Association between perceived life chaos and medication adherence in a postmyocardial infarction population

Individual and social determinants of adherence to sodium-glucose cotransporter 2 inhibitor therapy: A trajectory analysis

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are known to improve cardiovascular and renal outcomes in patients with type 2 diabetes (T2D). Understanding the longitudinal patterns of adherence and the associated predictors is critical to addressing the suboptimal use of this outcome-improving treatment. OBJECTIVE: To characterize the distinct trajectories of adherence to SGLT2is in patients with T2D and to identify patient characteristics and social determinants of health (SDOHs) associated with SGLT2i adherence. METHODS: In this retrospective cohort study, we identified patients with T2D who initiated and filled at least 1 SGLT2i prescription according to 2012-2016 national Medicare claims data. The monthly proportion of days covered with SGLT2is for each patient was incorporated into group-based trajectory models to identify groups with similar adherence patterns. A multinomial logistic regression model was constructed to examine the association between patient characteristics and group membership. In addition, the association between context-specific SDOHs (eg, neighborhood median income and neighborhood employment rate) and adherence to an SGLT2i regimen was explored in both the overall cohort and the racial and ethnic subgroups. RESULTS: The final sample comprised 6,719 patients with T2D. Four trajectories of SGLT2i adherence were identified: continuously adherent users (49.6%), early discontinuers (27.5%), late discontinuers (14.5%), and intermediately adherent users (8.4%). Patient age, sex, race, diabetes duration, and Medicaid eligibility were significantly associated with trajectory group membership. Areas with a higher unemployment rate, lower income level, lower high school education rate, worse nutrition environment, fewer health care facilities, and greater Area Deprivation Index scores were found to be associated with low adherence to SGLT2is. CONCLUSIONS: Four distinct trajectories of adherence to SGLT2is were identified, with only half of the patients remaining continuously adherent to their treatment regimen during the first year after initiation. Several contextual SDOHs were associated with suboptimal adherence to SGLT2is.

The Roles of Depression, Life Control and Affective Distress on Treatment Attendance and Perceived Disability in Chronic Back Pain Sufferers throughout the Duration of the Condition

The aims of this study were to examine psychological factors that predict treatment seeking and disability over the total duration of experiencing back pain. A sample of 201 adults experiencing chronic back pain was recruited through health professionals and completed the Depression, Anxiety and Stress Scale (DASS), the Oswestry Back Pain Disability Questionnaire (ODQ), the McGill Pain Questionnaire (MPQ) and the life control and affective distress variables of the West Haven-Yale Multidimensional Pain Inventory (WHYMP), and participants disclosed the number of treatment sessions attended over the course of the illness. Depression, life control and affective distress were tested as indirect predictors of disability severity that were mediated by treatment attendance. Each unit increase in life control predicted attending nearly 30 more treatment sessions, each unit increase in affective distress predicted attending 16 fewer treatments and each unit increase in depression predicted 4 fewer treatments, together explaining 44% of variance in treatment seeking. The effects of life control and affective distress on disability were explained by treatment attendance, whereas depression retained a direct effect on disability. Treatment attendance had an effect on disability. The findings show that participants with lower life control and higher affective distress and depression had higher levels of pain and disability, in part due to due to their treatment-seeking behaviour.

Relationship Between Unmet Social Needs and Care Access in a Veteran Cohort

BACKGROUND

The association between unmet social needs (e.g., food insecurity) and adverse health outcomes is well-established, especially for patients with and at risk for cardiovascular disease (CVD). This has motivated healthcare systems to focus on unmet social needs. Yet, little is known about the mechanisms by which unmet social needs impact health, which limits healthcare-based intervention design and evaluation. One conceptual framework posits that unmet social needs may impact health by limiting care access, but this remains understudied.

OBJECTIVE

Examine the relationship between unmet social needs and care access.

DESIGN

Cross-sectional study design using survey data on unmet needs merged with administrative data from the Veterans Health Administration (VA) Corporate Data Warehouse (September 2019-March 2021) and multivariable models to predict care access outcomes. Pooled and separate rural and urban logistic regression models were utilized with adjustments from sociodemographics, region, and comorbidity.

SUBJECTS

A national stratified random sample of VA-enrolled Veterans with and at risk for CVD who responded to the survey.

MAIN MEASURES

No-show appointments were defined dichotomously as patients with one or more missed outpatient visits. Medication non-adherence was measured as proportion of days covered and defined dichotomously as adherence less than 80%.

KEY RESULTS

Greater burden of unmet social needs was associated with significantly higher odds of no-show appointments (OR = 3.27, 95% CI = 2.43, 4.39) and medication non-adherence (OR = 1.59, 95% CI = 1.19, 2.13), with similar associations observed for rural and urban Veterans. Social disconnection and legal needs were especially strong predictors of care access measures.

CONCLUSIONS

Findings suggest that unmet social needs may adversely impact care access. Findings also point to specific unmet social needs that may be especially impactful and thus might be prioritized for interventions, in particular social disconnection and legal needs.

Life Instability Associated with Lower ART Adherence and Other Poor HIV-Related Care Outcomes in Older Adults with HIV

BACKGROUND

Life instability may be an important factor for HIV-related care outcomes in older adults living with HIV (OALWH). This study examined the degree to which an 11-item life instability index (LII) composed of individual- and community-level indicators was associated with HIV-related care outcomes-viral load, antiretroviral (ART) medication adherence, rates of detectable viral load, and HIV care appointment non-adherence among OALWH in the Miami area.

METHODS

Six hundred twenty-three OALWH completed an interviewer-administered assessment (English or Spanish), which was matched with medical record data.

RESULTS

Participants reported about six LII indicators each (M = 6.08, SD = 1.44). Greater index scores were associated with worse self-reported ART adherence (b =  - 1.14, p = 0.03), lower observed appointment adherence (b = 0.02, p < 0.01), higher viral load (b = 0.09, p = 0.02), and greater odds of viral detection (OR = 1.22, p = 0.01). Regarding health behaviors, life instability was significantly associated with increased illicit substance use among participants and not associated with depression or anxiety. The association of life instability to ART adherence remained significant (although attenuated) when controlling for the significant effects of substance use (b =  - 0.40, BSTP [- 0.87, - 0.09]).

CONCLUSION

This present study is the first to examine an additive life instability index and its association with HIV-related behavioral and biomedical health outcomes among a population of OALWH. Greater indicators of life instability among OALWH may lead to poorer HIV-related health outcomes above and beyond the net of the effects of depression, anxiety, and substance use.

The Associations between Remission Status, Discounting Rates, and Recovery from Substance Use Disorders

Background: Recovery from substance use disorders (SUDs) requires sustained and purposeful support to maintain long-term remission. Methods: This study investigated the association between assessment of recovery capital, household chaos, delay discounting (DD) and probability discounting (PD), and remission status among individuals in recovery from SUD. Data from 281 participants from the International Quit & Recovery Registry (IQRR), an ongoing online registry that aims to study the recovery process, were included in the analysis. Results: Lower DD rates and higher recovery capital were found among those in remission compared to those not in remission after controlling for demographics. In contrast, the association of household chaos and PD with remission status were insignificant. Overall, DD accounted for 20% of the total effect between the recovery capital and the remission status. Conclusion: This study contributes to the understanding of recovery as a multidimensional process, supports DD as a behavioral marker of addiction, and suggests areas for future research.

Managing Medications and Medication Adherence Among US Adults During the Early Phase of the COVID-19 Pandemic

PURPOSE

Before the COVID-19 pandemic and the disruptions it brought, medication adherence was already a challenging and complex health behavior. The purpose of this study was to describe patients' interactions in clinic, pharmacy, and home contexts and associated medication management and adherence during the early phase of the COVID-19 pandemic.

PATIENTS AND METHODS

A survey questionnaire was developed using the Medication Adherence Context and Outcomes framework and distributed via social media between May and July 2020 targeting adults taking a daily prescribed medication. Survey questions assessed sociodemographics, interactions with healthcare providers, clinics, pharmacies, medication management experiences, habit strength, and life chaos perceptions during the pandemic. Medication adherence was assessed by the self-report BAASIS© scale to measure implementation, discontinuation, and overall nonadherence.

RESULTS

A total of 134 adults from the United States, mean age 50.0 (SD 16.1) years were included in this analysis. Respondents took a median of 3.50 (interquartile range 4) daily medications. Delays in seeing a provider were reported by 47 (35.1%). Pharmacy encounters were impacted; 25 (18.7%) indicated their method for obtaining medication changed. Medication nonadherence was reported among 62 (46.3%) and was significantly greater among those who delayed prescription refills (p=0.032), pillbox users (p=0.047), and those who experienced greater life chaos (p=0.040) and lower habit strength (p<0.001) in the early phase of the pandemic.

CONCLUSION

Although the early phase of the pandemic affected access to care for nearly one-third of the sample, distance-accessible care options and strategies to obtain needed services without being in-person supported respondents medication management. Helpful strategies included provider accessibility, telehealth, home delivery/mail-order, drive-thru's, 90-day supplies, and online/automatic refills. Methods to develop and reestablish habits are critical. Care providers in clinic and pharmacy settings can educate and remind patients about services like distance-accessible technologies and online ordering of medications and establishing routines to support medication adherence.

Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol

INTRODUCTION

Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes).

METHODS AND ANALYSIS

We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04977583.

Family Caregivers of Veterans Experience Clinically Significant Levels of Distress Prepandemic and During Pandemic: Implications for Caregiver Support Services

BACKGROUND

Of the 26.4 million family caregivers in the United States, nearly 40% report high levels of emotional strain and subjective burden. However, for the 5 million caregivers of Veterans, little is known about the experiences of caregivers of Veterans during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

The aim was to examine pandemic-related changes of caregiver well-being outcomes.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

Using a pre/post design and longitudinal data of individual caregivers captured pre-COVID-19 and during COVID-19, we use multilevel generalized linear mixed models to examine pandemic-related changes to caregiver well-being (n=903). The primary outcome measures include Zarit Subjective Burden, Center for Epidemiologic Studies Short Depression Scale, perceived financial strain, life chaos, and loneliness.

RESULTS

During the pandemic, we observe slight improvements for caregivers across well-being measures except for perceived financial strain. Before the pandemic, we observed that caregivers screened positive for clinically significant caregiver burden and probable depression. While we do not observe worsening indicators of caregiver well-being during the COVID-19 pandemic, the average predicted values of indicators of caregiver well-being remain clinically significant for caregiving subjective burden and depression.

CONCLUSIONS

These findings illuminate pandemic-related impacts of caregivers receiving support through the Veterans Affairs (VA) pre-COVID and during the COVID-19 pandemic while caring for a population of frail, older care-recipients with a high burden of mental illness and other chronic conditions. Considering the long-term impacts of the pandemic to increase morbidity and the expected increased demand for caregivers in an aging population, these consistently high levels of distress despite receiving support highlight the need for interventions and policy reform to systematically support caregivers more broadly.

Race, Income, and Medical Care Spending Patterns in High-Risk Primary Care Patients: Results From the STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) Study

Rationale & Objective

Little is known about how socioeconomic status (SES) relates to the prioritization of medical care spending over personal expenditures in individuals with multiple comorbid conditions, and whether this relationship differs between Blacks and non-Blacks. We aimed to explore the relationship between SES, race, and medical spending among individuals with multiple comorbid conditions.

Study Design

Cross-sectional evaluation of baseline data from a randomized controlled trial.

Setting & Participants

The STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) study is a completed randomized controlled trial of Duke University primary care patients with diabetes, hypertension, and chronic kidney disease. Participants underwent survey assessments inclusive of measures of socio-demographics and medication adherence.

Predictors

Race (Black or non-Black) and socioeconomic status (income, education, and employment).

Outcomes

The primary outcomes were based on 4 questions related to spending, asking about reduced spending on basic/leisure needs or using savings to pay for medical care. Participants were also asked if they skipped medications to make them last longer.

Analytical Approach

Multivariable logistic regression stratified by race and adjusted for age, sex, and household chaos was used to determine the independent effects of SES components on spending.

Results

Of 263 STOP-DKD participants, 144 (55%) were Black. Compared with non-Blacks, Black participants had lower incomes with similar levels of education and employment but were more likely to reduce spending on basic needs (29.2% vs 13.5%), leisure activities (35.4% vs 20.2%), and to skip medications (31.3% vs 15.1%), all P < 0.05. After multivariable adjustment, Black race was associated with increased odds of reduced basic spending (OR, 2.29; 95% CI, 1.14-4.60), reduced leisure spending (OR, 1.94; 95% CI, 1.05-3.58), and skipping medications (OR, 2.12; 95% CI, 1.12-4.04).

Limitations

This study was conducted at a single site in Durham, North Carolina, and nearly exclusively included insured patients. Further, the impact of the number of comorbid conditions, medication costs, or copayments was not assessed.

Conclusions

In primary care patients with multiple chronic diseases, Black patients are more likely to reduce spending on basic needs and leisure activities to afford their medical care than non-Black patients of equivalent SES.

ClinicalTrials.gov Identifier

NCT01829256

Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9

Notable racial and ethnic differences and disparities exist in coronary artery disease (CAD) and stroke epidemiology and outcomes despite substantial advances in these fields. Racial and ethnic minority subgroups remain underrepresented in population data and clinical trials contributing to incomplete understanding of these disparities. Differences in traditional cardiovascular risk factors such as hypertension and diabetes play a role; however, disparities in care provision and process, social determinants of health including socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination within and outside of the health care system also drive racial and ethnic CAD and stroke disparities. Improved culturally congruent and competent communication about risk factors and symptoms is also needed. Opportunities to achieve improved and equitable outcomes in CAD and stroke must be identified and pursued.

Dynamics of inhaled corticosteroid use are associated with asthma attacks

Inhaled corticosteroids (ICS) suppress eosinophilic airway inflammation in asthma, but patients may not adhere to prescribed use. Mean adherence-averaging total doses taken over prescribed-fails to capture many aspects of adherence. Patients with difficult-to-treat asthma underwent electronic monitoring of ICS, with data collected over 50 days. These were used to calculate entropy (H) a measure of irregular inhaler use over this period, defined in terms of transitional probabilities between different levels of adherence, further partitioned into increasing (H_inc) or decreasing (H_dec) adherence. Mean adherence, time between actuations (Gap_max), and cumulative time- and dose-based variability (area-under-the-curve) were measured. Associations between adherence metrics and 6-month asthma status and attacks were assessed. Only H and H_dec were associated with poor baseline status and 6-month outcomes: H and H_dec correlated negatively with baseline quality of life (H:Spearman r_S = - 0·330, p = 0·019, H_dec:r_S = - 0·385, p = 0·006) and symptom control (H:r_S = - 0·288, p = 0·041, H_dec: r_S = - 0·351, p = 0·012). H was associated with subsequent asthma attacks requiring hospitalisation (Wilcoxon Z-statistic = - 2.34, p = 0·019), and H_dec with subsequent asthma attacks of other severities. Significant associations were maintained in multivariable analyses, except when adjusted for blood eosinophils. Entropy analysis may provide insight into adherence behavior, and guide assessment and improvement of adherence in uncontrolled asthma.

The Impact of Social Determinants of Health on Medication Adherence: a Systematic Review and Meta-analysis

BACKGROUND

Medication adherence (MA) is critical to successful chronic disease management. It is not clear how social determinants of health (SDH) impact MA. We conducted a systematic review and meta-analysis to summarize the evidence on the relationship between SDH and MA.

METHODS

We conducted a systematic review of the literature using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format. A literature search was performed using three databases: PubMed, Scopus, and Cochrane Clinical Trials Register in December of 2018. Included studies were completed in the USA, included adults aged 18 years and older, measured at least one social determinant of health, and medication adherence was the primary outcome measure. Data from included full texts were independently extracted using a standardized data extraction form. We then conducted a meta-analysis and pooled the odds ratios from the included studies for each social determinant as well as for all SDH factors collectively.

RESULTS

A total of 3137 unduplicated abstracts were identified from our database searches. A total of 173 were selected for full text review after evaluating the abstract. A total of 29 articles were included for this systematic review. Economic-related SDH factors and MA were mostly commonly examined. The meta-analysis revealed a significant relationship between food insecurity (aOR = 0.56; 95% CI 0.42-0.7), housing instability (aOR = 0.64; 95% CI 0.44-0.93), and social determinants overall (aOR = 0.75; 95% CI 0.65-0.88) and medication adherence.

DISCUSSION

Food insecurity and housing instability most consistently impacted medication adherence. Although included studies were heterogenous and varied widely in SDH and MA measurements, adverse social determinants overall were significantly associated with lower MA. The relationship between SDH and MA warrants more attention and research by health care providers and policymakers.

Transportation as a barrier to colorectal cancer care

BACKGROUND

Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits.

METHODS

Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos.

RESULTS

Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman's ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman's ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant.

CONCLUSIONS

Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Drug Use and Life Chaos as Potential Factors Contributing to HIV Viral Load among People with Lower Health Literacy

Lower health literacy is associated with poorer health outcomes in people living with HIV (PLWH), but the explanatory mechanisms for these associations are not well understood. Factors such as drug use and life chaos may at least in part account for the relationship between lower health literacy and poor health outcomes. The current study tested the hypothesis that lower health literacy would predict drug use, which in turn would predict life chaos, and that all three factors would be related to poorer heath, defined by higher concentrations of HIV viremia. Methods: Patients receiving HIV care (N = 251) at an HIV clinic in the southeastern United States completed computerized interviews and permission to access their medical records. Process modeling tested direct and indirect effects of all variables in a serial mediation model. Results: The direct effects of lower health literacy and drug use were significantly related to HIV viremia. In addition, the indirect effect of health literacy on HIV viremia through drug use was significant. However, results did not demonstrate any effect, direct or indirect, of life chaos on HIV viremia. Conclusion: Findings from this study bolster previous research demonstrating lower health literacy and drug use as barriers to HIV care, and show that lower health literacy impacts HIV viremia, at least in part, through drug use. Interventions aimed to improve HIV treatment outcomes in lower health literacy populations may be enhanced by integrating evidence-based approaches to reducing drug use.

Perceived Stress Among Patients With Heart Failure Who Have Low Socioeconomic Status: A Mixed-Methods Study

BACKGROUND

Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care-especially among patients with heart failure (HF).

OBJECTIVE

We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES.

METHODS

In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated.

RESULTS

Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score.

CONCLUSIONS

Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.

Addressing Social Determinants of Health Within Healthcare Delivery Systems: a Framework to Ground and Inform Health Outcomes

Social determinants of health (SDoH) are the conditions in which people live and work that shape access to essential social and economic resources. Calls for healthcare systems to intervene on unmet social needs have stimulated several large-scale initiatives across the country. Yet, such activities are underway in the absence of a unifying conceptual framework outlining the potential mechanisms by which healthcare-based unmet social need interventions can improve health outcomes. Drawing on theoretical foundations and empirical evidence about the relationship between unmet social needs and health, the authors developed the OASIS (Outcomes from Addressing SDoH in Systems) conceptual framework to map the known and hypothesized pathways by which unmet social need screening and referral interventions may impact outcomes. The OASIS framework may help guide policy makers, healthcare system leaders, clinicians, and researchers to utilize a more unified approach in their efforts to implement and evaluate unmet social need interventions and thus foster the development of an evidence base to inform healthcare systems to more effectively mitigate the consequences of unmet social needs. Adopting an overarching conceptual framework for addressing unmet social needs by healthcare systems holds promise for better achieving health equity and promoting health at the individual and population levels.

Predictors of Aspirin Nonadherence in Adults With Prior Myocardial Infarction

BACKGROUND

Medication nonadherence is an alarming public health concern due to its effect on both individual treatment success and overall health care costs. This study sought to identify the predictors of aspirin nonadherence in adults with prior myocardial infarction (MI).

METHODS

The 2017 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey, a nationally representative, cross-sectional survey, was utilized to identify a cohort of community-dwelling adults (age ≥ 18 years) with prior MI (n = 2173). The primary outcome of interest was presence of self-reported aspirin nonadherence.

RESULTS

Among 2173 participants with prior MI studied, a total of 550 participants (25.3%) reported aspirin nonadherence, whereas 1623 participants (74.7%) reported adherence to aspirin. Adults with aspirin nonadherence were younger and more likely to be female, Black, and of Hispanic ethnicity. They also had lower annual income and were less likely to have health insurance or own a home. Participants with aspirin nonadherence had less frequent medical checkups and lower rates of multiple comorbidities including diabetes mellitus, hypertension, hyperlipidemia, and obesity. In multivariable analysis, independent predictors of aspirin nonadherence included female sex [odds ratio (OR), 1.42; 95% confidence interval (CI), 1.14-1.83], Black race (OR, 1.64; 95% CI, 1.19-2.26), Hispanic ethnicity (OR, 2.27; 95% CI, 1.60-3.21), current employment (OR, 1.74; 95% CI, 1.28-2.36), and absence of homeowner status (OR, 0.71; 95% CI, 0.55-0.93).

CONCLUSIONS

In this observational contemporary study of adults with prior MI, predictors of aspirin nonadherence included female sex, Black race, Hispanic ethnicity, currently employed status, and absence of homeowner status.

Life Chaos is Associated with Reduced HIV Testing, Engagement in Care, and ART Adherence Among Cisgender Men and Transgender Women upon Entry into Jail

Life chaos, the perceived inability to plan for and anticipate the future, may be a barrier to the HIV care continuum for people living with HIV who experience incarceration. Between December 2012 and June 2015, we interviewed 356 adult cisgender men and transgender women living with HIV in Los Angeles County Jail. We assessed life chaos using the Confusion, Hubbub, and Order Scale (CHAOS) and conducted regression analyses to estimate the association between life chaos and care continuum. Forty-eight percent were diagnosed with HIV while incarcerated, 14% were engaged in care 12 months prior to incarceration, mean antiretroviral adherence was 65%, and 68% were virologically suppressed. Adjusting for sociodemographics, HIV-related stigma, and social support, higher life chaos was associated with greater likelihood of diagnosis while incarcerated, lower likelihood of engagement in care, and lower adherence. There was no statistically significant association between life chaos and virologic suppression. Identifying life chaos in criminal-justice involved populations and intervening on it may improve continuum outcomes.

Effect of Smoking Status on Exercise Perception and Intentions for Cardiac Rehabilitation Enrollment Among Patients Hospitalized With an Acute Cardiac Condition

PURPOSE

Cardiac rehabilitation (CR) attendance has been associated with higher smoking cessation (SC) rates. However, for unclear reasons, smokers are consistently less likely to enroll in CR than nonsmokers, and it is uncertain what might encourage them to attend.

METHODS

We surveyed patients eligible for CR who were cigarette smokers at the time of hospital admission. We assessed patient intention to quit smoking, start exercising, and enroll in CR. We also measured anxiety and depression levels.

RESULTS

Of the 105 patients approached, 81 (77%) completed the survey (69% males, aged 57 ± 10 y, 72% white). Most patients reported interest in SC (80%) and attending CR (78%). Many felt that SC medications (41%), stress management programs (35%), and an exercise program with SC counseling (30%) would increase their likelihood to attend CR; however, 30% stated that they would be less likely to enroll in CR if they continued smoking following discharge. Many patients indicated high levels of anxiety (51%) and depression (27%); many desired to reduce stress following discharge (73%), with 35% stating that stress management programs would increase their likelihood to attend CR.

CONCLUSIONS

Hospitalized smokers eligible for CR report significant interest in SC, attending CR, and beginning an exercise program. These patients show high levels of anxiety and depression and indicate a strong interest in stress management programs. These results suggest that messages emphasizing the role of CR in the treatment of depression, anxiety, and stress are likely to resonate with smokers, increase their enrollment in CR, and support long-term SC.

Daily Routine: Associations With Health Status and Urgent Health Care Utilization Among Older Adults

BACKGROUND AND OBJECTIVES

Chronically ill older adults must integrate self-care behaviors into their daily routine to promote health and reduce urgent health care utilization. Individuals of lower socioeconomic position (SEP) experience a disproportionate burden of stressors that challenge the formation of regular routines. We examined associations between the presence of a daily routine and older adults' health status and urgent health care utilization, to determine whether higher levels of daily routine mediates associations between SEP and health outcomes.

RESEARCH DESIGN AND METHODS

We used data from a cohort of older adult primary care patients in Chicago. Daily routine was measured using a brief, validated scale. A single factor score of SEP was created with measures of education, income, homeownership, and insurance status. Health status was assessed by Patient Reported Outcomes Measurement Information Service physical function, depression, and anxiety. Urgent health care utilization was patient reported. Multivariable models were used to assess the effect of routine and SEP on health status and urgent health care utilization.

RESULTS

Individuals reporting low levels of daily routine reported worse physical function (β = -2.34; 95% CI -4.18, -0.50), more anxiety (β = 2.73; 95% CI 0.68, 4.78) and depressive symptoms (β = 2.83; 95% CI 0.94, 4.74) than those with greater daily routine. No differences in urgent health care utilization were observed by daily routine. Daily routine varied by SEP (p < .001); routine partially mediated the relationship between SEP and physical function and anxiety symptoms (ps < .05).

DISCUSSION AND IMPLICATIONS

A daily routine may be an under recognized modifiable factor that could promote health outcomes among older adults.

Opportunities for improving use of evidence-based therapy in patients with type 2 diabetes and cardiovascular disease

Evidence‐based therapy that target hyperlipidemia, hypertension, smoking cessation, and weight loss have demonstrated significant benefits in reducing cardiovascular risks and related events. Although the benefit of intensively lowering blood glucose is unclear, newer antidiabetic drugs (glucagon‐like peptide‐1 receptor agonists and sodium‐glucose cotransporter‐2 inhibitors) have shown cardiovascular benefits in addition to their antihyperglycemic effect. Yet, studies suggest that recent use of evidence‐based therapy and management of cardiovascular risk among individuals with type 2 diabetes (T2D) and cardiovascular disease (CVD) remains largely suboptimal. The following narrative review first identifies barriers to translating research evidence to clinical practice at the levels of provider, health system, patient, and cost. Then it synthesizes previous implementation strategies that addressed multifaceted barriers and attempted to improve care for patients with T2D and CVD. In conclusion, team‐based care coordination, reminding systems in combination to pharmacist consultation and patient education, provider education compatible with clinical workflow, and coupled incentives between providers and patients appeared to be effective in reducing cardiovascular risks for patients with T2D and CVD, though the scalability and long‐term clinical effect of these strategies as well as the possibility of interventions involving payers and health systems remain uncertain.

Adherence to medication in adults with Cystic Fibrosis: An investigation using objective adherence data and the Theoretical Domains Framework

Objectives

Adherence to nebulizer treatment in adults with Cystic Fibrosis (CF) is poor, and interventions are needed. This research aimed to identify the factors affecting nebulizer adherence using the Theoretical Domains Framework (TDF) and to compare these for participants with different levels of adherence.

Design

Data‐prompted interviews using the TDF.

Methods

Eighteen semi‐structured interviews were conducted with adults with CF during which objectively measured adherence data were discussed. Framework analysis was used to code the data into TDF domains, and inductive qualitative content analysis was used to code different beliefs and experiences. Aspects of the TDF that differed between participants with different adherence levels were explored.

Results

Factors influencing adherence to treatment included all 14 domains of the TDF, 10 of which appeared to vary by adherence level: Skills; Memory and decision‐making; and Behavioural regulation; Environmental context and resources; Social influences; Beliefs about consequences; Beliefs about capability; Reinforcement; Social role and identify; Intentions; Optimism; and Emotions.

Conclusions

This study is the first to use objectively measured adherence data in a data‐prompted interview using the TDF framework to systematically assess the full range of factors potentially influencing adherence. The results highlighted that interventions need to consider issues of capability, opportunity, and motivation. Interventions that challenge dysfunctional beliefs about adherence and which support the development of routines or habits and problem‐solving may be particularly useful for adults with CF.

Measurement of health literacy in patients with cardiovascular diseases: A systematic review

BACKGROUND

While many instruments have been developed, validated, and used to assess health literacy skills, their use and appropriateness among patients with cardiovascular diseases (CVDs) are not widely studied.

OBJECTIVE

To identify, appraise, and synthesize available health literacy assessment instruments used in patients with CVDs.

METHODS

Electronic databases were searched for studies that used validated measures to assess health literacy in patients with CVDs. Included studies were assessed for risk of bias and the identified instruments were evaluated based on their psychometric properties. Data were synthesized using a narrative approach.

RESULTS

Forty-three studies were included in the review, of which 20 were cross-sectional studies and 12 were randomized controlled trials. Eleven health literacy assessment instruments were identified, of which only one was disease-specific. The Abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA) (n = 19) and the Rapid Estimate of Adult Literacy in Medicine (REALM) (n = 13) were found to be the most commonly used instruments to assess health literacy in CVDs.

CONCLUSIONS

The S-TOFHLA and the REALM are the most widely used instruments to evaluate health literacy in CVD population. More CVD-specific health literacy screening instruments are warranted. Assessment of health literacy should be a standard of care in patients with CVDs and effective interventions should be developed to improve the impact of limited health literacy on health outcomes in this population.

Factors Associated with Perceived Life Chaos among Post-Myocardial Infarction Survivors in a Malaysian Cardiac Care Facility

Background and objectives: Survivors of chronic life-threatening conditions like myocardial infarction (MI) are often confronted with multiple physical and psychological stressors as a consequence of elevated demands of lifestyle adjustments and modifications. Such stressors, collectively known as “life chaos”, cause disruption to one’s lifestyle equilibrium of having organized, calm, and regular routines. The objective of the current study was to determine the level of life chaos and its associated correlates among post-myocardial infarction (post-MI) survivors in Malaysia. Materials and Methods: An analytical cross-sectional study was conducted among 242 post-MI survivors in a Malaysian cardiac health facility from July to September 2016. A self-administered questionnaire in Malay that consisted of items on socio-demographics, health attributes, validated OSLO-3 Social Support Scale (OSS-3), and the Modified Confusion, Hubbub, and Order Scale (CHAOS-6) was utilized in this study. Descriptive, bivariate, and multivariate analyses were conducted. Results: The sample constituted of 208 (86%) men and 34 (14%) women. The average age was 55 years (SD = 11), and the age ranged between 24 and 96 years. Overall, 128 (52.9%) of the total post-MI survivors had highly chaotic lives. In multivariate analysis, younger age, lower household income, perceived financial insecurity, poor health status, and multiple comorbidities were related to the high chaos score, and these associations were statistically significant (p < 0.05). Conclusions: Highly chaotic lifestyles were prevalent in post-MI survivors. Demographic, health attributes, and socio-economic factors were important correlates of life chaos.

Psychiatric Illness, Substance Use, and Viral Suppression Among HIV-Positive Men of Color Who Have Sex with Men in Los Angeles

For individuals living with human immunodeficiency virus (HIV), viral suppression positively affects quality and length of life and reduces risks for HIV transmission. Men of color who have sex with men (MoCSM) who have been diagnosed with HIV have disproportionately low rates of viral suppression, with concomitant increases in incidence. We identified specific social, structural, and psychiatric factors associated with viral suppression among a sample of 155 HIV-positive MoCSM. Cigarette smoking and biological markers of recent drug use were significantly associated with detectable viral load. In contrast, individuals reporting a history of psychiatric illness during medical examination were more likely to be virally suppressed. Further analyses demonstrated that psychiatric illness may affect virologic outcomes through increased probability of being prescribed HIV medications. Alternatively, cigarette smoking and drug use appear to negatively affect subsequent HIV Care Continuum milestones such as medication adherence. Findings provide support for comprehensive intervention programs that emphasize prevention and treatment of cigarette, methamphetamine, and other drug use, and promote improved connection to psychiatric care. Continual achievement of this goal may be a crucial step to increase rates of viral suppression and slow HIV incidence in communities of MoCSM in Los Angeles and other urban areas.

Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction

BACKGROUND

Low health literacy is common in the United States and may affect outcomes after myocardial infarction (MI). How often hospitals screen for low health literacy is unknown.

METHODS

We surveyed 122 hospitals in the TRANSLATE-ACS study and divided them into those that reported routinely (>75% of patients), selectively (1%-75%), or never (0%) screening MI patients for low health literacy prior to discharge. We performed logistic regression with random intercepts to compare 6-week and 6-month patient-reported medication adherence and multivariable Cox regression to compare 1-year major adverse cardiovascular events and all-cause readmission risks between hospital groups.

RESULTS

Overall, 25 (20.5%), 47 (38.5%), and 50 (41.0%) hospitals reported routinely, selectively, or never screening patients for low health literacy, respectively. Patients discharged from hospitals that routinely screened were more likely to report 6-week medication adherence [routinely: adjusted odds ratio (OR) 1.26, 95% CI 1.01-1.57; selectively: adjusted OR 1.19, 95% CI 1.00-1.43, both referenced to those discharged from hospitals that never screened]. Compared with hospitals that never screened health literacy, 1-year major adverse cardiovascular events were similar for hospitals that reported routinely screening (adjusted HR 0.92, 95% CI 0.75-1.14) or selectively screening (adjusted HR 1.01, 95% CI 0.84-1.21). Hospitals that reported selectively screening health literacy were associated with a lower adjusted risk of 1-year all-cause readmission (adjusted HR 0.89, 95% CI 0.79-1.00, P=.041).

CONCLUSION

Only a minority of US hospitals routinely screen MI patients for low health literacy. Hospital screening was associated with higher medication adherence and lower readmission risk. Further investigation is needed to understand how inpatient screening can be implemented to improve longitudinal post-MI care.

Medicare utilization, screening, and costs among participants in the Southeastern Diabetes Initiative: A population-based evaluation

AIMS

Type 2 diabetes mellitus imposes significant burdens on patients and health care systems. Population-level interventions are being implemented to reach large numbers of patients at risk of or diagnosed with diabetes. We describe a population-based evaluation of the Southeastern Diabetes Initiative (SEDI) from the perspective of a payer, the Centers for Medicare & Medicaid Services (CMS). The purpose of this paper is to describe the population-based evaluation approach of the SEDI intervention from a Medicare utilization and cost perspective.

METHODS

We measured associations between the SEDI intervention and receipt of diabetes screening (i.e., HbA1c test, eye exam, lipid profile), health care resource use, and costs among intervention enrollees, compared with a control cohort of Medicare beneficiaries in geographically adjacent counties.

RESULTS

The intervention cohort had slightly lower 1-year screening in 2 of 3 domains (4% for HbA1c; 9% for lipid profiles) in the post-intervention period, compared with the control cohort. The SEDI intervention cohort did not have different Medicare utilization or total Medicare costs in the post-intervention period from surrounding control counties.

CONCLUSIONS

Our analytic approach may be useful to others evaluating CMS demonstration projects in which population-level health is targeted for improvement in a well-defined clinical population.

HIV-Related Stress and Life Chaos Mediate the Association Between Poverty and Medication Adherence Among People Living with HIV/AIDS

HIV treatment depends on high-levels of antiretroviral therapy (ART) adherence, which is severely impeded by poverty. Men and women living with HIV infection (N = 92) completed computerized interviews of demographic and health characteristics, poverty markers, stressful life events, and life chaos, as well as unannounced pill counts to determine prospective medication adherence and medical record chart abstractions for HIV viral load. Poverty markers were associated with both stressors and chaos, and the direct effects of all three factors predicted ART non-adherence. The multiple mediation model showed that accounting for stressors and chaos resulted in a non-significant association between poverty markers and ART adherence. The indirect effect of poverty markers on adherence through life chaos was significant, whereas the indirect effect of poverty markers on adherence through stressors was not significant. Factors that render HIV-related stress and create chaos offer intervention targets that are more amenable to change than poverty itself.

Confirmatory Factor Analysis of the Malay Version of the Confusion, Hubbub and Order Scale (CHAOS-6) among Myocardial Infarction Survivors in a Malaysian Cardiac Healthcare Facility

BACKGROUND

The six item Confusion, Hubbub and Order Scale (CHAOS-6) has been validated as a reliable tool to measure levels of household disorder. We aimed to investigate the goodness of fit and reliability of a new Malay version of the CHAOS-6.

METHODS

The original English version of the CHAOS-6 underwent forward-backward translation into the Malay language. The finalised Malay version was administered to 105 myocardial infarction survivors in a Malaysian cardiac health facility. We performed confirmatory factor analyses (CFAs) using structural equation modelling. A path diagram and fit statistics were yielded to determine the Malay version's validity. Composite reliability was tested to determine the scale's reliability.

RESULTS

All 105 myocardial infarction survivors participated in the study. The CFA yielded a six-item, one-factor model with excellent fit statistics. Composite reliability for the single factor CHAOS-6 was 0.65, confirming that the scale is reliable for Malay speakers.

CONCLUSION

The Malay version of the CHAOS-6 was reliable and showed the best fit statistics for our study sample. We thus offer a simple, brief, validated, reliable and novel instrument to measure chaos, the Skala Kecelaruan, Keriuhan & Tertib Terubahsuai (CHAOS-6), for the Malaysian population.

Racial differences in nocturnal dipping status in diabetic kidney disease: Results from the STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) study

While racial variation in ambulatory blood pressure (BP) is known, patterns of diurnal dipping in the context of diabetic kidney disease have not been well defined. The authors sought to determine the association of race with nocturnal dipping status among participants with diabetic kidney disease enrolled in the STOP-DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) trial. The primary outcome was nocturnal dipping-percent decrease in average systolic BP from wake to sleep-with categories defined as reverse dippers (decrease <0%), nondippers (0%-<10%), and dippers (≥10%). Twenty-four-hour ambulatory BP monitoring was completed by 108 participants (54% were nondippers, 24% were dippers, and 22% were reverse dippers). In adjusted models, the common odds of reverse dippers vs nondippers/dippers and reverse dippers/nondippers vs dippers was 2.6 (95% confidence interval, 1.2-5.8) times higher in blacks than in whites. Without ambulatory BP monitoring data, interventions that target BP in black patients may be unable to improve outcomes in this high-risk group.

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.

Identifying psychosocial predictors of medication non-adherence following acute coronary syndrome: A systematic review and meta-analysis

OBJECTIVE

Medication non-adherence following acute coronary syndrome (ACS) is associated with poor clinical outcomes. A systematic review and meta-analysis were undertaken to identify psychosocial factors associated with medication adherence in patients with ACS.

METHODS

A search of electronic databases (Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, International Pharmaceutical Abstracts, CINAHL, ASSIA, OpenGrey, EthOS and WorldCat) was undertaken to identify relevant articles published in English between 2000 and 2014. Articles were screened against our inclusion criteria and data on study design, sample characteristics, predictors, outcomes, analyses, key findings and study limitations were abstracted.

RESULTS

Our search identified 3609 records, of which 17 articles met our inclusion criteria (15 independent studies). Eight out of ten studies found an association between depression and non-adherence. A meta-analysis revealed that depressed patients were twice as likely to be non-adherent compared to patients without depression (OR=2.00, 95% CI 1.57-3.33, p=0.015). Type D personality was found to predict non-adherence in both studies in which it was measured. Three out of three studies reported that treatment beliefs based on the Necessity-Concerns Framework predicted medication non-adherence and there was some evidence that social support was associated with better adherence. There was insufficient data to meta-analyse all other psychosocial factors identified.

CONCLUSION

There was some evidence that psychosocial factors, particularly depression, were associated with medication adherence following ACS. Targeting depressive symptoms, screening for Type D personality, challenging maladaptive treatment beliefs, and providing better social support for patients may be useful strategies to improve medication adherence.

Potentially disruptive life events: what are the immediate impacts on chronic disease management? A case-crossover analysis

OBJECTIVE

To explore the association between unexpected potentially disruptive life events in a patient or family member that may challenge an individual's ability to take medications as prescribed and the discontinuation of evidence-based medications for common, chronic conditions. Understanding the relationship between medication adherence and life stressors, especially those that can be identified using administrative data, may help identify patients at risk of non-adherence.

DESIGN

Observational self-controlled case-crossover design.

SETTING

Individuals in a nationally representative US commercial health insurance database.

PARTICIPANTS

Adult individuals who initiated an oral hypoglycaemic, antihypertensive and/or statin and subsequently stopped the medication for ≥90 days.

MAIN OUTCOME MEASURE

Potentially disruptive life events among patients and their family members measured in the 30 days just before the medication was discontinued ('hazard period') compared with the 30 days before this period ('control period'). These events included personal injury, hospitalisation, emergency room visits, changes in insurance coverage, acute stress or acute anxiety.

RESULTS

Among the 326 519 patients meeting study criteria who discontinued their chronic disease medications, 88 896 (27.2%) experienced at least one potentially disruptive life event. Newly experiencing an injury (OR: 1.26, 95% CI 1.12 to 1.42), an emergency room visit (OR: 1.19, 95% CI 1.13 to 1.26) and acute stress (OR: 1.19, 95% CI 1.08 to 1.31) were associated with discontinuation. Life events among patients' family members did not appear to be associated with medication discontinuation or occurred less frequently just prior to discontinuation.

CONCLUSIONS

Potentially disruptive life events among individuals identified using routinely collected claims data are associated with discontinuation of chronic disease medications. Awareness of these events may help providers or payers identify patients at risk of non-adherence to maximise patient outcomes.

Patient-reported medication adherence barriers among patients with cardiovascular risk factors

BACKGROUND

Many patients experience barriers that make it difficult to take cardiovascular disease (CVD)-related medications as prescribed. The Cardiovascular Intervention Improvement Telemedicine Study (CITIES) was a tailored behavioral pharmacist-administered and telephone-based intervention for reducing CVD risk.

OBJECTIVES

To (a) describe patient-reported barriers to taking their medication as prescribed and (b) evaluate patient-level characteristics associated with reporting medication barriers.

METHODS

We recruited patients receiving care at primary care clinics affiliated with Durham Veterans Affairs Medical Center. Eligible patients were diagnosed with hypertension and/or hyperlipidemia that were poorly controlled (blood pressure of > 150/100 mmHg and/or low-density lipoprotein value > 130 mg/dL). At the time of enrollment, patients completed an interview with 7 questions derived from a validated medication barriers measure. Patient characteristics and individual medication treatment barriers are described. Multivariable linear regression was used to examine the association between a medication barrier score and patient characteristics.

RESULTS

Most patients (n = 428) were married or living with their partners (57%) and were men (85%) who were diagnosed with hypertension and hyperlipidemia (64%). The most commonly reported barriers were having too much medication to take (31%) and forgetting whether medication was taken at a particular time (24%). In adjusted analysis, those who were not employed (1.32, 95% CI = 0.50-2.14) or did not have someone to help with tasks, if needed (1.66, 95% CI = 0.42-2.89), reported higher medication barrier scores. Compared with those diagnosed with hypertension and hyperlipidemia, those with only hypertension (0.91, 95% CI = 0.04-1.79) reported higher medication barrier scores.

CONCLUSIONS

Barriers to medication adherence are common. Evaluating and addressing barriers may increase medication adherence.

Impact of cancer on adherence to glucose-lowering drug treatment in individuals with diabetes

AIMS/HYPOTHESIS

Adherence to glucose-lowering drug (GLD) treatment regimens is crucial for metabolic control and improving prognosis. Because a diagnosis of cancer might have an impact on adherence to medication, this study explored changes in adherence to GLDs following a cancer diagnosis.

METHODS

All new users of GLDs between 1998 and 2011 who lived in the Eindhoven Cancer Registry-PHARMO Database Network catchment area were selected. Those with a primary cancer diagnosis during follow-up were considered cases and matched with eligible controls without cancer during follow-up. Medication possession ratio (MPR) was used as indicator for medication adherence. Segmented linear auto-regression analysis with interrupted time series was used to assess changes in MPR for cases compared with controls (i.e. overall trend) due to (any) cancer diagnosis and specific cancer types.

RESULTS

From the 52,228 GLD users selected, 3,281 cases with cancer and 12,891 controls without cancer during follow-up were included in the study. In our analyses, before cancer diagnosis the MPR increased by 0.10% per month (95% CI 0.10, 0.10). Besides a significant drop in MPR at the time of cancer diagnosis of -6.3% (95% CI -6.5, -6.0), there was an ongoing, yet lower, monthly decline in MPR (-0.20%; 95% CI -0.21, -0.20) after cancer diagnosis. The largest drops in MPR at the time of cancer diagnosis, in the range of 11-15%, were seen among patients with stage IV disease and gastrointestinal or pulmonary cancers.

CONCLUSIONS/INTERPRETATION

Our findings indicate a clear decline in adherence to GLD treatment regimens following a cancer diagnosis. The reason for the decline in MPR needs to be further elucidated.

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.