The burden and management of dyslipidemia: practical issues

Abstract The objective of this study is to describe briefly the burden of dyslipidemia, and to discuss and present strategies for health professionals to improve dyslipidemia management, based on a review of selected literature focusing on interventions for dyslipidemia treatment adherence. Despite the availability of effective lifestyle and pharmaceutical therapies for dyslipidemias, they continue to present a significant economic burden in the United States. Adherence to evidence-based guidelines for the treatment of dyslipidemias is unsatisfactory. The reasons for medication nonadherence are complex and specific to each patient. The lack of progress in achieving optimal lipid targets is caused by many factors: patient (medication adherence, cost of medication, literacy), medication (adverse effects, complexity of regimen), provider (lack of adherence to evidence-based practice guidelines, poor communication), and the US healthcare system (being focused on acute care rather than prevention, lack of continuity of care, general lack of use of an electronic health record). Combined interventions that target each part of the system have been effective in improving treatment adherence and achieving lipid goals. Patients, providers, pharmacists, and employers all play a role in management of dyslipidemia. No single approach will solve the complex issue of improving dyslipidemia management. The required lifestyle changes are known and effective medications are available. The challenge is for all interested parties-including nurses, nurse practitioners, doctors, pharmacists, other health care professionals, employers, and health plans-to help patients achieve behavioral changes. (Population Health Management 2012;15:302-308).     

Out-of-pocket spending and medication adherence among dialysis patients in twelve countries

Few studies have examined drug costs and adherence in similar patient cohorts across countries. Using representative samples of hemodialysis patients from twelve countries, we examined out-of-pocket medication spending and cost-related nonadherence. Mean monthly spending ranged from $8 in the United Kingdom to $114 in the United States. The proportion of patients reporting nonadherence because of cost ranged from 3 percent in Japan to 29 percent in the United States. Out-of-pocket spending was related to national pharmaceutical financing policies and predicted national nonadherence rates. However, inconsistencies in the relationship between patient costs and nonadherence suggested that other social or policy factors also matter.     

Impact of decreasing copayments on medication adherence within a disease management environment

This paper estimates the effects of a large employer's value-based insurance initiative designed to improve adherence to recommended treatment regimens. The intervention reduced copayments for five chronic medication classes in the context of a disease management (DM) program. Compared to a control employer that used the same DM program, adherence to medications in the value-based intervention increased for four of five medication classes, reducing nonadherence by 7-14 percent. The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs.     

An integrated pharmacy-based program improved medication prescription and adherence rates in diabetes patients

A substantial threat to the overall health of the American public is nonadherence to medications used to treat diabetes, as well as physicians' failure to initiate patients' use of those medications. To address this problem, we evaluated an integrated, pharmacy-based program to improve patients' adherence and physicians' initiation rates. The study included 5,123 patients with diabetes in the intervention group and 24,124 matched patients with diabetes in the control group. The intervention consisted of outreach from both mail-order and retail pharmacists who had specific information from the pharmacy benefit management company on patients' adherence to medications and use of concomitant therapies. The interventions improved patients' medication adherence rates by 2.1 percent and increased physicians' initiation rates by 38 percent, compared to the control group. The benefits were greater in patients who received counseling in the retail setting than in those who received phone calls from pharmacists based in mail-order pharmacies. This suggests that the in-person interaction between the retail pharmacist and patient contributed to improved behavior. The interventions were cost-effective, with a return on investment of approximately $3 for every $1 spent. These findings highlight the central role that pharmacists can play in promoting the appropriate initiation of and adherence to therapy for chronic diseases.     

Techniques for Measuring Medication Adherence in Hypertensive Patients in Outpatient Settings

Lack of adherence to prescribed antihypertensive regimens constitutes a barrier to adequate blood pressure control and prevention of cardiovascular events. Various means of measuring adherence to antihypertensive medications are currently available for use in clinical practice. The choice of the specific measure used in clinical practice depends on the intended use of the information, the resources available to the provider, as well as patient acceptance and convenience of the method. This article presents an overview of the advantages and limitations of the methods used to measure medication adherence that are currently available for use in outpatient settings, it also outlines provider strategies for addressing adherence issues related to antihypertensive medications.Indirect methods used to measure adherence in the outpatient setting include self report, electronic adherence monitoring (e.g. medication event monitoring system), pharmacy refill rates, and pill counts. Direct methods include the use of bioassays or biomarkers, which involve laboratory detection of the drug or a metabolic product of the drug in a biologic fluid, or laboratory detection of a biologic marker. Direct observation of the patient taking the medication is also another direct method; however, it is impractical in the outpatient setting, especially for long-term treatment. Each of these methods has advantages and disadvantages; perhaps using a combination of methods may provide the most accurate assessment of adherence.The information gained from measurement of adherence can help to formulate recommendations for individual patients regarding necessary adjustments to their medication-taking behavior to achieve the optimum outcome. Part of the difficulty associated with achieving better medication adherence lies in the inherent complexity of medication-taking decisions and behavior and of relationships between patients, their healthcare providers, and often others involved in the patient’s care, such as family members. Poor medication adherence and ultimately, adverse cardiovascular outcomes, is related to a variety of factors: quality of life; complexity of medication regimens; costs of medications; adverse effects of medications; demographic, behavioral, treatment and clinical variables; knowledge of hypertension and healthcare system issues; and use of non-conventional therapies. To be effective, strategies employed in clinical practice to overcome nonadherence need to take into account patients’ individual characteristics. Frequently, more than one strategy is necessary to bring about the desired level of adherence. The benefits of proven medical treatments are only available to patients who actively use them; thus, patient adherence to healthcare provider recommendations is the key mediator between medical practice and health outcomes.     

Adherence to mental health treatment in a primary care clinic

BACKGROUND: Patient nonadherence is common for the standard mental health treatments in primary care: antidepressants and referrals to specialty mental health treatment. This is one of few studies to prospectively identify predictors of nonadherence. METHODS: We observed 95 veterans attending an internal medicine clinic prescribed antidepressant medication or referred to mental health treatment. We collected information on sociodemographic factors, health beliefs, preferences about treatment, past experiences, and treatment knowledge. RESULTS: At 1 month, medication adherence was greater when patients experienced previous pharmacy trouble and traveled for less than 30 minutes to reach the clinic. Appointment attendance improved when patients were ready for treatment, perceived benefits, and saw their physician as collaborative. At 6 months, medication adherence was greater when patients reported a preference for medicine treatment, traveled for less than 30 minutes, and perceived greater benefits. Fewer negative effects from previous mental health treatment improved adherence to appointments. In multivariate analyses examining adherence to all treatments, greater readiness for treatment predicted 1-month adherence, whereas being unmarried and seeing the physician as more collaborative improved 6-month adherence. CONCLUSIONS: Adherence to antidepressant medications and to mental health referrals should be examined separately. A brief initial assessment for nonadherence risk factors may identify persons for targeted adherence promoting interventions.     

The role of the allied health professional in improving patient adherence.

Patient nonadherence to a prescribed treatment has received recent recognition as a significant problem in medical care and rehabilitation. Increasingly, many allied health professionals are being asked to function in the role of patient counselor to help patients initiate and maintain medication regimens, and make health-related lifestyle changes. A review of the literature indicates five major factors that significantly affect patient adherence: (1) patient education, (2) patient-health care provider rapport, (3) patient assertiveness, (4) the degree to which treatment regimen fits the patient's lifestyle and (5) the use of specific behavior change strategy. The allied health professional can work with all of these factors to improve patient adherence.     

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage

OBJECTIVE: To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. DESIGN: Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. SETTING: General practices and midwifery practices in the Netherlands. SUBJECTS: 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. MAIN MEASURES: Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. RESULTS: In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. CONCLUSIONS: The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.     

Heart failure patients¿ experiences with continuity of care and its relation to medication adherence: a cross-sectional study

ABSTRACT: BACKGROUND: A growing number of health care providers are nowadays involved in heart failure care. This could lead to discontinuity and fragmentation of care, thus reducing trust and hence poorer medication adherence. This study aims to explore heart failure patients' experiences with continuity of care, and its relation to medication adherence. METHODS: We collected data from 327 primary care patients with chronic heart failure. Experienced continuity of care was measured using a patient questionnaire and by reviewing patients' medical records. Continuity of care was defined as a multidimensional concept including personal continuity (seeing the same doctor every time), team continuity (collaboration between care providers in general practice) and cross-boundary continuity (collaboration between general practice and hospital). Medication adherence was measured using a validated patient questionnaire. The relation between continuity of care and medication adherence was analysed by using chi-square tests. RESULTS: In total, 53% of patients stated not seeing any care provider in general practice in the last year concerning their heart failure. Of the patients who did contact a care provider in general practice, 46% contacted two or more care providers. Respectively 38% and 51% of patients experienced the highest levels of team and cross-boundary continuity. In total, 14% experienced low levels of team continuity and 11% experienced low levels of cross-boundary continuity. Higher scores on personal continuity were significantly related to better medication adherence (p < 0.01). No clear relation was found between team- or cross-boundary continuity and medication adherence. CONCLUSIONS: A small majority of patients that contacted a care provider in general practice for their heart failure, contacted only one care provider. Most heart failure patients experienced high levels of collaboration between care providers in general practice and between GP and cardiologist. However, in a considerable number of patients, continuity of care could still be improved. Efforts to improve personal continuity may lead to better medication adherence.     

Does gender discrimination impact regular mammography screening? Findings from the race differences in screening mammography study

ABSTRACT Objective: To determine if gender discrimination, conceptualized as a negative life stressor, is a deterrent to adherence to mammography screening guidelines. Methods: African American and white women (1451) aged 40-79 years who obtained an index screening mammogram at one of five urban hospitals in Connecticut between October 1996 and January 1998 were enrolled in this study. This logistic regression analysis includes the 1229 women who completed telephone interviews at baseline and follow-up (average 29.4 months later) and for whom the study outcome, nonadherence to age-specific mammography screening guidelines, was determined. Gender discrimination was measured as lifetime experience in seven possible situations. Results: Gender discrimination, reported by nearly 38% of the study population, was significantly associated with nonadherence to mammography guidelines in women with annual family incomes of > or =$50,000 (OR 1.99, 95% CI 1.33, 2.98) and did not differ across racial/ethnic group. Conclusions: Our findings suggest that gender discrimination can adversely influence regular mammography screening in some women. With nearly half of women nonadherent to screening mammography guidelines in this study and with decreasing mammography rates nationwide, it is important to address the complexity of nonadherence across subgroups of women. Life stressors, such as experiences of gender discrimination, may have considerable consequences, potentially influencing health prevention prioritization in women.     

ADHERENCE TO ANTIRETROVIRAL MEDICATIONS IN HIV/AIDS CARE: A NARRATIVE EXPLORATION OF ONE WOMAN’S FORAY INTO INTENTIONAL NONADHERENCE

Intentional nonadherence occurs when patients deliberately do not take their medications. This phenomenon has not been studied within HIV/AIDS care, a significant omission due to the difficulty of adherence to antiretroviral medications for HIV/AIDS patients and the severe risks associated with nonadherence. The purpose of this study was to explore, using HIV-positive women’s own recollections collected in diary format, how and why women living with HIV/AIDS intentionally fail to adhere to their antiretroviral medications. We examined the journal entries of 20 HIV-positive women written during a 1-month period. Although three participants wrote about their intentional nonadherence, the journal entries of only one woman are presented in detail. This woman’s story highlights the complex reasons for intentional nonadherence and the social/emotional ramifications of such nonadherence. Results suggest that intentional nonadherence is emotionally trying for patients and that patients’ adherence decisions are continually renegotiated, underscoring the need for routine provider–patient adherence communication.     

Combination Therapy for Asthma

As treatment for moderate to severe persistent asthma, inhaled corticosteroid drugs combined with long-acting β-adrenoceptor agonists are being marketed in a single inhaler device. These combination products have important benefits (e.g. convenience, improved adherence, and improved day-to-day asthma symptom control); however, there are also problems (e.g. risk of severe asthma flares associated with long-acting β-adrenoceptor agonist therapy, high price of combination inhalers, and limited ability to titrate the dose of each component independently). Combination therapy is most likely to benefit patients with moderate to severe persistent asthma whose disease is not controlled on inhaled corticosteroids alone. Some patients may prefer this combination product to inhaled corticosteroids plus a leukotriene modifier or theophylline. For other patients with moderate to severe persistent asthma, inhaled corticosteroid adherence may be improved by use of the combination product. Combination long-acting β-adrenoceptor agonist/inhaled corticosteroid therapy is not appropriate for patients with predominantly exercise-induced asthma, patients unable to use the inhaler device, patients with either mild intermittent or mild persistent asthma, and patients whose asthma can be controlled on a low to moderate dose of inhaled corticosteroid medication alone.As currently priced, combination long-acting β-adrenoceptor agonist/inhaled corticosteroid therapy leads to increased costs compared with inhaled corticosteroids alone; however, in appropriately selected patients, this cost is offset by improvements in asthma symptoms and lung function. Some patients may value increases in symptom-free days, convenience, and a less offensive taste (especially with a dry-powder inhaler delivery system). Others may prefer drug minimization and/or may prefer metered-dose inhaler or nebulizer delivery systems. Providers need to be able to match the medication to the medical needs and preferences of the patient/family as best as possible. Providers need to be able to educate the patient and/or parents on the role of the medication, expected results, and inhalation techniques. Inappropriate use of combination therapy, such as for individuals with only mild asthma whose asthma can be controlled on simpler therapy, should be avoided. Health plans are accountable for both quality and costs of care. They are interested in restricting inappropriate use of combination therapy.