Randomized trial of telephone outreach to improve medication adherence and metabolic control in adults with diabetes

Artificial intelligence based predictive tools for identifying type 2 diabetes patients at high risk of treatment Non-adherence: A systematic review

AIMS

Several Artificial Intelligence (AI) based predictive tools have been developed to predict non-adherence among patients with type 2 diabetes (T2D). Hence, this study aimed to describe and evaluate the methodological quality of AI based predictive tools for identifying T2D patients at high risk of treatment non-adherence.

METHODS

A systematic search was conducted across multiple databases including, EMBASE, Cochrane Library, MedLine, and Google Scholar search. The Prediction model Risk Of Bias ASsessment Tool (PROBAST) was used to assess the quality of studies. The performances of tools were assessed by Area Under the Curve (AUC), precision, recall, C-index, accuracy, sensitivity, specificity or F1 score.

RESULTS

Most studies measured predictive ability using AUC (75 %), and some only reported precision (25 %), recall (12.5 %), C-index (12.5 %), accuracy (37.5), sensitivity (12.5 %), specificity (12.5 %) or F1 score (25 %). All tools had moderate to high predictive ability (AUC > 0.70). However, only one study conducted external validation. Demographic characteristics, HbA1c, glucose monitoring data, and treatment details were typical factors used in developing tools.

CONCLUSIONS

The existing AI based tools holds significant promise for improving diabetes care. However, future studies should focus on refining the existing tools, validating in other settings, and evaluating the cost-effectiveness of AI-supported interventions.

Audio-Based Care for Managing Diabetes in Adults: A Systematic Review

OBJECTIVES

We compared the effectiveness of audio-based care, as a replacement or a supplement to usual care, for managing diabetes.

BACKGROUND

Diabetes is a chronic condition afflicting many in the United States. The impact of audio-based care on the health of individuals with diabetes is unclear, particularly for those at risk for disparities-many of whom may only be able to access telehealth services through telephone.

METHODS

We used systematic review methods to synthesize available evidence. We systematically searched for English-language articles from 2012 reporting randomized controlled trials of adults diagnosed with diabetes. We abstracted data on clinical outcomes (including A1c), patient-reported health and quality-of-life, health care access and utilization, care quality and experience, and patient safety.

RESULTS

Evidence for replacing in-person care with audio care was limited (n = 2), with low certainty of evidence for greater and comparable effectiveness for A1c and harms, respectively. Supplemental audio care (n = 23) had a positive effect on A1c (pooled mean difference A1c -0.20%; n = 8763; 95% CI: -0.36% to -0.04%), with moderate certainty of evidence. Stratified results indicated that audio interventions supplementing usual care performed more favorably in individuals with A1c ≤ 9%; populations not at risk of disparities; interventions with at least monthly contact; and interventions using remote monitoring tools.

CONCLUSIONS

This evidence base reveals some promise for managing diabetes with audio-based care as a supplement to in-person care. Future studies could further investigate the effectiveness of audio-based care as a replacement and modify interventions to better serve individuals with poor glucose control and those at risk for disparities.

Pharmacist-Led Digital Health Interventions for Patients with Diabetes: A Systematic Review

Digital health interventions have emerged as a promising approach for patient care. The aim of this study was to conduct a systematic review of pharmacist-led digital health interventions for patients with diabetes. The PubMed database was used to select randomized controlled trials that assess the effectiveness of digital health interventions on clinical outcomes among patients with type 1 and 2 diabetes from January 2005 to May 2024. We included randomized controlled trial (RCT) studies on type 1 and 2 diabetes mellitus, analyzing the effects of all digital health interventions by pharmacists, including telephone-based intervention, web-based intervention, and mobile health application, as compared to usual care. The outcomes were a reduction in HbA1c, changes in medication adherence, and reduction of adverse effects. We used the PRISMA reporting standard to implement and report the results. A total of 19 studies were included. Among these, the included digital health interventions were telephone monitoring (n = 15), web-based intervention (n = 2), mobile health application (n = 1), and text-message reminder (n = 1). The findings showed variability: around half of the studies (n = 10, 52.63%) indicated that patients receiving digital health interventions had reduced HbA1c levels compared to those receiving usual care, while five studies (26.31%) found no difference between the intervention and usual care. Five studies (26.31%) showed that such interventions increased medication adherence, while two studies (10.53%) found no difference when compared to standard care. Effectiveness of the intervention is related to several factors, including practicability and patient engagement, frequency of the intervention, and the provision of personalized communication. Tailoring interventions to individual patient profiles and providing adequate support for enhancing practicability of these tools may improve their effectiveness. Further research assessing the cost-effectiveness of such intervention is necessary to inform healthcare policy.

Initial non-adherence to lipid-lowering medication: a systematic literature review

BACKGROUND

The impact on cardiovascular health is lost when a patient does not obtain a newly prescribed lipid-lowering medication, a situation termed "initial medication nonadherence" (IMN). This research summarizes the published evidence on the prevalence, associated factors, consequences, and solutions for IMN to prescribed lipid-lowering medication in the United States.

METHODS

A systematic literature search using PubMed and Google Scholar, along with screening citations of systematic reviews, identified articles published from 2010 to 2021. Studies reporting results of IMN to lipid-lowering medications were included. Studies that evaluated non-adult or non-US populations, used weaker study designs (e.g., case series), or were not written in English were excluded.

RESULTS

There were 19 articles/18 studies that met inclusion and exclusion criteria. Estimates of the prevalence of IMN to newly prescribed lipid-lowering medications ranged from 10 to 18.2% of patients and 1.4-43.8% of prescriptions (n = 9 studies). Three studies reported prescriber and patient characteristics associated with IMN. Hispanic ethnicity, Black race, lower Charlson Comorbidity Index score and no ED visits or hospitalization were associated with IMN. Lipid lowering prescriptions from primary care providers were also associated with IMN. Four studies described patient-reported reasons for IMN, including preference for lifestyle modifications, lack of perceived need, and side effect concerns. Four intervention studies reported mixed results with automated calls, live calls, or letters. One study reported worse clinical outcomes in patients with IMN: higher levels of low-density lipoprotein and greater risk of emergency department visits.

CONCLUSIONS

Up to one-fifth of patients fail to obtain a newly prescribed lipid-lowering medication but there is limited information about the clinical consequences. Future research should assess outcomes and determine cost-effective approaches to address IMN to lipid-lowering therapy.

Clinical and cost-effectiveness of telemedicine among patients with type 2 diabetes in primary care: A systematic review and meta-analysis

AIMS

Telemedicine has been promoted as an effective way of managing type-2 diabetes (T2DM) in primary care. However, the effectiveness of telemedicine is unclear. We investigated the clinical and cost-effectiveness of different telemedicine interventions for people with T2DM, compared to usual care.

METHODS

We searched Medline, Embase, Cochrane, CINHAL, ProQuest and EconLit for randomized controlled trials (RCTs) that examined the effectiveness of telemedicine interventions on clinical outcomes (HbA1c, body mass index [BMI], weight, diastolic blood pressure [DBP], systolic blood pressure [SBP], fasting blood glucose, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, total cholesterol and triglyceride) in adults with T2DM, published in English from inception until 31 December 2022. Meta-analyses were conducted using random-effects models pooling mean differences, heterogeneity was quantified using the I2 statistic. Publication bias was assessed using funnel plots, Egger tests and trim and fill. Subgroup analyses included type of telemedicine intervention, telemedicine mode of delivery and type of healthcare professionals. This study was registered with PROSPERO, CRD 42022375128.

RESULTS

Of the 4093 records identified, 21 RCTs, 10,732 participants from seven regions, were included. Reported interventions included telephone (k = 16 studies), internet-based (k = 2), videoconference (k = 2) and telephone and emails (k = 1). We observed no statistically significant differences between synchronous or asynchronous telemedicine interventions compared to usual care for HbA1c (-0.08% (-0.88 mmol/mol); 95% CI: -0.18, 0.02), BMI (0.51 kg/m2; 95% CI: -0.21, 1.22), SBP (-1.48 mmHg; 95% CI: -3.22, 0.26), DBP (3.23 mmHg; 95% CI: -0.89, 7.34), HDL-cholesterol (0.01 mmol/L; 95% CI: -0.03, 0.05), LDL-cholesterol (0.08 mmol/L; 95% CI: -0.22, 0.37), triglycerides (-0.08 mmol/L, 95% CI: -0.31, -0.15), total cholesterol (-0.10 mmol/L; 95% CI: -0.25, 0.04) and weight (-0.50 kg; 95% CI: -1.21, 0.21).

CONCLUSIONS

Telemedicine was as effective as usual care in improving health outcomes of people with T2DM. They can provide a safe solution in times of rising demands for primary healthcare services, or in extreme events, like a global pandemic. More high-quality RCTs are needed on the cost evaluation of telemedicine.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Telephone calls and glycemic control in type 2 diabetes: A PRISMA-compliant systematic review and meta-analysis of randomized clinical trials

AIMS

In-depth and updated systematic reviews evaluating telephone calls in type 2 diabetes (T2DM) management are missing. This study aimed to assess the effect of this intervention on glycemic control in T2DM patients when compared with usual care.

METHODS

We systematically searched for randomized controlled trials (RCT) on T2DM using Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and LILACS, up to March 2021. The Risk of Bias 2.0 (Rob 2.0) tool and GRADE were used for the quality evaluation. The intervention effect was estimated by the change in glycated hemoglobin (HbA1c). PROSPERO registry CRD42020204519.

RESULTS

3545 references were reviewed and 32 were included (8598 patients). Telephone calls, all approaching education, improved HbA1c by 0.33% [95% CI, -0.48% to -0.18%; I2 = 78%; p < 0.0001] compared to usual care. A greater improvement was found when the intervention included pharmacologic modification (-0.82%, 95% CI, -1.42% to -0.22%; I2 = 92%) and when it was applied by nurses (-0.53%, 95% CI, -0.86% to -0.2%; I2 = 87%). Meta-regression showed no relationship between DM duration and HbA1c changes.

CONCLUSION

The telephone call intervention provided a benefit regarding T2DM glycemic control, especially if provided by nurses, or if associated with patient education and pharmacological treatment modification.

Real-world primary nonadherence to antiobesity medications

BACKGROUND: Primary nonadherence (PNA), when a medication is newly prescribed but not filled, has been identified as a major research gap potentially impacting the optimal treatment of patients with overweight and obesity who are newly prescribed antiobesity medications (AOMs). OBJECTIVES: To assess PNA among patients with newly prescribed AOMs and to examine factors associated with PNA to AOMs. METHODS: This was a retrospective study that used the Optum Integrated Clinical plus Claims database to identify individuals who had at least 1 prescription order for an AOM the US Food and Drug Administration approved for long-term use. Individuals with prescription orders between January 1, 2012, and February 28, 2019, were identified, and patient demographics, clinical characteristics, medication prescribed, baseline health care utilization, and obesity-related complications were described by PNA status. PNA was defined as no pharmacy claim for the AOM within 60 days of the date of the new prescription order as identified in electronic health record data. A multivariable logistic regression model was used to examine factors associated with PNA. RESULTS: The study sample included a total of 1,563 patients. The mean body mass index was 38.4 kg/m2; 10.7% were prescribed liraglutide 3.0 mg, 26.0% were prescribed lorcaserin, 36.3% of patients were prescribed naltrexone-bupropion, 5.4% were prescribed orlistat, and 21.6% were prescribed phentermine-topiramate. Most patients (91.1%) exhibited PNA, with only 8.9% filling their newly prescribed AOM within 60 days. Both the adherent and nonadherent groups were predominately female sex, White, and covered by commercial insurance. The mean age was similar between the 2 groups. Most obesity-related complications were less prevalent in the adherent group, although the Charlson comorbidity index score was similar between the 2 groups. After adjustment for patient demographics and clinical characteristics, there was not a statistically significant association between the specific AOM and PNA (P = 0.299). Patients with depression or living in the Midwest or South regions were at significantly increased risk of PNA. CONCLUSIONS: The rate of PNA to AOMs was very high, suggesting barriers in effective medical management of patients with overweight and obesity. Future research is warranted to understand reasons for PNA to AOMs and how to address these barriers. DISCLOSURES: Dr Kan, Dr Bae, Dr Dunn, and Dr Ahmad are employees of Eli Lilly and Company. Ms Buysman and Dr Gronroos are employees of Optum. Dr Swindle was an employee of Optum at the time the study was conducted and is currently employed at Evidera. Dr Bengtson is employed at Boehringer Ingelheim Pharmaceuticals, Inc. (Boehringer Ingelheim has no connection to this study), and during the conduct of this study was employed at Optum.

Effectiveness of the Telemedical Lifestyle Intervention Program TeLIPro for Improvement of HbA1c in Type 2 Diabetes: A Randomized-Controlled Trial in a Real-Life Setting

The effectiveness of the multimodal Telemedical Lifestyle Intervention Program (TeLIPro) was proven in the advanced stages of type 2 diabetes mellitus (T2DM). Since its therapeutic potential focusing on telemedical coaching without using a formula diet is unknown, we evaluated improvements in HbA1c, HbA1c normalisation rate, cardiometabolic risk factors, quality-of-life, and eating behaviour in real life. In this randomized-controlled trial, AOK Rhineland/Hamburg insured T2DM patients (n = 1163) were randomized (1:1) into two parallel groups, and 817 received the allocated intervention. In addition to routine care, all participants got scales, step counters, and access to an online portal. The TeLIPro group additionally received equipment for self-monitoring of blood glucose and telemedical coaching. Data were collected at baseline, after 6 and 12 months of intervention as well as after a 6-month follow-up. The primary endpoint after 12 months was (i) the estimated treatment difference (ETD) in HbA1c change and (ii) the HbA1c normalisation rate in those with diabetes duration < 5 years. The TeLIPro group demonstrated significantly stronger improvements in HbA1c (ETD -0.4% (-0.5; -0.2); p < 0.001), body weight, body-mass-index, quality-of-life, and eating behaviour, especially in T2DM patients with diabetes duration ≥ 5 years (ETD -0.5% (-0.7; -0.3); p < 0.001). The HbA1c normalisation rate did not significantly differ between groups (25% vs. 18%). Continuous addition of TeLIPro to routine care is effective in improving HbA1c and health-related lifestyle in T2DM patients with longer diabetes duration in real life.

Application, Benefits, and Limitations of Telepharmacy for Patients with Diabetes in the Outpatient Setting

After the COVID-19 pandemic, telepharmacy has become increasingly widely used as an alternative to pharmaceutical care by remote pharmacists. Patients with diabetes mellitus are one of the patients who get benefit the most from telepharmacy practices, which allow patients to consult without meeting face to face and minimize the risk of virus transmission. The authors conduct an assessment of the benefits and limitations of using telepharmacy that are used throughout the world and then hopes that they can become a reference in the development of telepharmacy in the future. A total of 23 relevant articles were used for analysis in this narrative review after searching for articles in three sources, including PubMed, Google Scholar and ClinicalTrials.gov, until October 2022. This narrative review shows that telepharmacy plays an important role in improving clinical outcomes, patient therapy adherence and reduce the number of patient visit and hospitalization, but telepharmacy also has limitations in its use related to security and privacy, as well as pharmacist intervention that has not been maximized. However, telepharmacy has great potential to facilitate diabetes mellitus patients in pharmaceutical services.

Effectiveness of synchronous teleconsultation for patients with type 2 diabetes mellitus: a systematic review and meta-analysis

The popularity of teleconsultation during the COVID-19 pandemic enabled increased accessibility for individuals with type 2 diabetes mellitus (T2DM). However, previous studies did not distinguish between synchronous and asynchronous teleconsultation. We evaluated the effectiveness of synchronous teleconsultation for patients with T2DM. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library and Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to July 2021. All included studies were randomized controlled trials of synchronous teleconsultation for adults with T2DM compared with usual care. Reviewers independently extracted data and used the Cochrane tool to evaluate risk of bias. Meta-analyses were conducted using random-effects models. A pooled mean difference for both HbA1c (%) and body mass index (BMI) (kg/m²), systolic blood pressure (SBP) (mm Hg), diastolic blood pressure (DBP) (mm Hg), and low density lipoprotein cholesterol (LDL-cholesterol) (mg/dL) were calculated. Patient-reported outcomes, such as depression, medication adherence, and quality of life, were also assessed. A total of 9807 abstracts were identified and 27 trials were included. Synchronous teleconsultation significantly resulted in greater decrease in HbA1c compared with usual care group (n=8746, 0.35, 95% CI 0.20 to 0.49, I²=73%, p<0.001). No significant effects on BMI (n=699, 0.08 kg/m², 95% CI -0.54 to 0.69), SBP (n=5512, 1.32 mm Hg, 95% CI -0.09 to 2.73), DBP (n=2898, 0.17 mm Hg, 95% CI -1.18 to 1.52), or LDL-cholesterol (n=5276, 3.21 mg/dL, 95% CI -1.75 to 8.17) were found. The effect of teleconsultation in improving patient-reported outcomes was uncertain. Thus, synchronous teleconsultation could be an alternative to usual care. Systematic review registration is PROSPERO CRD42021267019.

Improving Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care: Pilot trial of a complex intervention

Introduction

The Initial Medication Adherence (IMA) intervention is a multidisciplinary and shared decision-making intervention to improve initial medication adherence addressed to patients in need of new treatments for cardiovascular diseases and diabetes in primary care (PC). This pilot study aims to evaluate the feasibility and acceptability of the IMA intervention and the feasibility of a cluster-RCT to assess the effectiveness and cost-effectiveness of the intervention.

Methods

A 3-month pilot trial with an embedded process evaluation was conducted in five PC centers in Catalonia (Spain). Electronic health data were descriptively analyzed to test the availability and quality of records of the trial outcomes (initiation, implementation, clinical parameters and use of services). Recruitment and retention rates of professionals were analyzed. Twenty-nine semi-structured interviews with professionals (general practitioners, nurses, and community pharmacists) and patients were conducted to assess the feasibility and acceptability of the intervention. Three discussion groups with a total of fifteen patients were performed to review and redesign the intervention decision aids. Qualitative data were thematically analyzed.

Results

A total of 901 new treatments were prescribed to 604 patients. The proportion of missing data in the electronic health records was up to 30% for use of services and around 70% for clinical parameters 5 months before and after a new prescription. Primary and secondary outcomes were within plausible ranges and outliers were barely detected. The IMA intervention and its implementation strategy were considered feasible and acceptable by pilot-study participants. Low recruitment and retention rates, understanding of shared decision-making by professionals, and format and content of decision aids were the main barriers to the feasibility of the IMA intervention.

Discussion

Involving patients in the decision-making process is crucial to achieving better clinical outcomes. The IMA intervention is feasible and showed good acceptability among professionals and patients. However, we identified barriers and facilitators to implementing the intervention and adapting it to a context affected by the COVID-19 pandemic that should be considered before launching a cluster-RCT. This pilot study identified opportunities for refining the intervention and improving the design of the definitive cluster-RCT to evaluate its effectiveness and cost-effectiveness.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05094986.

Development and assessment of novel machine learning models to predict medication non-adherence risks in type 2 diabetics

Background

Medication adherence is the main determinant of effective management of type 2 diabetes, yet there is no gold standard method available to screen patients with high-risk non-adherence. Developing machine learning models to predict high-risk non-adherence in patients with T2D could optimize management.

Methods

This cross-sectional study was carried out on patients with T2D at the Sichuan Provincial People's Hospital from April 2018 to December 2019 who were examined for HbA1c on the day of the survey. Demographic and clinical characteristics were extracted from the questionnaire and electronic medical records. The sample was randomly divided into a training dataset and a test dataset with a radio of 8:2 after data preprocessing. Four imputing methods, five sampling methods, three screening methods, and 18 machine learning algorithms were used to groom data and develop and validate models. Bootstrapping was performed to generate the validation set for external validation and univariate analysis. Models were compared on the basis of predictive performance metrics. Finally, we validated the sample size on the best model.

Results

This study included 980 patients with T2D, of whom 184 (18.8%) were defined as medication non-adherence. The results indicated that the model used modified random forest as the imputation method, random under sampler as the sampling method, Boruta as the feature screening method and the ensemble algorithms and had the best performance. The area under the receiver operating characteristic curve (AUC), F1 score, and area under the precision-recall curve (AUPRC) of the best model, among a total of 1,080 trained models, were 0.8369, 0.7912, and 0.9574, respectively. Age, present fasting blood glucose (FBG) values, present HbA1c values, present random blood glucose (RBG) values, and body mass index (BMI) were the most significant contributors associated with risks of medication adherence.

Conclusion

We found that machine learning methods could be used to predict the risk of non-adherence in patients with T2D. The proposed model was well performed to identify patients with T2D with non-adherence and could help improve individualized T2D management.

Complex multidisciplinary intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): mixed-methods process evaluation protocol

INTRODUCTION

Medication non-initiation, or primary non-adherence, is a persistent public health problem that increases the risk of adverse clinical outcomes. The initial medication adherence (IMA) intervention is a complex multidisciplinary intervention to improve adherence to cardiovascular and diabetes treatments in primary care by empowering the patient and promoting informed prescriptions based on shared decision-making. This paper presents the development and implementation strategy of the IMA intervention and the process evaluation protocol embedded in a cluster randomised controlled trial (the IMA-cRCT) to understand and interpret the outcomes of the trial and comprehend the extent of implementation and fidelity, the active mechanisms of the IMA intervention and in what context the intervention is implemented and works.

METHODS AND ANALYSIS

We present the protocol for a mixed-methods process evaluation including quantitative and qualitative methods to measure implementation and fidelity and to explore the active mechanisms and the interactions between the intervention, participants and its context. The process evaluation will be conducted in primary care centres and community pharmacies from the IMA-cRCT, and participants include healthcare professionals (general practitioners, nurses and community pharmacists) as well as patients. Quantitative data collection methods include data extraction from the intervention operative records, patient clinical records and participant feedback questionnaires, whereas qualitative data collection involves semistructured interviews, focus groups and field diaries. Quantitative and qualitative data will be analysed separately and triangulated to produce deeper insights and robust results.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Research Ethics Comittee (CEIm) at IDIAP Jordi Gol (codeCEIm 21/051 P). Findings will be disseminated through publications and conferences, as well as presentations to healthcare professionals and stakeholders from healthcare organisations.

TRIAL REGISTRATION NUMBER

NCT05026775.

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.

Effectiveness of telepharmacy diabetes services: A systematic review and meta-analysis

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Although pharmacist-provided diabetes services have been shown to be effective, the effectiveness of telepharmacy (TP) in diabetes management has not been clearly established. This systematic review and meta-analysis aims to evaluate the effectiveness of diabetes TP services.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from inception through September 2021) to identify published studies that evaluated the effect of TP services in patients with diabetes mellitus and reported either glycosylated hemoglobin (HbA1c) or fasting blood glucose (FBG) outcomes. Mean difference (MD), weighted mean difference (WMD), relative risk (RR), and 95% confidence intervals were calculated using the DerSimonian and Laird random-effects model.

RESULTS

36 studies involving 13,773 patients were included in the systematic review, and 23 studies were included in the meta-analysis. TP was associated with a statistically significant decrease in HbA1c (MD, -1.26%; 95% CI, -1.69 to -0.84) from baseline. FBG was not significantly affected (MD, -25.32 mg/dL; 95% CI, -57.62 to 6.98). Compared to non-TP service, TP was associated with a lower risk of hypoglycemia (RR, 0.48; 95% CI, 0.30-0.76). In a subset of studies that compared TP to face-to-face (FTF) pharmacy services, no significant difference in HbA1c lowering was seen between the 2 groups (WMD, -0.09%; 95% CI, -1.07 to 0.90).

CONCLUSION

Use of TP was associated with reduction of HbA1c and the risk of hypoglycemia in patients with diabetes mellitus. High-quality randomized controlled trials are needed to validate the effectiveness of diabetes TP services relative to FTF services.

Dietary Succinoglycan Riclin Improves Glycemia Control in Mice with Type 2 Diabetes

Riclin is a typical succinoglycan produced by an agrobacterium isolate. Our previous investigation has revealed that oral riclin restores the islet function in type 1 diabetic mice. However, whether dietary riclin improves glycemic control in type 2 diabetes (T2D) is unknown. Here, we found that dietary riclin (20 and 40 mg/kg) for 4 weeks significantly decreased fasting blood glucose (55 and 67%), improved insulin sensitivity, and decreased insulin resistance in high-fat-diet/streptozocin (HFD/STZ)-induced T2D. Riclin reduced the proportion of T helper 1 cell subsets in diabetic mice, alleviated pancreatic inflammation, and protected islet function. Moreover, dietary riclin enriched the diversity of gut microflora and restored the relative abundance of several bacterial genera in diabetes, including the strains of Clostridium, Parasutterella, Klebsiella, and Bacteroides. In db/db diabetic mice, riclin also improves glycemia control as observed in HFD/STZ-induced T2D mice. These data suggest that riclin has potential to be a functional food to treat T2D.

Initial non-adherence to antihypertensive medications in the United States: a systematic literature review

An important component of hypertension management is the initiation and continuation of antihypertensive medications. Non-adherence during the long-term use of antihypertensive medications is well studied. However, there is a paucity of research about the frequency and clinical consequences of failing to take the first dose of an antihypertensive, a treatment challenge known as initial medication non-adherence (IMN). This systematic literature review summarizes the published evidence from 2010 to 2019 on the prevalence, associated factors, consequences, and solutions for IMN to antihypertensive medications in the United States. Of the fifteen studies identified, nine studies reported the prevalence of IMN, two studies examined patient-reported reasons for IMN, and four studies evaluated interventions aimed to lower IMN. It is estimated that 5-34% of patients do not obtain their new antihypertensive medications. Factors and reasons cited include patient demographics, patient beliefs or perceptions about medications, cost or financial barriers, and clinical characteristics, such as a new hypertension diagnosis or higher co-morbid disease burden. The clinical, economic, and patient-reported outcomes of IMN are not well researched. In addition, interventions to address IMN have yielded inconsistent results. Significant opportunities exist for further research into this dimension of patient behavior to better understand and address IMN to new antihypertensive medications.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Telepharmacy: A Potential Alternative Approach for Diabetic Patients During the COVID-19 Pandemic

The use of telepharmacy technology allows pharmacists to provide clinical pharmaceutical services to patients with diabetes mellitus (DM) who need regular services during the COVID-19 pandemic while maintaining distance and minimizing face-to-face meetings. The purpose of this review article was to identify the impact of telepharmacy intervention by pharmacists in diabetic patients by reviewing clinical outcomes and patient therapy adherences. A literature search was conducted through the PubMed database using the terms "telemedicine", "telepharmacy", "telehealth" and "telephone" in combination with "pharmacist", 'diabetes' and 'COVID-19' or "Pandemic". From a total of 67 articles identified, 14 research articles conform to the inclusion criteria. Telephone is the most widely used communication model (n = 11). All studies had a positive impact on clinical outcomes and three studies did not provide significant result on therapy adherence. The use of telepharmacy can be maximized and used on a vast scale, with the design of devices and technologies making it easier for pharmacists and diabetic patients to provide and receive clinical pharmaceutical services during the COVID-19 pandemic.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

BACKGROUND

Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors by lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD.

OBJECTIVES

To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two other databases on 7 January 2020. We also searched two clinical trials registers on 5 February 2020. We searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The main outcomes of interest were objective measures of medication adherence (blood pressure (BP) and cholesterol), CVD events, and adverse events. We contacted study authors for further information when this was not reported.

MAIN RESULTS

We included 14 trials with 25,633 randomised participants. Participants were recruited from community-based primary and tertiary care or outpatient clinics. The interventions varied widely from those delivered solely through short messaging service (SMS) to those involving a combination of modes of delivery, such as SMS in addition to healthcare worker training, face-to-face counselling, electronic pillboxes, written materials, and home blood pressure monitors. Some interventions only targeted medication adherence, while others additionally targeted lifestyle changes such as diet and exercise. Due to heterogeneity in the nature and delivery of the interventions and study populations, we reported most results narratively, with the exception of two trials which were similar enough to meaningfully pool in meta-analyses. The body of evidence for the effect of mobile phone-based interventions on objective outcomes of adherence (BP and cholesterol) was of low certainty, due to most trials being at high risk of bias, and inconsistency in outcome effects. Two trials were at low risk of bias. Among five trials (total study enrolment: 5441 participants) recording low-density lipoprotein cholesterol (LDL-C), two studies found evidence for a small beneficial intervention effect on reducing LDL-C (-5.30 mg/dL, 95% confidence interval (CI) -8.30 to -2.30; and -9.20 mg/dL, 95% CI -17.70 to -0.70). The other three studies found results varying from a small reduction (-7.7 mg/dL) to a small increase in LDL-C (0.77 mg/dL). All of which had wide confidence intervals that included no effect. Across 13 studies (25,166 participants) measuring systolic blood pressure, effect estimates ranged from a large reduction (MD -12.45 mmHg, 95% CI -15.02 to -9.88) to a small increase (MD 2.80 mmHg, 95% CI 0.30 to 5.30). We found a similar range of effect estimates for diastolic BP, ranging from -12.23 mmHg (95% CI 14.03 to -10.43) to 1.64 mmHg (95% CI -0.55 to 3.83) (11 trials, 19,716 participants). Four trials showed intervention benefits for systolic and diastolic BP with confidence intervals excluding no effect, and among these were all three of the trials evaluating self-monitoring of blood pressure with mobile phone-based telemedicine. The fourth trial included SMS and provider support (with additional varied features). Seven studies (19,185 participants) reported 'controlled' BP as an outcome, and intervention effect estimates varied from negligible effects (odds ratio (OR) 1.01, 95% CI 0.76 to 1.34) to large improvements in BP control (OR 2.41, 95% CI: 1.57 to 3.68). The three trials of clinician training or decision support combined with SMS (with additional varied features) had confidence intervals encompassing benefits and harms, with point estimates close to zero. Pooled analyses of the two trials of interventions solely delivered through SMS were indicative of little or no beneficial intervention effect on systolic BP (MD -1.55 mmHg, 95% CI -3.36 to 0.25; I2 = 0%) and small increases in controlled BP (OR 1.32, 95% CI 1.06 to 1.65; I2 = 0%). Based on four studies (12,439 participants), there was very low-certainty evidence (downgraded twice for imprecision and once for risk of bias) relating to the intervention effect on combined (fatal and non-fatal) CVD events. Two studies (2535 participants) provided low-certainty evidence for the effect of the intervention on cognitive outcomes, with little or no difference between trial arms for perceived quality of care and satisfaction with treatment. There was moderate-certainty evidence (downgraded due to risk of bias) that the interventions did not cause harm, based on six studies (8285 participants). Three studies reported no adverse events attributable to the intervention. One study reported no difference between groups in experience of adverse effects of statins, and that no participants reported intervention-related adverse events. One study stated that potential side effects were similar between groups. One study reported a similar number of deaths in each arm, but did not provide further information relating to potential adverse events.

AUTHORS' CONCLUSIONS

There is low-certainty evidence on the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD. Trials of BP self-monitoring with mobile-phone telemedicine support reported modest benefits. One trial at low risk of bias reported modest reductions in LDL cholesterol but no benefits for BP. There is moderate-certainty evidence that these interventions do not result in harm. Further trials of these interventions are warranted.

Perceptions of a mobile phone-based approach to promote medication adherence: A cross-sectional application of the technology acceptance model

Background

Objectives

Methods

Results

Conclusion

•

Medication adherence strategies using mobile phones are common

•

New mobile phone-based approach called caller tunes was tested for feasibility

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Intention to use the caller tunes for enhancing medication adherence was high

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Making caller tunes free to download increased intention to use

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Caller tunes could be a novel strategy to promote medication adherence

Feasibility trial of metformin XR in people with pre-diabetes and stroke (MIPPS)-randomised open blinded endpoint controlled trial

AIMS

Pre-diabetes is a common condition that affects about 16.4% of Australian adults. Hyperglycaemia is a strong risk factor for the development of stroke. Metformin XR is an approved medication to treat type 2 diabetes in Australia but not pre-diabetes. Additionally, whether it is tolerated following a stroke is unclear. In this pilot study, we aimed to assess the feasibility of Metformin XR in people with stroke and pre-diabetes.

METHODS

In this PROBE design trial, people who had recent stroke (within 3 months) with pre-diabetes were randomized to either the active arm (n = 13) receiving usual care plus Metformin XR (500 mg daily increased to a total daily dose of 1500 mg) or the control group receiving only usual care (n = 13). At baseline & after four months of intervention, clinical and biomedical characteristics, cardiovascular risk factors and medication data were recorded. At one month and 2.5 months into the study, compliance rateandside effects were determined.

RESULTS

This trial showed that it is feasible to recruit, retain and monitor participants. However, the compliance rate was low. Adherence to metformin XR was 52% (IQR:42% to 61%) based on the remaining tablets in the container after 4 months of intervention. None of the reported side effects were deemed to be related to the study treatment and no significant differences were observed between the metformin XR and the control group.

CONCLUSION

Treatment with Metformin XR in participants admitted with stroke and with pre-diabetes is feasible and safe. Strategies are needed to improve adherence in future trials.

Effect of Interactive eHealth Interventions on Improving Medication Adherence in Adults With Long-Term Medication: Systematic Review

Background

Medication nonadherence leads to suboptimal treatment outcomes, making it a major priority in health care. eHealth provides an opportunity to offer medication adherence interventions with minimal effort from health care providers whose time and resources are limited.

Objective

The aim of this systematic review is twofold: (1) to evaluate effectiveness of recently developed and tested interactive eHealth (including mHealth) interventions on medication adherence in adult patients using long-term medication and (2) to describe strategies among effective interventions.

Methods

MEDLINE, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from January 2014 to July 2019 as well as reference lists and citations of included articles. Eligible studies fulfilled the following inclusion criteria: (1) randomized controlled trial with a usual care control group; (2) a total sample size of at least 50 adult patients using long-term medication; (3) applying an interactive eHealth intervention aimed at the patient or patient’s caregiver; and (4) medication adherence as primary outcome. Methodologic quality was assessed using the Cochrane risk of bias tool. Selection and quality assessment of studies were performed by 2 researchers (BP and BvdB or JV) independently. A best evidence synthesis was performed according to the Cochrane Back Review Group.

Results

Of the 9047 records screened, 22 randomized clinical trials were included reporting on 29 interventions. Most (21/29, 72%) interventions specified using a (mobile) phone for calling, SMS text messaging, or mobile apps. A majority of all interactive interventions (17/29) had a statistically significant effect on medication adherence (P<.05). Of these interventions, 9 had at least a small effect size (Cohen d ≥ 0.2) and 3 showed strong odds for becoming adherent in the intervention group (odds ratio > 2.0). Our best evidence synthesis provided strong evidence for a positive effect of interventions using SMS text messages or interactive voice response, mobile app, and calls as mode of providing adherence tele-feedback. Intervention strategies “to teach medication management skills,” “to improve health care quality by coordinating medication adherence care between professionals,” and “to facilitate communication or decision making between patients and health care providers” also showed strong evidence for a positive effect.

Conclusions

Overall, this review supports the hypothesis that interactive eHealth interventions can be effective in improving medication adherence. Intervention strategies that improve patients’ treatment involvement and their medication management skills are most promising and should be considered for implementation in practice.

Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART)

BACKGROUND

There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM).

METHODS

In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed.

RESULTS

At least 296 participants and approximately 75 peer supporters will be enrolled.

DISCUSSION

Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03689530.

Effectiveness of self-management interventions in young adults with type 1 and 2 diabetes: a systematic review and meta-analysis

AIM

Diabetes in young adulthood has been associated with poor outcomes. Self-management is fundamental to good diabetes care, and self-management interventions have been found to improve outcomes in older adults. We performed a systematic review and meta-analysis to assess the effectiveness of self-management interventions in young adults (aged 15-39 years) with type 1 or type 2 diabetes.

METHODS

We searched five databases and two clinical trial registries from 2003 to February 2019, without language restrictions. We included randomized controlled trials (RCTs) comparing the effectiveness of self-management interventions with usual care or enhanced usual care in young adults. Outcomes of interest included clinical outcomes, psychological health, self-care behaviours, diabetes knowledge and self-efficacy. Pairwise meta-analysis was conducted using a random effects model and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. We followed Cochrane gold standard systematic review methodology and reported this systematic review according to PRISMA guidelines. The protocol was registered with PROSEPRO (CRD42018110868).

RESULTS

In total, 13 studies (1002 participants) were included. Meta-analysis showed no difference between self-management interventions and controls in post-intervention HbA_1c levels, BMI, depression, diabetes-related distress, overall self-care, diabetes knowledge and self-efficacy. Quality of evidence ranged from very low to moderate due to study limitations, inconsistency and imprecision.

CONCLUSIONS

Current self-management interventions did not improve outcomes in young adults with diabetes. Our findings, which contrast with those from systematic reviews in older adults, highlight the need for the development of more effective interventions for young adults with diabetes.

Prevalence of and factors associated with primary medication non-adherence in chronic disease: A systematic review and meta-analysis

BACKGROUND

Primary medication non-adherence (PMN), defined as failure to obtain newly prescribed medications, results in adverse clinical and economic outcomes. We aimed to (a) assess the prevalence of PMN in six common chronic diseases: asthma and/ or chronic obstructive pulmonary disease, depression, diabetes mellitus, hyperlipidaemia, hypertension and osteoporosis; (b) identify and categorise factors associated with PMN; (c) explore characteristics that contributed to heterogeneity between studies.

METHODS

We performed a systematic search in MEDLINE, Embase, Cochrane Library, CINAHL and PsycINFO. Studies published in English between January 2008 and August 2018 assessing PMN in subjects aged ≥18 years were included. We used the Cochrane risk of bias tool, Newcastle-Ottawa Scale and National Heart, Lung and Blood Institute Quality Assessment Tool to assess the quality of randomised controlled trials, cohort and cross-sectional studies, respectively. Findings were reported using the PRISMA checklist. PMN rates were pooled using a random effects model. We summarised factors associated with PMN descriptively. Subgroup analysis was performed to explore sources of heterogeneity.

RESULTS

We screened 3083 articles and included 33 (5 randomised controlled trials, 26 cohort and 2 cross-sectional studies, n = 539 156), of which 31 (n = 519 971) were used in meta-analysis. The pooled PMN rate was 17% (95% CI: 15%-20%). Pooled PMN rates were highest in osteoporosis (25%, 95% CI: 7%-44%) and hyperlipidaemia (25%, 95% CI: 18%-32%) and lowest in diabetes mellitus (10%, 95% CI: 7%-12%). Factors commonly associated with PMN include younger age, number of concurrent medications, practitioner specialty and higher co-payment. Type of chronic disease, age, study setting and PMN definition contributed to heterogeneity between studies (all P < 0.001).

CONCLUSION

Primary medication non-adherence is common among patients with chronic diseases and more needs to be done to address this issue in order to improve patient outcomes. Future PMN studies could benefit from greater standardisation to enhance comparability.

Telemedical coaching for weight loss in overweight employees: a three-armed randomised controlled trial

OBJECTIVES

We examined the effect of a telemedical coaching (TMC) programme accompanied with or without telemonitoring on weight loss in an occupational healthcare setting with a three-armed randomised controlled trial (NCT01837134 'Pre-results').

METHODS

Overweight employees (n=104, body mass index [BMI] ≥25 kg/m2) were invited by their medical corporate department and randomised into either a TMC group (n=34) or in one of the two control groups (C1, n=34; C2, n=36). TMC and C1 were equipped with telemonitoring devices (scales and pedometers) at baseline, and C2 after 6 months. Telemonitoring devices automatically transferred data into a personalised online portal. TMC was coached with weekly care calls in months 3-6 and monthly calls from months 7 to 12. C2 had a short coaching phase in months 6-9. C1 received no further support. After the 12-month intervention phase, participants could take advantage of further company health promotion offers. Follow-up data were determined after 12 months of intervention and per-protocol (PP) and intention-to-treat (ITT) analyses were performed. Weight change was followed up after 36 months. Estimated treatment difference (ETD) was calculated for weight reduction.

RESULTS

ETD from TMC to C1 (-3.6 kg 95% CI -7.40 to -0.1, p=0.047) and to C2 (-4.2 kg [-7.90 to -0.5], p=0.026) was significantly different at the 12 months follow-up in the PP-analysis, but lost significance in the ITT analysis. All groups reduced weight after 12 months (-3.3 to -8.4 kg [5.5-10.3 kg], all p<0.01) and sustained it during the 36 months follow-up (-4.8 to -7.8 kg [5.6-12.8 kg], all p<0.01). ETD analyses revealed no difference between all groups neither in the PP nor in the ITT analysis at the 3 years follow-up. All groups reduced BMI, systolic and diastolic blood pressure and improved eating behaviour in the PP or ITT analyses.

CONCLUSIONS

TMC and/or telemonitoring support long-term weight reduction in overweight employees. The combination of both interventions points towards an additional effect.

TRIAL REGISTRATION NUMBER

NCT01837134.

Interventions to Improve Medication Adherence: A Review

IMPORTANCE

Among adults with chronic illness, 30% to 50% of medications are not taken as prescribed. In the United States, it is estimated that medication nonadherence is associated with 125 000 deaths, 10% of hospitalizations, and $100 billion in health care services annually.

OBSERVATIONS

PubMed was searched from January 1, 2000, to September 6, 2018, for English-language randomized clinical trials of interventions to improve medication adherence. Trials of patients younger than 18 years, trials that used self-report as the primary adherence outcome, and trials with follow-up periods less than 6 months were excluded; 49 trials were included. The most common methods of identifying patients at risk for nonadherence were patient self-report, electronic drug monitors (pill bottles), or pharmacy claims data to measure gaps in supply. Patient self-report is the most practical method of identifying nonadherent patients in the context of clinical care but may overestimate adherence compared with objective methods such as electronic drug monitors and pharmacy claims data. Six categories of interventions, and characteristics of successful interventions within each category, were identified: patient education (eg, recurrent and personalized telephone counseling sessions with health educators); medication regimen management (using combination pills to reduce the number of pills patients take daily); clinical pharmacist consultation for chronic disease co-management (including education, increased frequency of disease monitoring via telephone or in-person follow-up visits, and refill reminders); cognitive behavioral therapies (such as motivational interviewing by trained counselors); medication-taking reminders (such as refill reminder calls or use of electronic drug monitors for real-time monitoring and reminding); and incentives to promote adherence (such as reducing co-payments and paying patients and clinicians for achieving disease management goals). The choice of intervention to promote adherence will depend on feasibility and availability within a practice or health system. Successful interventions that are also clinically practical include using combination pills to reduce daily pill burden, clinical pharmacist consultation for disease co-management, and medication-taking reminders such as telephone calls to prompt refills (maximum observed absolute improvements in adherence of 10%, 15%, and 33%, respectively).

CONCLUSIONS AND RELEVANCE

Adherence can be assessed and improved within the context of usual clinical care, but more intensive and costly interventions that have demonstrated success will require additional investments by health systems.

Telemedical Coaching Improves Long-Term Weight Loss in Overweight Persons: A Randomized Controlled Trial

Background

Lifestyle interventions have shown to be effective when continuous personal support was provided. However, there is lack of knowledge whether a telemedical-approach with personal coaching contributes to long-term weight losses in overweight employees. We, therefore, tested the hypothesis that telemedical-based lifestyle interventions accompanied with telemedical coaching lead to larger weight losses in overweight persons in an occupational health care setting.

Methods

Overweight employees (n=180) with a body mass index (BMI) of >27 kg/m² were randomized into either a telemedical (TM) group (n=61), a telemedical coaching (TMC) group (n=58), or a control group (n=61). Both intervention groups were equipped with scales and pedometers automatically transferring the data into a personalized online portal, which could be monitored from participants and coaches. Participants of the TMC group received additionally one motivational care call per week by mental coaches to discuss the current data (current weight and steps) and achieving goals such as a healthy lifestyle or weight reduction. The control group remained in routine care. Clinical and anthropometric data were determined after the 12-week intervention. Additionally, weight change was followed up after 12 months.

Results

Participants of TMC (-3.1 ± 4.8 kg, p<0.0001) and TM group (-1.9 ± 4.0 kg; p=0.0012) significantly reduced weight and sustained it during the 1-year follow-up, while the control group showed no change. Compared to the control group only weight loss in the TMC group was significantly different (p<0.001) after 12 months. TMC and TM group also reduced BMI, waist circumference, and LDL cholesterol. Moreover, TMC group improved additionally systolic and diastolic blood pressure, total cholesterol, HDL cholesterol, and HbA1c.

Conclusions

Telemedical devices in combination with telemedical coaching lead to significant long-term weight reductions in overweight persons in an occupational health care setting. This study is registered with NCT01868763, ClinicalTrials.gov.

Effect of pharmaceutical care interventions on glycemic control in patients with diabetes: a systematic review and meta-analysis

Purpose

Diabetes is a chronic lifelong condition, and adherence to medications and self-monitoring of blood glucose are challenging for diabetic patients. The dramatic increase in the prevalence of diabetes is largely due to the incidence of type 2 diabetes in low- and middle-income countries (LMIc) besides high-income countries (HIc). We aimed to evaluate whether pharmacist care (PC) service model in LMIc and HIc could improve clinical outcomes in diabetic patients by performing a meta-analysis.

Methods

PubMed, Embase, and ProQuest Dissertations Unlimited Published Literature database were searched to find publications pertaining to pharmacist-led intervention in patients with diabetes. The inclusion criteria were as follows: 1) randomized controlled trials, 2) confirmed diabetic patients (type 1 or type 2), 3) pharmaceutical care intervention by clinical pharmacist or/and multidisciplinary team, and 4) reporting HbA1c at baseline and end of study or the mean change in these values.

Results

A total of 37 articles were included in the meta-analysis. The overall result was significant and in favor of PC intervention on HbA1c change (standard difference in mean values [SDM]: 0.379, 95% CI: 0.208–0.550, P<0.001). The stratified meta-analysis showed that PC was significant in both HIc (n=20; SDM: 0.351, 95% CI: 0.207–0.495) and LMIc (n=15; SDM: 0.426, 95% CI: 0.071–0.780). More than 6 months is needed to obtain adequate effects on clinical diabetes parameters.

Conclusion

Our study presented that an adequate duration of pharmacist-led pharmaceutical care was effective in improving HbA1c in patients with diabetes in both LMIc and HIc.

Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults

BACKGROUND

Cardiovascular disease (CVD) is a major cause of disability and mortality globally. Premature fatal and non-fatal CVD is considered to be largely preventable through the control of risk factors via lifestyle modifications and preventive medication. Lipid-lowering and antihypertensive drug therapies for primary prevention are cost-effective in reducing CVD morbidity and mortality among high-risk people and are recommended by international guidelines. However, adherence to medication prescribed for the prevention of CVD can be poor. Approximately 9% of CVD cases in the EU are attributed to poor adherence to vascular medications. Low-cost, scalable interventions to improve adherence to medications for the primary prevention of CVD have potential to reduce morbidity, mortality and healthcare costs associated with CVD.

OBJECTIVES

To establish the effectiveness of interventions delivered by mobile phone to improve adherence to medication prescribed for the primary prevention of CVD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two other databases on 21 June 2017 and two clinical trial registries on 14 July 2017. We searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials investigating interventions delivered wholly or partly by mobile phones to improve adherence to cardiovascular medications prescribed for the primary prevention of CVD. We only included trials with a minimum of one-year follow-up in order that the outcome measures related to longer-term, sustained medication adherence behaviours and outcomes. Eligible comparators were usual care or control groups receiving no mobile phone-delivered component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We contacted study authors for disaggregated data when trials included a subset of eligible participants.

MAIN RESULTS

We included four trials with 2429 randomised participants. Participants were recruited from community-based primary care or outpatient clinics in high-income (Canada, Spain) and upper- to middle-income countries (South Africa, China). The interventions received varied widely; one trial evaluated an intervention focused on blood pressure medication adherence delivered solely through short messaging service (SMS), and one intervention involved blood pressure monitoring combined with feedback delivered via smartphone. Two trials involved interventions which targeted a combination of lifestyle modifications, alongside CVD medication adherence, one of which was delivered through text messages, written information pamphlets and self-completion cards for participants, and the other through a multi-component intervention comprising of text messages, a computerised CVD risk evaluation and face-to-face counselling. Due to heterogeneity in the nature and delivery of the interventions, we did not conduct a meta-analysis, and therefore reported results narratively.We judged the body of evidence for the effect of mobile phone-based interventions on objective outcomes (blood pressure and cholesterol) of low quality due to all included trials being at high risk of bias, and inconsistency in outcome effects. Of two trials targeting medication adherence alongside other lifestyle modifications, one reported a small beneficial intervention effect in reducing low-density lipoprotein cholesterol (mean difference (MD) -9.2 mg/dL, 95% confidence interval (CI) -17.70 to -0.70; 304 participants), and the other found no benefit (MD 0.77 mg/dL, 95% CI -4.64 to 6.18; 589 participants). One trial (1372 participants) of a text messaging-based intervention targeting adherence showed a small reduction in systolic blood pressure (SBP) for the intervention arm which delivered information-only text messages (MD -2.2 mmHg, 95% CI -4.4 to -0.04), but uncertain evidence of benefit for the second intervention arm that provided additional interactivity (MD -1.6 mmHg, 95% CI -3.7 to 0.5). One study examined the effect of blood pressure monitoring combined with smartphone messaging, and reported moderate intervention benefits on SBP and diastolic blood pressure (DBP) (SBP: MD -7.10 mmHg, 95% CI -11.61 to -2.59; DBP: -3.90 mmHg, 95% CI -6.45 to -1.35; 105 participants). There was mixed evidence from trials targeting medication adherence alongside lifestyle advice using multi-component interventions. One trial found large benefits for SBP and DBP (SBP: MD -12.45 mmHg, 95% CI -15.02 to -9.88; DBP: MD -12.23 mmHg, 95% CI -14.03 to -10.43; 589 participants), whereas the other trial demonstrated no beneficial effects on SBP or DBP (SBP: MD 0.83 mmHg, 95% CI -2.67 to 4.33; DBP: MD 1.64 mmHg, 95% CI -0.55 to 3.83; 304 participants).Two trials reported on adverse events and provided low-quality evidence that the interventions did not cause harm. One study provided low-quality evidence that there was no intervention effect on reported satisfaction with treatment.Two trials were conducted in high-income countries, and two in upper- to middle-income countries. The interventions evaluated employed between three and 16 behaviour change techniques according to coding using Michie's taxonomic method. Two trials evaluated interventions that involved potential users in their development.

AUTHORS' CONCLUSIONS

There is low-quality evidence relating to the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of CVD; some trials reported small benefits while others found no effect. There is low-quality evidence that these interventions do not result in harm. On the basis of this review, there is currently uncertainty around the effectiveness of these interventions. We identified six ongoing trials being conducted in a range of contexts including low-income settings with potential to generate more precise estimates of the effect of primary prevention medication adherence interventions delivered by mobile phone.

Primary nonadherence to chronic disease medications: a meta-analysis

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence.

OBJECTIVES

The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications.

MATERIALS AND METHODS

We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model.

RESULTS

Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence.

CONCLUSION

Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review

BACKGROUND

Utilization of telemedicine allows pharmacists to extend the reach of clinical interventions, connecting them with patients and providers, but the overall impact of these services is under-studied.

OBJECTIVE

Identify the impact of clinical pharmacist telemedicine interventions on clinical outcomes, subsequently defined as clinical disease management, patient self-management, and adherence, in outpatient or ambulatory settings.

METHODS

A literature search was conducted from database inception through May 2016 in Medline, SCOPUS, and EMBASE. Broad terms "telemedicine", "telehealth", and "telephone" were used in combination with "pharmacist" or "pharmacy" and "telepharmacy". The search and extraction process followed PRISMA guidelines. Results were screened for pharmacist interventions and reviewed to identify studies in outpatient our ambulatory settings. Studies of non-clinical outcomes (i.e. dispensing or product preparation) and with no comparator were excluded. The final studies were categorized by types of outcomes reported: clinical disease management, patient self-management, and adherence.

RESULTS

Only 34 studies measured clinical outcomes against a comparator, consistent with the research question. The majority utilized scheduled models of care (n = 29). Telephone was the most common communication method (n = 25). The most utilized interventions were pharmacist-led telephonic clinics (n = 10). Most studies focused on chronic disease management in adults including hypertension, diabetes, anticoagulation, depression, hyperlipidemia, asthma, heart failure, HIV, PTSD, CKD, stroke, COPD and smoking cessation. Twenty-three studies had a positive impact with one reporting negative results. Higher positive impact rate was observed for scheduled (72.4%, 21/29) and continuous (100%, 2/2) models compared to responsive/reactive (25%, 1/4).

CONCLUSIONS

Clinical pharmacy telemedicine interventions in the outpatient or ambulatory setting, primarily via phone, have an overall positive impact on outcomes related to clinical disease management, patient self-management, and adherence in the management of chronic diseases. Commonalities among studies with positive impact included utilization of continuous or scheduled models via telephone, with frequent monitoring and interventions. Studies identified did not evaluate benefits of video capability over telephone or cost-effectiveness, both of which are useful directions for future study.

Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings

OBJECTIVES

Poorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings.

DESIGN

Systematic review.

SETTING

Primary care and community settings.

INCLUDED STUDIES

Randomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%).

INTERVENTIONS

Interventions were classified as organisational, patient-oriented, professional, financial or regulatory.

OUTCOMES

Primary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity.

RESULTS

Forty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by -0.34% (95% CI -0.46% to -0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good.

CONCLUSIONS

This review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective.

Efficacy of the Telemedical Lifestyle intervention Program TeLiPro in Advanced Stages of Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVE

Lifestyle interventions are the foundation of treatment in newly diagnosed type 2 diabetes. However, their therapeutic potential in advanced disease stages is unknown. We evaluated the efficacy of the Telemedical Lifestyle intervention Program (TeLiPro) in improving metabolic control in advanced-stage type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this single-blind, active comparator, intervention study, patients with type 2 diabetes (with glycated hemoglobin [HbA_1c] ≥7.5% [58.5 mmol/mol]), and BMI ≥27 kg/m² and on ≥2 antidiabetes medications) were recruited in Germany and randomized 1:1 using an electronically generated random list and sealed envelopes into two parallel groups. The data analyst was blinded after assignment. The control group (n = 100) got weighing scales and step counters and remained in routine care. The TeLiPro group (n = 102) additionally received telemedical coaching including medical-mental motivation, a formula diet, and self-monitored blood glucose for 12 weeks. The primary end point was the estimated treatment difference in HbA_1c reduction after 12 weeks. All available values per patient (n = 202) were analyzed. Analyses were also performed at 26 and 52 weeks of follow-up.

RESULTS

HbA_1c reduction was significantly higher in the TeLiPro group (mean ± SD -1.1 ± 1.2% vs. -0.2 ± 0.8%; P < 0.0001). The estimated treatment difference in the fully adjusted model was 0.8% (95% CI 1.1; 0.5) (P < 0.0001). Treatment superiority of TeLiPro was maintained during follow-up (week 26: 0.6% [95% CI 1.0; 0.3], P = 0.0001; week 52: 0.6% [0.9; 0.2], P < 0.001). The same applies for secondary outcomes: weight (TeLiPro -6.2 ± 4.6 kg vs. control -1.0 ± 3.4 kg), BMI (-2.1 ± 1.5 kg/m² vs. -0.3 ± 1.1 kg/m²), systolic blood pressure (-5.7 ± 15.3 mmHg vs. -1.6 ± 13.8 mmHg), 10-year cardiovascular disease risk, antidiabetes medication, and quality of life and eating behavior (P < 0.01 for all). The effects were maintained long-term. No adverse events were reported.

CONCLUSIONS

In advanced-stage type 2 diabetes, TeLiPro can improve glycemic control and may offer new options to avoid pharmacological intensification.

A coordinated PCP-Cardiologist Telemedicine Model (PCTM) in China's community hypertension care: study protocol for a randomized controlled trial

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease, and its control rate has remained low worldwide. Studies have found that telemonitoring blood pressure (BP) helped control hypertension in randomized controlled trials. However, little is known about its effect in a structured primary care model in which primary care physicians (PCPs) are partnering with cardiology specialists in electronic healthcare data sharing and medical interventions. This study aims to identify the effects of a coordinated PCP-cardiologist model that applies telemedicine tools to facilitate community hypertension control in China.

METHODS/DESIGN

Patients with hypertension receiving care at four community healthcare centers that are academically affiliated to Shanghai Chest Hospital, Shanghai JiaoTong University are eligible if they have had uncontrolled BP in the previous 3 months and access to mobile Internet. Study subjects are randomly assigned to three interventional groups: (1) usual care; (2) home-based BP telemonitor with embedded Global System for Mobile Communications (GSM) module and unlimited data plan, an app to access personal healthcare record and receive personalized lifestyle coaching contents, and proficiency training of their use; or (3) this plus coordinated PCP-cardiologist care in which PCPs and cardiologists share data via a secure CareLinker website to determine interventional approaches. The primary outcome is mean change in systolic blood pressure over a 12-month period. Secondary outcomes are changes of diastolic blood pressure, HbA1C, blood lipids, and medication adherence measured by the eight-item Morisky Medication Adherence Scale.

DISCUSSION

This study will determine whether a coordinated PCP-Cardiologist Telemedicine Model that incorporates the latest telemedicine technologies will improve hypertension care. Success of the model would help streamline the present community healthcare processes and impact a greater number of patients with uncontrolled hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02919033 . Registered on 23 September 2016.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials

BACKGROUND

Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care.

METHODS

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (≤ 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic.

RESULTS

From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia.

INTERPRETATION

Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

A systematic review of interventions to improve adherence to statin medication: What do we know about what works?

Suboptimal adherence to statin medication is common and leads to serious negative health consequences but may respond to intervention. This review evaluated the effectiveness of interventions intended to improve adherence to statin medication. Data sources included peer-reviewed publications from Cochrane Register of Randomized Controlled Trials (RCTs), PubMed, CINAHL, and EMBase indexed between 01 October 2008 and 18 October 2015 and studies from reference lists and technical experts. RCTs that evaluated an intervention targeting adherence to self-administered statin medication for primary or secondary prevention were eligible. Two investigators independently reviewed trials, extracted data, and evaluated risk of bias. Twenty-nine RCTs reporting on 39,769 patients met inclusion. Identified RCTs exhibited methodological weaknesses: all but one failed to set inclusion parameters for medication adherence; nearly half lacked sufficient power to detect meaningful effects; and the majority had a risk of bias. Interventions were categorized into five classes (simplification of regimen, prescription cost coverage, reminders, education and information, and multi-faceted) and effects were pooled within each class. Prescription cost coverage, Hedges' g=0.15, 95%CI [0.11:0.21], simplification of drug regimen, Hedges' g=0.38, 95%CI [0.22:0.55], the provision of education, Hedges' g=0.19, 95%CI [0.01:0.37], and the use of multi-faceted interventions, Hedges' g=0.16, 95%CI [0.05:0.27], had small positive effects on statin adherence relative to usual care and reminders were promising, Hedges' g=0.0.27, 95%CI [-0.05:0.60]. In conclusion, there are some successful interventions to improve adherence to statin medication but the effects are small and additional methodologically rigorous trials are needed.

Integrative health coaching: a behavior skills approach that improves HbA1c and pharmacy claims-derived medication adherence

OBJECTIVE

Medication adherence requires underlying behavior skills and a supporting mindset that may not be addressed with education or reminders. Founded in the study of internal motivation and health psychology, integrative health coaching (IHC) helps patients gain insight into their behaviors and make long-term, sustainable lifestyle changes. The purpose of the study is to determine whether IHC improves oral medication adherence, glycated hemoglobin (HbA1c), and psychosocial measures, and to assess whether adherence changes are sustained after the intervention.

METHODS

Using a prospective observational design, participants (n=56) received 14 coaching calls by telephone over 6 months. Medication possession ratio (MPR) was calculated for time intervals before, during, and after the intervention. HbA1c and patient-reported psychosocial outcomes were obtained to test interactions with MPR.

RESULTS

Medication adherence (MPR) increased from 0.74±0.197 to 0.85±0.155 during coaching, and was sustained at 0.82±0.175 during a 6-month period after the study. Better adherence correlated with a greater decrease in HbA1c. HbA1c decreased from 8.0±1.92% to 7.7±1.70% over the 6-month intervention. All psychosocial measures showed significant improvement. In addition to discussing medication adherence strategies with their coach, patients discussed nutrition and exercise (86.9% of calls), stress management (39.8%), and social support and relationships (15.4%).

CONCLUSIONS

IHC targets internal motivation and supports behavior change by facilitating patients' insight into their own behaviors, and it uses this insight to foster self-efficacy. This approach may yield sustainable results for medication adherence and warrants further exploration for health-related behavior change.

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial

Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

Automated Outreach for Cardiovascular-Related Medication Refill Reminders

The objective of this study was to evaluate the effectiveness of an automated telephone system reminding patients with hypertension and/or cardiovascular disease to obtain overdue medication refills. The authors compared the intervention with usual care among patients with an overdue prescription for a statin or lisinopril-hydrochlorothiazide (lisinopril-HCTZ). The primary outcome was refill rate at 2 weeks. Secondary outcomes included time to refill and change in low-density lipoprotein cholesterol and blood pressure. Significantly more patients who received a reminder call refilled their prescription compared with the usual-care group (statin cohort: 30.3% vs 24.9% [P<.0001]; lisinopril-HCTZ cohort: 30.7% vs 24.2% [P<.0001]). The median time to refill was shorter in patients receiving the reminder call (statin cohort: 29 vs 36 days [P<.0001]; lisinopril-HCTZ cohort: 24 vs 31 days [P<.0001]). There were no statistically significant differences in mean low-density lipoprotein cholesterol and blood pressure. These findings suggest the need for interventions that have a longer-term impact.