to investigate the extent of theory use to guide intervention development.

METHODS

We systematically searched for controlled trials, published from 1990 onwards in Medline, Embase, CINAHL, PsycINFO and the Cochrane library, that evaluated interventions based on monitoring and brief messaging to support medication adherence in patients with Type 2 diabetes, to examine the effectiveness of such interventions.

RESULTS

A total of 11 trials, comparing 15 interventions, were identified. Only a small minority presented a low risk of bias. Three interventions were based on delivering brief messages, six were based on monitoring medication adherence, and six used both strategies. Messaging interventions included the use of short message service text messages, web-based feedback, and messages delivered through monitoring devices. Monitoring interventions included remote self-reporting of medication and telephone calls with healthcare staff. Improvements in medication adherence were observed in six interventions, although effect sizes were generally moderate. Only two interventions improved both adherence and clinical outcomes. A meta-analysis of five trials (eight interventions) combining monitoring and messaging strategies showed that the pooled difference in medication adherence between intervention and control was moderate and not statistically significant [standardized mean difference = 0.22 (95% CI -0.05; 0.49)]. Only four trials were based on explicit theoretical frameworks.

CONCLUSIONS

Although interventions based on messaging and monitoring have the potential to improve medication adherence in patients with Type 2 diabetes, evidence of their efficacy is limited and additional high-quality, theory-based research is needed.

Clinical backgrounds associated with discrepancy between subjective and objective assessments of medication adherence in Japanese type 2 diabetic patients

Although medication adherence can be easily assessed by self-reports in clinical practice, accuracy is sometimes questionable. To make full use of self-reports on medication adherence in clinical practice, understanding the discrepancy between subjectively and objectively assessed adherence is important. The aim of this study was to investigate which clinical characteristics would be associated with such discrepancy regarding adherence to oral antidiabetic drugs (OADs) in type 2 diabetic patients. Our study assessed 406 Japanese type 2 diabetic outpatients treated with OADs. Medication adherence to OADs was evaluated in percentage, both subjectively by self-report and objectively by pill counts on the same day. We developed a common regression model by extending the generalized linear mixed model and statistically detected the difference in the impact of clinical characteristics between the two measures. Subjectively measured adherence was higher than objectively measured adherence, showing a 1.6-fold difference in odds (p < 0.001). Male gender, older age, longer diabetic duration, and taking more than two OADs daily were independently associated with the overrating of medication adherence by self-report compared with the objectively measured adherence. On the other hand, higher glycocylated hemoglobin (HbA1_c) levels, taking medication before meals, and taking medication outside the home were independently associated with underrating medication adherence by self-report. In conclusion, this study demonstrated clinical characteristics associated with overrating and underrating of medication adherence by self-report in Japanese type 2 diabetic patients treated with OADs.

Treatment adherence in newly diagnosed type 2 diabetes: patient characteristics and long-term impact of adherence on inpatient care utilization

OBJECTIVES

The purpose of this study was to evaluate the impact of antidiabetic medication adherence on hospital utilization in patients with newly diagnosed type 2 diabetes mellitus (T2D). This study specifically analyzed patients with newly diagnosed T2D with the intent of lessening intragroup disease severity differences, and adjusting for a range of other clinical and demographic characteristics.

METHODS

This retrospective US claims database study evaluated adults with newly diagnosed T2D who started antidiabetic medications in 2005-2009, had ≥ 2 antidiabetic medication claims after their first (baseline). Medication adherence was evaluated using the medication possession ratio (MPR) of any or all antidiabetic medication(s) during the 3-year post-baseline period. Repeated-measures analyses examined changes in inpatient utilization from the pre- to post-baseline period. The impact of adherence on hospital utilization during the post-baseline period was evaluated with a logistic regression model to adjust for confounding factors.

RESULTS

The study included 192,717 patients (mean age, 55.0 years). Mean MPR for antidiabetic therapy was 0.74. MPR was highest in elderly patients and Medicare beneficiaries. Mean annualized inpatient admissions during the 3-year post-baseline period were significantly lower in patients with MPR ≥ 0.80 (1.4) than in those with MPR < 0.80 (2.2; P < 0.05). Logistic regression analysis, adjusting for patient characteristics and prior inpatient utilization, showed 39% lower odds of hospitalization (OR = 0.61; 95% CI = 0.534-0.693) for patients with MPR ≥ 0.80. People with T2D-related complications or hospitalization had approximately 2- to 3-fold higher risk of subsequent hospitalization.

CONCLUSIONS

In newly diagnosed T2D patients with antidiabetic therapy in the first three ensuing years, higher antidiabetic medication adherence was significantly associated with lower hospital inpatient utilization before and after adjusting for patient characteristics.

The Medicines Advice Service Evaluation (MASE): a randomised controlled trial of a pharmacist-led telephone based intervention designed to improve medication adherence

AIM

To test the effectiveness of a tailored, pharmacist-led centralised advice service to improve adherence to patients on established medications.

METHODS

A parallel group randomised controlled trial was conducted. Patients prescribed at least one oral medication for type 2 diabetes and/or lipid regulation were eligible to participate. 677 patients of a mail-order pharmacy were recruited and randomised (340 intervention, 337 control). The intervention comprised two tailored telephone consultations with a pharmacist, 4-6 weeks apart, plus a written summary of the discussion and a medicines reminder chart. The primary outcome was self-reported adherence to medication at 6-month follow-up, collected via a postal questionnaire, analysed using generalised estimating equations. Secondary outcomes included prescription refill adherence, lipid and glycaemic control and patient satisfaction.

RESULTS

In intention-to-treat analysis 36/340 (10.6%) of the intervention group were non-adherent (<90% of medication taken in the past 7 days) at 6 months compared with 66/337 (19.6%) in the control group, yielding an unadjusted OR of 1.54 (95% CI 1.11 to 2.15, p=0.01). Analyses of dispensing data also showed that the odds of being classified as adherent (≥90%) were 60% greater for the intervention group compared with the control group (OR 1.60, 95% CI 1.14 to 2.24, p<0.01). In a subsample of patients who provided blood samples, glycaemic and lipid control did not differ significantly between groups (p=0.06 and p=0.24, respectively) but positive trends were observed. Ninety-two per cent of intervention group patients reported that they were satisfied with the service overall.

CONCLUSIONS

A telephone intervention, led by a pharmacist and tailored to the individuals' needs, can significantly improve medication adherence in patients with long-term conditions, using a mail-order pharmacy. Further work is needed to confirm a trend towards improved clinical outcome.

TRIAL REGISTRATION NUMBER

NCT01864239.

A Systematic Review of Interventions Addressing Adherence to Anti-Diabetic Medications in Patients with Type 2 Diabetes--Components of Interventions

Background

Poor adherence to anti-diabetic medications contributes to suboptimal glycaemic control in patients with type 2 diabetes (T2D). A range of interventions have been developed to promote anti-diabetic medication adherence. However, there has been very little focus on the characteristics of these interventions and how effectively they address factors that predict non-adherence. In this systematic review we assessed the characteristics of interventions that aimed to promote adherence to anti-diabetic medications.

Method

Using appropriate search terms in Medline, Embase, CINAHL, International Pharmaceutical Abstracts (IPA), PUBmed, and PsychINFO (years 2000–2013), we identified 52 studies which met the inclusion criteria.

Results

Forty-nine studies consisted of patient-level interventions, two provider-level interventions, and one consisted of both. Interventions were classified as educational (n = 7), behavioural (n = 3), affective, economic (n = 3) or multifaceted (a combination of the above; n = 40). One study consisted of two interventions. The review found that multifaceted interventions, addressing several non-adherence factors, were comparatively more effective in improving medication adherence and glycaemic target in patients with T2D than single strategies. However, interventions with similar components and those addressing similar non-adherence factors demonstrated mixed results, making it difficult to conclude on effective intervention strategies to promote adherence. Educational strategies have remained the most popular intervention strategy, followed by behavioural, with affective components becoming more common in recent years. Most of the interventions addressed patient-related (n = 35), condition-related (n = 31), and therapy-related (n = 20) factors as defined by the World Health Organization, while fewer addressed health care system (n = 5) and socio-economic-related factors (n = 13).

Conclusion

There is a noticeable shift in the literature from using single to multifaceted intervention strategies addressing a range of factors impacting adherence to medications. However, research limitations, such as limited use of standardized methods and tools to measure adherence, lack of individually tailored adherence promoting strategies and variability in the interventions developed, reduce the ability to generalize the findings of the studies reviewed. Furthermore, this review highlights the need to develop multifaceted interventions which can be tailored to the individual patient’s needs over the duration of their diabetes management.

Effectiveness and Content Analysis of Interventions to Enhance Oral Antidiabetic Drug Adherence in Adults with Type 2 Diabetes: Systematic Review and Meta-Analysis

OBJECTIVES

To estimate the pooled effect size of oral antidiabetic drug (OAD) adherence-enhancing interventions and to explore which of the behavior change techniques (BCTs) applied in the intervention groups modified this pooled intervention effect size.

METHODS

We searched relevant studies published until September 3, 2013, on MEDLINE, Embase, PsycInfo, the Cochrane Library, CINAHL, Current Contents Connect, and Web of Science. Selected studies were qualitatively synthesized, and those of at least medium quality were included in the meta-analysis. A random-effects model was used to pool effectiveness (Hedges's g) and to examine heterogeneity (Higgins I(2)). We also explored the influence on the pooled effectiveness of unique intervention BCTs (those delivered to the intervention groups but not control groups in a trial) by estimating their modifying effects.

RESULTS

Fourteen studies were selected for the qualitative synthesis and 10 were included in the meta-analysis. The pooled effectiveness of the interventions was 0.21 (95% confidence interval -0.05 to 0.47; I(2) = 82%). Eight unique BCTs were analyzed. "Cope with side effects" (P = 0.003) and "general intention formation" (P = 0.006) had a modifying effect on the pooled effectiveness. The pooled effectiveness of the interventions in which "cope with side effects" was applied was moderate (0.64; 95% confidence interval 0.31-0.96; I(2) = 56%).

CONCLUSIONS

The overall effectiveness of OAD adherence-enhancing interventions that have been tested is small. Helping patients cope with side effects or formulate desired treatment outcomes could have an impact on the effectiveness of OAD adherence-enhancing interventions. Only those interventions that include helping patients to cope with side effects appear to be particularly effective in improving OAD adherence.