Interventional tools to improve medication adherence: review of literature

Improving Care for People with Chronic Respiratory Diseases: Taking a Policy Lens

Chronic respiratory diseases (CRDs) affect almost 470 million people worldwide, and this number is growing. CRDs take a significant toll on the capacity of health systems and economies, and their effect on people's lives can be devastating. Despite high rates of prevalence and mortality, CRDs are underprioritised by policymakers and governments. Tackling these conditions will require a holistic, multisectoral approach, including government-led strategies for prevention, diagnosis, management and investment in research. In this article, we provide a clear rationale for prioritising CRDs to advance population health. Proactive steps in countries of all income levels must be taken promptly to limit the growing prevalence and impact of CRDs both now and in the future.

Feasibility and Acceptability of Engaging Care Partners of Persons Living With Dementia With Electronic Outreach for Deprescribing

BACKGROUND AND OBJECTIVES

Care partners are critical for making treatment decisions in persons living with dementia. However, identifying them is challenging, hindering the broader use of interventions, such as those using digital technologies. We aimed to (i) assess the feasibility of identifying and contacting care partners using electronic health record (EHR) systems, and (ii) elicit their perspectives on electronic interventions for deprescribing.

RESEARCH DESIGN AND METHODS

We systematically identified care partners of persons living with dementia ≥65 years of age via structured EHR data in a large health care system. Eligible care partners were contacted by patient portal (if they were an established proxy), mail, and phone to complete a survey.

RESULTS

Of 4,138 eligible persons living with dementia identified, 1,084 (26%) had a care partner name recorded in the EHR. Out of 259 (6%) with sufficient care partner contact information for outreach, 74 (29%) completed the survey. Among care partners, 62 (84%) reported being confident in managing dementia medications, 59 (80%) were willing to stop ≥1 medications, and 43 (58%) were very/extremely interested in using digital tools for decision-making.

DISCUSSION AND IMPLICATIONS

Despite the low percentage of care partners with sufficient contact information, reach rates were high for contacted care partners, suggesting feasibility for pragmatic system-level interventions. Most care partners showed great interest in using digital health tools for decision-making and managing medications. Therefore, electronic tools could help with identifying care partners and engaging them. However, scaling up interventions requires better care partner documentation or extracting information from free text.

Medication adherence in the curricula of future European physicians, pharmacists and nurses - a cross-sectional survey

AIM

Many patients are not taking their medicines. It has substantial negative medical and economic consequences for patients and healthcare systems but there is limited knowledge on how medication adherence is integrated in medical education. This study seeks to investigate to what extent students in medicine, pharmacy and nursing in Europe are taught about medication adherence.

METHODS

A cross-sectional online survey was distributed to 731 persons teaching relevant courses across 142 European universities between February and June 2024. The survey addressed definitions of adherence and The ABC Taxonomy; methods to support adherence, methods to identify and monitor non-adherence; consequences and outcomes of non-adherence, and methods applied in teaching. They were also asked to provide links to their curricula. Responses from quantitative questions were analyzed descriptively. Word frequency and qualitative thematic analysis was used for the curricula inventory and analysis of free-text answers, respectively.

RESULTS

In total, 212 participants from 114 universities in 34 countries completed the survey. Respondents agreed to similar level on the need to enhance medication adherence teaching, with 72% in pharmacy, 71% medical, and 59% agreement in nursing education. The most taught topic across educations was the clinical impact of non-adherence, according to 89% in pharmacy, 84% medical, and 76% in nursing education. The ABC Taxonomy was taught in more than half of all pharmacy (73%), nursing (60%) and medical education (52%). In the qualitative analysis of free text-answers respondents emphasized the value of early, mixed method teaching. They reported a lack of guidance in teaching medication adherence, causing inconsistency in the educational quality and depth. Time constraints were highlighted as a significant challenge, while interprofessional collaboration and use of medication adherence technologies were seen as opportunities, though not widely implemented in teaching. The curricula inventory showed a substantial variance in how medication adherence content was described.

CONCLUSION

There is a lack of consistent teaching on medication adherence in Europe, underlining the necessity to establish a unified curriculum incorporating the ABC taxonomy, and to include a more patient-centred approach to support medication adherence.

Correlation Between Objective Habit Metrics and Objective Medication Adherence: Retrospective Study of 15,818 Participants From Clinical Studies

BACKGROUND

Medication adherence, or how patients take their medication as prescribed, is suboptimal worldwide. Improving medication-taking habit might be an effective way to improve medication adherence. However, habit is difficult to quantify, and conventional habit metrics are self-reported, with recognized limitations. Recently, several objective habit metrics have been proposed, based on objective medication-taking data.

OBJECTIVE

We aim to explore the correlation between objective habit metrics and objective medication adherence on a large dataset.

METHODS

The Medication Event Monitoring System Adherence Knowledge Center, a database of anonymized electronic medication intake data from ambulant participants enrolled in past clinical studies, was used as the data source. Electronic medication intake data from participants following a once-daily regimen and monitored for 14 days or more were used. Further, two objective habit metrics were computed from each participant's medication intake history: (1) SD of the hour of intake, representing daily variability in the timing of medication intakes, and (2) weekly cross-correlation, representing weekly consistency in the timing of medication intakes. The implementation component of medication adherence was quantified using (1) the proportion of doses taken and (2) the proportion of correct days.

RESULTS

A total of 15,818 participants met the criteria. These participants took part in 108 clinical studies mainly focused on treatments for hypertension (n=4737, 30%) and osteoporosis (n=3353, 21%). The SD of the hour of intake was significantly negatively correlated with the 2 objective adherence metrics: proportion of correct days (Spearman correlation coefficient, ρS=-0.62, P<.001) and proportion of doses taken (ρS=-0.09, P<.001). The weekly cross-correlation was significantly positively correlated with the 2 objective adherence metrics: proportion of correct days (ρS=0.55, P<.001) and proportion of doses taken (ρS=0.32, P<.001). A lower daily or weekly variability in the timing of medication intakes is thus associated with better medication adherence. However, no variability is not the norm, as only 3.6% of participants have 95% of their intakes in a 1-hour window. Among the numerous factors influencing medication adherence, habit strength is an important one as it explains over 30% of the variance in medication adherence.

CONCLUSIONS

Objective habit metrics are correlated to objective medication adherence. Such objective habit metrics can be used to monitor patients and identify those who may benefit from habit-building support.

Stakeholder perspectives on facilitators and barriers to implementing a zero-dollar copay program for chronic conditions study

BACKGROUND

Type 2 diabetes mellitus (T2D) remains a pressing public health concern. Despite advancements in antidiabetic medications, suboptimal medication adherence persists among many individuals with T2D, often due to the high cost of medications. To combat this issue, Blue Cross and Blue Shield of Louisiana (Blue Cross) introduced the $0 Drug Copay (ZDC) program, providing $0 copays for select drugs. This study sought to explore barriers and facilitators to the successful implementation of Blue Cross's ZDC program (updated version).

METHODS

Focus group discussions and interviews were conducted with health plan leadership, health coaches and providers who participate in the health plan organization's healthcare quality improvement program. Focus group discussions and semi-structured interviews were conducted between October 2022 and July 2023. Discussion guides were developed collaboratively and tailored to each participant group. Interviews were recorded, transcribed and analysed using NVivo® qualitative analysis software. A descriptive, qualitative analysis was conducted, resulting in the identification of seven codes and subsequent candidate themes.

RESULTS

In total, 15 participants were interviewed: 6 were Blue Cross administrators, 5 were health coaches and 4 were Quality Blue providers. Overall, participants had positive feedback on the ZDC program and perceived that it has significant benefits for patients and the health system but could be improved, and four themes related to implementation barriers and facilitators, effectiveness and potential areas of improvement were identified: (1) the ZDC program reduces friction for patients, prescribers and the health system; (2) the program is aligned with the values of health systems, insurers and providers, facilitating implementation success; (3) expanding coverage (drug classes and conditions) and education (for providers and patients) could maximize program benefits; and (4) coronavirus disease 2019 (COVID-19) did not negatively impact program administration because the $0 copay was programmed at the benefit level.

CONCLUSIONS

The ZDC program aligns goals and can benefit patients, providers and patients. The program can have the largest potential if it is expanded to include new medications and new conditions, and if there is more education for patients and providers. Regardless of challenges, reduced-copay programs have the potential to improve medication adherence, improve HbA1C control and improve overall health outcomes. Trial Registration This study was approved by the Tulane University Institutional Review Board, IRB #2020-1986.

Cost-effectiveness of a Low-cost Educational Messaging and Prescription-fill Reminder Intervention to Improve Medication Adherence Among Individuals With Intellectual and Developmental Disability and Hypertension

BACKGROUND

Adults with intellectual and developmental disabilities (IDDs) have a similar prevalence of hypertension as the general population, but a higher rate of medication nonadherence at 50% compared with the average of 30%.

OBJECTIVES

To assess the cost-effectiveness of educational messaging and prescription-fill reminders to adults with IDD and hypertension and their helpers among Medicaid members in a randomized control trial.

RESEARCH DESIGN

The authors calculated net cost savings by subtracting per-participant intervention costs from differences in spending between preintervention/postintervention cases versus controls. Using bootstrap samples, they assessed the probability of positive cost savings. They used quantile and logistic regression to examine which members contributed to the cost savings and to identify future high-cost members at baseline.

SUBJECTS

Four hundred twelve members with IDD and their helpers were recruited from the South Carolina Medicaid agency in 2018.

MEASURES

Intervention costs were determined using labor and communication costs. Health expenditures were obtained from South Carolina's all-payer claims database, using actual Medicaid expenditures and total all-payer expenditures estimated with cost-to-charge ratios.

RESULTS

The intervention, which cost $26.10 per member, saved $1008.02 in all-payer spending and $1126.42 in Medicaid payments per member, respectively, with 78% and 91% confidence. Cost savings occurred among members above the 85th percentile of spending, and those using the emergency department or inpatient services at least twice at baseline were predicted to be future high-cost members.

CONCLUSIONS

The intervention is cost-saving, and insurers can prospectively identify and target members who will likely benefit.

Adherence, Fears, and Beliefs about Biologic Drugs in Rheumatoid Arthritis Patients: A North African Pilot Study

Purpose

To investigate the impact of beliefs in adherence to biologic drugs among patients with rheumatoid arthritis (RA).

Methods

This was a cross-sectional study, including RA patients who were on biologic disease-modifying antirheumatic drugs (bDMARDs). Therapeutic adherence was evaluated arbitrarily using a self-reported method by asking them the following question: "Do you regul arly take your biologic drug as prescribed by your doctor?". The Beliefs about Medicines Questionnaire (BMQ) was used to evaluate medication beliefs [general overuse, general harm, specific necessity, specific concerns].

Results

Seventy-five RA patients were included (80.0% females, 33.3% illiterate, and 68.0% unemployed, mean age: 57±9 years, mean disease activity score: 3.94±1.32). Adherence to the current biologic drug was reported by 71 patients (94.7%). The means ± standard deviation scores for general overuse, general harm, specific necessity, and specific concerns were 14.0±2.4, 10.8±4.4, 20.6±5.7, and 10.3±3.3, respectively. Compared to the adherent group (n=71), the non-adherent group (n=4) had a lower specific necessity score (21.0±5.4 vs. 13.5±7.5, respectively, p=0.009), a higher specific concern score (10.1±3.13 vs. 15.0±2.8, respectively, p=0.036), and similar scores for general overuse and general harm (10.0±2.3 vs. 9.5±1.9, p=0600; 13.3±4.4 vs. 11.5±4.1, p=0.400, respectively). In logistic regression, specific necessity and specific concerns scores were significantly associated with adherence (Odds-ratio (OR)= 0.855, 95% confidence interval (CI) [0.726-1.006], and 1.438, 95% CI [1.004-1.980], respectively).

Conclusion

Our study showed that RA patients have strong beliefs about the necessity to take biologic drugs which significantly influence the adherent behaviour therapy.

Exploration of Features of Mobile Applications for Medication Adherence in Asia: Narrative Review

BACKGROUND

Medication is crucial for managing chronic diseases, yet adherence rates are often suboptimal. With advanced integration of IT and mobile internet into health care, mobile apps present a substantial opportunity for improving adherence by incorporating personalized educational, behavioral, and organizational strategies. However, determining the most effective features and functionalities for these apps within the specific health care context in Asia remains a challenge.

OBJECTIVE

We aimed to review the existing literature, focusing on Asian countries, to identify the optimal features of mobile apps that can effectively enhance medication adherence within the unique context of Asian societies.

METHODS

We conducted a narrative review with the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. We identified studies on mobile apps for medication adherence from January 2019 to August 2024 on PubMed and Scopus. Key search terms included "Asia," "chronic disease," "app," "application," "survey," "experiment," "questionnaire," "group," "medical adherence," "medication adherence," "case-control," "cohort study," "randomized controlled trial," "clinical trial," "observational study," "qualitative research," "mixed methods," and "analysis," combined using logical operators "OR" and "AND." The features of mobile apps identified in the studies were evaluated, compared, and summarized based on their disease focuses, developers, target users, features, usability, and use.

RESULTS

The study identified 14 mobile apps designed to enhance medication adherence. Of these, 11 were developed by research teams, while 3 were created by commercial companies or hospitals. All the apps incorporated multiple features to support adherence, with reminders being the most common, present in 11 apps. Patient community forums were the least common, appearing in only 1 app. In total, 6 apps provided lifestyle modification functions, offering dietary and exercise recommendations, generating individualized plans, and monitoring progress. In addition, 6 apps featured health data recording and monitoring functions, with 4 allowing users to export and share records with researchers or health care professionals. Many apps included communication features, with 10 enabling feedback from researchers or health care professionals and 7 offering web-based consultation services. Educational content was available in 8 apps, and 7 used motivation strategies to encourage adherence. Six studies showed that mobile apps improved clinical outcomes, such as blood glucose, lipid, and pressure, while reducing adverse events and boosting physical activities. Twelve studies noted positive humanistic effects, including better medication adherence, quality of life, and user satisfaction.

CONCLUSIONS

This review has identified key components integrated into mobile apps to support medication adherence. However, the lack of government and corporate involvement in their development limits the generalizability of any individual app. Beyond basic reminder functions, features such as multiuser support, feedback mechanisms, web-based consultations, motivational tools, and socialization features hold significant promise for improving medication adherence. Further pragmatic research is necessary to validate the effectiveness of these selected apps in enhancing adherence.

Association between low cognitive performance and diabetes-related health indicators across racial and ethnic groups in adults with diabetes

AIM

To examine the associations between low cognitive performance (LCP) and diabetes-related health indicators (including body mass index [BMI], HbA1c, systolic blood pressure [SBP], low-density lipoprotein [LDL] and self-reported poor physical health) and whether these associations vary across racial/ethnic subgroups.

METHODS

We identified adults aged 60 years or older with self-reported diabetes from the 2011-2014 National Health and Nutrition Examination Survey. Individuals with cognitive test scores in the lowest quartile were defined as having LCP. We used regression models to measure the associations of LCP with diabetes-related biometrics (BMI, HbA1c, SBP and LDL); and self-reported poor physical health. Moreover, we explored potential variations in these associations across racial/ethnic subgroups.

RESULTS

Of 873 (261 with LCP) adults with diabetes, LCP was associated with higher HbA1c, SBP and LDL (adjusted difference: 0.41%, 5.01 mmHg and 5.08 mg/dL, respectively; P < .05), and greater odds of reporting poor physical health (adjusted odds ratio: 1.59, P < .05). The association between LCP and HbA1c was consistent across racial/ethnic groups, and notably pronounced in Hispanic and Other. BMI worsened with LCP, except for non-Hispanic Black. Excluding the Other group, elevated SBP was observed in people with LCP, with Hispanic showing the most significant association. LDL levels were elevated with LCP for Hispanic and Other. Physical health worsened with LCP for both non-Hispanic Black and Hispanic.

CONCLUSIONS

We quantified the association between LCP and diabetes-related health indicators. These associations were more pronounced in Hispanic and Other racial/ethnic groups.

Tensions in caring for chronic patients' medication adherence: A qualitative study in Cyprus

Medication adherence (MA) to recommended treatment is a multi-faceted problem and an ongoing challenge for healthcare providers (HCPs) to monitor. This qualitative study with 10 HCPs in Cyprus aims to explore HCPs' perceptions and strategies used on addressing medication non-adherence (MNA) in patients with chronic conditions. Two main themes emerged from the analysis reflecting the ways that HCPs described their reactions to MNA of their patients: (1) "Relying on information provision to improve MA" and (2) "Trying to understand patients' perspective." HCPs reported empathizing with patients and engaging in discussions to understand patients' perspective and reasons for MNA, so as to explore alternative solutions. Simultaneously, some HCPs reflected that the techniques used to improve MA are solely centered around information on medication and side-effects. HCPs experienced an internal conflict between providing patient-centered care versus using directive approaches to improve MA. Findings suggest how HCPs could thoroughly address patients' individual barriers.

Adapting malaria indicator surveys to investigate treatment adherence: a pilot study on Bioko Island, Equatorial Guinea

BACKGROUND

Adherence to anti-malarial treatment regimens is an important aspect of understanding and improving the impact of malaria case management. However, both adherence to artemisinin-based combination therapy (ACT) and the factors driving it vary widely. While many other evaluation activities have been conducted on Bioko Island, until now adherence to anti-malarial treatments, and in particular ACT has not been evaluated.

METHODS

The implementation of a malaria indicator survey (MIS) conducted on Bioko in 2023 was leveraged to evaluate adherence to ACT provided to individuals testing positive following the survey. A follow-up team visited the targeted households, physically observed treatment blisters where possible, and provided messaging to household members on the importance of adhering to the treatment guidelines to household members. The team used survey data from the targeted households to make messaging as relevant to the household's particular context as possible.

RESULTS

Overall ACT adherence on Bioko Island was low, around 50%, and this varied demographically and geographically. Some of the highest transmission areas had exceptionally low adherence, but no systematic relationship between proper adherence and Plasmodium falciparum prevalence was detected. Estimates of adherence from follow-up visits were much lower than survey-based estimates in the same households (52.5% versus 87.1%), suggesting that lack of proper adherence may be a much larger issue on Bioko Island than previously thought.

CONCLUSION

Representative surveys can be easily adapted to provide empirical estimates of adherence to anti-malarial treatments, complementary to survey-based and health facility-based estimates. The large discrepancy between adherence as measured in this study and survey-based estimates on Bioko Island suggests a health facility-based study to quantify adherence among the population receiving treatment for symptomatic malaria may be necessary.

Medication non-adherence and its associated factors among kidney transplant patients in a large teaching hospital in Ethiopia

BACKGROUND

This study examines medication adherence among kidney transplant patients at St. Paul's Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia, focusing on the level of adherence and associated factors to immunosuppressant medicines.

METHODS AND MATERIALS

A cross-sectional study was conducted on 270 patients from October 2021 to January 2022 using a structured questionnaire analyzed with SPSS version 26. The prevalence of medication adherence was computed, and a binary logistic regression was fitted to estimate the association. Medication adherence level measurement in post-kidney transplant patients was assessed using the Simplified Medication Adherence Questionnaire (SMAQ) and Basel Adherence Assessment Scale in Immunosuppressants (BAASIS). A 95% confidence interval and p-value < 0.05 were used for statistical significance.

RESULTS

The study found that 71.5% of kidney transplant patients were male, with a median age of 37 and a mean duration of 3.55 years. Medication adherence in post-kidney transplant patients was 81.9%. Post-transplant duration above 5 years and missing follow-up visits more than two times was associated with a 92.6% and 91.2% in medication non-adherence rate respectively. Additionally, forgetfulness was associated with a 90.6%, non-adherence level compared to drug unavailability and financial reasons.

CONCLUSION AND RECOMMENDATION

The study indicates that our patients exhibit higher medication adherence than WHO-measured levels, suggesting the need for healthcare providers to strengthen their intervention, especially for those above 5 years post-kidney transplant. The reason for increased adherence could be explained by the health education program about the medication name, dosing, frequency of ingestion and adverse effects of the drug, and effects of non-adherence.

Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review

INTRODUCTION

Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions.

METHODS

We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest.

RESULTS

Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling).

DISCUSSION

The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions.

CONCLUSIONS

There is substantial evidence that community- and home-based interventions, digital health interventions and adherence counselling interventions can improve adherence to medication for chronic conditions. Future research should answer if existing interventions can be used to develop less complicated multifaceted adherence intervention strategies.

Long-term effects of motivational interviewing vs. traditional counseling on dog owners' adherence to veterinary dental home care: a three-year follow-up study

Introduction

Periodontal disease is one of the most common health issues in dogs. However, disease is largely preventable by eliminating dental plaque, best achieved by daily tooth brushing. Unfortunately, owner adherence is low to the recommendation of daily tooth brushing in dogs.

Objective

This study aimed to evaluate the impact of various communication strategies, traditional advice (TA) versus motivational interviewing (MI), and compare them to a control group receiving no additional communication (CG), on dog owners' performance of dental home care and the oral health of their dogs.

Methods

The study was conducted as a longitudinal clinical intervention study spanning 3 years, and involved 75 dog owners with young dogs who were randomly assigned to one of three groups: TA, MI, or CG. Intervention groups received annual telephone consultations based on their assigned methodology. A questionnaire was administered twice to all groups, and the dental health of the dogs was assessed at the study's conclusion.

Result

Tooth brushing frequency demonstrated a significant increase in the MI group compared to the CG group (p < 0.01), albeit with a relatively low occurrence of daily brushing among owners. Dental health assessment revealed a significantly lower plaque index in the MI group compared to the CG group (p < 0.05), and a lower calculus index in the TA group compared to the CG group (p < 0.01). No statistically significant differences were observed between the MI and TA groups in terms of dental health.

Conclusion

Regular veterinary communication appears to have a positive influence on dog owner adherence to veterinary recommendations concerning dental care in dogs. Communication with veterinarians (MI and traditional advice) improved owner knowledge, attitude, and decreased frequency of not brushing. Although dental health parameters improved, the effect size was small, suggesting the complexity of adherence. Personalized calls to dog owners offer potential for dental health improvement, warranting further comparison of MI with traditional advice.

Opinions and perceptions of patients with cardiovascular disease on adherence: a qualitative study of focus groups

BACKGROUND

Cardiovascular diseases are becoming more frequent throughout the world. Adherence to both pharmacological and non-pharmacological treatment, as well as lifestyles, is important for good management and control of the disease. This study aims to explore the opinions and perceptions of patients with ischemic heart disease on the difficulties associated with therapeutic adherence.

METHODS

An interpretive phenomenological study was carried out using focus groups and one semi-structured interview. The MAXQDA qualitative data analysis program was used for inductive interpretation of the group discourses and interview. Data were coded, and these were grouped by categories and then consolidated under the main themes identified.

RESULTS

Two in-person focus groups and one remote semi-structured interview were performed. Twelve participants (6 men and 6 women) from the Hospital de San Juan de Alicante participated, two of them being family companions . The main themes identified were aspects related to the individual, heart disease, drug treatment, and the perception of the health care system.

CONCLUSIONS

Adhering to recommendations on healthy behaviors and taking prescribed medications for cardiovascular disease was important for most participants. However, they sometimes found polypharmacy difficult to manage, especially when they did not perceive the symptoms of their disease. Participants related the concept of fear to therapeutic adherence, believing that the latter increased with the former. The relationship with health professionals was described as optimal, but, nevertheless, the coordination of the health care system was seen as limited.

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.

Key Features of Smart Medication Adherence Products: Updated Scoping Review

BACKGROUND

Older adults often face challenges in self-managing their medication owing to physical and cognitive limitations, complex medication regimens, and packaging of medications. Emerging smart medication dispensing and adherence products (SMAPs) offer the options of automated dispensing, tracking medication intake in real time, and reminders and notifications. A 2021 review identified 51 SMAPs owing to the rapid influx of digital technology; an update to this review is required.

OBJECTIVE

This review aims to identify new products and summarize and compare the key features of SMAPs.

METHODS

Gray and published literature and videos were searched using Google, YouTube, PubMed, Embase, and Scopus. The first 10 pages of Google and the first 100 results of YouTube were screened using 4 and 5 keyword searches, respectively. SMAPs were included if they were able to store and allowed for the dispensation of medications, tracked real-time medication intake data, and could automatically analyze data. Products were excluded if they were stand-alone software applications, not marketed in English, not for in-home use, or only used in clinical trials. In total, 5 researchers independently screened and extracted the data.

RESULTS

This review identified 114 SMAPs, including 80 (70.2%) marketed and 34 (29.8%) prototypes, grouped into 15 types. Among the marketed products, 68% (54/80) were available for consumer purchase. Of these products, 26% (14/54) were available worldwide and 78% (42/54) were available in North America. There was variability in the hardware, software, data collection and management features, and cost of the products. Examples of hardware features include battery life, medication storage capacity, availability of types and number of alarms, locking features, and additional technology required for use of the product, whereas software features included reminder and notification capabilities and availability of manufacturer support. Data capture methods included the availability of sensors to record the use of the product and data-syncing capabilities with cloud storage with short-range communications. Data were accessible to users via mobile apps or web-based portals. Some SMAPs provided data security assurance with secure log-ins (use of personal identification numbers or facial recognition), whereas other SMAPs provided data through registered email addresses. Although some SMAPs were available at set prices or free of cost to end users, the cost of other products varied based on availability, shipping fees, and subscription fees.

CONCLUSIONS

An expanding market for SMAPs with features specific to at-home patient use is emerging. Health care professionals can use these features to select and suggest products that meet their patients' unique requirements.

Patient satisfaction survey of the "Healthy Heart" pharmaceutical care service - evaluation of pharmacy labelling with pharmaceutical pictograms

INTRODUCTION

Low adherence is a major challenge in healthcare worldwide, being particularly dangerous for patients with chronic diseases, such as cardiovascular diseases and heart failure, where strict adherence is essential. Non-adherence is observed in almost half of patients, and the consequences encompass a lack of therapeutic effects, health deterioration, decreased quality of life, and even death. For cardiovascular patients, the great importance of health education and pharmaceutical education can be provided within pharmaceutical care in community pharmacies. Therefore, our study aimed at evaluating the level of satisfaction with the "Healthy Heart" pharmaceutical service, in which patients received pictograms with dosage information affixed to their medication.

MATERIAL AND METHODS

The study was designed for patients who had been prescribed an antiplatelet medication for the first time. The patients were recruited by 577 pharmacies that took part in the study after completing a special course. Ultimately, 1590 patients were enrolled in the study. The project ran from November 2019 to January 2022.

RESULTS

Most of patients had a positive attitude to the "Healthy Heart" pharmaceutical service. More than 85% of the respondents were of the opinion that the pictograms facilitated the use of the medication, and 81.7% of the respondents stated that the system of labels helped in adherence. Over 66% of the respondents thought that such labels should be included in pharmacy services, and 77.92% of the participants reported that this system of labelling medications should be offered through all pharmacies.

CONCLUSIONS

Pharmaceutical labels in the pharmacists' everyday practice can largely improve patient adherence. These efforts, provided as part of their pharmaceutical services, can have a huge influence on optimisation of patient health outcomes.

Using an Intervention Mapping Approach to Improve Adherence to Disease-Modifying Treatment in Multiple Sclerosis

BACKGROUND

Up to 50% of individuals with multiple sclerosis (MS) who are prescribed disease-modifying treatments (DMTs) do not take them as advised. Although many studies report on DMT adherence rate, few studies report on interventions involving individuals with MS. The current paper describes the development of an intervention aimed at improving adherence to DMTs among identified nonadherent individuals with MS.

METHODS

An intervention was developed using an Intervention Mapping approach, recommendations from reviews on medication adherence, and input from individuals with MS. Its content was determined by theories of health behavior (specifically, a perceptions and practicalities approach), empirical evidence collected among the specific target population (an observational "needs assessment" stage [n = 186]), and other studies.

RESULTS

A personalized intervention was tailored to the reasons for nonadherence, uncovered during the observational needs assessment stage, to be delivered sequentially by a neurologist and a psychologist. After the intervention objectives were identified, components of the intervention were set: psychoeducation and ways of coping with adverse effects; modification of unhelpful treatment beliefs (such modifications were found predictive of adherence in the observational phase of the study); improving confidence and self-efficacy; and developing strategies for remembering to take DMTs. These components were embedded within motivational interviewing.

CONCLUSIONS

Intervention Mapping was useful in developing an intervention grounded both in the theoretical approach of perceptions and practicalities and in empirical evidence from the literature and the target sample; concurrently, identifying determinants that the intervention did not address. The effectiveness of the intervention-which could potentially improve adherence among individuals with MS-needs to be examined.

Antimicrobial Stewardship for Outpatients with Chronic Bone and Joint Infections in the Orthopaedic Clinic of an Academic Tertiary Hospital, South Africa

Bone and joint infections are associated with prolonged hospitalizations, high morbidity and complexity of care. They are difficult to treat, and successful therapy requires organism-specific antimicrobial therapy at high doses for a prolonged duration as recommended in standard treatment guidelines (STGs). Adherence to the treatment plan is equally important, which is enhanced with knowledge of the condition as well as appropriate antibiotics. Consequently, the aim of this study was to provide antimicrobial stewardship (AMS) services to outpatients with chronic bone and joint infections presenting to the orthopaedic clinic at a public South African tertiary hospital. A total of 44 patients participated in this study. Chronic osteomyelitis was diagnosed in 39 (89%) patients and septic arthritis in 5 (11%). The majority (43%) of infections were caused by Staphylococcus aureus followed by Pseudomonas aeruginosa (14%). Seventy-one antibiotics were prescribed at baseline with rifampicin prescribed the most (39%), followed by ciprofloxacin (23%). The majority (96%) of the antibiotics were not prescribed according to the South African STG; however, interventions were only needed in 31% of prescribed antibiotics (n = 71) since the STG only recommends empiric therapy directed against Staphylococcus aureus. Seventy-seven percent of the patients obtained a high self-reported adherence score at baseline. Consequently, there is a need to improve AMS in bone and joint infections to improve future care.

Medication self-management toolkits for adults with multiple sclerosis: A scoping review

Background

Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions.

Objective

The main purpose of this review was to identify and summarize medication self-management toolkits for MS, as related to the design, delivery, components, and measures used to evaluate implementation and/or outcomes.

Methods

A scoping review was conducted following guidelines by JBI. Articles were included if they focused on adults (18 years or older) with MS.

Results

Six articles reporting on four unique toolkits were included. Most toolkits were technology-based, including mobile or online applications, with only one toolkit being paper-based. The toolkits varied in type, frequency, and duration of medication management support. Varying outcomes were also identified, but there were improvements reported in symptom management, medication adherence, decision-making, and quality of life. The six studies were quantitative in design, with no studies exploring the user experience from a qualitative or mixed-methods design.

Conclusions

There is limited research on medication self-management toolkits among adults with MS. Future development, implementation, and evaluation mixed-methods research are needed to explore user experiences and overall design of toolkits.

Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders

OBJECTIVE

To enhance the quality of care and clinical outcomes for children and adolescents with major depressive disorder (MDD) and persistent depressive disorder (PDD). The aims are as follows: (1) to summarize empirically based guidance about the psychosocial and psychopharmacologic treatment of MDD and PDD in children and adolescents; and (2) to summarize expert-based guidance about the assessment of these disorders as an integral part of treatment, and the implementation of empirically based treatments for these disorders in clinical practice.

METHOD

Statements about the treatment of MDD and PDD are based upon empirical evidence derived from a critical systematic review of the scientific literature conducted by the Research Triangle Institute International-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center under contract with the Agency for Healthcare Research and Quality (AHRQ). Evidence from meta-analyses published since the AHRQ/RTI-UNC review is also presented to support or refute the AHRQ findings. Guidance about the assessment and clinical implementation of treatments for MDD and PDD is informed by expert opinion and consensus as presented in previously published clinical practice guidelines, chapters in leading textbooks of child and adolescent psychiatry, the DSM-5-TR, and government-affiliated prescription drug information websites.

RESULTS

Psychotherapy (specifically, cognitive-behavioral and interpersonal therapies) and selective serotonin reuptake inhibitor (SSRI) medication have some rigorous (randomized controlled trials, meta-analyses) empirical support as treatment options. Because effective treatment outcomes are predicated in part upon accuracy of the diagnosis, depth of the clinical formulation, and breadth of the treatment plan, comprehensive, evidence-based assessment may enhance evidence-based treatment outcomes.

CONCLUSION

Disproportionate to the magnitude of the problem, there are significant limitations in the quality and quantity of rigorous empirical support for the etiology, assessment, and treatment of depression in children and adolescents. In the context of a protracted severe shortage of child and adolescent-trained behavioral health specialists, the demonstration of convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatment of MDD and PDD is a key research need. Other research priorities include the sequencing and comparative effectiveness of depression treatments, delineation of treatment mediators and moderators, effective approaches to treatment nonresponders and disorder relapse/recurrence, long-term effects and degree of suicide risk with SSRI use, and the discovery of novel pharmacologic or interventional treatments.

Lost Therapeutic Benefit of Delayed Low-Density Lipoprotein Cholesterol Control in Statin-Treated Patients and Cost-Effectiveness Analysis of Lipid-Lowering Intensification

OBJECTIVES

Attainment of low-density lipoprotein cholesterol (LDL-C) therapeutic goals in statin-treated patients remains suboptimal. We quantified the health economic impact of delayed lipid-lowering intensification from an Australian healthcare and societal perspective.

METHODS

A lifetime Markov cohort model (n = 1000) estimating the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment in statin-treated patients with uncontrolled LDL-C, at moderate to high risk of CHD with no delay or after a 5-year delay, compared with standard of care (no intensification), starting at age 40 years. Intensification was tested with high-intensity statins or statins + ezetimibe. LDL-C levels were extracted from a primary care cohort. CHD risk was estimated using the pooled cohort equation. The effect of cumulative exposure to LDL-C on CHD risk was derived from Mendelian randomization data. Outcomes included CHD events, quality-adjusted life-years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICERs). All outcomes were discounted annually by 5%.

RESULTS

Over the lifetime horizon, compared with standard of care, achieving LDL-C control with no delay with high-intensity statins prevented 29 CHD events and yielded 30 extra QALYs (ICERs AU$13 205/QALY) versus 22 CHD events and 16 QALYs (ICER AU$20 270/QALY) with a 5-year delay. For statins + ezetimibe, no delay prevented 53 CHD events and gave 45 extra QALYs (ICER AU$37 271/QALY) versus 40 CHD events and 29 QALYs (ICER of AU$44 218/QALY) after a 5-year delay.

CONCLUSIONS

Delaying attainment of LDL-C goals translates into lost therapeutic benefit and a waste of resources. Urgent policies are needed to improve LDL-C goal attainment in statin-treated patients.

Adherence to oral hormonal therapy in advanced prostate cancer: a scoping review

Background

Orally administrated agents play a key role in the management of prostate cancer, providing a convenient and cost-effective treatment option for patients. However, they are also associated with adherence issues which can compromise therapeutic outcomes. This scoping review identifies and summarizes data on adherence to oral hormonal therapy in advanced prostate cancer and discusses associated factors and strategies for improving adherence.

Methods

PubMed (inception to 27 January 2022) and conference databases (2020-2021) were searched to identify English language reports of real-world and clinical trial data on adherence to oral hormonal therapy in prostate cancer using the key search terms 'prostate cancer' AND 'adherence' AND 'oral therapy' OR respective aliases.

Results

Most adherence outcome data were based on the use of androgen receptor pathway inhibitors in metastatic castration-resistant prostate cancer (mCRPC). Self-reported and observer-reported adherence data were used. The most common observer-reported measure, medication possession ratio, showed that the vast majority of patients were in possession of their medication, although proportion of days covered and persistence rates were considerably lower, raising the question whether patients were consistently receiving their treatment. Study follow-up for adherence was generally around 6 months up to 1 year. Studies also indicate that persistence may drop further with longer follow-up, especially in the non-mCRPC setting, which may be a concern when years of therapy are required.

Conclusions

Oral hormonal therapy plays an important role in the treatment of advanced prostate cancer. Data on adherence to oral hormonal therapies in prostate cancer were generally of low quality, with high heterogeneity and inconsistent reporting across studies. Short study follow-up for adherence and focus on medication possession rates may further limit relevance of available data, especially in settings that require long-term treatment. Additional research is required to comprehensively assess adherence.

Enhancing Medication Adherence Among Patients With Schizophrenia and Schizoaffective Disorder: Mobile App Intervention Study

Introduction

Technology has permeated every aspect of our existence and the mental health sector is not exempt from this.

Objectives

The aim of this study was to test the impact of using a mobile phone app (MyTherapy pill reminder and medication tracker) on medication adherence in patients with schizophrenia and/or schizoaffective disorder.

Methods

Time series design was used. Fifty-one participants were recruited from tertiary hospitals in Oman. The Medication Adherence Rating Scale was used for assessing medication adherence. The data related to medication adherence were collected at baseline, 3 months later and 3 months after installing the program on participants' smartphones. SPSS data set used to analyze the data.

Results

A repeated-measures ANOVA found no significant change in the level of adherence among patients with schizophrenia and schizoaffective disorders at the start and 12 weeks later when the mobile app was installed (p  =  .371). However, adherence scores improved significantly 12 weeks after installation of mobile app compared with the same group at the baseline and 12 weeks before the installation of mobile app (p < .001).

Conclusion

The mobile phone app was effective in improving the adherence level among patients. Installation of the program and teaching patients how to use it to improve their level of adherence is recommended.

Study of Adherence Level and the Relationship Between Treatment Adherence, and Superstitious Thinking Related to Health Issues Among Chronic Disease Patients in Southern Jordan: Cross-Sectional Study

BACKGROUND

For disease management, numerous drugs are prescribed. However, long-term treatment adherence is still unsatisfactory. Culture influences beliefs regarding medication, particularly irrational ideas that affect treatment adherence. The Middle East, notably Jordan, is affected by a lack of awareness of these attitudes with regard to treatment adherence.

OBJECTIVE

Investigating the adherence level among patients with chronic diseases in southern Jordan. To determine whether certain demographic traits, different disease factors, and superstitions have any impact on treatment adherence.

PATIENTS AND METHODS

A cross-sectional study that assessed treatment adherence and superstitious thinking-related health issues were conducted among chronic disease patients who had reviewed intrinsic medicine clinics at the Karak governmental hospital.

RESULTS

For 314 participants, treatment adherence was categorized into three levels low-adherent patients made up 27.7% highly-adherent patients made up 49.4%, and the remaining adhered at a medium level. Treatment non-adherence was more common in the elderly and female, according to the chi-square analysis. Additionally, the classification of superstitious beliefs into three categories revealed that different percentages of the study population held low superstitious beliefs 21%, medium superstitions 54.1% and high superstitions 24.8% beliefs. The chi-square analysis revealed that the elderly, female, and low-educated patient groups were the highest in superstitious thinking. Multiple regression analysis revealed that educational level and superstitious thinking explained 0.223 of the treatment adherence variances. Treatment adherence is positively influenced by educational level β (0.244) value, but superstitious thinking is negatively influenced by β (-0.302) value.

CONCLUSION

In conclusion, about half of the participants highly adhered. The results of the multiple-regression analysis indicate that superstition and education were two variables that impacted treatment adherence in this study. While superstitious beliefs lead to lower treatment adherence, education has the opposite effect. Finally, it is recommended to promote patient education to reduce superstitious beliefs, improve medication adherence.

Analyzing the Spatial Equity of Walking-Based Chronic Disease Pharmacies: A Case Study in Wuhan, China

Chronic diseases place a substantial financial burden on both the patient and the state. As chronic diseases become increasingly prevalent with urbanization and aging, primary chronic disease pharmacies should be planned to ensure that patients receive an equitable distribution of resources. Here, the spatial equity of chronic disease pharmacies is investigated. In this study, planning radiuses and Web mapping are used to assess the walkability and accessibility of planned chronic disease pharmacies; Lorenz curves are used to evaluate the match between the service area of the pharmacies and population; location quotients are used to identify the spatial differences of the allocation of chronic disease pharmacies based on residents. Results show that chronic disease pharmacies have a planned service coverage of 38.09%, an overlap rate of 58.34%, and actual service coverage of 28.05% in Wuhan. Specifically, chronic disease pharmacies are spatially dispersed inconsistently with the population, especially the elderly. The allocation of chronic disease pharmacies is directly related to the standard of patients' livelihood. Despite this, urban development does not adequately address this group's equity in access to medication. Based on a case study in Wuhan, China, this study aims to fill this gap by investigating the spatial equity of chronic disease medication purchases.

A Pharmacist-Driven Education and Intervention Program that Improves Outcomes for Hypertensive Patients

Purpose: Uncontrolled hypertension is serious and may lead to severe cardiovascular events and death. To better educate and empower patients to meet their blood pressure (BP) management goals, a large, integrated academic healthcare system implemented the Blood Pressure Goals Achievement Program (BPGAP), a longitudinal intervention embedding community pharmacists within healthcare teams. This study evaluated BPGAP on its ability to promote patient BP management goals. Methods: A pre-/post-intervention analysis was conducted whereby BP measurements were evaluated longitudinally within acuity groups determined by k-means clustering. Generalized linear mixed models evaluated trends in BP by time period, and proportions of patients meeting BP management goals (<140/90 mmHg) were assessed in relation to BPGAP enrollment date. Results: There were 5,125 patients who were clustered into Uncontrolled, Borderline, and Controlled blood pressure groups; 2,108 patients had BP measurements across 4 time periods before and after BPGAP enrollment. Groups differed by patient age, sex, and other demographics (p<0.0001). Patients in the Uncontrolled and Borderline BP clusters demonstrated significant BP decreases after BPGAP enrollment, continuing at least to 1-year post-intervention; Controlled cluster patients maintained BPs throughout the study period. The proportion of patients with controlled BPs increased from 56% immediately pre-BPGAP to 74% in the 3- to 6-months following enrollment. Conclusion: BPGAP is effective at helping patients achieve their BP management goals. Pharmacists may play a key role in hypertension control through measuring BPs and including updates and recommendations in the electronic health record, educating patients, and engaging in communication with healthcare teams.

Online survey of owners' experiences of medicating their cats at home

OBJECTIVES

The aim of this study was to use an online survey to obtain information from cat owners about their experiences of medicating their cats.

METHODS

An online survey containing 35 questions on experiences of medicating cats was circulated to cat owners globally.

RESULTS

In total, 2507 surveys from 57 countries were analysed; 1724 from 'cat owners' and 783 from 'cat owners+' (respondents with significant cat experience, including veterinary professionals). Around half (50.7%) of cat owners were 'sometimes' or 'never' provided with information or advice on how to administer medication; however, 91.8% of those given information found it 'somewhat' or 'very' useful. Around half (53.6%) of owners sought information from the internet about how to administer medication. Total cat owners (cat owners and cat owners+) administered liquids (61.3%), pastes (45.3%) or tablets (39.5%) directly into their cat's mouth; fewer (22.6-24.1%) hid these medications in food. Total cat owners rated tablets significantly harder to administer than liquids; 53.0% chose liquids as their first-choice formulation while 29.3% chose tablets. Insulin injections and 'spot-ons' were significantly easier to administer than any oral medications. Over half (51.6%) of owners reported that medicating their cat(s) had changed their relationship with them; 77.0% reported that their cat(s) had tried to bite or scratch them when medicating. Other challenges included the cat(s) spitting out tablets (78.7%), refusing medication in food (71.7%) and running away (52.7%). Of the owners who failed to complete a course of medication (35.4%), 27.8% stopped near the end of the course, while 19.3% stopped after a few doses, in both cases as medicating was too difficult.

CONCLUSIONS AND RELEVANCE

Owners appreciate being provided with information about the administration of medication. Frequent challenges when medicating cats include potential human injury and damage to the owner-cat relationship. Pharmaceutical companies should provide a range of formulations to ease compliance. Veterinary clinics should provide information/demonstrations and internet links when prescribing medications.

Experience of Elderly Korean Women with Diabetes and Multimorbidity in Elderly Couple Households: A Qualitative Study

Elderly women with multimorbidity in elderly couple households face the double burden of managing their diseases while fulfilling their gender roles. This study aimed to investigate the daily life experiences of elderly women with diabetes and multimorbidity living as part of couple households in Korea. Ten women aged 65 or more with diabetes and multimorbidity and living as part of elderly couple households participated in this phenomenological qualitative study. The data were analyzed with van Manen’s method of study of analytical phenomena. Four essential themes were identified. Participants regarded diabetes and multimorbidity as a part of the aging process and continued to function as caregivers for their husbands and themselves, avoiding becoming a burden to their adult children. The findings of this study could help healthcare providers better understand elderly women with diabetes and multimorbidity and assist in improving the health of such women.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BACKGROUND

Between 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.

METHODS

The IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.

DISCUSSION

The IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05026775 . Registered 30th August 2021.

Reimbursed Medication Adherence Enhancing Interventions in European Countries: Results of the EUREcA Study

Introduction: Current literature lacks detailed understanding of the reimbursement framework of medication adherence enhancing interventions (MAEIs). As part of the ENABLE COST Action, the EUREcA (“EUropen REimbursement strategies for interventions targeting medication Adherence”) study aimed to provide an in-depth overview of reimbursed MAEIs currently available in European countries at national and regional levels and to pave the way for further MAEIs to be implemented in the future.

Methods: A web-based, cross-sectional survey was performed across 38 European countries and Israel. The survey questionnaire was developed as a result of an iterative process of discussion informed by a desk review. The survey was performed among invited ENABLE collaborators from June to July 2021. Besides descriptive analysis, association between country income and health care expenditure, and the availability of reimbursed MAEIs were also assessed.

Results: The survey identified 13 reimbursed MAEIs in nine countries: multi-dose drug dispensing (n = 5), medication review (n = 4), smart device (n = 2), mobile application (n = 1), and patient education (n = 1). The median GDP per capita of countries having ≥1 reimbursed MAEI was significantly higher compared to countries having no reimbursed adherence intervention (33,888 EUR vs 16,620 EUR, respectively; p = 0.05).

Conclusions: Our findings highlight that to date only a small number of MAEIs have been reimbursed in European countries. Comprehensive health technology assessment recommendations and multi-stakeholder collaboration could help removing barriers related to the implementation and reimbursement of MAEIs.

Scalability of effective adherence interventions for patients using cardiovascular disease medication - a realist synthesis inspired systematic review

Upscaling of medication adherence interventions to routine care is still challenging. This realist theory inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains; (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: 1) Complexity of the intervention 2) training; 3) customization of the intervention; 4) drivers of the intervention; 5) technical interventions 6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development.

Medication Self-Management in Hospitalised Patients with Schizophrenia or Bipolar Disorder: The Perceptions of Patients and Healthcare Providers

Aim(s): The aim of the study was to explore perspectives of hospitalised patients with schizophrenia or a bipolar disorder and their healthcare providers on medication self-management. Methods: In a qualitative descriptive design, semi-structured interviews were used. Forty-nine interviews were completed (nurses n = 18; psychiatrists n = 3; hospital pharmacists n = 2; patients n = 26). Data analysis was iterative using an inductive and thematic approach. Results: From the thematic analysis of the interviews, three main themes emerged: monitoring and shared decision-making, relationship based on trust, and patient satisfaction and rehabilitation; as well as three sub-themes: available tools, patient readiness, and safety. Regular monitoring and follow-ups were considered conditions for medication self-management. All stakeholders considered that the patient, the nursing staff, and the psychiatrist should all be involved in the process of medication self-management. All healthcare providers emphasized the importance of regular re-evaluations of the patient and were worried about medication errors and misuse. Most patients considered medication self-management during hospitalisation to increase their confidence, self-reliance, and satisfaction. Many participants thought it would make a positive contribution to the recovery process. Discussion: All stakeholders were positive towards medication self-management under specific conditions. According to the participants, medication self-management offered many benefits, including the implementation of more structure for the patient, an ameliorated preparatory phase towards discharge, and an actual improvement of future adherence. All participants considered medication self-management to contribute to more profound medication knowledge and an overall improvement of their health literacy. Implications and future perspectives: These findings will be used to develop a medication self-management tool in hospitalised patients with schizophrenia or bipolar disorders.

An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence

Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.

Management of Myeloproliferative Neoplasms (MPNs)

PURPOSE

To provide up to date guidance, practice recommendations and highlight barriers to medication adherence in the long-term management of chronic myeloproliferative neoplasms (MPNs).

AIM

Current drug therapy for MPN is not curative and has not been shown to prolong survival. The main indication for treatment is the prevention of thrombosis and medication adherence remains a challenge in this group of patients. Identifying potentially modifiable barriers to medication adherence including primary nonadherence and non-persistent adherence enables timely interventions to be put in place and improve overall medication adherence.

METHODS

A systematic review of peer-reviewed literature and expert opinions was performed using electronic databases (PubMed, EMBASE, MEDLINE, and Web of Science) that were searched for articles reporting MPN and medication adherence. Discussions A case vignette is discussed throughout the article and expert opinion with international peer reviewed guidelines that are authored to support clinical decision making at the point of care were utilised. The evidence base was combined with more practical/clinical (data based) insight from real world clinical practice. Adoption of a broad range of digital health care activities and services in the health care system (telehealth applications) by the advanced practice providers (Non-Medical Prescribers-NMPs) in MPN clinics included medication prescribing and management, oral drug compliance and adherence evaluations, interventions, chronic care management, counselling and patient education on treatments.

CONCLUSION

Current drug therapy for MPN is neither curative nor has it been shown to prolong survival, and medication adherence remains a challenge in this group of patients. The longevity of the patients' disease course may contribute to the high risk of non-adherence in this patient cohort. Poor adherence to long-term therapies severely compromises the effectiveness of treatment. Adherence interventions should be tailored to the needs of the patient in order to achieve maximum impact. Interventions aimed at improving adherence provide the best experience and outcome for the patient and their families and can have a profound impact on the quality of life and mitigation of disease consequences.

Effect of Pillbox Organizers with Alarms on Adherence to Pharmacotherapy in Parkinson Disease Patients Taking Three and More Daily Doses of Dopaminergic Medications

Improvement of adherence to pharmacotherapy in patients with Parkinson’s disease (PD) is a challenge in routine clinical practice. Our study was aimed at the effect of pillbox organizers with alarms improving adherence to pharmacotherapy and its impact on clinical outcomes. Forty nonadherent patients with PD being treated with ≥ 3 daily doses of levodopa and/or dopamine agonists were pseudorandomized and consecutively ranked to groups A (early-start intervention) and B (delayed-start intervention). We used the following validated diagnostic instruments: MMAS-8 (adherence), PDQ-8 (quality of life, QoL), GDS (depression), NMSS (non-motor symptoms), MDS-UPDRS III (motor involvement), MDS-UPDRS IV, and WOQ-9 (motor and non-motor fluctuations and dyskinesias). We proved a significantly improved rate of adherence with the use of pillbox organizers with alarms. Moreover, after only four weeks of using the pillbox organizer, we detected an improvement in QoL scores, motor involvement, motor-, and non-motor fluctuations. Our study showed that pillbox organizers with alarms are efficient in improving adherence to pharmacotherapy in PD. It also could contribute to better motor states, less severe fluctuations, and improved QoL.

Digital Medication Adherence Support: Could Healthcare Providers Recommend Mobile Health Apps?

Adherence to prescribed medication is suboptimal in 50% of the chronic population, resulting in negative medical and economic outcomes. With the widespread use of mobile phones worldwide, medication adherence apps for mobile phones become promising medication adherence aids thanks to simplicity, user-friendliness, and accessibility for the public. Yet, until today, there is insufficient evidence in favor of using mobile health (mHealth) apps to increase medication adherence. This study aims to develop a methodology for scientific and end-user (patient) mHealth evaluation (a) to identify medication adherence apps search terms, (b) to evaluate identified apps based on scientific criteria, and (c) to report best smartphone apps evaluated by patients. Search terms were identified via literature review and expertise. Firstly, an online questionnaire was developed to identify frequently used search terms by recruited patients. Related medication adherence apps were identified and selected using predefined inclusion criteria. Secondly, identified apps were evaluated thanks to a scientific evaluation method and a created online questionnaire for patient feedback. Recruited patients were invited to test and evaluate the selected apps. Out of 1,833 free-of-charge and 307 paid apps identified, only four free-of-charge and three paid apps remained included in the study after eligibility criteria. None of the selected app reached a high score. Looking at the overall scores, Medisafe (59%), MyTherapy (56%), and Meds on time (44%) received the highest scores in the scientific app evaluation. In the patient evaluation, Dosecast (3.83 out of five points), Medisafe (3.62), and SwissMeds (3.50) received the highest scores. None of the apps in this research has undergone a process for certification, for example, CE marking, through a notified body. Security and data protection aspects of existing apps highly contribute to these low evaluation scores through little information on patient's data processing and storage. This might be corrected through the introduction of General Data Protection Regulation (GDPR) in the European Economic Area (EEA) and more scrutiny through regulatory bodies in the EU/EEA and the USA. None of the applications should be recommended by healthcare providers. In addition, clinical studies with chronic patients are necessary to measure long-term app impacts.

Exploring Stem Cell Transplanted Patients' Perspectives on Medication Self-Management and Electronic Monitoring Devices Measuring Medication Adherence: A Qualitative Sub-Study of the Swiss SMILe Implementation Science Project

PURPOSE

Little is known about allogeneic stem cell transplant (alloSCT) patients' medication adherence strategies. Acceptability and preferences regarding electronic monitoring (EM) systems to assess all three phases of medication adherence (ie, initiation, implementation, persistence) are crucial to allow their successful implementation in clinical or research settings but have not yet been evaluated. We therefore aimed to explore: 1) alloSCT patients' medication adherence and self-management strategies; and 2) their acceptability and preferences of three different EM systems (MEMS Cap, Helping Hand, Button) as part of the Swiss SMILe study.

PATIENTS AND METHODS

Respecting anti-pandemic measures, we used a purposive sample of six adult alloSCT patients from the University Hospital Basel, Switzerland (USB)-6 weeks to 2 years post-alloSCT-to conduct three focus group sessions with two patients each. Using a semi-structured outline, we explored 1) patients' medication adherence strategies and medication self-management; and 2) their acceptance and preferences regarding EM use. The three tested EM systems were available for testing during each session. Discussions were audio-recorded, visualized using mind-mapping and analyzed using Mayring's qualitative content analysis.

RESULTS

Patients (33% females; mean age 54.6±16.3 years; 10.4±8.4 months post-alloSCT) used medication adherence enhancing strategies (eg, preparing pillbox, linking intake to a habit). Still, they indicated that post-alloSCT medication management was challenging (eg, frequent schedule changes). All participants preferred the MEMS Button. Participants said its small size and the possibility to combine it with existing pillboxes (eg, putting it into/next to them) made them more confident about implementing it in their daily lives.

CONCLUSION

Regarding EM systems for medication adherence, end-user preferences and acceptability influence adoption and fidelity. Of the three systems tested, our sample found the MEMS Button most acceptable and most preferable. Therefore, we will use it for our USB SMILe study.

Technology-based interventions to improve adherence to antihypertensive medications - An evidence-based review

Background

Poor adherence to anti-hypertensive medications leads to poorly controlled blood pressure which is associated with worse cardiovascular outcomes. Emerging technologies may be utilised advantageously in interventions to improve adherence and reduce morbidity and mortality from poorly controlled hypertension.

Objective

To determine the efficacy of technology-based interventions in improving adherence to antihypertensive medications.

Methods

PubMed and EMBASE databases were searched using keywords and MeSH terms. Included studies met the following criteria: randomized controlled trial (RCT); adults ≥ 18 years old taking anti-hypertensives; intervention delivered by or accessed using a technological device or process; intervention designed to improve adherence.

Results

12 papers met inclusion criteria for the current review: 5 studies significantly improved adherence when compared to usual care; of these 5 studies, 2 had corresponding significant improvement in blood pressure. Successful interventions were: electronic medication bottle cap with audio-visual reminder; short message service (SMS) containing educational information (2 studies); reporting of self-measured blood pressure to a telephone-linked computer system; sending a video of every drug ingestion to obtain monetary rewards.

Conclusion

RCTs on technological interventions to improve adherence and those showing significant effect are rare. Some of the interventions show potential to be applied to other populations, especially if targeted at patients with poor adherence at baseline.

Pharmacists' and patients' perceptions about the importance of pharmacist services types to improve medication adherence among patients with diabetes in Indonesia

BACKGROUND

Various pharmacist services are available to improve medication adherence, including consultation, brochure, etc. Challenges arise on which services are best implemented in practice. Knowledge about patients' and pharmacists' preferences can help to prioritize services. This study explores the pharmacists' and patients' perceptions about the importance of pharmacist services to improve medication adherence among patients with diabetes in Indonesia.

METHODS

This questionnaire-based cross-sectional study involved adult outpatients with diabetes type 2 and pharmacists from community health centers (CHCs) and hospitals in Surabaya, Indonesia. Random sampling was used to identify 57 CHCs in the study. In addition, based on convenient sampling, three hospitals participated. All pharmacists working at the CHCs and hospitals, who were willing to participate, were included in the study. For patients, minimum sample size was calculated using Slovin's formula. Patients and pharmacists were asked to rank five pharmacist service types (consultation, brochure/leaflet, patient group discussion, medication review, and phone call refill reminder) according to their importance to improve medication adherence. A face validity test of the self-developed questionnaire was conducted before the data collection. Rank ordered probit models were estimated (STATA 15th software).

RESULTS

A total of 457 patients from CHCs, 579 patients from hospitals, and 99 pharmacists from both medical facilities were included. Consultation (CHC patients 56.0% vs hospital patients 39.7% vs pharmacists 75.2%) and brochure (CHC patients 23.2% vs hospital patients 27.5% vs pharmacists 11.9%) were the most preferred pharmacist services. Patients with experience getting medication information from pharmacists valued consultation higher than brochure and patient group discussions. Older patients ranked a brochure higher than other services. Patients without formal education in CHCs had a lower probability of giving a high rank to a brochure to improve medication adherence. There was significant positive correlation between the ranking of phone call refill reminder and medication review (0.6940) for patients in CHCs.

CONCLUSION

For both patients and pharmacists, consultation, brochure, and group discussion were the highest-ranked services. Education, age, experience with pharmacist services, and medical facility features need to be considered when evaluating which pharmacist services to implement in Indonesia.

Investigation of Barriers and Facilitators to Medication Adherence in Patients With Type 2 Diabetes Across Different Health Literacy Levels: An Explanatory Sequential Mixed Methods Study

Type 2 diabetes (T2D) incurs tremendous healthcare costs associated with various complications due to poor blood sugar control. Medication adherence, which is correlated with patients’ health literacy, should be consistently practiced to achieve optimal control of blood sugar. A comprehensive understanding of specific communication and psychosocial factors related to medication-taking behaviors across different levels of health literacy among people with T2D will guide the development of effective interventions and strategies to enhance medication adherence. To understand barriers and facilitators to medication adherence in people with T2D across different health literacy levels, the Health Literacy Pathway Model was used to identify the psychosocial and communication factors that may influence medication adherence. This mixed methods study used an explanatory sequential design, including a quantitative survey followed by qualitative semi-structured interviews. Two hundred and five participants completed the survey questionnaire, and 23 participants completed semi-structured interviews. Confirmed by quantitative and qualitative data, having stronger self-efficacy and fewer concerns about medications, as well as experiencing fewer perceived barriers to medication-taking, are necessary for better medication adherence among those with low adherence. Our findings will be useful to tailor interventions for diabetes care through addressing concerns among low-adherent patients with low health literacy and emphasizing self-efficacy and perceived barriers to medication adherence among all low-adherent patients with T2D.

User Perception of Automated Dose Dispensed Medicine in Home Care: A Scoping Review

(1) Background: Automated dose dispensing (ADD) systems are today used around the world. The ADD robots are placed in patients' homes to increase medication safety as well as medication adherence; however, little is known about how ADD robots affect the patient's day-to-day lives, receiving the daily doses of medicine from a machine rather than from a human healthcare professional. The aim of this study is to review the available literature on users' perceptions of having an ADD robot and collect evidence on how they perceive having less human contact after implementing this technology in their homes. (2) Methods: References were searched for in Embase and PubMed. Literature investigating ADD robots in primary healthcare was included in this study and literature in a hospital setting was excluded. After screening processes, eleven publications were included in this review. (3) Results: The literature reported high medication adherence when using ADD robots and general satisfaction in terms of user experiences with the acceptability and functionality of ADD. (4) Conclusion: The review is the first focusing on user experience and perceptions regarding ADD robots. General satisfaction was shown towards ADD robots as an intervention, but the review indicates that research is missing on healthcare professionals and patient perceptions on how ADD affects their routines, both in relation to work and daily life.

Adherence to Non-Selective Beta Blockers for Prevention of Variceal Bleeding in Cirrhotic Patients

BACKGROUND AND AIM

Long-term use of non-selective beta blockers (NSBBs) is essential for the prevention of esophageal variceal bleeding in liver cirrhosis but may impair the patient's adherence. The present study aimed to investigate the adherence to NSBBs to prevent variceal bleeding in cirrhotic patients.

METHODS

All patients who had an indication of NSBBs for the prophylaxis of variceal bleeding between February 2018 and June 2019 were screened. Clinical pharmacists gave pre-medication education and recorded the adherence to NSBBs during the patients' hospitalizations. Factors associated with poor adherence were evaluated by univariate logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The relationship between poor adherence during follow-up and variceal bleeding after discharge was also evaluated.

RESULTS

Overall, 108 patients were screened, of whom 12 were intolerant to NSBBs. Among the 96 remaining patients who could take NSBBs, the average change of heart rate after NSBBs was -10.49 b.p.m. Twenty-two (22.9%) patients had poor adherence to NSBBs due to their refusal to take NSBBs (n = 2), complete forgetfulness to take NSBBs (n = 10), and refusal or forgetfulness to monitor heart rate (n = 10). Univariate logistic regression analysis demonstrated that only older age was significantly associated with poor adherence (OR: 1.065, 95% CI: 1.019-1.114, P = 0.005). Patients with poor adherence during follow-up were more likely to develop variceal bleeding after discharge.

CONCLUSION

A significant proportion of cirrhotic patients had poor adherence to NSBBs during their hospitalizations. Further studies should explore how to improve the patient's adherence to NSBBs.