Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy

Gender-Related Factors in Medication Adherence for Metabolic and Cardiovascular Health

This review explores the impact of gender on medication adherence in the context of metabolic and cardiovascular diseases. Optimal adherence to medication is crucial for achieving treatment goals and preventing adverse outcomes in chronic diseases. The review examines specific conditions such as type 2 diabetes, hypercholesterolemia, arterial hypertension, cardiovascular diseases, and heart failure. In type 2 diabetes, female sex, younger age, new drug prescription, non-white ethnicity, low education level, and low income were identified as predictors of non-adherence. Depressive disorders were also found to influence adherence. In hypercholesterolemia, women exhibited poorer adherence to statin therapy compared to men, with statin-related side effects and patient perception being significant factors. Adherence to anti-hypertensive therapy showed conflicting results, with studies reporting both higher and lower adherence in women. Limited evidence suggests that women may have poorer adherence after acute myocardial infarction and stroke. Regarding heart failure, adherence studies have shown inconsistent findings. The reasons for gender differences in medication adherence are multifactorial and include sociodemographic, disease-related, treatment-related, and psychological factors. This review emphasizes the need for further research to better understand these differences and develop gender-customized interventions that can improve medication adherence and reduce the burden of metabolic and cardiovascular diseases.

Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices

BACKGROUND

Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes.

METHODS

Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index.

RESULTS

A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001).

CONCLUSION

Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity.

REGISTRATION AND PROTOCOL

The current study was registered with PROSPERO, ID: CRD42022334482.

Socio-economic inequalities in the use of drugs for the treatment of chronic diseases in Italy

Background

Since the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position. 

Methods

A cross-sectional study design was used to define the “prevalent” users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only “chronic” patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users.

Results

The results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend.

Conclusions

This study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits.

Educational Inequalities in COVID-19 Vaccination: A Cross-Sectional Study of the Adult Population in the Lazio Region, Italy

Several studies reported socioeconomic inequalities during the COVID-19 pandemic. We aimed at investigating educational inequalities in COVID-19 vaccination on 22 December 2021. We used the cohort of all residents in the Lazio Region, Central Italy, established at the beginning of the pandemic to investigate the effects of COVID-19. The Lazio Region has 5.5 million residents, mostly distributed in the Metropolitan Area of Rome (4.3 million inhabitants). We selected those aged 35 years or more who were alive and still residents on 22 December 2021. The cohort included data on sociodemographic, health characteristics, COVID-19 vaccination (none, partial, or complete), and SARS-CoV-2 infection. We used adjusted logistic regression models to analyze the association between level of education and no vaccination. We investigated 3,186,728 subjects (54% women). By the end of 2021, 88.1% of the population was fully vaccinated, and 10.3% were not vaccinated. There were strong socioeconomic inequalities in not getting vaccinated: compared with those with a university degree, residents with a high school degree had an odds ratio (OR) of 1.29 (95% confidence interval, CI, 1.27-1.30), and subjects with a junior high or primary school attainment had an OR = 1.41 (95% CI: 1.40-1.43). Since a comprehensive vaccination against COVID-19 could help reduce socioeconomic inequalities raised with the pandemic, further efforts in reaching the low socioeconomic strata of the population are crucial.

The impact of in-hospital cardiac rehabilitation program on medication adherence and clinical outcomes in patients with acute myocardial infarction in the Lazio region of Italy

Background

Medication adherence is a recognized key factor of secondary cardiovascular disease prevention. Cardiac rehabilitation increases medication adherence and adherence to lifestyle changes. This study aimed to evaluate the impact of in-hospital cardiac rehabilitation (IH-CR) on medication adherence as well as other cardiovascular outcomes, following an acute myocardial infarction (AMI).

Methods

This is a population-based study. Data were obtained from the Health Information Systems of the Lazio Region, Italy (5 million inhabitants). Hospitalized patients aged ≥ 18 years with an incident AMI in 2013–2015 were investigated. We divided the whole cohort into 4 groups of patients: ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI) who underwent or not percutaneous coronary intervention (PCI) during the hospitalization. Primary outcome was medication adherence. Adherence to chronic poly-therapy, based on prescription claims for both 6- and 12-month follow-up, was defined as Medication Possession Ratio (MPR) ≥ 75% to at least 3 of the following medications: antiplatelets, β-blockers, ACEI/ARBs, statins. Secondary outcomes were all-cause mortality, hospital readmission for cardiovascular and cerebrovascular event (MACCE), and admission to the emergency department (ED) occurring within a 3-year follow-up period.

Results

A total of 13.540 patients were enrolled. The median age was 67 years, 4.552 (34%) patients were female. Among the entire cohort, 1.101 (8%) patients attended IH-CR at 33 regional sites. Relevant differences were observed among the 4 groups previously identified (from 3 to 17%). A strong association between the IH-CR participation and medication adherence was observed among AMI patients who did not undergo PCI, for both 6- and 12-month follow-up. Moreover, NSTEMI-NO-PCI participants had lower risk of all-cause mortality (adjusted IRR 0.76; 95% CI 0.60–0.95), hospital readmission due to MACCE (IRR 0.78; 95% CI 0.65–0.94) and admission to the ED (IRR 0.80; 95% CI 0.70–0.91).

Conclusions

Our findings highlight the benefits of IH-CR and support clinical guidelines that consider CR an integral part in the treatment of coronary artery disease. However, IH-CR participation was extremely low, suggesting the need to identify and correct the barriers to CR participation for this higher-risk group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02261-6.

Chronic polytherapy after myocardial infarction: the trade-off between hospital and community-based providers in determining adherence to medication

Background

The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications.

Methods

This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010–2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, β-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR).

Results

A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001).

Conclusion

Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01969-9.

In-hospital myocardial infarction and adherence to evidence-based drug therapies: a real-world evaluation

OBJECTIVES

This study aimed to measure adherence to chronic polytherapy following an acute myocardial infarction (AMI) and to find out associations between adherence and the setting of AMI onset (in vs out of hospital) as well as other determinants.

DESIGN

Retrospective follow-up study.

SETTING

Population living in the Lazio Region, Italy.

PARTICIPANTS

This study included 25 779 hospitalised patients with a first diagnosis of AMI in 2012-2016, after the exclusion of those with hospital admission for AMI or related causes in the previous 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were classified as in-hospital AMI (IH-AMI) or out of hospital AMI (OH-AMI) according to present-on-admission codes. Adherence was measured based on prescription claims during a 6-month follow-up after hospital discharge, using medication possession ratio (MPR). Adherence to chronic polytherapy was defined as MPR ≥75% to at least 3 of the following medications: antithrombotics, betablockers, ACE inhibitors/angiotensin receptor blockers and statins.

RESULTS

Among the entire cohort, 1 044 (4%) patients suffered IH-AMI. Overall, 15 440 (60%) patients were deemed adherent to chronic polytherapy. Female gender, older age, mental disorders, renal disease, asthma and ongoing concomitant treatments were factors associated with poor adherence. By contrast, patients with more severe AMI and those already taking evidence-based (E-B) drugs were more likely to be adherent. A strong association between the setting of AMI onset and adherence was observed: IH-AMI patients were 46% less likely to be adherent to E-B medications during their 6-month follow-up as compared with OH-AMI patients (OR 0.54; 95% CI 0.47 to 0.62; p<0.001).

CONCLUSION

Pharmacotherapy is not consistent with clinical guidelines, especially for IH-AMI patients. Our findings provide evidence on a previously unidentified groups of patients at risk for poor adherence, who might benefit from greater medical attention and dedicated healthcare interventions.

Therapy Discontinuation after Myocardial Infarction

The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients.

MATERIAL AND METHODS

The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data.

RESULTS

Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42-18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45-16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y12 receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)-1.59; 95% CI 1.15-2.19; p = 0.0049) and prior revascularization (HR-1.44; 95% CI 1.04-2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications.

CONCLUSIONS

The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation.

Medication adherence and its determinants in patients after myocardial infarction

Non-adherence to prescribed medication is a serious limitation of long-term treatment in patients after myocardial infarction (MI), which can be associated with medical, social and economical consequences. Improvement of medication adherence has been shown to be a challenge for healthcare providers. The aim of this study was to evaluate changes in medication adherence and variability of adherence determinants during follow-up in patients after MI. A single-center, cohort observational study was conducted in 225 post-MI patients treated with primary coronary intervention (PCI) (27% women and 73% men) aged 30–91 years. Adherence was defined as availability of evaluated drugs within 1-year after discharge from hospital, based on completed prescriptions data obtained from the National Health Fund. The analysis of therapeutic plan realization (adherence to medication prescribed at discharge from hospital) embraced only reimbursed drugs: ACEIs (ramipril, perindopril), P2Y12 receptor inhibitors (clopidogrel) and statins (atorvastatin, simvastatin, rosuvastatin). Sufficient adherence was defined as ≥ 80%. During 1-year follow-up, adherence for all three drug classes was 64 ± 25%, with 67 ± 32% for ACEIs, 62 ± 34% for P2Y12 receptor inhibitor and 64 ± 32% for statins. A gradual decline in adherence was observed from 65% ± 26% in the first quarter of follow-up to 51% ± 34% in the last quarter of follow-up (p < 0.00001). Sufficient adherence for all drugs classes was found only in 29% of patients throughout the whole follow-up period (44% for ACEI, 36% for P2Y12 receptor inhibitor and 41% for statins). According to a multivariate analysis, age, prior CABG, level of education, place of residence, economic status and marital status were independent predictors of drug adherence. Whereas patients > 65 years and having a history of prior CABG more often had an insufficient adherence to drugs, married and hypertensive patients, city inhabitants and patients with higher education tended to have a sufficient drug adherence. Adherence to pharmacotherapy after myocardial infarction decreases over time in a similar manner for all pivotal groups of drugs prescribed after MI. A number of socioeconomic and clinical factors have been identified to affect medication adherence over time.

Association between follow-up in health services and antihypertensive medication adherence

OBJECTIVE

To analyze the association between the characteristics of follow-up in health services and adherence to antihypertensive medication in patients with cardiovascular disease.

METHOD

Analytical study carried out with 270 patients suffering from hypertension and hospitalized due to cardiovascular complications. Data collection occurred between November 2015 and April 2016, involving sociodemographic variables, presence of self-reported diabetes, accessibility and use of health services, blood pressure levels and medication adherence (analyzed through the Morisky-Green Test).

RESULTS

The rate of adherence to antihypertensive therapy was 63.0%. Enrollment in the Hiperdia program had no statistical significance to medication adherence. People who attended at least between 4 and 6 nursing consultations throughout the data collection period (p = 0.02) had better adherence.

CONCLUSION

The study's findings provide support for the reorientation of health services and their public policies towards improving adherence to antihypertensive therapeutics.

Drug prescribing during pregnancy in a central region of Italy, 2008-2012

Background

Drug consumption during pregnancy is a matter of concern, especially regarding drugs known or suspected to be teratogens. Little is known about drug use in pregnant women in Italy. The present study is aimed at examining the prevalence, and to detect potential inappropriateness of drug prescribing among pregnant women in Latium, a region of central Italy.

Methods

This retrospective study was conducted on a cohort of women aged 18-45 years who delivered between 2008 and 2012 in public hospitals. Women were enrolled through the Regional Birth Register. After linking the regional Health Information Systems and the Regional Drug Claims Register, women’s clinical data and prescribed medications were analyzed. Italian Medicine Agency (AIFA) and US Food and Drug Administration (FDA) evidence were used to investigate inappropriate prescribing and teratogenic risk.

Results

Excluding vitamins and minerals, 80.6% (n = 153,079) of the women were prescribed at least one drug during pregnancy, with an average of 4.6 medications per pregnancy. Drugs for blood and hematopoietic organs were the most commonly prescribed (53.0%,), followed by anti-infectives for systemic use (50.7%). Among the inappropriate prescriptions, progestogen supplementation was given in 20.1% of pregnancies; teratogen drugs were prescribed in 0.8%, mostly angiotensin co-enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) (0.3%).

Conclusions

In Latium, drugs are widely used in pregnancy. Prescriptions of inappropriate drugs are observed in more than a fifth of pregnancies, and teratogens are still used, despite their known risk. Continuous updates of information provided to practitioners and an increased availability of information to women might reduce inappropriate prescribing.

Safety and Effectiveness of Direct Oral Anticoagulants Versus Vitamin K Antagonists: Pilot Implementation of a Near-Real-Time Monitoring Program in Italy

Background

Real‐time monitoring is used to the ends of postmarketing observational research on newly marketed drugs. We implemented a pilot near‐real‐time monitoring program on the test case of oral anticoagulants. Specifically, we evaluated the safety and effectiveness of direct oral anticoagulants compared to vitamin K antagonists in nonvalvular atrial fibrillation secondary prevention during 2013‐2015 in the Lazio Region, Italy.

Methods and Results

A cohort study was conducted using a sequential propensity‐score–matched new user parallel‐cohort design. Sequential analyses were performed using Cox models. Overall, 10 742 patients contributed to the analyses. Compared with vitamin K antagonists, direct oral anticoagulant use was associated with a reduction of all‐cause mortality (0.81; 95% confidence interval [CI] 0.66‐0.99), cardiovascular mortality (0.71; 95% CI 0.54‐0.93), myocardial infarction (0.67; 95% CI 0.43‐1.04), ischemic stroke (0.87; 95% CI 0.52‐1.45), hemorrhagic stroke (0.25; 95% CI 0.07‐0.88), and with a nonsignificant increase of gastrointestinal bleeding (1.26; 95% CI 0.69‐2.30).

Conclusions

The present pilot study is a cornerstone to develop real‐time monitoring for new drugs in our region.

Prevalence of antibiotic prescription in pediatric outpatients in Italy: the role of local health districts and primary care physicians in determining variation. A multilevel design for healthcare decision support

BACKGROUND

According to scientific literature, antibacterials are prescribed for common pediatric conditions that do not benefit from antibiotic therapy. The link between antibiotic use and bacterial resistance is well known. Antibiotic overprescribing generates high social costs and severe consequences for children. Our objectives were to analyze antibiotic prescription patterns in pediatric outpatients residing in the Lazio region (Italy), to identify physicians' characteristics associated with increased propensity for prescription, to identify the priority axes for action to improve the rational use of antibiotics.

METHODS

We enrolled all children aged 13 years or less in 2014. Antibiotic prescription patterns were analyzed during a one-year follow-up period. The main outcome measures were the antibiotic prescription prevalence, and the geographic variation in antibiotic prescribing. Multilevel models were performed to analyze variation. Variation was expressed as Median Odds Ratios (MORs). If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.

RESULTS

We enrolled 636,911 children. Most of them were aged 6-13 years (57.3%). In 2015, the antibiotic prescription prevalence was 46% in the 0-13, 58% in the 0-5, and 37% in the 6-13 age group. Overall, penicillins were the most prescribed antibiotics, their consumption increased from 43% to 52% during the 2007-2015 period. In 2015, the antibiotic prescription prevalence ranged from 30% to 62% across local health districts (LHDs) of the region. Moreover, a significant (p < 0.001) variation was observed between physicians working in the same LHD: MORs were equal to 1.52 (1.48-1.56) and 1.46 (1.44-1.48) in the 0-5 and 6-13 age groups, respectively. The probability of prescribing antibiotics was significantly (p < 0.001) lower for more-experienced physicians.

CONCLUSIONS

Pediatric antibiotic use in the Lazio region is much higher than in other European countries. The intra-regional drug prescribing variability underlines the lack of therapeutic protocols shared at regional level and raises equity issues in access to optimal care. Both LHD managers and individual physicians should be involved in training interventions to improve the targeted use of antibiotics and mitigate the effect of contextual variables, such as the spatial-related socioeconomic status of the patient/parent binomial.

The prevalence of medication nonadherence in post-myocardial infarction survivors and its perceived barriers and psychological correlates: a cross-sectional study in a cardiac health facility in Malaysia

BACKGROUND

Although evidence-based practice has shown the benefits of prescribed cardioprotective drugs in post-myocardial infarction (MI) survivors, adherence rates remain suboptimal. The aim of this study was to determine the prevalence and factors associated with medication nonadherence among post-MI survivors in Malaysia.

MATERIALS AND METHODS

This cross-sectional study was conducted from February to September 2016 among 242 post-MI survivors aged 24-96 years at the cardiology outpatient clinic in a Malaysian cardiac specialist center. The study utilized an interviewer-administered questionnaire that consisted of items adapted and modified from the validated Simplified Medication Adherence Questionnaire, sociodemographics, health factors, perceived barriers, and novel psychological attributes, which employed the modified Confusion, Hubbub, and Order Scale and the Verbal Denial in Myocardial Infarction questionnaire.

RESULTS

The prevalence of medication nonadherence was 74%. In the multivariable model, denial of illness (AOR 1.2, 95% CI 0.9-1.8; P=0.032), preference to traditional medicine (AOR 8.7, 95% CI 1.1-31.7; P=0.044), lack of information about illness (AOR 3.3, 95% CI 1.1-10.6; P=0.045), fear of side effects (AOR 6.4, 95% CI 2.5-16.6; P<0.001), and complex regimen (AOR 5.2, 95% CI 1.9-14.2; P=0.001) were statistically significant variables associated with medication nonadherence.

CONCLUSION

The relatively higher medication-nonadherence rate in this study was associated with patient-, provider-, and therapy-related factors and the novel psychological attribute denial of illness. Future research should explore these factors using robust methodological techniques to determine temporality among these factors.

Role of Tiotropium in Reducing Exacerbations of Chronic Obstructive Pulmonary Disease When Combined With Long-Acting β2 -Agonists and Inhaled Corticosteroids: The OUTPUL Study

Combined inhaled therapy in chronic obstructive pulmonary disease (COPD) is commonly used, but its benefits remain controversial. We assessed the effect of tiotropium in reducing COPD exacerbations when combined with long-acting β2 agonists (LABA) and/or inhaled corticosteroids (ICS). This new-user cohort study is based on administrative data from 3 Italian regions. We identified adults hospitalized for COPD from 2006 to 2009 who were newly prescribed a fixed LABA/ICS combination (double therapy). We classified patients according to whether tiotropium was also prescribed (triple therapy), using both intention-to-treat and as-treated approaches, and followed them for 1 year. COPD exacerbations were measured as outcomes. Multivariate and propensity score-adjusted hazard ratios (HRs, 95%CI) were calculated with Cox regression models. We identified 5717 new users of LABA/ICS of which 31.9% initiated triple therapy. In the intention-to-treat analysis, the multivariate adjusted HR for moderate, severe, and any exacerbations were 1.02 (95%CI 0.89-1.16), 0.92 (95%CI 0.76-1.12), and 1.08 (95%CI 0.91-1.28), respectively. The propensity score adjustment produced similar results. In the subcohort of patients with previous exacerbations, triple therapy was significantly associated with reduced risk of moderate exacerbations, compared to double therapy (HR 0.68, 95%CI 0.48-0.98 in intention-to-treat approach). In conclusion, the addition of tiotropium to LABA/ICS did not reduce COPD exacerbations compared to LABA/ICS alone. A protective role for moderate exacerbations was found in patients at risk of frequent exacerbations. Given the impact of exacerbations on health status and prognosis, it is crucial to target COPD patients for optimal treatment.

Pharmacological treatments of cardiovascular diseases: Evidence from real-life studies

The management of chronic cardiovascular diseases has evolved greatly in the last decades. Over the last thirty years, the management of acute coronary syndrome has improved, leading to an important lowering of the mortality in the acute phase of the event. Consequently, the optimal management of the secondary prevention of acute coronary syndrome has greatly evolved. Moreover, the increased number of pharmacological alternatives for patients affected by chronic heart failure and by non-valvular atrial fibrillation reserves a number of challenges for their correct management. Moreover, these diseases are without any reasonable doubt the largest contributor to global mortality in the present and will continue to be it in the future. The aim of this study was to provide the most updated information of the real-life drug use and their effectiveness. This review was performed to assess the potential knowledge gaps in the treatments of these diseases and to indicate potential perspective of pharmaco-epidemiological research in this area.

The impact of adherence to inhaled drugs on 5-year survival in COPD patients: a time dependent approach

Purpose

Whether inhaled medications improve long‐term survival in Chronic Obstructive Pulmonary Disease (COPD) is an open question. The purpose of this study is to assess the impact of adherence to inhaled drug use on 5‐year survival in COPD.

Methods

A population‐based cohort study in three Italian regions was conducted using healthcare linked datasets (hospitalization, mortality, drugs). Individuals (45+ years) discharged after COPD exacerbation in 2006–2009 were enrolled. Inhaled drug daily use during 5‐year follow‐up was determined through Proportion of Days Covered on the basis of Defined Daily Doses. Five levels of time‐dependent exposure were identified: (i) long‐acting β2 agonists and inhaled corticosteroids (LB/ICS) regular use; (ii) LB/ICS occasional use; (iii) LB regular use; (iv) LB occasional use; and (v) respiratory drugs other than LB. Cox regression models adjusted for baseline (socio‐demographic, comorbidities, drug use) and time‐dependent characteristics (COPD exacerbations, cardiovascular hospitalizations, cardiovascular therapy) were performed.

Results

A total of 12 124 individuals were studied, 46% women, mean age 73,8 years. Average follow‐up time 2,4 year. A total of 3415 subjects died (mortality rate = 11.9 per 100 person years). In comparison to LB/ICS regular use, higher risks of death for all remaining treatments were found, the highest risk for respiratory drugs other than LB category (HR = 1.63, 95%CI 1.43–1.87). Patients with regular LB use had higher survival than those with LB/ICS occasional use (HR = 0.89, 95%CI 0.79–0.99).

Conclusions

These findings support clinical guidelines and recommendations for the regular use of inhaled drugs to improve health status and prognosis among moderate–severe COPD patients. © 2016 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.

Socioeconomic inequalities in access to treatment for coronary heart disease: A systematic review

Strong socioeconomic inequalities exist in cardiovascular mortality and morbidity. The current review aims to synthesize the current evidence on the association between socioeconomic status (SES) and access to treatment of coronary heart disease (CHD). We examined quantitative studies analyzing the relationship between SES and access to CHD treatment that were published between 1996 and 2015. Our data sources included Medline and Web of Science. Our search yielded a total of 2066 records, 57 of which met our inclusion criteria. Low SES was found to be associated with low access to coronary procedures and secondary prevention. Access to coronary procedures, especially coronary angiography, was mainly related to SES to the disadvantage of patients with low SES. However, access to drug treatment and cardiac rehabilitation was only associated with SES in about half of the studies. The association between SES and access to treatment for CHD was stronger when SES was measured based on individual-level compared to area level, and stronger for individuals living in countries without universal health coverage. Socioeconomic inequalities exist in access to CHD treatment, and universal health coverage shows only a minor effect on this relationship. Inequalities diminish along the treatment pathway for CHD from diagnostic procedures to secondary prevention. We therefore conclude that CHD might be underdiagnosed in patients with low SES. Our results indicate that there is an urgent need to improve access to CHD treatment, especially by increasing the supply of diagnostic angiographies, to reduce inequalities across different healthcare systems.

Adherence to evidence-based drug therapies after myocardial infarction: is geographic variation related to hospital of discharge or primary care providers? A cross-classified multilevel design

OBJECTIVES

To measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications.

SETTING

This is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants).

PARTICIPANTS

Patients hospitalised with incident MI in 2007-2010.

OUTCOME MEASURE

The outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins.

DESIGN AND ANALYSIS

A 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.

RESULTS

A total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001).

CONCLUSIONS

Secondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.

Adherence to antiplatelet therapy after percutaneous coronary intervention: a population study in a region of Italy

AIMS

We evaluated adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for patients in the Lazio region of Italy and the impact of discharge ward type on therapy discontinuation.

METHODS

From the Hospital Information System, we selected patients who underwent PCI from 2006 to 2007 and obtained Regional Drug Dispense Registry data for antiplatelet drugs prescribed for 12 months after discharge. Appropriate therapy was defined as DAPT with prescribed daily doses for each drug covering at least 75% of each individual follow-up period. The association between discharge ward type and antiplatelet therapy adherence at 12 months post discharge was estimated using multilevel logistic regression analysis.

RESULTS

A total of 11 186 patients with PCI were included, and fewer than half (4984; 44.56%) were on adequate DAPT. Only 2930 of 5390 patients (54.36%) with DAPT in the first 6 months post discharge continued DAPT in the second 6 months. Patients discharged from cardiology units or intensive coronary care units were more likely (odds ratio = 1.26; P = 0.003) to receive appropriate antiplatelet therapy, and elderly patients were less likely (odds ratio = 0.65; P < 0.001) to do so.

CONCLUSION

The proportion of PCI patients receiving appropriate DAPT after discharge is suboptimal in this region, and elderly patients are less likely to receive appropriate therapy. These findings could be important for improving patient management and ensuring adherence to clinical guidelines and indicate the need for a systematic evaluation of the appropriateness of postdischarge therapy.

The impact of time-window bias on the assessment of the long-term effect of medication adherence: the case of secondary prevention after myocardial infarction

OBJECTIVES

Time-window bias was described in case-control studies and led to a biased estimate of drug effect. No studies have measured the impact of this bias on the assessment of the effect of medication adherence on health outcomes. Our goals were to estimate the association between adherence to drug therapies after myocardial infarction (MI) and the incidence of a new MI, and to quantify the error that would have been produced by a time-window bias.

SETTING

This is a population-based study. Data were obtained from the Regional Health Information Systems of the Lazio Region in Central Italy (around 5 million inhabitants).

PARTICIPANTS

Patients discharged after MI in 2006-2007 were enrolled in the cohort and followed through 2009.

OUTCOME MEASURE

The study outcome was reinfarction: either mortality, or hospital admission for MI, whichever occurred first.

DESIGN

A nested case-control study was performed. Controls were selected using both time-dependent and time-independent sampling. Adherence to antiplatelets, β-blockers, ACE inhibitors/angiotensin receptor blockers (ACEI/ARBs) and statins was calculated using the proportion of days covered (PDC).

RESULTS

A total of 6880 patients were enrolled in the cohort. Using time-dependent sampling, a protective effect was detected for all study drugs. Conversely, using time-independent sampling, the beneficial effect was attenuated, as in the case of antiplatelet agents and statins, or completely masked, as in the case of ACEI/ARBs and β-blockers. For ACEI/ARBs, the time-dependent approach produced ORs of 0.83 (95% CI 0.57 to 1.21) and 0.72 (0.55 to 0.95), respectively, for '0.5 < PDC ≤ 0.75' and 'PDC>0.75' versus '0 ≤ PDC ≤ 0.5'. Using the time-independent approach, the ORs were 0.96 (0.65 to 1.43) and 1.00 (0.76 to 1.33), respectively.

CONCLUSIONS

A time-independent definition of a time-dependent exposure introduces a bias when the length of follow-up varies with the outcome. The persistence of time-related biases in peer-reviewed papers strongly suggests the need for increased awareness of this methodological pitfall.

Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy

Background

Primary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF.

Methods

The study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners’ monodisciplinary organizational arrangement, and implementation of a specific HF care pathway).

Results

The 1873 study patients had a median age of 83 years (interquartile range 77–87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35–0.92; medium-term: IRR=0.70, 95%CI=0.51–0.96; mid-long-term: IRR=0.79, 95%CI=0.64–0.98; long-term: IRR=0.82, 95%CI=0.67–0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57–0.94).

Conclusion

Our study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.

Secondary prevention medication after myocardial infarction: persistence in elderly people over the course of 1 year

AIMS

Persistent use of guideline-recommended drugs after acute myocardial infarction (AMI) is frequently reported to be inadequate in the elderly and scarce knowledge exists about factors that influence persistence in outpatient care. Our aim was to evaluate drug use and its predictors in survivors of AMI above 64 years from hospital discharge to 1-year post-AMI.

METHODS

In a single-centre randomised controlled trial, discharge medication of 259 patients with AMI was obtained from medical records at hospital stay. Follow-up drug use and use of the healthcare system were self-reported to study nurses over 1 year in 3-month intervals. Predictors for persistence were modelled with multivariate logistic regression analysis considering demographics, co-morbidities and treatment characteristics.

RESULTS

At discharge, 99.2 % of the patients used anti-platelets, 86.5 % beta blockers, 95.0 % statins and 90.4 % angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Use of the combination of all four drug classes decreased from discharge to 1 year post-AMI from 74.1 to 37.8 % and was significantly reduced by age ≥75 years (odds ratio [OR] 0.49; 95 % confidence interval [CI] 0.29-0.85) and ten or more visits with general practitioners (GPs) over 1 year (OR 0.29; 95 % CI 0.17-0.51). Persistence from month 3 to 12 was significantly associated with drug use at discharge for the single drug classes, but not for the drug combination.

CONCLUSION

Older age and frequent GP visits are associated with decreased use of the guideline-recommended drug combination after AMI. Further research is needed to specify underlying reasons and develop measures to improve persistence.

Medication non-adherence after myocardial infarction: an exploration of modifying factors

BACKGROUND

Medication non-adherence is a major impediment to the management of cardiovascular disease risk factors. A better understanding of the modifying factors underlying medication non-adherence among individuals with known cardiovascular disease may inform approaches for addressing non-adherence.

OBJECTIVE

The purpose of this study was to identify demographic and patient characteristics, medical comorbidities, psychosocial factors, and health belief-related factors associated with medication non-adherence among patients with known cardiovascular disease.

DESIGN

We performed secondary analysis of baseline data from a randomized trial.

PATIENTS

The study included 405 patients with a diagnosis of hypertension and history of acute myocardial infarction that was diagnosed within a three-year period prior to enrollment.

MAIN MEASURES

Baseline demographics and patient characteristics, medical comorbidities, psychosocial factors, health belief-related factors, and patient-reported medication non-adherence were analyzed.

KEY RESULTS

Of 405 patients, 173 (42.7 %) reported medication non-adherence. Factors associated with non-adherence in bivariate analysis included younger age, non-white race, having less than 12 years of education, smoking, financial insecurity, identifying as nervous or tense, higher life chaos score, greater worry about having a myocardial infarction, and greater worry about having a stroke. Using multivariable modeling, we determined that age (OR 0.97 per additional year, 95 % CI, 0.95-0.99), life chaos (OR 1.06 per additional point, 95 % CI, 1.00-1.11), and worry about stroke (OR 1.12 per additional point, 95 % CI, 1.01-1.25) remained significantly associated with self-reported medication non-adherence.

CONCLUSIONS

We found that worry about having a stroke, higher life chaos, and younger age were all significantly associated with self-reported medication non-adherence in patients with cardiovascular disease and a history of myocardial infarction. Further research exploring these factors as targets for intervention is needed, as is additional research examining modifiable causes of medication non-adherence among patients with cardiovascular disease.

Effect of evidence-based drug therapy on long-term outcomes in patients discharged after myocardial infarction: a nested case–control study in Italy

Purpose

There are some methodological concerns regarding results from observational studies about the effectiveness of evidence-based (EB) drug therapy in secondary prevention after myocardial infarction. The present study used a nested case–control approach to address these major methodological limitations.

Methods

A cohort of 6880 patients discharged from hospital after acute myocardial infarction (AMI) in 2006–2007 was enrolled and followed-up throughout 2009. Exposure was defined as adherence to each drug in terms of the proportion of days covered (cutoff ≥ 75%). Composite treatment groups, that is, groups with no EB therapy or therapy with one, two, three, or four EB drugs), were analyzed. Outcomes were overall mortality and reinfarction. Nested case–control studies were performed for both outcomes, matching four controls to every case (841 deaths, 778 reinfarctions) by gender, age, and individual follow-up. The association between exposure to EB drug therapy and outcomes was analyzed using conditional logistic regression, adjusting for revascularization procedures, comorbidities, duration of index admission, and use of the study drugs prior to admission.

Results

Mortality and reinfarction risk decreased with the use of an increasing number of EB drugs. Combinations of two or more EB drugs were associated with a significant protective effect (p < 0.001) versus no EB drugs (mortality: 4 EB drugs: OR_adj = 0.35; 95%CI: 0.21–0.59; reinfarction: 4 EB drugs: OR_adj = 0.23; 95%CI: 0.15–0.37).

Conclusions

These findings of the beneficial effects of EB polytherapy on mortality and morbidity in a population-based setting using a nested case–control approach strengthen existing evidence from observational studies. Copyright © 2013 John Wiley & Sons, Ltd.

Influence of hospitalisation on the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in elderly hypertensive patients

BACKGROUND AND AIMS

The underutilization of beneficial cardiovascular medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in the elderly patients continues to be a matter of concern. The aim of the presented study was to compare the prescription of ACEI and ARB in elderly hypertensive patients at the time of hospital admission and discharge and to identify patient-related factors which determine the prescription of ACEI/ARB.

METHODS

The study sample (n = 1111) was selected from 2,157 patients hospitalised at long-term care departments of three municipal hospitals during the period between January 1, 2008 and December 31, 2009 and included hypertensive patients aged ≥65 years suffering from myocardial infarction, heart failure, atrial fibrillation, diabetes mellitus or nephropathy.

RESULTS

In hypertensive patients with myocardial infarction, diabetes mellitus and nephropathy, a significant increase was found in the use of ACEI/ARB during hospitalisation. However, there was no similar change in the use of such medications during hospitalisation in patients with heart failure and atrial fibrillation. Age ≥85 years (OR = 0.59 and OR = 0.50 at hospital admission and discharge, respectively), depression (OR = 0.63 at hospital discharge) and the systolic blood pressure ≤115 mmHg (OR = 0.45 at hospital discharge) decreased the probability of ACEI/ARB prescription. On the other hand, increasing the number of evaluated co-morbid conditions increased the patient's likelihood of being an "ACEI/ARB user" (OR = 1.20 at hospital discharge).

CONCLUSIONS

Our study has identified a subset of elderly hypertensive patients (with heart failure, atrial fibrillation) in whom the use of ACEI/ARB could be improved.

Pharmacogenomics, pharmacokinetics and pharmacodynamics: interaction with biological differences between men and women

Pharmacological response depends on multiple factors and one of them is sex-gender. Data on the specific effects of sex-gender on pharmacokinetics, as well as the safety and efficacy of numerous medications, are beginning to emerge. Nevertheless, the recruitment of women for clinical research is inadequate, especially during the first phases. In general, pharmacokinetic differences between males and females are more numerous and consistent than disparities in pharmacodynamics. However, sex-gender pharmacodynamic differences are now increasingly being identified at the molecular level. It is now even becoming apparent that sex-gender influences pharmacogenomics and pharmacogenetics. Sex-related differences have been reported for several parameters, and it is consistently shown that women have a worse safety profile, with drug adverse reactions being more frequent and severe in women than in men. Overall, the pharmacological status of women is less well studied than that of men and deserves much more attention. The design of clinical and preclinical studies should have a sex-gender-based approach with the aim of tailoring therapies to an individual's needs and concerns.

Pneumonia burden in elderly patients: a classification algorithm using administrative data

BACKGROUND

Pneumonia has traditionally been classified into two subtypes: community-acquired pneumonia (CAP) and nosocomial pneumonia (NP). Recently, a new entity has been defined, called healthcare-associated pneumonia (HCAP). Few studies have investigated the potential of population-based, electronic, healthcare databases to identify the incidences of these three subtypes of pneumonia. The aim of this study was to estimate the burden of the three subtypes of pneumonia in elderly patients (aged 65+ years) in a large region of central Italy.

METHODS

A retrospective cohort study was performed using linked regional Hospital Information System and Mortality Register. All episodes of pneumonia in elderly patients, who were discharged from the hospital in 2006-2008, were selected for the study. Following a validated ICD-9-coding algorithm, incidents of pneumonia events were classified into three groups (HCAP; probable nosocomial pneumonia, PNP; and CAP). Hospitalisation rates were calculated by age group (65-79, 80+), gender, and year, using the population from the Institute of Statistics (ISTAT) census estimates as denominators.

RESULTS

A total of 26,239 pneumonia events occurred in 24,338 patients residing in the Lazio region, aged 65+ years: 2257 HCAP, 6775 PNP, and 17,107 CAP. For all subtypes, the proportion of males was greater than females. Comorbidity status was more severe in HCAP than in the other categories. In-hospital mortality, 30-day mortality, and length of hospital stay were twice higher in HCAP than in CAP episodes. The annual incidence rates were 0.7, 2.1, and 5.4 episodes per 1000 residents for HCAP, PNP, and CAP, respectively. From 2006 to 2008, incidence rates slightly increased for all three subtypes.

CONCLUSION

Health care databases can be used to give a timely and inexpensive picture of the epidemiology of pneumonia. HCAP represents a distinct category of pneumonia, with the longest stay, highest mortality, and the greatest comorbidity.

Use patterns of long-acting bronchodilators in routine COPD care: the OUTPUL study

BACKGROUND

COPD is the fourth leading cause of death in the world. In the case of exacerbations or persistent symptoms, regular treatment with long-acting bronchodilators is recommended to control the symptoms, reduce exacerbations and improve health status. Objectives. To describe patterns of drug utilization among patients diagnosed with COPD, to measure continuity with long-acting bronchodilators, to identify determinants of not receiving long-acting therapy continuously.

METHODS

We identified a cohort of patients discharged from hospital with diagnosis of COPD between 2006 and 2008. Patients were observed for a two-year follow-up period, starting from the day of discharge. Follow-up was segmented in six-month periods, in order to dynamically evaluate prescription patterns of Long-Acting Beta-Agonists (LABA), tiotropium, and inhaled corticosteroids. Patients with prescriptions for LABA and/or tiotropium in each of the six-month periods were defined as "continuously treated with long-acting bronchodilators." The degree of drug treatment coverage was measured through the Medication Possession Ratio (MPR). Logistic regression was performed to identify determinants of not receiving long-acting bronchodilators continuously.

RESULTS

A total of 11,452 patients diagnosed with COPD were enrolled. Only 34.8% received long-acting bronchodilators continuously. The MPR was greater than 75% in 19.6% of cases. Among the determinants of not receiving long-acting bronchodilators continuously, older age and co-morbidities played an important role.

CONCLUSIONS

In clinical practice, the COPD pharmacotherapy is not consistent with clinical guidelines. Medical education is needed to disseminate evidence-based prescribing patterns for COPD, and to raise awareness among physicians and patients on the health benefits of an appropriate pharmacological treatment.

Does the use of an electronic reminder device with or without counseling improve adherence to lipid-lowering treatment? The results of a randomized controlled trial

BACKGROUND

Lipid-lowering treatment with statins has proven to be effective in reducing cardiovascular events and mortality. In daily practice, however, adherence to medication is often low and this compromises the therapeutic effect. The aim of this study was to assess the effectiveness of an electronic reminder device (ERD) with or without counseling to improve refill adherence and persistence for statin treatment in non-adherent patients.

METHODS

A multicenter, community pharmacy-based, randomized controlled trial was conducted in 24 pharmacies in the Netherlands among patients with pre-baseline refill adherence rates between 50 and 80%. Eligible patients aged 65 years or older were randomly assigned to 1 of 3 groups: (1) counseling with an ERD (n = 134), (2) ERD with a written instruction (n = 131), and a (3) control group that received the usual treatment (n = 134).

MAIN OUTCOME MEASURE

refill adherence to statin treatment for a 360-day period after inclusion (PDC360). Patients with a refill rate ≥80% were considered adherent. The effect among subgroups was also assessed.

RESULTS

There were no relevant differences at baseline. In the counseling with ERD group 54 of 130 eligible patients received the counseling with ERD. In the ERD group, 117 of 123 eligible patients received the ERD. The proportions of adherent patients in the counseling with ERD-group (69.2%) and in the ERD group (72.4%) were not higher than in the control group (64.8%). Among women using statins for secondary prevention, more patients were adherent in the ERD group (86.1%) than in the control group (52.6%) (p < 0.005). In men using statins for secondary prevention the ERD was found to have no effect.

CONCLUSION

In this randomized controlled trial, no statistically significant improvement of refill adherence was found if an ERD was used with or without counseling. However, in a subgroup of women using statins for secondary prevention the ERD did improve adherence significantly.