Patient Characteristics Associated with Medication Adherence

Objective

Despite evidence indicating therapeutic benefit for adhering to a prescribed regimen, many patients do not take their medications as prescribed. Non-adherence often leads to morbidity and to higher health care costs. The objective of the study was to assess patient characteristics associated with medication adherence across eight diseases.

Design

Retrospective data from a repository within an integrated health system was used to identify patients ≥18 years of age with ICD-9-CM codes for primary or secondary diagnoses for any of eight conditions (depression, hypertension, hyperlipidemia, diabetes, asthma or chronic obstructive pulmonary disease, multiple sclerosis, cancer, or osteoporosis). Electronic pharmacy data was then obtained for 128 medications used for treatment.

Methods

Medication possession ratios (MPR) were calculated for those with one condition and one drug (n=15,334) and then for the total population having any of the eight diseases (n=31,636). The proportion of patients adherent (MPR ≥80%) was summarized by patient and living-area (census) characteristics. Bivariate associations between drug adherence and patient characteristics (age, sex, race, education, and comorbidity) were tested using contingency tables and chi-square tests. Logistic regression analysis examined predictors of adherence from patient and living area characteristics.

Results

Medication adherence for those with one condition was higher in males, Caucasians, older patients, and those living in areas with higher education rates and higher income. In the total population, adherence increased with lower comorbidity and increased number of medications. Substantial variation in adherence was found by condition with the lowest adherence for diabetes (51%) and asthma (33%).

Conclusions

The expectation of high adherence due to a covered pharmacy benefit, and to enhanced medication access did not hold. Differences in medication adherence were found across condition and by patient characteristics. Great room for improvement remains, specifically for diabetes and asthma.     

Improving Advanced Practice Provider Knowledge and Assessment of Medication Adherence in Patients with Cardiovascular Disease

Medication nonadherence is a widespread problem among cardiovascular patients. Advanced practice providers (APPs) play a critical role in assessing for medication adherence upon hospital admission. A pre–post intervention design was used to determine the effect of an education module on APP knowledge and assessment of medication adherence in cardiovascular patients over a 12-week period in the Division of Cardiology. We found a statistically significant increase in cardiology APP knowledge and assessment of medication adherence upon hospital admission using an education module and providing a valid and reliable assessment tool in the electronic health record.     

Patient Characteristics Associated With Self-Reported Adherence to Chiropractic Treatment Recommendations: A Feasibility Study

ObjectiveThe purpose of this study was to examine the feasibility of developing and administering a patient adherence survey to assess self-reported adherence to treatment recommendations from a chiropractic doctor within an academic health center.MethodsThe survey items were developed by the authors and vetted by the university's students and faculty, who serve as health care practitioners at an academic health center. Adult patients with spine pain who were seen by a doctor of chiropractic at an academic health center were included in this survey study. A 32-item survey was administered between October 2019 and March 2020.ResultsA total of 62 respondents completed the anonymous survey. We found that 89% of respondents adhered to their clinic appointments. Although 82% of respondents said that their doctor's recommendation made sense, only 44% reported completely following treatment recommendations for at-home stretching and exercise.ConclusionThis study determined that it is feasible to assess patient self-reported adherence to chiropractic treatment within an academic health center setting. In our sample we found that although patient adherence to clinic appointments was high, adherence to treatments was not.     

Motivational Interviewing: Addressing Ambivalence to Improve Medication Adherence in Patients with Bipolar Disorder

Poor adherence to psychotropic medication is a significant issue for patients with bipolar disorder. The effectiveness of medication treatment is limited by high rates of medication non-adherence among this population. Motivational Interviewing is an evidence-based intervention that has been efficacious in promoting behavioral health regimens and treatment recommendations, including medication adherence. By using a patient-centered approach, Motivational Interviewing has been shown to enhance patients’ insight and attitudes toward treatment. This article aims to describe to mental health nurses how to use Motivational Interviewing with bipolar patients to address ambivalence and improve adherence to psychotropic medication regimens.     

小儿先天性心脏病介入术后阿司匹林服药依从性的管理

目的探讨抗凝药物服药监测和随访机制对于先天性心脏病患儿服药依从性的影响。方法采用前瞻、随机、对照方法,将120例先天性心脏病患儿及家属分为对照组和干预组。对照组予常规药物健康宣教,干预组在此基础上采用服药监测和随访机制。术后半年,比较两组阿司匹林认知程度及服药依从性的差异。结果干预组阿司匹林认知程度和服药依从性明显高于对照组,药物不良反应发生率明显低于对照组(P<0.05)。结论设计并应用药物服用监测记录表,完善并增加电话随访和复诊,可提高先天性心脏病介入术后阿司匹林服药依从性,减少不良反应。     

CC4-03: The Use of Administrative Data and Natural Language Processing to Estimate the Incidence of Statin-related Rhabdomyolysis

Background/Aims Despite the problem of misclassification, many studies of adverse drug reactions (ADRs) rely on administrative data rather than events validated by medical record review. We evaluated the new ICD-9 code for rhabdomyolysis (728.88) and natural language processing (NLP) as methods to identify cases of statin-related rhabdomyolysis, and estimated the incidence with various statins and doses. Methods We conducted a population-based study of statin users in Group Health Cooperative from 2006-2010. Person-years of statin use among all enrollees by statin and dose were estimated using computerized pharmacy records. Trained abstractors reviewed the medical records of selected statin users to identify cases of statin-related rhabdomyolysis and myopathy, defined as muscle injury with a peak creatine kinase level = 10x and 5-10x the upper limit of normal, in the absence of other likely etiologies. Results Review of medical records for 361 statin users with a qualifying administrative code yielded 24 cases of statin-related rhabdomyolysis and 12 of myopathy. The positive predictive value of the rhabdomyolysis ICD-9 code was only 7.5% (22/292). NLP methods identified another 5 cases of rhabdomyolysis and 6 of myopathy. Using validated cases, the rhabdomyolysis incidence rate (IR) per 100,000 person-years of statin use was 13.2 for simvastatin compared with 5.2 for users of other statins (IRR 2.61; 95% CI, 1.03-7.84), and 64.8 for the 80 mg/day dose of simvastatin compared with 5.3 for the 20 mg/day dose (IRR 12.2; 95% CI, 3.6-52.3). In an analysis using only the ICD-9 code for rhabdomyolysis, the IRR for simvastatin compared with other statins was 1.03 (95% CI 0.80-1.34), and for 80 mg/day dose of simvastatin compared with 20 mg/day it was 1.77 (95% CI 1.05-2.88). Discussion Use of the administrative diagnostic code for rhabdomyolysis was highly nonspecific for this ADR and resulted in weaker associations than methods that verified ADRs with medical record review. The use of administrative data alone in surveillance studies of other medication ADRs with multiples causes, such as drug-induced liver injury, may fail to detect actionable and clinically important harms.     

Adherence to Medication Regimen in Patients with Severe and Chronic Psychiatric Disorders: A Qualitative Study

Nonadherence to treatment is common in patients with chronic psychiatric disorders. Few studies have been conducted in Iran on lack of adherence to medication regimen in patients with severe psychiatric disorders. The present study was carried out with the purpose of gaining insight into the experiences of patients, their family members, and nurses on the medication adherence in patients with severe and chronic psychiatric disorders in selected hospitals in Ahvaz, Iran. A qualitative content analysis study was used in the study and the participants included 7 nurses, 5 patients, and 4 family members. The patients were being treated in psychiatric wards of the hospitals of Ahvaz, in southern Iran. The results of data analysis revealed three main themes: 1) Intentional abandonment of medications; 2) Catalysts of medication discontinuation (including side effects, asymptomatic periods, lack of knowledge of family members, and cultural shame of medication use); and 3) Consequences of medication discontinuation. According to the findings of the study, cultural attitudes play an important role in adherence to treatment regimen among the patients with chronic psychiatric disorders. It is recommended to arrange different programs to improve the situation with an emphasis on improving the general attitude of society towards mental illnesses and the need for regular use of the medications.     

Risk Factors Associated with Emergency Room Drug Abuse Admissions in Urban Taiwan, 1998-1999

The present study examined the risk factors associated with admissions for drug abuse among patients who visited an accident and emergency (A & E) department at a large metropolitan teaching hospital in Taipei, Taiwan. Two hundred and fifty-four consecutive patients reporting problems related to suspected intentional drug poisoning or acute intoxication from drugs of misuse were matched to 254 patients with internal medicine conditions unrelated to drug abuse by age within three years. Risk factors and drug use information was obtained by questionnaire. Between December 1998 and November 1999, 272 (0.7%) patients had visited the A & E for treatment of drug-related problems. Among these patients, 254 (93%) completed questionnaires and were enrolled in this study. Major reasons for hospital visits were suicide (51%), and acute drug poisoning (49%); primary drugs used were sedatives/hypnotics (81.7%) and narcotics (4.7%); most drugs came from pharmacies and drug stores (47.2%), hospitals and clinics (25.2%), or were bought from friends (7.1%) or others (11.1%). Being single (OR = 1.7, 95% CI 1.1-2.7), female (OR = 3.4, 95% CI 1.4-10.0), having an alcohol drinking habit (OR = 3.0, 95% CI 1.3-7.2), and having higher depressive scores (OR = 1.3, 95% CI 1.2-1.4) were independently associated with drug abuse. Important preventive measures against drug abuse included improving access to psychological counseling for users and controlling dispension of drugs at pharmacies.     

CB7-03: A Diverse Autism Registry for Etiologic and Effectiveness Studies: Prevalence and Demographic Characteristics

Background/Aims Diagnoses of Autism Spectrum Disorders (ASDs) continue to rise, yet few effectiveness studies of autism treatments exist. The major limitations to conducting such studies include locating, characterizing, and enrolling sufficiently large and representative ASD patient samples. This project has created a large, comprehensive, and dynamic ASD registry across five integrated not-for-profit health systems participating in the NIMH Mental Health Research Network (MHRN). This registry will enable rapid identification and enrollment of patients into large-scale studies investigating treatment interventions as well as pharmacogenomic and etiologic hypotheses. Methods Nine study sites compose the MHRN, which serve a diverse population of 10 million people in 11 states. The ASD registry is based in five MHRN sites: Kaiser Permanente (KP) Northern California, KP Southern California, KP Northwest, KP Georgia, and Harvard Pilgrim Health Plan. ASD registry investigators developed algorithms which identify children with ASD from electronic medical records and health claims data. ASD diagnoses are validated using structured record review and expert review. Diagnostic and demographic data recorded in health plan electronic databases from 1995-2010 on all 0-17 year olds who were health plan members as of December 2010 were used to describe ASD prevalence in this population. Results Overall prevalence of ASD was 1.2% (23,811/2,049,442), and ranged from 0.86% (458/53,297) to 1.6% (3,425/212,375) across all sites. Most ASD cases were 10-14 years old (36% (8,165/22,606), range: 35% (2,717/7,775) - 41% (617/1,515)) or 5-9 (35% (7,848/22,606), range: 30% (459/1,515) - 37% (161/432)). Fewer cases were 15-17 years old (18% (4,064/22,606), range: 16% (1,578/9,641) - 22% (329/1,515)) or 0-4 years old (11% (2,529/22,606), range: 7% (110/1,515) - 12% (1,159/9,641)). The overall ratio of male to female cases was 4.29 (range: 3.71-5.11). Of children diagnosed with an ASD, 59% were diagnosed with Autistic Disorder ((14,061/23,811), range: 33% (1,131/3,425) - 71% (7,154/10,068)). Discussion Demographic diversity and extensive electronic health records make this registry an ideal environment for studying ASDs. Future aims include investigating use of services not provided by HMOs, collection of genetic material from individuals and families with ASD's, and harmonization of data from many sources such as birth certificates and census data.     

PS1-54: Retrospective Cohort Study of Medication Adherence History and Risk for 90-day Hospital Readmission in a Medicare Cost Plan

Background/Aims Identifying factors related to readmission is important for successfully targeting appropriate interventions to groups at risk for readmission. The objective of this study was to investigate the association of long-term medication adherence with hospital readmission in a cohort of beneficiaries enrolled in a Medicare cost plan. Methods The study employed a retrospective cohort design using pharmacy and healthcare utilization claims from a Medicare Cost Contract plan for January 2009 through December 2009. Inpatient hospitalization was identified based on the revenue code (100-169, and 200-219). Eligible members were continuously enrolled through the study period, and experienced at least one hospitalization in 2009 after which they were discharged to home. About 1767 members were eligible and included in the analysis. Approximately 13% had a claim for a subsequent readmission during the study period. Medication adherence in the year before the index hospitalization was measured with the medication possession ratio (MPR), defined as the supply of medications in days minus the last fill days supply divided by the total number of days between the last fill date and the first fill date for drugs for chronic medication. Likelihood of readmission within 90 days was estimated using the logistic regression. Covariates entered into the model included demographics, MPR (both continuous and categorical with 3 categories: low (MPR<0.5), medium (.5 < MPR<.8), and high (MPR>.8 adherence), and having an office visits within 30 days of discharge. Results Members with high medication adherence were less likely than those with low adherence to have a claim indicating 90-day readmission (OR=.35, p=0.01). When considered as continuous, higher MPR was associated with decreasing risk of readmission (OR=0.24, p=0.02). Having an office visit within 30 days from the date of discharge was as associated with a decreased risk of readmission (OR=0.06, p<0.001). Discussion The health behavior of long-term adherence to medications was associated with risk of readmission. A major study limitation is the underestimation of readmission rates due to lack of complete capture of hospital claims. An important next step will be to replicate the study with a larger population for which all claims are captured.     

CB8-03: Models of Integrated Care for Adolescent Alcohol and Drug Use in Pediatrics: Predictors and Implications for Practice and Policy

Background/Aims We describe findings from a longitudinal study of adolescent substance use (SU) treatment, a web survey of pediatric primary care providers (PCPs), and a pilot study of a Screening, Brief Intervention and Referral to Treatment (SBIRT) model of primary care-based adolescent behavioral healthcare. Methods The treatment study (N=419) examined pathways to treatment, co-morbidities, and outcomes. The survey (N=437) examined PCP attitudes and knowledge, patient characteristics, and environmental influences, (e.g., mental health parity and medical marijuana laws), and from electronic medical records (EMR), we examined patient demographics, comorbidity, and services utilization. We examined how PCP, panel, and organizational characteristics influence screening practices. The pilot examined whether SBIRT versus usual care increased problem identification and specialty treatment rates, and the feasibility of SBIRT in Pediatrics. Results Intakes had high levels of medical and psychiatric comorbidities, and frequent primary care visits, but few had SU problems identified or were referred for treatment by PCPs. Integrated treatment produced better short- and long-term outcomes. The survey found that PCPs were less concerned about alcohol and marijuana than other drug use, rated alcohol use as more difficult to discuss (19% v s 15%) or diagnose (56% vs. 70%) than depression, and were more comfortable discussing sexual practices than alcohol (32% vs. 22%). They were more likely to screen boys than girls, with male PCPs even more likely: 23% vs. 6% (p<.0001). Self-reported screening rates were far higher than actual (EMR-documented) rates for all substances. Experience, specialty, and recent AOD training (all p<.05) predicted self-reported rates; only patient age predicted actual rates. Organizational approaches (e.g., EMR tools and workflow guidelines) may matter more than PCP or patient characteristics in determining adolescent alcohol and drug use screening practices. The SBIRT model of care tested in the pilot proved highly feasible. PCPs said that it improved care; more (77) teens were identified and referred for further assessment, and specialty treatment initiation increased from 8.73% to 12% (p<.0001). Discussion Organizational factors, lack of training, and discomfort with screening may impact adolescent screening and intervention. We discuss the development of integrated models of care for adolescent behavioral healthcare.     

Valvular Heart Disease Associated with Long-term Treatment by Methysergide: a Case Report

This case report concerns a woman treated continuously since at least 10 years by methysergide for cluster headache. The echocardiographic and histological features of the severe valve fibrosis presented by this patient are very similar to those described with 5 HT_2B receptors agonistic drugs.     

CC1-04: Online Patient Access to Their Medical Record and Health Providers is Associated With a Greater Use of Clinical Services

Background/Aims To compare utilization of office and telephone encounters by patients with online access to their electronic medical record (EMR) to patients without online access. Methods Administrative data for ambulatory care patients enrolled in a group model HMO from May 2006 through June 2009, using an electronic medical record with an online patient access feature, which includes: appointment requests, results review, medication list, refill request, problem list, care instructions, and email communication with their healthcare providers. We collected administrative data for health plan utilization documented in the EMR for patients 12 months before and after the activation of their online access and for a matched cohort of patients without online access. The analytic data set included those with and without online access matched on propensity scores within a 5% range based on age, gender, and co-morbidity within baseline visit and year strata. Results The propensity matched cohorts (N = 51,535; in each cohort) contained 54.2% females, an average age of 43.7 years, 6.9% were less than age 20, 36.2% ages 20-39, 43.3% ages 40-59, and 13.7% ages 60 and over. Eighty-six percent of the cohort had none of four chronic illnesses, 7.4% with asthma, 5.7% with diabetes, 1.5% with coronary artery disease, and 1% with congestive heart failure. In the year following activation of their on-line access, this cohort had increased rates (per patient per year) of office visits (3.1 vs. 2.2, p<0.001), telephone contacts (3.9 vs. 3.4, p<0.001), after-hour clinic visits (0.1 vs. 0.07, p<0.001), in-patient hospitalizations (0.07 vs. 0.06, p<0.01) compared to a matched cohort of patients without on-line access. However, on-line access patients had a decreased incidence rate of emergency department use (0.15 vs. 0.18, p <0.001) during the year of follow-up compared to the cohort without on-line access. Discussion Patients with online access to their health information and to their healthcare providers also had an increased use of clinical services. Further research is needed to understand this association and to evaluate the effect online access has on patient health outcomes.     

United States ED Visits by Adult Women for Nonfatal Intimate Partner Strangulation, 2006 to 2014: Prevalence and Associated Characteristics

IntroductionNonfatal intimate partner strangulation poses significant acute and long-term morbidity risks and also heightens women’s risk for future femicide. The lifetime prevalence of nonfatal intimate partner strangulation has been estimated to be approximately 10%, or 11 million women, in the general United States population. Given the potential for significant health risks and serious consequences of strangulation, this study adds to the limited literature by estimating prevalence and describing the associated characteristics of strangulation-related visits among United States ED visits by adult women after intimate partner violence.MethodsPrevalence estimation as well as simple and multivariable logistic regression analyses were completed using data from the Nationwide Emergency Department Sample spanning the years 2006 to 2014.ResultsThe prevalence of strangulation codes was estimated at 1.2% of all intimate partner violence visits. Adjusting for visits, hospital characteristics, and visit year, higher odds of strangulation were noted in younger women, metropolitan hospitals, level I/II trauma centers, and non-Northeast regions. Increases in strangulation events among intimate partner violence–related visits in recent years were also observed.DiscussionA relatively low prevalence may reflect an underestimate of true nonfatal intimate partner strangulation visits owing to coding or a very low rate of ED visits for this issue. Higher odds of strangulation among intimate partner violence visits by women in more recent years may be due to increased recognition and documentation by frontline clinicians and coding teams. Continued research is needed to further inform clinical, postcare, and social policy efforts.