Translation and validation of the Arabic version of the General Medication Adherence Scale (GMAS) in Saudi patients with chronic illnesses

PurposeThe study aimed to translate and validate the Arabic version of General Medication Adherence Scale (GMAS) in Saudi patients with chronic diseases.MethodsA multi-center cross sectional study was conducted for a month in out-patient wards of hospitals in Khobar, Dammam, Makkah, and Madinah, Saudi Arabia. Patients were randomly selected from a registered patient pools at hospitals and the item-subject ratio was kept at 1:20. The tool was assessed for factorial, construct, convergent, known group and predictive validities as well as, reliability and internal consistency of scale were also evaluated. Sensitivity, specificity, and accuracy were also evaluated. Data were analyzed using SPSS v24 and MedCalc v19.2. The study was approved by concerned ethics committees (IRB-129-25/6/1439) and (IRB-2019-05-002).ResultsA total of 282 responses were received. The values for normed fit index (NFI), comparative fit index (CFI), Tucker Lewis index (TLI) and incremental fit index (IFI) were 0.960, 0.979, 0.954 and 0.980. All values were >0.95. The value for root mean square error of approximation (RMSEA) was 0.059, i.e., <0.06. Hence, factorial validity was established. The average factor loading of the scale was 0.725, i.e., >0.7, that established convergent validity. Known group validity was established by obtaining significant p-value <0.05, for the associations based on hypotheses. Cronbach’s α was 0.865, i.e., >0.7. Predictive validity was established by evaluating odds ratios (OR) of demographic factors with adherence score using logistic regression. Sensitivity was 78.16%, specificity was 76.85% and, accuracy of the tool was 77.66%, i.e., >70%.ConclusionThe Arabic version of GMAS achieved all required statistical parameters and was validated in Saudi patients with chronic diseases.     

Adherence to prophylactic dual antiplatelet therapy in patients with acute coronary syndrome – A study conducted at a Saudi university hospital

ObjectivesThe aim of this study was to evaluate patients’ self-reported adherence to dual antiplatelet therapy (DAPT) and determine the factors associated with premature discontinuation of DAPT.MethodsThe cross-sectional interview-based study was conducted among adult outpatients who visited the outpatient department of King Khalid University Hospital, Cardiac Center in Riyadh, Saudi Arabia, over a period of 3 months from May to July of 2016. Medication adherence was assessed using the Self-efficacy for Appropriate Medication Use Scale (SEAMS), which is composed of 13 items with a 3-point Likert scale.ResultsA total of 192 patients participated in the study. The majority of the participants were male (82.1%), and the mean age was 55.66 ± 10.80 years. More than 84% (84.4%) of the patients reported that they were “confident” in taking several medications each day. The minimum and maximum SEAMS scores were 22 and 39, respectively, with the mean score being 30.8 ± 3.5. Almost all patients had moderate scores and adherence; only one patient got a score of 39. Among sociodemographic characteristics, only health insurance and income were significantly associated with the medication adherence score (p < 0.05).ConclusionsStudy results concluded that patients had a moderate level of adherence towards DAPT in Saudi Arabia, however Patient education on DAPT is essential to improve adherence to medication treatment. More effective intentions and education methods should be developed to improve long-term DAPT adherence.     

The 8-item Morisky Medication Adherence Scale: Validation of a Brazilian–Portuguese version in hypertensive adults

BackgroundThe Morisky Medication Adherence Scale (MMAS-8) remains one of the most widely used mechanisms to assess patient adherence. Its translation and testing on languages in addition to English would be very useful in research and in practice.ObjectiveTo translate and examine the psychometric properties of the Portuguese version of the structured self-report eight-item Morisky Medication Adherence Scale among patients with hypertension.MethodsThe study was designed as a cross-sectional survey conducted in six Family Health Units of the Brazilian Unified Health System, in Maceió, between March 2011 and April 2012. After a standard “forward–backward” procedure to translate MMAS-8 into Portuguese, the questionnaire was applied to 937 patients with hypertension. Reliability was tested using a measure of internal consistency (Cronbach's alpha), and test–retest reliability. Validity was confirmed using known groups validity. Three levels of adherence were considered based on the following scores: 0 to <6 (low); 6 to <8 (medium); 8 (high).ResultsThe mean age of respondents was 57.1 years (SD = 12.7 years), and 71.5% were female. The mean number of prescribed antihypertensives per patient was 1.62 (SD = 0.67). The mean score for the medication adherence scale was 5.78 (SD = 1.88). Moderate internal consistency was found (Cronbach's alpha = 0.682), and test–retest reliability was satisfactory (Spearman's r = 0.928; P < 0.001). A significant relationship between MMAS-8 levels of adherence and BP control (chi-square, 8.281; P = 0.016) was found. 46.0%, 33.6%, and 20.4% of patients had low, medium, and high adherence, respectively. The self-report measure sensitivity, specificity, positive and negative predictive values were 86.1%, 31.2%, 57.4% and 68.3% respectively.ConclusionsPsychometric evaluation of the Portuguese version of the MMAS-8 indicates that it is a reliable and valid measure to detect patients at risk of non-adherence. The MMAS-8 could still be used in routine care to support communication about the medication-taking behavior in hypertensive patients.     

中国高血压患者用药依从性的meta分析

目的：对中国高血压患者的药物依从性（Medication Adherence,MA）的研究进行了Meta分析,并探讨了不同年龄组、性别和文化程度的MA差异。 方法：使用三个英文数据库（Pubmed,Web of Science和Embase）和三个中文数据库（知网,万方和维普）检索2010年1月至2018年9月的相关文献。随机效应模式被应用去计算效应量大小和95％CI。另外进行了亚组分析,以确定这些比较中潜在的异质性来源。Egger’s的测试和Begg’s测试用于评估发表偏倚。 结果：共27篇文献被纳入本次研究,包括来自14个省、3个直辖市和1个特别行政区的20,140名参与者。整体纳入研究的汇总效应大小值为42.0％（95％CI：36.0％-48.0％）。通过亚组分析,合并的8项Morisky药物依从性量表（MMAS-8）值为49.4％（95％CI：38.9％-59.9％）。4项Morisky药物依从量表（MMAS-4）值为37.5％（95％CI：31.1％-44.0％）。具有初中或以下,高中,大专或以上学历的患者的MA结果分别为49.5％,49.6％和53.6％。男性患者（47.5％）的药物依从性略低于女性（48.4％）。 60岁及以上的患者（51.0％）的MA高于60岁以下的患者（46.9％）。在发达地区的参与者的MA（48.3％）比不发达地区（37.5％）更高。 结论：中国高血压患者MA相对较低,不同的测量工具会可能会影响患者的MA测量结果,学历、性别、经济水平是高血压患者MA的影响因素。目前急需有效的干预措施来解决和缓解这一问题。     

Studying the impact of a medication use evaluation by the community pharmacist (Simenon): Patient-reported outcome measures

BackgroundIn the SIMENON study, medication use reviews were conducted for older polymedicated home-dwelling patients across 56 Belgian community pharmacies.ObjectiveTo evaluate the impact of the service on patient-reported outcome measures and patient-reported experience measures, and to evaluate the suitability of the chosen instruments.MethodsA before-after design was used to measure the impact of the medication use review in a subset of patients, participating in the SIMENON study. Patients completed self-report questionnaires before and 3 and 12 weeks after the intervention by letter, phone or e-mail. Six outcomes were evaluated: medication-related quality of life, adherence, self-management, patient satisfaction, fall incidents and use of emergency healthcare services.ResultsQuestionnaires at baseline and endpoint were available for 83 patients (median age 77 years; median of 7 drugs) of 24 pharmacies. The Living with Medicines Questionnaire showed low medication burden at baseline (84.8/205) which increased to 85.7 three weeks later (n = 57; p = 0.219). Scores significantly reduced to 81.9 at twelve weeks (p = 0.031). The Probabilistic Medication Adherence Scale (n = 67) showed high median adherence scores at baseline (14/18) which remained unaltered (p = 0.974). The patient activation measure found low self-management in one third of the sample at baseline and endpoint (35.5% and 37.1% respectively; p = 0.243). The Patient Satisfaction with Pharmacist Services Questionnaire (n = 66) demonstrated high patient satisfaction. The number of patients with a hospitalization in the last three months decreased non-significantly from 14.8% to 11.1% in the post-measurement after 12 weeks (p = 0.227). No effect was observed on emergency room visits and falls.ConclusionsThe medication use review reduced medication burden but did not impact the patient's adherence and self-management. However, adherence scores were high, medication burden was low at baseline and the sample size was limited. The Living with Medicines instrument is a promising instrument for future research to assess medication-related quality of life in older polymedicated patients.     

The federal standard medication plan in practice: An observational cross-sectional study on prevalence and quality

BackgroundMedication plans are instruments used to document drug therapies, guide patients, and ensure medication safety. In Germany, patients who take at least 3 long-term medications are eligible to receive a medication plan. It has been statutory to use the federal standard layout (German: “Bundeseinheitlicher Medikationsplan”) since April 2017.ObjectivesThis study explores the prevalence, availability, medication discrepancies, and conformance with statutory regulations of medication plans since the introduction of the format of the federal standard medication plan in Germany.MethodsMedication reconciliation was performed for hospitalized patients according to the Best Possible Medication History principle. The collected medication lists were analyzed for medication discrepancies and conformance with the statutory regulations. The medication discrepancies were (1) omitted drugs, (2) additional drugs, and (3) dosing errors.ResultsAfter hospitalization, 524 patients taking drugs were included. The majority (n = 424 patients) were eligible for a medication plan. While 241 medication lists were present, only 24.1% (n = 58) matched the federal standard format. The mean number of drugs was 6.3 ± 3.6, with 3315 medications (3046 long-term and 269 as needed) reconciled totally. The 84 medication lists with omitted or additional drugs included 166 medication discrepancies upon 774 drugs listed. Of the 253 patients with dosing errors, 146 had a medication list. Inappropriate dosages were due to single dose (n = 195), daily dose (n = 225) or frequency of application (n = 255).ConclusionMedication plans are valuable tools for patients and health care providers. This study shows that the introduced paper-based federal standard medication plan in Germany falls short of its expectations regarding availability and correctness. Switching to an electronic patient record system may overcome some of the current pitfalls.     

Comparing medication adherence tools scores and number of controlled diseases among low literacy patients discharged from a Brazilian cardiology ward

Background Adherence to prescribed drug therapy is associated with lower rates of cardiovascular causes of death. In view of the relevance for public health, it is important to understand the relation between medication adherence tools’ scores, especially in low literacy patients discharged from a cardiology ward. Objectives We aimed to assess: (a) the association between number of controlled clinical conditions and adherence tools scores, and (b) the correlation between the scores of three instruments to assess adherence. Methods We conducted a prospective study and included patients discharged from a specialized cardiovascular ward in Brazil. The results of the Beliefs about Medicines questionnaire (BMQ), the Adherence to Refills and Medication Scale (ARMS) and the MedTake test were compared. Results Of 53 included patients, most of them were elderly, and did not complete primary school. On average, there were six health conditions per patient, where two of them were not controlled. ARMS was the only tool that was associated with number of controlled health conditions (r = ?0.312, p < 0.05). Moreover, ARMS (average score 15.6 ± 3.4) had significant correlation with MEDTAKE (r = 0.535, p < 0.01) and BMQ (r = 0.38, p < 0.01). BMQ and MEDTAKE were also positively correlated (r = 0.311, p < 0.05). Conclusions Clinically, higher ARMS scores (>12) suggest assumed non-adherence. It is also negatively correlated with the number of controlled clinical conditions in low literacy elderlies with cardiovascular diseases.     

Correlation between medication regimen complexity and quality of life in patients with heart failure

PurposeTo determine if a correlation exists between the medication regimen complexity index (MRCI) and quality of life (QoL) in patients with heart failure (HF) assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).MethodsRetrospective chart review from July 2012 through June 2018 identified patients for inclusion who completed an MLHFQ. Baseline and, if available, follow-up MLHFQ scores were collected. The medication list documented on the date of the MLHFQ was used to calculate the MRCI.ResultsPatients with a documented MLHFQ score were included (n = 72) in the primary analysis. No correlation existed between baseline MRCI and MLHFQ (r = 0.07; p = 0.55). A secondary analysis of correlation between change in MRCI and MLHFQ was conducted for patients (n = 30) with a follow-up MLHFQ score. A moderate, negative correlation (r = −0.47; p = 0.009) existed between change in MRCI and MLHFQ from baseline to follow-up.ConclusionNo significant correlation between MRCI and MLHFQ scores were found at baseline. Patients with follow-up MLHFQ scores demonstrated improvements in QoL, despite increasingly complex medication regimens. Medication regimen complexity alone is likely an insufficient marker for predicting QoL in patients with HF.     

Adherence to evidence-based guidelines for the management of pneumonia in a tertiary teaching hospital in Riyadh

BackgroundAdherence to therapeutic guidelines is crucial when treating pneumonia, as it reduces mortality rate, length of hospital stay and duration of antibiotic therapy. However, the high non-adherence rate to treatment guidelines, in general, and to the Infectious Disease Society of America (IDSA) guidelines, are still reported globally. According to our knowledge, no existing data is available regarding the rate of physicians' adherence to the IDSA guidelines for managing pneumonia in Saudi Arabia. Therefore, we aim to assess the adherence rate and the clinical outcomes among patients treated according to the IDSA guidelines, in a tertiary care center in Riyadh.MethodsA single-centered, retrospective, cross-sectional, observational study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. All data were extracted from the hospital's electronic information system, known as Esihi. Adult patients (≥18 years old) diagnosed and treated in the hospital for community-acquired pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia from Nov 2019 to Nov 2021 were included.ResultsA total of 148 patients were included in this study, and the management of 50% of them (74 patients) adhered to the guidelines' recommendations. Even though the patients who received guidelines-adhered management were older (70 ± 16 vs 59 ± 22; p = 0.001), and had a higher CURB-65 score for pneumonia severity (1.86 ± 1.03 vs 1.39 ± 1.26; p = 0.026) and an average calculated Charlson comorbidity index (4.62 ± 2.19 vs 3.28 ± 2.80; p = 0.001) than patients who were treated irrespectively of the guidelines, yet they had a better cure rate (95% vs 84%; adjusted OR, 3.9; 95% CI, 0.82–18.58), lower mortality (5% vs 14%; adjusted OR, 0.38; 95% CI, 0.04–4.05) and shorter length of hospital stay (LOS) (6.5 vs 8 days; p = 0.082); compared to patients who were treated irrespectively of the guidelines.ConclusionsComparable to previous literature, non-adherence to evidence-based guidelines has been observed in 50% of patients treated for pneumonia. Despite being nonsignificant, higher clinical cure rates, shorter LOS, and lower mortality rates have been observed in patients who were treated based on evidence-based guidelines. Further measures to improve guidelines compliance in pneumonia treatment are needed.     

Patient adherence to warfarin therapy and its impact on anticoagulation control

Warfarin is a commonly prescribed oral anticoagulant in Saudi Arabia and yet patient adherence to warfarin therapy and its impact on anticoagulation control have not been well researched here. A cross-sectional survey was conducted over 6 weeks at the outpatient anticoagulant clinic on patients who were receiving warfarin. Adherence was assessed using the translated Arabic version of the Morisky Medication Adherence Scale (MMAS-8). Levels of adherence were classed as low (score ⩽ 7), or high (score = 8) based on the scores. Good anticoagulation control was defined as percent Time INR in Therapeutic Range (TTR) ⩾ 75% using the Rosendaal method. A total of 192 patients completed a questionnaire with a response rate of 68.1%. It was established that no association was found between adherence to warfarin therapy and INR control groups. Among the 89 (46.4%) patients who had high adherence, only 34 (38.2%) had an acceptable INR control. This was versus 103 (53.6%) patients who had low adherence but also 34 (33.0%) had good INR control. Multivariate logistic regression (MLR) analysis showed that when studying females and occupational status of unemployment, they were independently associated with poor INR control with an OR 2.31, 95% CI 1.10–4.92, and OR 2.71, 95% CI 1.12–6.61 respectively. MLR analysis also showed that age <50 years alongside no formal education was independently associated with low adherence to warfarin therapy with an OR 2.67, 95% CI 1.29–5.52 and OR 2.63, 95% CI 1.01–6.93 respectively. The demographic background influences adherence and INR control, but no association was found between adherence and anticoagulation control.     

慢病患者药物依从性量表的研究

目的:介绍几种常用的依从性评价量表,为临床以及科研中药物依从性量表的选择提供参考。方法:通过文献研究,总结归纳各种依从性评价问卷的特点。结果:不同量表具有各自的功能特点、适用人群。药物依从性问卷(MAQ)发展最早,条目少,简单易操作,适合初筛;8项Morisky药物依从性量表(MMAS-8)在MAQ的基础上发展而来,比MAQ具有更高的实用性,适用范围广,是现在使用最广泛的量表;适当用药的自我效能量表(SEAMS)侧重于自我效能的评估,但是分值计算较困难,比较耗时;简要药物依从性问卷(BMQ)包含了三方面的评估,包含详细的用药回顾但花费时间长;Hill-Bone量表只针对于高血压患者开发,包含钠的摄入和预约诊疗状况,更适用于黑色人种的高血压患者;药物依从性比率量表(MARS)是适用于慢性精神疾病患者依从性评价的工具,简单易评分。结论:现有的依从性评价工具中,并不存在一种金标准。在各种常用的依从性评价量表中,要根据临床及科研的目的、经济因素、时间因素等选择最适合的量表。     

基于跨理论模型的健康教育策略对乳腺癌患者内分泌治疗依从性的影响研究

目的 探讨以跨理论模型为基础的健康教育策略对乳腺癌患者内分泌治疗依从性的影响。方法 选取长沙市某三甲医院乳腺外科乳腺癌术后拟实施内分泌辅助治疗的154例患者为研究对象,应用方便抽样法分为干预组和对照组,每组77例。对照组患者实施常规的健康教育,干预组患者实施以跨理论模型为基础的干预方案,比较干预前后两组患者不同行为阶段人数占比,分别评价两组干预前、干预后1个月和干预后6个月的服药依从性和合理用药自我效能。结果 干预后,干预组患者各行为阶段人数占比显著高于对照组,差异有统计学意义（P<0.05）。重复测量方差分析结果显示,两组患者服药依从性和合理用药自我效能组间主效应、时间主效应和交互作用均具有统计学意义（P<0.05）。结论 应用以跨理论模型为基础的健康教育策略可帮助乳腺癌患者建立良好的服药行为,从而提高其辅助内分泌治疗依从性,是一种具有一定效果的健康教育方法。     

Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study

BackgroundAdherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored.MethodsA prospective design was utilized to measure AF patients’ self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3–4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8).ResultsThe included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching.ConclusionPatients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.     

Medication persistence among patients with asthma/COPD drugs

Objective To determine medication possession ratio (MPR) of patients with asthma/COPD drugs. Method Individual patient’s volumes of asthma/COPD drugs (ATC-code R03) for 2000–2004 were obtained from a pharmacy record database. For each patient the MPR was calculated as the percentage of the treatment time that the patient had drugs available. Main outcome measure Medication possession ratio (MPR). Results A total of 1,812 patients, 20 years and older, with dispensed asthma/COPD drugs were registered in the database, 928 patients (51%) had acquired drugs less than once per year (68% for 20–29 years old) during the 5-year study. Only 13% of the patients had steroids and steroid combinations available to allow continuous treatment. Eight percent of the patients 20–29 years old had MPR ≥ 80% of all the included drugs and 5% when only steroids and steroid combinations were considered. About 25% of the patients had acquired 80% of the total volume of asthma/COPD drugs. Conclusion The majority of the patients, and particularly those in the youngest age group used asthma/COPD drugs only sporadically. This may indicate undermedication which is likely to have a negative impact on patient outcome.     

Effectiveness of a pharmacist-led structured group-based intervention in improving medication adherence and glycaemic control among type 2 diabetes mellitus patients: A randomized controlled trial

BackgroundA pharmacist-led structured group-based intervention (MEDIHEALTH) was formulated to improve medication adherence among Malay type 2 diabetes mellitus (T2DM) patients in the Malaysian state of Sarawak.ObjectivesThe objective of this study was to examine the effectiveness of MEDIHEALTH and its mechanism of impact for improving medication adherence and the glycated haemoglobin (HbA1c) level.MethodsA two group and parallel randomised controlled trial with a twelve months follow-up period was conducted at two primary health clinics in Malaysia that were surrounded by Malay communities. Malay T2DM patients whose HbA1c was >7% and total score on the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) was <26 were recruited and parallelly randomised to the MEDIHEALTH or usual care (control) groups. The extended theory of planned behaviour was employed to test the mechanism of impact. Repeated measure analysis of variance was used to assess the difference in the estimated marginal mean of the SEAMS scores and HbA1c level between the intervention and control groups at different times.ResultsA total of 142 participants were recruited and randomised; three from the intervention group and eight from the control group withdrew before receiving any treatment. Hence, 68 participants in the intervention group and 63 in the control group were included for analyses. The MEDIHEALTH group had a significantly greater increase in the SEAMS score compared to the control group (p < 0.001) at one, three, six and twelve months post-intervention. There was also a significantly greater reduction in HbA1c in the MEDIHEALTH compared to the control group at one, three, six and twelve months post-intervention (p < 0.001). These improvements were mediated by enhancements in perceived behavioural control and knowledge about medications.ConclusionsThe MEDIHEALTH may improve medication adherence and glycaemic control among Malay T2DM patients.