Limited significance of bicarbonate therapy in the treatment of diabetic ketoacidosis: a rare case report in the periphery of Nepal

Introduction and importance

An uncontrolled hyperglycaemia accompanied by metabolic acidosis and an increase in total body ketone, if left untreated, has the potential to develop into complications, including diabetes ketoacidosis (DKA). Management of this complication with IV hydration, IV Insulin, and potassium (KCL) maintenance is a comprehensive approach. On the contrary, bicarbonate therapy is generally not regarded as a standard treatment due to its unfavourable outcome.

Case presentation

The authors present a case of a 21-year-old female who was brought in a semiconscious state to the emergency department with complaints of pain in the abdomen, headache, and vomiting. DKA was diagnosed following the patient's symptoms and arterial blood gas analysis report. She was managed with IV fluids, IV insulin, and KCL.

Clinical discussion

Generally, pH less than 6.8 has a poor patient survival outcome. Here, the patient presented with pH less than 6.6, where she was managed with the standard regimen without the need to administer bicarbonate therapy.

Conclusion

DKA is a life-threatening condition that can be precipitated by non-adherence to medications and infections with IV insulin and hydration playing a pivotal role in its management while bicarbonate offers no beneficial effect.

Medication non-adherence and its influencing factors in persons with schizophrenia in rural China

BACKGROUND

Few studies have been conducted to explore medication non-adherence in persons with schizophrenia (PWS) and its influencing factors in rural China. This study aimed to investigate the medication non-adherence and its influencing factors among PWS in rural China.

METHODS

A total of 269 PWS and their family caregivers in Xinjin district, Chengdu, China were investigated on medication adherence and related factors. Logistic regression was employed to identify the influencing factors.

RESULTS

The results showed that 37.6% of PWS had medication non-adherence. PWS living with family caregivers had significantly lower rate of medication non-adherence (34.7%) than those not living with family caregivers (60.0%) (p < 0.01). Family caregivers' affiliate stigma of mental illness, knowledge of mental illness and self-esteem were significantly related to patients' medication non-adherence (p < 0.05). PWS' employment status, living with family caregiver, present mental status and social support were significantly related to medication adherence.

CONCLUSION

This study shows medication non-adherence is severe among PWS in rural China. Both patient- and family-related factors affect patients' medication adherence seriously. Except improving patients' treatment and mental status, development of family caregiving, social support network and intervention on reducing stigma of mental illness should be crucial for enhancing PWS' medication adherence.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

The effects of adequate dietary calcium intake in patients with hypoparathyroidism non-adherent to treatment: a prospective randomized controlled trial

OBJECTIVE

A significant problem that compels clinicians in the conventional treatment of hypoparathyroidism is patients' non-adherence to treatment. This study aimed to evaluate the effects of adequate Ca intake with dietary recommendations among hypoparathyroidism patients who persistently use Ca supplementation irregularly on plasma Ca and phosphate levels.

METHODS

This prospective, randomized, controlled study was conducted on patients diagnosed with chronic hypoparathyroidism who persistently interrupt Ca supplementation therapy and therefore have a hypocalcemic course. Patients with a total daily Ca intake below 800 mg were randomized. All patients were advised to keep the doses of active vitamin D and Ca supplements they were currently using. The patients in the study group (n=32) were advised to consume 1,000-1,200 mg of Ca daily, and the patients in the control group (n=35) were advised to continue their diet according to their daily habits. After 12 weeks of follow-up, the patients' laboratory values were compared between groups to assess treatment goals.

RESULTS

The mean of the total Ca level was 8.56±0.36 mg/dL in the study group and was found to be significantly higher than that in the control group, which was 7.67±0.48 mg/dL (p<0.001). The mean serum phosphate and serum Ca-P product levels were significantly higher in the study group (p<0.001) but did not exceed the safe upper limits in any patient.

CONCLUSION

A suitable increase in dietary Ca intake could effectively control hypocalcemia in patients with hypoparathyroidism who persistently interrupt the recommended calcium supplementation.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Detecting medication non-adherence in schizophrenia: A comparison of different methods among outpatients from a North Indian center

Background

The rates of medication non-adherence among Indian patients with schizophrenia are high, and its detection poses problems. Comparisons of suitable measures to detect medication non-adherence in schizophrenia from Indian outpatient settings are scarce.

Aim

This study compared simple and inexpensive methods of detecting medication non-adherence in schizophrenia among outpatients from a tertiary-care center in North India.

Materials and Method

A longitudinal comparison of two self-reports, the Morisky Medication Adherence Questionnaire and the Drug Attitude Inventory-10, clinicians' ratings employing the Compliance Rating Scale, and clinic-based pill counts was conducted among 70 outpatients with schizophrenia. The rates and detection of medication non-adherence, associations with determinants of treatment non-adherence, and agreement between measures were examined at intake and after six months of follow-up (n = 53).

Results

The self-reports had greater ability to detect medication adherence (specificity 41-65%; positive predictive values 25-51%; negative likelihood ratios 0.86-1.14) and moderate ability to detect medication non-adherence (sensitivity 27-65%; negative predictive values 49-69%; positive likelihood ratios 0.78-1.10). They yielded higher medication non-adherence rates, detected changes in medication non-adherence over time, and were associated with the other measures and the well-known correlates of medication non-adherence. Clinicians' ratings and pill counts had high sensitivity (56-90%) but low specificity (35-49%) to detect medication non-adherence.

Conclusion

Self-reports are comparatively better screening options for detecting medication non-adherence among Indian outpatients with schizophrenia. However, the sequential use of different measures could lead to better recognition of medication non-adherence.

Medication Adherence among Allogeneic Haematopoietic Stem Cell Transplant Recipients: A Systematic Review

Recipients of a haematopoietic stem cell transplantation (HSCT) may experience issues in medication adherence (MA) when discharged. The primary aim of this review was to describe the oral MA prevalence and the tools used to evaluate it among these patients; the secondary aims were to summarise factors affecting medication non-adherence (MNA), interventions promoting MA, and outcomes of MNA. A systematic review (PROSPERO no. CRD42022315298) was performed by searching the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane Library, Excerpta Medica dataBASE (EMBASE), PsycINFO, PubMed and Scopus databases, and grey literature up to May 2022 by including (a) adult recipients of allogeneic HSCT, taking oral medications up to 4 years after HSCT; (b) primary studies published in any year and written in any language; (c) with an experimental, quasi-experimental, observational, correlational, and cross-sectional design; and (d) with a low risk of bias. We provide a qualitative narrative synthesis of the extracted data. We included 14 studies with 1049 patients. The median prevalence of MA was 61.8% and it has not decreased over time (immunosuppressors 61.5% [range 31.3-88.8%] and non-immunosuppressors 65.2% [range 48-100%]). Subjective measures of MA have been used most frequently (78.6%) to date. Factors affecting MNA are younger age, higher psychosocial risk, distress, daily immunosuppressors, decreased concomitant therapies, and experiencing more side effects. Four studies reported findings about interventions, all led by pharmacists, with positive effects on MA. Two studies showed an association between MNA and chronic graft-versus-host disease. The variability in adherence rates suggests that the issues are relevant and should be carefully considered in daily practice. MNA has a multifactorial nature and thus requires multidisciplinary care models.

Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients

BACKGROUND

Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes.

METHODS

We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation.

RESULTS

Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant.

CONCLUSIONS

Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.

The impact of adverse drug reactions on medication adherence and outpatient treatment outcomes in female breast cancer: A review protocol

AIM

Discover the impact of adverse drug reactions of hormonal and chemotherapy on medication adherence and outpatient treatment outcomes in the breast cancer patient population.

DESIGN

A systematic review following the reporting guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guided by the Joanna Briggs Institute methodology will be conducted.

DATA SOURCES

A literature search will be conducted using the following databases: PubMed, CINAHL, Web of Science, Medline and Scopus.

REVIEW METHODS

Studies published in English before 2022 that report adverse drug reactions with medication adherence and outpatient treatment outcomes as primary outcome measures, following the initiation of one or more oral hormonal, endocrine and chemotherapy agents in female patients with diagnoses of breast cancer will be identified. Observational studies will be included for review, and two reviewers will independently screen study titles, abstracts and full text for inclusion. The quality assessment will be conducted using the Joanna Briggs Institute tools. A meta-analysis will be conducted where sufficient data are available.

RESULTS

This is a systematic review study protocol, and results are not available at the time of the submission. All results will be reported on the completion of this study.

DISCUSSION

This systematic review will highlight the impact of medication non-adherence on the breast cancer patient population, support determining strategies to address this issue and identify areas for further research.

PATIENT OR PUBLIC CONTRIBUTION

This protocol article will identify the impact of adverse drug reactions on medication non-adherence and treatment outcomes in the female breast cancer patient population. A unique contribution of our study is to support determining strategies to address this ongoing public health issue and identify areas for further research.

TRIAL REGISTRATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number CRD 42021291364).

Factors Affecting Immunosuppressive Medication Adherence in Liver Transplant Recipients with Poor Adherence: A Qualitative Study

Purpose

Preserving graft functions and preventing rejection is closely related to immunosuppressive medication adherence in liver transplant recipients. Therefore, it is essential to determine factors affecting immunosuppressive medication use positively or negatively in liver transplant recipients. This study aimed to explore the use of immunosuppressive medication experience in liver transplant recipients with poor adherence and reveal the factors affecting the medication adherence.

Material and Methods

The study was conducted as a qualitative study with phenomenological approach. Seven adult liver transplant recipients were included in this study, who had poor adherence to immunosuppressive medication. Data was collected via in-depth personal interviews. Data analysis was conducted through inductive content analysis with three steps of preparation, organization, and reporting phases.

Results

Content analysis revealed four main categories, nine categories and 31 sub-categories. Four main categories emerged from the interview data: medication adherence perception, types of medication non-adherence, factors affecting medication adherence negatively and factors affecting medication adherence positively.

Conclusion

This study explored that there are several factors affecting immunosuppressive medication adherence among liver transplant recipients, both positively and negatively. In order to achieve liver transplant recipients' total adherence to immunosuppressive medication, the factors affecting medication adherence positively and negatively should be understood. The study results are expected to contribute developing strategies to improve immunosuppressive medication adherence in liver transplant recipients.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Identifying the predictors of adherence to oral endocrine therapy in racial/ethnic minority patients with low socioeconomic status

Background Adherence to oral endocrine therapy (OET) is crucial in ensuring its maximum benefit in prevention and treatment of hormone receptor-positive (HR+) breast cancer (BC) in patients. Medication use behavior is suboptimal especially in racial/ethnic minorities of lower socioeconomic status (SES). We aimed to assess the OET adherence and its predictors in racial/ethnic minority patients of lower SES. Aim We aimed to assess the OET adherence and determine the predictors of OET nonadherence in racial/ethnic minority patients of lower SES. Method A retrospective study was conducted at the Harris Health System in Houston, Texas. Since the study period included the COVID-19 pandemic, data was collected during the 6 months prior and 6 months after the start of the pandemic. The adherence was assessed using the prescription refill data using the proportion of days covered. Multivariable logistic regression model was used to identify predictors of nonadherence. Eighteen years or older patients on appropriate doses of OET for prevention or treatment of BC were included. Result In 258 patients, the adherence was significantly lower during the pandemic (44%) compared to before the pandemic (57%). The predictors of OET nonadherence before the pandemic were Black/African American, obesity/extreme obesity, prevention setting, tamoxifen therapy, and 4 or more years on OET. During the pandemic, prevention setting and those not using home delivery were more likely to be nonadherent. Conclusion Racial/ethnic minority patients of lower SES, especially African Americans and those using OET for prevention of BC, require individualized interventions to improve adherence.

The diabetes health plan and medication adherence among individuals with low incomes

OBJECTIVE

To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM).

DATA SOURCES AND STUDY SETTING

Cohort of adults (18-64) with T2DM, an annual household income <USD 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least two years between 2009 and 2014.

STUDY DESIGN

We employed a linear regression Difference-In-Differences (DID) approach with a matched comparison group. To assess for differential DHP effects across adherent versus non-adherent patients, we ran a Difference-in-Difference-in-Differences (DDD) analysis by including an interaction term that included indicators for DHP exposure status and time, and low versus high baseline medication adherence.

DATA COLLECTION

The analytic data set is limited to employer groups that purchased the DHP and standard benefit plans from UnitedHealthcare, had internal pharmacy contracts; complete pharmacy claims data, and sufficient medical claims and lab data to identify employees and their dependents with T2DM.

PRINCIPAL FINDINGS

Our DID analysis did not show improved medication adherence associated with employer DHP adoption. However, the DDD model suggested a difference between DHP-exposed and comparison beneficiaries when comparing the relative effect on individuals who were adherent versus non-adherent at baseline, as suggested by the significant three-way interaction term (10.2,p = 0.028). This effect was driven by the 8.2 percentage point increase in medication adherence for the DHP subsample that was non-adherent at baseline.

CONCLUSIONS

The DHP may benefit low-income patients with low baseline medication adherence. Value-based insurance design may be an important strategy for mitigating income disparities in T2DM outcomes.

Medication Adherence among Patients with Chronic Diseases in Saudi Arabia

Introduction: The management of chronic illnesses commonly includes a long-term pharmacological approach. Although these medications effectively control disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Medication adherence has become a big concern to clinicians and healthcare systems in Saudi Arabia and worldwide because of growing evidence associating nonadherence with adverse outcomes and higher costs of care. Despite it being a well-recognized problem, few studies have investigated medication adherence in Saudi Arabia. Therefore, this study aims to gain a better perspective on medication adherence among patients with chronic diseases in Saudi Arabia. Method: A questionnaire-based cross-sectional study was conducted among patients with chronic diseases in the Makkah region, Saudi Arabia, from 1 May to 31 July 2021. Patients aged 18 years and above who were taking prescribed or over-the-counter medications were included. Descriptive statistics were used to describe the participants’ characteristics, and categorical variables were reported as frequencies and percentages. A Chi-square test was used to test the relations between variables. Results: In total, 239 participants were included in the study. Females represented 62% of the participants. In terms of the history of chronic diseases, 44% had hypertension, 40% had diabetes mellitus, 21% had heart diseases and 9% had asthma. Nearly half (49%) of participants did not follow up regularly with a primary healthcare center and 42% said that they had forgotten to take their medications in the past. However, most of the participants (78%) stated that they took their medicine as instructed by their doctor or pharmacist, and 61% took their medications on time. The majority of participants (85%) said that the pharmacist explained the method of using the medications and the instructions for use, while 30% thought that the medications they took were too much. In regard to the reasons for medication nonadherence, having no specific reasons for medication nonadherence was the most common cause for nonadherence in our study. The relationship between patients taking medications as instructed by a healthcare provider (the doctor or pharmacist) and the healthcare provider giving clear instructions to patients about medication use was significant (p < 0.001). Conclusions: Failure to adhere is a significant problem that not only affects the patient but also the healthcare system. Additional research is needed to monitor medication adherence and identify factors contributing to this problem to provide successful strategies to improve medication adherence in Saudi Arabia.

Active neural networks to detect mentions of changes to medication treatment in social media

Objective

We address a first step toward using social media data to supplement current efforts in monitoring population-level medication nonadherence: detecting changes to medication treatment. Medication treatment changes, like changes to dosage or to frequency of intake, that are not overseen by physicians are, by that, nonadherence to medication. Despite the consequences, including worsening health conditions or death, 50% of patients are estimated to not take medications as indicated. Current methods to identify nonadherence have major limitations. Direct observation may be intrusive or expensive, and indirect observation through patient surveys relies heavily on patients’ memory and candor. Using social media data in these studies may address these limitations.

Methods

We annotated 9830 tweets mentioning medications and trained a convolutional neural network (CNN) to find mentions of medication treatment changes, regardless of whether the change was recommended by a physician. We used active and transfer learning from 12 972 reviews we annotated from WebMD to address the class imbalance of our Twitter corpus. To validate our CNN and explore future directions, we annotated 1956 positive tweets as to whether they reflect nonadherence and categorized the reasons given.

Results

Our CNN achieved 0.50 F₁-score on this new corpus. The manual analysis of positive tweets revealed that nonadherence is evident in a subset with 9 categories of reasons for nonadherence.

Conclusion

We showed that social media users publicly discuss medication treatment changes and may explain their reasons including when it constitutes nonadherence. This approach may be useful to supplement current efforts in adherence monitoring.

Validation of an Arabic Version of the Adherence to Refills and Medications Scale (ARMS)

BACKGROUND

Medication non-adherence is a complex multifactorial phenomenon impacting patients with various health conditions worldwide. Therefore, its detection can improve patient outcomes and minimize the risk of adverse consequences. Even though multiple self-reported medication adherence assessment scales are available, very few of them exist in Arabic language. Therefore, the aim of this study was to validate a newly translated Arabic version of the Adherence to Refills and Medications Scale (ARMS) among patients with chronic health conditions.

METHODS

This is a single-center cross-sectional study that was conducted between October 10th 2018 and March 23rd 2021. ARMS was first translated to Arabic using the forward-backward translation method. The translated scale was then piloted among 21 patients with chronic health conditions (e.g., diabetes, hypertension, etc.…) to examine its reliability and comprehensibility using the test-retest method. Thereafter, the Arabic-translated ARMS was self-administered to adult patients aged ≥18 years with chronic health conditions visiting the primary care clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia. Construct validity was examined using factor analysis with varimax rotation.

RESULTS

Of the 264 patients who were invited to participate, 202 (76.5%) consented and completed the questionnaire. Most of the participants were males (69.9%), married (75.2%), having a college degree or higher (50.9%), retired or unemployed (65.2%), aged ≥ 50 years (65.2%), and are diabetic (95.9%). The 12-item Arabic-translated ARMS mean score was 17.93 ± 4.90, and the scale yielded good internal consistency (Cronbach's alpha = 0.802) and test-retest reliability (Intraclass correlation coefficient = 0.97). Two factors were extracted explaining 100% of the of the total variance (factor 1 = 52.94% and factor 2 = 47.06%).

CONCLUSIONS

The 12-item Arabic version of ARMS demonstrated good validity and reliability. Therefore, it should help in the detection of medication non-adherence among Arabic-speaking patient population and minimize the risk of adverse consequences.

Prevalence and predictors of medication non-adherence among older community-dwelling people with chronic disease in Singapore

AIMS

To determine the prevalence and predictors of medication non-adherence among older community-dwelling people with at least one chronic disease in Singapore.

DESIGN

A single-centre cross-sectional study.

METHODS

The study was conducted in the largest tertiary public hospital in Singapore between May 2019 and December 2019. The community nurses of the hospital recruited a total of 400 community-dwelling older people aged ≥60 years old, who were diagnosed with at least one chronic disease and prescribed with at least one long-term medication. Medication non-adherence was assessed using the self-report 5-item Medication Adherence Report Scale, operationalized as a score of <25. A list of potential factors of medication non-adherence was structured based on the World Health Organization five-domain framework and collected using a self-report questionnaire.

RESULTS

Sixty percent (n = 240) of our participants were non-adherent to their medication regime. Older people who smoked (OR 2.89, 95% CI 1.14-7.33), perceived their medication regime as being complicated (OR 2.54, 95% CI 1.26-5.13), felt dissatisfied with their regime (OR 2.50, 95% CI 1.17-5.31), did not know the purpose of all their medications (OR 2.56, 95% CI 1.42-4.63) and experienced side effects (OR 3.32, 95% CI 1.14-9.67) were found to be predictive of medication non-adherence.

CONCLUSION

Medication adherence was found to be poor in community-dwelling older people in Singapore. The predictors identified in this study can help guide healthcare professionals in identifying older people who are at risk of medication non-adherence and inform the development of interventions to improve adherence.

IMPACT

Medication non-adherence, especially in the older population with chronic diseases, constitutes a serious problem as it undermines the efforts to reduce morbidity and mortality associated with the underlying chronic diseases. To improve adherence, our findings propose the importance of assessing the older person's treatment satisfaction, which includes examining the aspects of side effects, effectiveness and convenience. Additionally, we highlight the need to address the older person's medication knowledge deficit.

Factors influencing non-adherence to opioids in cancer patients: a mixed-methods cross-sectional study

Background: Strong opioids are mainly utilized to attenuate pain in cancer patients. Adherence to analgesic drugs significantly promotes adequate pain management and improves quality of life. We aimed to identify the factors influencing non-adherence to strong opioids in cancer patients. Methods: A descriptive, cross-sectional, two-phased, mixed methods design was conducted prospectively to evaluate a cohort of 101 cancer patients who are currently prescribed strong opioids from a pain clinic in Thailand between January and March 2018. Participants were asked to complete a questionnaire that included the following sections: general characteristics; the Medication Taking Behavior in Thai (MTB-Thai) for assessing adherence to medications; and factors influencing nonadherence, which were analyzed using multivariate logistic regression. In addition, face-to-face in depth interviews were conducted with patients showing non-adherence to strong opioids (MTB-Thai score ≤21) and analyzed using thematic content analysis.  Results: Of 101 cancer pain patients that completed the questionnaire, 39.6% showed non-adherence to strong opioids. Illness understanding (P=0.047) and the use of more than three types of pain medication (P=0.032) were significant factors influencing non-adherence. Qualitative analysis indicated that fear of long-term outcomes, opioid side effects, ineffective pain control, attempts to make the regimen more acceptable, poor understanding, and non-acceptance of disease related to non-adherence. Conclusion: Non-adherence to opioids for cancer patients is a common problem. Awareness of patient factors, medication-related factors, and illness-related factors will provide the knowledge and adequate advice that may enhance adherence to medications.

Factors influencing non-adherence to opioids in cancer patients: a mixed-methods cross-sectional study

Background: Strong opioids are mainly utilized to attenuate pain in cancer patients. Adherence to analgesic drugs significantly promotes adequate pain management and improves quality of life. We aimed to identify the factors influencing non-adherence to strong opioids in cancer patients. Methods: A descriptive, cross-sectional, two-phased, mixed methods design was conducted prospectively to evaluate a cohort of 101 cancer patients who are currently prescribed strong opioids from a pain clinic in Thailand between January and March 2018. Participants were asked to complete a questionnaire that included the following sections: general characteristics; the Medication Taking Behavior in Thai (MTB-Thai) for assessing adherence to medications; and factors influencing nonadherence, which were analyzed using multivariate logistic regression. In addition, face-to-face in depth interviews were conducted with patients showing non-adherence to strong opioids (MTB-Thai score ≤21) and analyzed using thematic content analysis.  Results: Of 101 cancer pain patients that completed the questionnaire, 39.6% showed non-adherence to strong opioids. Illness understanding (P=0.047) and the use of more than three types of pain medication (P=0.032) were significant factors influencing non-adherence. Qualitative analysis indicated that fear of long-term outcomes, opioid side effects, ineffective pain control, attempts to make the regimen more acceptable, poor understanding, and non-acceptance of disease related to non-adherence. Conclusion: Non-adherence to opioids for cancer patients is a common problem. Awareness of patient factors, medication-related factors, and illness-related factors will provide the knowledge and adequate advice that may enhance adherence to medications.

Medication adherence/persistence among patients with active multiple sclerosis in Finland

Objectives

To explore adherence, persistence, and treatment patterns in patients with multiple sclerosis (MS) in Finland treated with disease‐modifying therapies (DMTs) for active MS in 2005‐2018.

Materials and Methods

The study cohort was identified using the Drug Prescription Register of Social Insurance Institute, Finland. All patients had at least one prescription of glatiramer acetate (GA), beta‐interferons, teriflunomide, or delayed‐release dimethyl fumarate (DMF). Adherence was calculated using proportion of days covered (PDC) (cutoff ≥0.8). Time to non‐persistence was calculated by the number of days on index DMT treatment before the first treatment gap (≥90 days) or switch and analyzed with time‐to‐event methodology.

Results

The cohort included 7474 MS patients (72.2% female; mean age 38.9 years). Treatment switches were steady over 2005‐2012, peaked in 2015. PDC means (standard deviations) were GA, 0.87 (0.17); beta‐interferons, 0.88 (0.15); DMF, 0.89 (0.14); teriflunomide, 0.93 (0.10). Adherence frequencies were GA, 78.4%; beta‐interferons, 81.3%; DMF, 86.9%; teriflunomide, 91.7%. Logistic regression showed that age group, DMT and the starting year, sex, and hospital district independently affected adherence. Patients receiving teriflunomide and DMF, males, and older patients were more likely to persist on treatment. There was no difference in persistence between patients prescribed teriflunomide and DMF, or between GA and beta‐interferons.

Conclusions

Oral DMTs had greater adherence and persistence than injectable DMTs.

Violent behavior by involuntarily committed female offenders with mental disorders: A population-based case series

The goal of the current study was to investigate the socio-demographic, psychiatric, and criminological characteristics of female violent offenders with mental disorders involuntarily committed to a forensic psychiatric hospital. The present study was a population-based retrospective case series including all female offenders with mental disorders found not guilty by reason of insanity by the criminal courts in the state of Rio de Janeiro, Brazil, and involuntarily committed to a forensic psychiatric facility (n = 27). Patients were assessed with Structured Clinical Interview for DSM-IV Axis I Disorders and the Positive and Negative Syndrome Scale. We found that most offenders were Afro-Brazilian, uneducated unmarried women. Schizophrenia with active psychotic symptoms was the most common clinical condition. Relatives were the frequent victims of aggressive behavior. Most patients had already been diagnosed with a mental disorder and placed under psychiatric treatment, but poor adherence and treatment dropout were common. Violent behavior in psychiatrically ill female patients is associated with a specific socio-demographic and clinical profile and is thus potentially amenable to prevention particularly if the mental health and social services are to provide the much-needed support for economically, socially, and psychologically vulnerable women.

Medication Non-Adherence and Associated Factors Among Diabetic Patients Visiting General Hospitals in the Eastern Zone of Tigrai, Northern Ethiopia

INTRODUCTION

Medication non-adherence is a major public health problem among diabetes mellitus patients. However, there is a lack of data regarding its magnitude and the factors contributing to Ethiopia's non-adherence, especially in the Tigrai region. This study was conducted to assess the magnitude of non-adherence and its contributing factors among diabetes mellitus patients in the Eastern Zone of Tigrai, Northern Ethiopia.

MATERIALS AND METHODS

A hospital-based cross-sectional study was conducted at Adigrat and Wukro General Hospitals using a pre-tested, self-administered, semi-structured questionnaire developed from the relevant literature and a checklist developed to review patient medical cards for the period of the 15th of March to the 15th of July, 2019. Data were analyzed using Statistical Package for Social Sciences version 20. Association between the dependent and the independent variable was performed using logistic regression and a p-value of <0.05 was considered significant.

RESULTS

From a total of 321 study participants, 63.9% of the patients were non-adherent to their medications. Two-month dose issued on each visit (AOR = 2.865, 95% CI 1.380-5.949), dose issued for more than three months (AOR = 4.314, 95% CI 1.526-12.195), monthly income below 500 birr (AOR = 5.048, 95% CI 2.094-12.168), monthly income between 500 and 2000 birr (AOR = 2.593, 95% CI 1.032-6.517), distance greater than 24 kilometers from hospital to home (AOR = 10.091, 95% CI 3.509-29.020), more than four prescribed medications per visit (AOR=7.192, 95% CI= 2.171-23.824), never receiving counseling (AOR=22.334, 95% CI= 9.270-53.810), and diabetes-related admission (AOR=0.248, 95% CI= 0.078-0.789) were significantly associated with patients' non-adherence to diabetes mellitus medications.

CONCLUSION

The level of diabetic medication adherence was suboptimal, and our study highlights that better monthly earning, nearby health-care accessibility, fewer prescribed medication, and getting appropriate counseling about diabetes mellitus were predictive of adherence to medications. Hence, an urgent intervention targeting the development of guidelines that involve these determinates should be employed to improve health care.

Modifiable Factors Associated with Non-adherence to Antihypertensive or Antihyperlipidemic Drugs Are Dissimilar: a Multicenter Study Among Patients with Diabetes in Indonesia

BACKGROUND

To develop targeted and tailored interventions for addressing medication non-adherence, it is important to identify underlying factors.

OBJECTIVE

To identify factors associated with non-adherence as well as subtypes of non-adherence to antihypertensive or antihyperlipidemic drugs among patients with type 2 diabetes in Indonesia.

DESIGN

An observational multicenter cross-sectional survey.

PARTICIPANTS

Patients with type 2 diabetes using either antihypertensive or antihyperlipidemic drugs in four regions in Indonesia.

MAIN MEASURES

Non-adherence and its subtypes of intentional and unintentional non-adherence were assessed using the Medication Adherence Report Scale. Necessity and concern beliefs were assessed with the Beliefs about Medicines Questionnaire. We applied binary and multinomial logistic regression to assess associations of medication beliefs, sociodemographic factors, and clinical-related factors to non-adherence and report odds ratios (OR) with 95% confidence intervals (CI).

KEY RESULTS

Of 571 participating patients (response rate 97%), 45.5% and 52.7% were non-adherent to antihypertensive and antihyperlipidemic drugs, respectively. Older age was associated with non-adherence to antihypertensive drugs (60-69 years) (OR, 5.65; 95% CI, 2.68-11.92), while higher necessity beliefs (OR, 0.92; 95% CI, 0.88-0.95) were associated with less non-adherence. Factors associated with non-adherence to antihyperlipidemic drugs were female gender (OR, 1.84; 95% CI, 1.03-3.27) and higher concern beliefs (OR, 1.10; 95% CI, 1.03-1.18), while higher necessity beliefs (OR, 0.89; 95% CI, 0.83-0.96) were associated with less non-adherence.

CONCLUSIONS

The main factors associated with non-adherence to antihypertensive and antihyperlipidemic drugs are modifiable. In general, beliefs about the necessity of the drug are important but for antihyperlipidemic drugs concerns are important as well. Healthcare providers should pay attention to identify and address medication beliefs during patient counselling.

"Don't Let Medicines Go to Waste"-A Survey-Based Cross-Sectional Study of Pharmacists' Waste-Reducing Activities Across Gulf Cooperation Council Countries

Objectives

Medication waste has a negative environmental and economic impact. From avoiding unnecessary supply to recycling medicines that are no longer needed, pharmacists are placed in an advantageous position to minimise medication waste. Thus, the aim of this study was to detect waste-minimising activities undertaken by pharmacists to limit medication waste and to evaluate their importance for medication waste minimisation and feasibility for implementation.

Methods

A cross-sectional survey of 277 participants, conveniently selected from six Gulf countries. The eligibility criteria were pharmacists or pharmacy technicians, Arabic- or English-speaking individuals, aged ≥18 years, and living in the Gulf countries. An online self-administered survey was distributed during December 2019 and February 2020, via e-mail and social networks; it included the purpose of the study with a link to the webpage that hosted the questionnaire. Data were collected through the online survey site QuestionPro.com. All analyses were performed in SPSS Version 23 and Microsoft Excel.

Results

The majority of participants were female (175/277; 63%), hospital pharmacists (206/277; 74%), and had more than 10 years of work experience (100/277; 36%). This study indicates that most of the suggested activities (14/21) were implemented by the majority of pharmacists for minimising medication waste, except four activities in the dispensing stage and three activities in the leftover stage. Activities performed at the prescribing, dispensing and leftover stages were considered very important or important for reducing medication waste and very feasible or feasible for implementation in practice.

Conclusions

Many waste-minimising activities were undertaken by pharmacists in the prescribing, dispensing, and leftover stages. However, although waste-minimising activities were perceived as important for reducing waste and feasible for implementation in practice, not all activities were implemented in daily practice.

Factors Influencing Medication Non-Adherence among Chinese Older Adults with Diabetes Mellitus

Objectives: This study aimed to examine the prevalence of medication non-adherence among older adults with diabetes mellitus (DM) in Shandong province, China and to identify its influencing factors. Methods: A sample of 1002 older adults aged 60 or above with DM was analyzed. Medication adherence was measured using the Morisky–Green–Levine (MGL) Medication Adherence Scale. Descriptive statistical analysis, chi-square test, univariate and multivariate logistic regression analyses were employed. Results: The prevalence of self-reported medication non-adherence among older adults with DM was 19.9%. Female respondents (adjusted odds ratio (AOR) = 1.56, 95% CI: 1.09–2.24) and respondents who perceived medication adherence to be unimportant (AOR = 1.69, 95% CI: 1.05–2.74) were more likely to experience medication non-adherence. Respondents with 5 years of disease duration or longer were less likely (AOR = 0.63, 95% CI: 0.46–0.87) to experience medication non-adherence. Conclusions: This study showed that about one out of five older adults with DM in Shandong province, China, experienced medication non-adherence, and that gender, disease duration and perceived importance of medication adherence were associated with medication non-adherence in this population group. Provision of counseling and health education programs could be the future priority to raise patients’ awareness of the importance of medication adherence and improve patients’ self-management of DM.

Rheumatologists' insight into medication adherence in patients with rheumatoid arthritis: A qualitative study

BACKGROUND

Medication non-adherence is prevalent among patients with rheumatoid arthritis (RA). Rheumatologists are specialists in medication prescribing and counselling for RA, but their insights regarding medication adherence have not been studied.

OBJECTIVE

To explore rheumatologists' insights into medication adherence in patients with RA.

METHODS

A qualitative study using semi-structured interviews with 10 rheumatologists in Iran was undertaken. Thematic analysis was conducted to identify how rheumatologists assess medication adherence and their perceived determinants of adherence. The identified determinants of adherence were mapped according to the Andersen's Behavioral Model of Health Service Use.

RESULTS

Six participants were male, and the mean age was 47 years. The mean years of experience as a rheumatologist was 8.6 (SD = 7.1) years. Rheumatologists did not use a validated tool for medication adherence assessment. They assessed medication adherence either by asking their patients simple questions or using laboratory test results. The identified determinants of adherence were divided into 3 groups: patient-, rheumatologist- and healthcare organization-related determinants. The proposed suggestions to improve adherence were: (a) to understand a patient's financial situation before prescribing more expensive medications; (b) to employ a dose-reducing strategy; (c) to give hope to patients regarding remission; and (d) to arrange a session with the nurse educator.

CONCLUSION

The findings of this study provide insight into rheumatologists' perspectives on medication adherence of patients with RA. The identified determinants of adherence could be considered when developing initiatives to improve medication adherence in this group of patients.

Evaluation of pharmacy-based telephone interventions on medication pick-up rates: a retrospective, quality improvement study at charity outpatient clinics

OBJECTIVES

To evaluate a live telephonic outreach intervention made by clinical pharmacists and clinical pharmacy technicians on medication pick-up rates.

METHODS

A retrospective, quality improvement study conducted at six outpatient charity clinics in Dallas-Fort Worth area between 1 January 2017 and 31 July 2017. A live telephonic call was made by a pharmacy team member if the patient did not pick-up at least one prescription item. Patients may receive more than one call if they did not pick-up medication(s) more than once during the study period. A live telephonic call resulted in three categories: contacted, left a voice message and unable to contact. Medication pick-up rates were obtained from a pharmacy claims database.

KEY FINDINGS

The study population included 1726 individual patients who failed to pick-up at least one medication from Baylor Scott & White Health pharmacy. A total of 2551 live telephonic calls were made for the study population. A total of 1175 live telephonic calls (46.1%, n = 2551) resulted in a patient picking up medication(s). Results from the generalized estimating equation logistic regression models showed that patients who received a voice message (OR: 1.37; 95% CI: 1.05 to 1.80; P < 0.021) or was contacted (OR: 1.99; 95% CI: 1.54 to 2.60; P < 0.001) were more likely to pick-up their medications as compared to the 'unable to contact' group.

CONCLUSIONS

Telephonic interventions from the pharmacy team can serve as a successful means to increase medication pick-up rates among charity clinic patients.

Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study

AIM

First, to assess the clinical characteristics and medication adherence to oral rheumatoid arthritis (RA) medications in patients with RA. Second, to examine adherence determinants with a focus on the effect of medication out-of-pocket (OOP) costs on medication adherence to oral RA medications. Lastly, to examine cost-related medication non-adherence (CRN) in patients with RA.

METHODS

A cross-sectional study of patients with RA was conducted at rheumatology outpatient clinics in Shiraz, Iran. The data collection survey consisted of 5 sections including demographic questions, disease-related questions, Compliance Questionnaire Rheumatology (CQR), CRN questions and an open-ended question. SPSS version 24 was used for analysis.

RESULTS

A total of 308 completed surveys were collected. Adherence to oral RA medications was 40.3%. Just under 20% of participants were biologic disease-modifying antirheumatic drugs (bDMARDs) users and these bDMARDs users were 0.82 times less likely to be adherent to their oral RA medications compared to non-bDMARDs users (P < 0.05). There was no statistically significant association between OOP costs and adherence to oral RA medications (P > 0.05). However, 28.7% of participants reported not refilling, delaying to refill, skipping doses or taking smaller doses due to cost. In findings of the open-ended question, medication costs and affordability were the most commonly mentioned barriers to medication adherence.

CONCLUSION

Non-adherence to oral RA medications was prevalent among Iranian patients with RA and OOP costs were a barrier to medication adherence.

The use of motivational interviewing in improving medication adherence for individuals with asthma: a systematic review

OBJECTIVE:

This review was conducted to examine current literature on the use of motivational interviewing (MI) as a strategy to promote individuals with asthma to make behavioral changes and improve health outcomes. This article systematically reviews empirical MI studies which were used to promote asthma medication adherence in children, adolescents, and adults.

METHODS:

Studies were obtained from several databases. We searched CINAHL, MEDLINE, PyscINFO, PubMed, and Cochrane database for articles on the use of MI to improve asthma medication adherence in individuals diagnosed with moderate to severe asthma. Various combinations of the following search terms were used: motivational interviewing, asthma, medication adherence, medication non-adherence, and MI.

RESULTS:

MI intervention showed evidence of improved self-efficacy, asthma, self-management, and positive behavior change for individuals diagnosed with asthma. The results suggest that MI is a feasible and promising approach to improve attitudes toward asthma medication adherence.

CONCLUSION:

The generally favorable results indicate MI merged with other interventions and support is effective in improving medication adherence and is also more sustainable than MI as a stand-alone intervention. Additional research is necessary to assess the effectiveness of MI in ensuring individuals fill their prescriptions and use their medications as recommended.

Impacts of Type D Personality and Depression, Alone and in Combination, on Medication Non-Adherence Following Percutaneous Coronary Intervention

Background: Medication adherence after percutaneous coronary intervention (PCI) is essential to preventing the risk of restenosis. Even though Type D personality and depression have been known to affect medication non-adherence, their combined influence on PCI patients remains unclear. Aim: We aimed to identify how both Type D personality and depression were associated with medication non-adherence for 3 months after successful PCI. Methods: This prospective cohort study included 257 PCI patients, who took 3 or more cardiac medications, at a university hospital. We measured sociodemographic and clinical variables, Type D personality, depression, and medication non-adherence using face-to-face interviews and medical record reviews. Results: The total prevalence of medication non-adherence at the one- and three-month follow-ups was 14% and 16%, respectively. At one month, the prevalence of those with a combination of Type D personality and depression (23.4%) and depression alone (24%) was significantly higher than other groups. At three months, the prevalence of the Type D personality-only group (39.1%) was the highest. Type D personality increased the risk of medication non-adherence 5.089 times at three months, while depression increased it 2.6 times at one month. However, the risk of medication non-adherence was not increased in patients with combined Type D personality and depression. Conclusions: Individual assessments of Type D personality and depression are required. Therefore, psychological interventions focusing on personality and depression are crucial. Longitudinal follow-up studies must explore the interaction or individual impact of Type D personality and depression on medication non-adherence and other negative outcomes.

Regimen Difficulty and Medication Non-Adherence and the Interaction Effects of Gender and Age

Medication non-adherence is a global health issue. Numerous factors predict it. This study is aimed to identify the association between regimen difficulty and medication non-adherence among patients with chronic conditions and testing the interaction effects of gender and age on the same. It was a cross-sectional study conducted among 479 outpatients from India. Convenience sampling method was used. Multiple regression analyses were performed to find the predictors of non-adherence and to test interaction effects. Regimen difficulty predicted medication non-adherence. The patient's gender and age have interaction effects on the relationship between regimen difficulty and medication non-adherence.

A Reexamination of Nonpsychiatric Medication Adherence in Individuals With Bipolar Disorder and Medical Comorbidities

Individuals with bipolar disorder (BD) have high rates of nonadherence, medical illness, and premature mortality. This analysis reexamined correlates of poor adherence to nonpsychiatric medication in 73 patients with BD and medical comorbidities. The majority was female (74%) and African American (77%) with mean age of 48.08 (SD, 8.04) years, mean BD duration of 28.67 (SD, 10.24) years, mean years of education of 12.01 (SD, 1.87), and mean proportion of days with missed doses in past week of 43.25 (SD, 31.14). Sex, age, education, race, and living alone did not correlate with adherence. More BD medications and more severe psychiatric symptoms correlated with worse adherence. Specifically, poor adherence correlated with the retardation and vegetative factors of Montgomery-Åsberg Depression Rating Scale and affect factor of the Brief Psychiatric Rating Scale. Among poorly adherent patients with BD and medical comorbidities, the number of BD medications, tension/anxiety, and somatic symptoms of depression related to worse nonpsychiatric medication adherence.

Case study: Idiopathic hemothorax in a patient with status asthmaticus

INTRODUCTION

Idiopathic spontaneous hemothorax has been rarely described in the literature.

CASE STUDY

A case of status asthmaticus and spontaneous hemothorax is described in a 29-year-old female of African descent who presented to the emergency room after 2 days of severe cough productive of yellow sputum, otalgia, sore throat, subjective fevers, chills, headache, progressive wheezing, chest tightness and dyspnea. She had a history of 7 years of asthma and was non-adherent with her controller asthma medications. Prophylactic subcutaneous administration of enoxaparin 40 milligrams was initiated upon hospitalization. The patient initially had a normal chest radiograph but subsequently developed a large, left hemothorax that required tube thoracostomy placement followed by video-assisted thoracoscopic surgery (VATS).

RESULTS

The patient was transferred to the Intensive Care Unit (ICU) and tube thoracostomy resulted in evacuation of 1,400 milliliters of blood-like fluid, which had a pleural fluid hematocrit greater than 50% of the serum hematocrit. A contrast-enhanced computed tomography (CT) scan of the chest did not reveal any source for the bleeding and a technetium bone scan of the chest was normal. The patient required transfusion of 5 units of packed red blood cells. She was then taken to the operating room for VATS because of continued chest tube drainage (3,200 milliliters of fluid over a 48-hour period).

CONCLUSION

The etiology of the hemothorax was unknown despite surgical exploration but was felt to be secondary to cough and bronchospasm associated with status asthmaticus.

Differences in Adherence and Non-Adherence Behaviour Patterns to Inhaler Devices Between COPD and Asthma Patients

Differences between COPD and asthma may also differentially affect adherence to inhaled drugs in each disease. We aimed to determine differences in behaviour patterns of adherence and non-adherence to inhaled therapy between patients with COPD and patients with asthma using the Test of Adherence to Inhalers (TAI) questionnaire. A total of 910 patients (55% with asthma, 45% with COPD) participated in a cross-sectional multicentre study. Data recorded included sociodemographics, education level, asthma or COPD history, TAI score, the Asthma Control Test (ACT), the COPD Assessment Test (CAT) and spirometry. Asthma patients were statistically significant less adherents, 140 (28%) vs. 201 (49%), and the pattern of non-adherence was more frequently erratic (66.8% vs. 47.8%) and deliberate (47.2% vs. 34.1%) than COPD patients; however unwitting non-adherence was more frequently observed in COPD group (31.2% vs. 22.8%). Moreover, taking together all sample studied, only being younger than 50 years of age (OR 1.88 [95% CI: 1.26-2.81]) and active working status (OR 1.45 [95% CI: 1.00-2.09]) were risk factors for non-adherence in the multivariate analysis, while having asthma remained in the limits of the significance (OR 1.44 [95%CI: 0.97-2.14]). Even though non-adherence to inhalers is more frequently observed in asthma than in COPD patients and exhibited a different non-adherence patterns, these differences are more likely to be related to sociodemographic characteristics. However, differences in non-adherence patterns should be considered when designing specific education programmes tailored to each disease.

Prediction of medication non-adherence and associated outcomes in pediatric kidney transplant recipients

Studies have continued to evaluate risk factors associated with post-transplant non-adherence in pediatric patients. However, many of these studies fail to evaluate how risk factors can be utilized to predict MNA. The aims of this study were to (i) determine salient risk factors associated with MNA to develop an adequate predictive risk model and (ii) assess transplant outcomes based on the presence of MNA in a large, diverse cohort of pediatric KTX recipients. One hundred and seventy-five solitary pediatric KTX recipients transplanted from 1999 to 2013 were included. AA, males, older patients, those who lived in urban environments, had legal issues, and lived shorter distances from the transplant center were more likely to have MNA. Using logistic regression, a parsimonious model applying nine risk factors together was developed for predicting MNA, demonstrating a PPV of 69% and a NPV of 81%. Patients with MNA had more than twice the risk of biopsy proven acute rejection, 1.6 times the risk of hospitalization, and 1.8 times the risk of graft loss. Utilization of a predictive model to determine risk of MNA after pediatric KTX may offer clinicians the ability to efficiently and effectively monitor MNA following transplant.

Validation of the 'Test of the Adherence to Inhalers' (TAI) for Asthma and COPD Patients

Background: To validate the ‘Test of Adherence to Inhalers’ (TAI), a 12-item questionnaire designed to assess the adherence to inhalers in patients with COPD or asthma.

Methods: A total of 1009 patients with asthma or COPD participated in a cross-sectional multicenter study. Patients with electronic adherence ≥80% were defined as adherents. Construct validity, internal validity, and criterion validity were evaluated. Self-reported adherence was compared with the Morisky-Green questionnaire.

Results: Factor analysis study demonstrated two factors, factor 1 was coincident with TAI patient domain (items 1 to 10) and factor 2 with TAI health-care professional domain (items 11 and 12). The Cronbach's alpha was 0.860 and the test-retest reliability 0.883. TAI scores correlated with electronic adherence (ρ=0.293, p=0.01). According to the best cut-off for 10 items (score 50, area under the ROC curve 0.7), 569 (62.5%) patients were classified as non-adherents. The non-adherence behavior pattern was: erratic 527 (57.9%), deliberate 375 (41.2%), and unwitting 242 (26.6%) patients. As compared to Morisky-Green test, TAI showed better psychometric properties.

Conclusions: The TAI is a reliable and homogeneous questionnaire to identify easily non-adherence and to classify from a clinical perspective the barriers related to the use of inhalers in asthma and COPD.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Parental asthma education and risks for nonadherence to pediatric asthma treatments

OBJECTIVES

Targeted parental education reduces acute visits for pediatric asthma. Whether the use of education sources readily available to parents relates to nonadherence to asthma treatments is uncertain. This study describes asthma education sources and assesses for a relationship to risks for nonadherence.

METHODS

Caregivers of children with asthma completed a cross-sectional survey at 2 sites: a pediatric emergency department (ED) and an asthma clinic (AC). Measured items included the use of 7 education sources (primary care, ED, AC, friends/family, TV, internet, and printed materials), scores of child asthma morbidity, parental asthma knowledge, and risks for nonadherence, the primary outcome. Recruitment site, preferred language (English/Spanish), and demographics were recorded. Descriptive statistics, bivariate analyses, and multivariate regressions were performed.

RESULTS

A total of 260 participants, 158 from ED and 102 from AC, used a variety of education sources. They reported 4.1 (2.0) of 13 risk factors for nonadherence, with more risks in ED parents than AC parents (4.8 vs 3.9, P < 0.001). The ED parents worried more about medications and had worse access to primary care. The regression did not show a significant relationship between education sources and risks for nonadherence, but ED recruitment, Spanish language, and worse morbidity contributed to higher risks.

CONCLUSIONS

The use of more asthma education sources was not associated with reduced risks for nonadherence. Of the education sources, a primary care provider may benefit ED parents, who also need refills and education about medications. Spanish-speaking parents report more risks for nonadherence, warranting further study of Spanish-language asthma education.

Randomized, placebo-controlled trial of bupropion in methamphetamine-dependent participants with less than daily methamphetamine use

AIMS

Two previous randomized trials found an effect for bupropion in reducing methamphetamine use in the subgroup with lower frequency of methamphetamine use at baseline. This study aimed to replicate these results by comparing bupropion versus placebo in methamphetamine-dependent participants with less than daily methamphetamine use at baseline.

METHODS

Methamphetamine-dependent volunteers reporting methamphetamine use on ≤29 of past 30 days were randomized to bupropion 150 mg twice daily (n = 41) or placebo (n = 43) and out-patient counseling for 12 weeks. The primary outcome was the proportion achieving end-of-treatment (EOT) methamphetamine abstinence (weeks 11 and 12) for bupropion versus placebo. A post-hoc analysis compared EOT abstinence by medication adherence assessed via plasma bupropion/hydroxybupropion level.

RESULTS

There was no significant difference in EOT abstinence between bupropion (29%, 12 of 41) and placebo (14%, six of 43; P = 0.087). Among participants receiving bupropion, EOT abstinence was significantly higher in participants assessed as medication adherent by plasma bupropion/hydroxybupropion levels (54%, seven of 13) compared to non-adherent participants (18%, five of 28; P = 0.018). Medication adherence by plasma levels was low (32%).

CONCLUSIONS

Bupropion may be efficacious for reducing methamphetamine in people with less than daily baseline methamphetamine use, but the evidence remains inconclusive.

Locus of control and anti-hypertensive medication adherence in Ghana

Introduction

Medication non-adherence is a major public health problem in Ghana. Locus of control (LoC) may influence adherence to medication. In this study we examine the association between locus orientation and adherence to hypertensive medication among adult patients. We also take into account the role of medication side effects.

Methods

We conducted a hospital-based cross-sectional study involving two tertiary hospitals in southern and northern Ghana. Data were collected from 400 hypertensive patients using a structured questionnaire. We gathered information on patient’s sociodemographic characteristics, health LoC, side effects of anti-hypertensive medication and adherence to anti-hypertensive medication.

Results

Participants exhibited features of mixed LoC (both internal and external) usually referred to as bi-local expectancy. However, orientation was skewed towards external LoC. Females were marginally more likely than males to have an internal LoC. Education was associated with a greater likelihood of internal LoC. While most patients (93.3%) poorly adhered to antihypertensive medications, logistic regression model revealed that non-adherence was significantly associated with low internal LoC, medication side effects and the combined effect of medication side effects and external LoC.

Conclusion

Medication non-adherence, experiences of medication side effects and LoC are associated. Multifaceted intervention programmes highlighting personality characteristics like LoC may improve anti-hypertensive medication adherence.

Perceived need to take medication is associated with medication non-adherence in patients with rheumatoid arthritis

BACKGROUND

This is the first cross-sectional study that aims to examine associations between beliefs about medication and non-adherence in patients with rheumatoid arthritis (RA) using disease-modifying antirheumatic drugs, taking potential psychological confounders into account.

METHODS

Eligible patients (diagnosed with RA for ≥1 year or ≥18 years, using greater than or equal to one disease-modifying antirheumatic drug) were included by their rheumatologist during regular outpatient visits between September 2009 and September 2010. Included patients received questionnaires. The Beliefs about Medicines Questionnaire was used to measure the perceived need to take medication (necessity beliefs), the concerns about taking medication (concern beliefs), general medication beliefs, and attitudes toward taking medication. Medication non-adherence (no/yes) was measured using the Compliance Questionnaire Rheumatology (CQR). Associations between beliefs and non-adherence, and the influence of demographical, clinical, and psychological factors (symptoms of anxiety/depression, illness cognitions, self-efficacy) were assessed using logistic regression.

RESULTS

A total of 580 of the 820 eligible patients willing to participate were included in the analyses (68% female, mean age 63 years, 30% non-adherent to their medication). Weaker necessity beliefs (OR [odds ratio]: 0.8, 95% CI [confidence interval]: 0.8-0.9) and an unfavorable balance between necessity and concern beliefs (OR: 0.9, 95% CI: 0.9-1.0) were associated with CQR non-adherence. Also, having an indifferent attitude toward medication (no/yes) was associated with CQR non-adherence (OR: 5.3, 95% CI: 1.1-25.8), but the prevalence of patients with an indifferent attitude toward medication was low. The associations were barely confounded by demographical, clinical, and psychological factors.

CONCLUSION

Increasing necessity beliefs about medication in clinical practice might be worthwhile in improving medication adherence in RA patients.

Differential impact of longitudinal medication non-adherence on mortality by race/ethnicity among veterans with diabetes

OBJECTIVE

To examine the differential effect of medication non-adherence over time on all-cause mortality by race/ethnicity.

RESEARCH DESIGN AND METHODS

Data on a longitudinal cohort of veterans with type 2 diabetes was examined. The main outcome was time to death. Primary independent variables were race/ethnicity and mean medication possession ratio (MPR) categorized into quintiles over the study period. Cox regression was used to model the association between time to death and MPR quintiles and race/ethnicity, adjusting for relevant covariates.

RESULTS

The cohort of 629,563 veterans was followed for 5 years. After adjusting for all covariates, the hazard ratios (HR) for subjects in the lowest versus highest MPR quintile was 12.21 (95 % CI 11.89, 12.55) for non-Hispanic white (NHW), 10.01 (95 % CI 9.18, 10.91) for non-Hispanic black (NHB), 12.65 (95 % CI 11.10, 14.43) for Hispanic and 10.41 (95 % CI 9.06, 11.96) for Other race veterans. Furthermore, type of diabetes therapy (oral versus insulin) maintained a significant relationship with mortality that varied by racial/ethnic group.

CONCLUSIONS

This study demonstrates the differential impact of medication non-adherence on mortality by race. It also demonstrates that type of diabetes therapy (insulin with or without oral agents) is associated with mortality and varies by racial/ethnic group.

Diagnosing medication non-adherence in a patient with myocardial infarction

BACKGROUND

Medication non-adherence continues to be a major challenge facing the healthcare system. A case is presented of a 48-year-old man with myocardial infarction who was found to be non-adherent to multiple medications. Conceptual models are reviewed along with current approaches for assessment and treatment of medication non-adherence.

DESIGN

Case report and literature review.

DISCUSSION

A theoretical model for medication non-adherence built on the Theory of Planned Behavior is presented. Empirical evidence is reviewed for determinants of non-adherent behavior such as health beliefs and self-efficacy. Current methods to assess medication non-adherence, including self-report, pill count, biological drug levels, pharmacy refill, and electronic bottles are summarized along with their limitations. Finally, an individualized approach for assessment is described using the case presented and the conceptual framework outlined above. Follow-up for the patient and potential interventions to improve medication adherence are discussed.

CONCLUSION

Despite the challenges, a conceptual framework for medication non-adherence can guide assessment and treatment. Further research for innovative and effective methods to detect and treat medication non-adherence is urgently needed to aid clinicians in treating this pervasive behavioral problem.