Medication non-adherence: an overlooked target for quality improvement interventions

Are threat perceptions associated with patient adherence to antibiotics? Insights from a survey regarding antibiotics and antimicrobial resistance among the Singapore public

BACKGROUND

Public health strategies to improve patient adherence to antibiotics rely mostly on raising awareness of the threat of antimicrobial resistance (AMR) and improving knowledge about antibiotics. We aimed to evaluate how adherence to antibiotics relates to knowledge and the threat perceptions proposed by the Protection Motivation Theory (PMT).

METHOD

A cross-sectional online survey was conducted in September-December 2020 with 1002 participants aged 21-70 years in Singapore. Two items, which were reverse coded, evaluated adherence to antibiotics: 'how often do you obtain antibiotics that were left over from the previous prescription' and 'how often did you treat yourself with antibiotics in the past year'. Questions about the PMT-related constructs, and knowledge regarding antibiotics and AMR knowledge were also included. Hierarchical regression models were performed at a 5% significance level.

RESULTS

Adherence to antibiotics was associated with knowledge level (β = 0.073, p < 0.05), education level (β = - 0.076, p < 0.01), and four of the five PMT constructs: "perceived response cost" (β = 0.61, p < 0.01), "perceived response efficacy of adherence to antibiotic" (β = 0.096, p < 0.01), "perceived susceptibility to AMR" (β = 0.097, p < 0.01), and "perceived severity of AMR" (β = - 0.069, p < 0.01). Knowledge about AMR, perceived self-efficacy in adhering to antibiotics, age, and sex were not associated with adherence.

CONCLUSIONS

In Singapore, patient adherence to antibiotics appear to be driven by the perceived costs of visiting a doctor to obtain antibiotics, followed by perceptions of AMR as a threat and to a lesser extent, knowledge about antibiotics. Public health strategies to mitigate antibiotic misuse should consider these patient barriers to medical care.

Geographic variation in and contextual factors related to biguanide adherence amongst medicaid enrolees with type 2 Diabetes Mellitus

Much is known about the adverse impacts on diabetes outcomes of non-adherence to diabetes medication. Less is known about how adherence to diabetes medication varies geographically, and the correspondence of this variation to social and contextual factors. Using pharmacy claims data over a two-year period, this study analysed non-adherence to biguanide medication for N=24,387 adult Medicaid enrolees diagnosed with Type 2 Diabetes Mellitus (T2DM) and residing in Ohio. Spatial analysis was used to detect clusters of census tract level rates of non-adherence, defined as the proportion of patients below the Proportion Days Covered (PDC) threshold of 80%, the level at which patients have a reasonable likelihood of achieving most clinical benefit from their medication. Multilevel models were used to understand associations between medication non-adherence and contextual factors including social vulnerability, urbanicity and distance to utilised pharmacy, with adjustment for individual-level covariates. These findings indicate that contextual factors are associated with medication non-adherence in Medicaid clients with T2DM. They suggest a need for spatially specific, multifaceted intervention programmes that target and/or account for the features of residential settings beyond individual and health system-level factors alone. While “environmental” considerations are often acknowledged, few intervention initiatives are predicated on explicit knowledge of spatially variable influences that can be targeted to enable and support medication adherence.

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Medication adherence is a problem amongst Type 2 Diabetes patients on Medicaid.

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Social and contextual factors' influence on medication adherence is underexplored.

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Higher social vulnerability is associated with non-adherence to biguanides.

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Adopting spatial analysis techniques enables geographic targeting of health risk.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial

BACKGROUND

Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data.

RESULTS

Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group.

CONCLUSIONS

A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice.

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.