How can osteoporosis patients benefit more from their therapy? Adherence issues with bisphosphonate therapy

OBJECTIVE: To review the evidence on adherence with bisphosphonates and evolving dosing strategies for osteoporosis treatment. DATA SOURCES: Articles were identified by searching MEDLINE (1975-December 2005) using the following terms: osteoporosis, postmenopausal, fracture, adherence, compliance, persistence, drug therapy, bisphosphonates, alendronate, risedronate, ibandronate, and zoledronate. Additional data included bibliographies from identified articles. STUDY SELECTION AND DATA EXTRACTION: All pertinent English-language articles that discussed adherence issues in patients with osteoporosis were included. Both those that reviewed overall issues of medication adherence in osteoporosis and those that focused specifically on adherence to bisphosphonates were included, as were articles that addressed strategies for overcoming nonadherence. DATA SYNTHESIS: Inadequate diagnosis and treatment of osteoporosis result in a higher risk of fractures than is necessary. Even patients who are diagnosed and beginning treatment often do not persist with their osteoporosis medication because they perceive their fracture risk to be low and, given the asymptomatic nature of osteoporosis, do not experience the benefit of symptom reduction after taking the drugs. Factors that affect adherence to osteoporosis therapy include drug costs, adverse effects, dosing frequency, disease education, patient follow-up, and patient involvement in treatment decisions. CONCLUSIONS: By considering and implementing strategies that can improve adherence and persistence, primary care providers and pharmacists (via counseling) may enhance long-term outcomes for patients with osteoporosis.     

Opioids: How to Improve Compliance and Adherence

Abstract: Chronic pain has been recognized as a major worldwide health care problem. Today, medical experts and health agencies agree that chronic pain should be treated with the same priority as the disease that caused it, and patients should receive adequate pain relief. To achieve good analgesia, patient adherence to a prescribed pain treatment is of high importance. Patients with chronic pain often do not use their medication as prescribed, but change the frequency of intake. This can result in poor treatment outcomes and may necessitate additional emergency treatment, which increases the overall costs. Factors that influence adherence include knowledge of the disease, realistic treatment expectations, perceived benefit from treatment, side effects, depression, dosing frequency, and attitudes of relatives/significant others toward opioids. Addressing all these factors should ensure a good treatment outcome. Good adherence to pain therapy is associated with improved efficacy in pain relief and quality of life. Opioids have become an integral part of the treatment of moderate to severe chronic noncancer pain. They may cause unpleasant side effects such as nausea, vomiting, and constipation. Patients should be informed adequately about side effects, which should be treated pro‐actively to foster adherence to treatment. Signs of tolerance, hyperalgesia, and drug abuse should be monitored as these may occur in some patients. An individualized treatment algorithm with a clear treatment goal and regular treatment reassessment is key for successful treatment. Long‐acting opioids offer sustained pain relief over 24 hours with manageable side effects—they simplify treatment thereby supporting treatment adherence.     

Associations between adherence to guidelines for antipsychotic dose and health status, side effects, and patient care experiences

BACKGROUND: One approach to improving quality of care is to encourage physicians to follow evidence-based practice guidelines. Examples of evidence-based guidelines are the PORT recommendations for the treatment of schizophrenia. However, few studies have examined the relationship between adherence to guidelines and patient outcomes in clinical settings. OBJECTIVE: The purpose of this article is to report the relationship between guideline adherence to antipsychotic medication dose and self-reported health status, side effects, and perceptions of care. RESEARCH DESIGN: This report is based on a subsample of patients from a larger prospective observational study of disabled Massachusetts Medicaid beneficiaries treated for schizophrenia. SUBJECTS: Participants were 329 acutely ill, vulnerable, high-risk Medicaid adult beneficiaries enrolled after visiting any 1 of 8 psychiatric emergency screening teams for hospital admission evaluation. MEASURES: Dose levels, symptoms, and functioning from medical records; self-reports as data collected from BASIS-32, SF-12, and CABHS; and paid health benefit claims for psychiatric treatment were measured. RESULTS: Approximately 40% of the patients in this study had daily antipsychotic doses well above the recommended range, but there was no evidence that their health status was better than those on doses below 1000 CPZ units recommended for acute episodes. High-dose levels had no relationship to baseline symptom profile or referral source. CONCLUSIONS: There was no evidence that health status was better on higher-than-recommended doses, but we cannot conclude that lower doses for some would have led to poorer outcomes. Physicians who believe that higher doses are more therapeutic for patients need to demand rigorous effectiveness research that tests whether there are benefits of higher doses and determine the ratio of those benefits to the clinical costs, including the risk of side effects.     

Adherence to oral therapy for type 2 diabetes: opportunities for enhancing glycemic control

PURPOSE: Although diet and exercise are important parts of type 2 diabetes treatment, most patients require pharmacological intervention with multiple agents to maintain adequate glycemic control. This article addresses the numerous patient-related, disease-related, and demographic variables affecting medication adherence in this patient population. DATA SOURCES: Extensive review of scientific literature, clinical practice guidelines, and Internet sources. CONCLUSIONS: Studies have demonstrated that treatments including multiple medications or frequent dosing had a negative impact on adherence. Practitioners have used several approaches in an effort to improve adherence to oral antidiabetic medical therapy, including increased communication between health care providers and patients, implementation of multidisciplinary programs, and use of treatment regimens with easier dosing (i.e., reduced number of drugs or doses taken per day). IMPLICATIONS FOR PRACTICE: Options for type 2 diabetes treatments that combine effective medications into a simpler oral-dosage form may motivate and improve patient adherence. Ultimately, simplifying dosing may lead to better glycemic control, thereby reducing the risks associated with long-term consequences of the disease.     

Observations of nonadherence to recombinant human growth hormone therapy in clinical practice

Background: The effectiveness of all prescribed treatments is contingent on patient adherence. The reported levels of adherence to recombinant human growth hormone (r-hGH) therapy are highly variable, but it has been suggested that nonadherence might be as high as 36% to 49%. Objectives: This commentary discusses the factors that affect long-term adherence to injection treatment, of which r-hGH therapy is a particular challenge. It also explores potential strategies to improve adherence to injection treatments in clinical practice. Methods: The opinion of the authors was validated and supported by published literature. A PubMed literature search was conducted in November 2006, identifying English-language articles containing key terms growth hormone, adherence, and compliance. Results: This study found that factors associated with poor adherence to injection treatments include patients' lack of understanding of their disease, patient age, chronicity of the disease, complex treatment regimens, and insufficient information on the implications of nonad-herence. Strengthening the patient-physician relationship by providing the patient with a clear understanding of his/her disease and the benefits of adherence, making improvements in injection devices, and eliminating subjective illness concepts, might increase adherence to SC injection treatments, thereby reducing increasing health care costs associated with nonadherence. Conclusions: Poor adherence to r-hGH therapy has a dual effect, in that it leads to reduced efficacy out-comes and increased health care costs. Implementing strategies to improve adherence with injection treatment might be of particular clinical benefit to patients undergoing r-hGH therapy.     

Quality and the nursing workforce: APNs, patient outcomes and health care costs

Quality in health care requires access, appropriate and acceptable treatment plans, responsible patient follow through, a workforce of sufficient numbers and qualification and agreement on health care quality indicators. The purpose of this article is to describe APN workforce and dose effects on quality, reflected in patient outcomes and health care costs with current quality indicators. Stakeholders measure “quality indicators” differently. Nursing practices are often absent in databases and systems of reimbursement. Research overwhelmingly indicates equal outcomes for physician and APN care plus value-added APN effects on use of preventive services, adjustment to illness, stress management, treatment compliance, satisfaction, and reduced emergency room visits and rehospitalizations. APN dose has an important positive effect on patient outcomes and healthcare costs. Research is needed on the level of APN dose, staff mix and use of APNs, and balance of physician and APN dose in different stages of patient health, illness, and recovery to achieve quality outcomes.     

Evidence-based practice for acute low back pain in primary care: patient outcomes and cost of care

Provider adherence with clinical practice guidelines (CPGs) for acute low back pain (LBP) and its impact on clinical outcomes and cost are controversial. A panel and cross-sectional design was used to determine the rate of provider adherence to the Department of Defense/Veteran's Administration CPG for Acute LBP which included ergonomic and psychosocial intervention. The relationship among adherent care, patient satisfaction, general health, functional outcome, and cost was examined. Direct health services and patient survey data 1 year before and 3 years following guideline implementation were analyzed. The sample consisted of 15,789 LBP cases (CPG) and 14,409 upper extremity cases used as controls (no CPG). Ten to 40% of LBP cases received CPG-adherent care across the 4 years. No differences were found between LBP and upper extremity diagnoses groups in the rates of change in the four outcomes over years. Multivariable regression analyses controlling for demographic variables and perceived health indicated that CPG adherence was related to better functional outcomes, Odds ratio (OR)=1.45 [95% CI=1.31-1.60] and lower healthcare costs (beta=-230.15, p<0.001). Cases receiving more adherent care also reported higher levels of patient satisfaction (beta=0.09, p<0.05) and general health, OR=1.44 [95% CI=1.29-1.60]. Higher levels of adherent care which included efforts to address both ergonomic and psychosocial factors in the course of acute back pain were related to better clinical outcomes and lower costs.     

Maximizing effectiveness of bisphosphonate therapy for osteoporosis

While highly prevalent, osteoporosis is greatly underdiagnosed and undertreated in clinical practice. Even when appropriate treatments are prescribed, patient adherence to bisphosphonate therapy is low. As osteoporosis is a silent disease, and therapy is required for many months before benefit is realized, strategies to increase bone mineral density (BMD) and improve medication adherence are important aspects of every patient's care plan. Osteoporotic bone loss occurs without symptoms, and there are often no warning signs before a fracture occurs. Osteoporotic fractures are the most severe consequence of osteoporosis. Bisphosphonates are the most frequently prescribed treatment option for postmenopausal osteoporosis, as they effectively increase BMD, slow bone turnover, and reduce fracture rates. Strategies to improve adherence to osteoporosis therapy include reducing dosing frequency, changing the route of administration, educating the patient about optimum bisphosphonate administration, and sending patient reminders.     

Nurse to patient ratios in American health care

BACKGROUND: Nurses are employed in large numbers throughout health care. When their salary cost is considered as a percentage of total salary cost, they are arguably the most costly group of employees. Healthcare facilities have the potential to achieve large financial savings by reducing the number of nurses they employ. However, this may have negative consequences for staff, patients and the organisation as a whole. CONCLUSION: Research has shown that by reducing the number of nurses, patient outcomes deteriorate and length of stay increases. Curtailing nurse staffing levels can also lead to poor staff morale, nurse retention and recruitment problems and malpractice suits, which can raise costs far above the expense of employing more nurses. By reducing nurse to patient ratios, that is, by reducing the number of patients (see nurse to patient ratio box opposite), it is probable that patient care will improve along with patient satisfaction, poor morale will dissipate, fewer lawsuits will be filed and agency nurse use will decrease, all of which will help to reduce hospital costs in the long-term.     

Dosing patterns for continuous renal replacement therapy at a large academic medical center in the United States

PURPOSE: We sought to retrospectively review the dosing patterns of continuous renal replacement therapy (CRRT) in patients with acute renal failure (ARF) and determine their actual delivered dosage of CRRT. MATERIALS AND METHODS: Computerized records of patients (n = 115) who received CRRT for ARF at a single, large, academic, tertiary care hospital from September 1, 1999 through August 31, 2000 were reviewed. The delivered dose of CRRT for each patient/day was calculated from the hourly effluent flow rate, the patient's weight, and the duration (in hours) of CRRT for that day. A mean effluent flow rate (in L/h) for each patient was then calculated. RESULTS: The average number of hours/day on CRRT was 16.1 +/- 3.53 (mean +/- SD), with a mean flow rate (averaged over 24 h) of 1.36 +/- 0.31 L/h.The mean CRRT dose prescribed for these patients was 24.46 +/- 6.73 mL/Kg/h, but the mean dose delivered was only 16.55 +/- 5.41 mL/Kg/h (68% of the prescribed dose, P <.000001). CONCLUSIONS: Many patients are prescribed low doses of CRRT. Furthermore, the dose delivered is considerably lower than that prescribed. Methods and procedures to extend CRRT system life may improve the dose delivery.     

Association between adherence measurements of metoprolol and health care utilization in older patients with heart failure

OBJECTIVE: Data from electronic dosing monitors and published pharmacokinetic parameters were used to derive medication adherence measures for immediate-release metoprolol and examine their association with health care utilization of outpatients aged 50 years or older with heart failure. METHODS: We used a 1-compartment model and published population pharmacokinetic parameters to estimate mean plasma metoprolol concentrations for patients treated for 6 to 12 months. In the absence of directly measured plasma concentrations, we calculated the intended mean plasma concentration (Cp'(ave)) under the assumption of perfect adherence to the prescribed dose and frequency of administration. Projected mean plasma concentrations (Cp(ave)) were estimated by use of data from recorded dosing times. In addition to taking adherence (percentage of dose taken) and scheduling adherence (percentage of doses taken on schedule), we calculated the deviation from the intended exposure (DeltaCp(ave) = Cp'(ave) - Cp(ave)) and the proportion of intended exposure achieved by the patient (Cp(ave) /Cp'(ave)). We assessed the association between the adherence measures and the numbers of emergency department visits and hospital admissions experienced by the patients. RESULTS: Patients (N = 80) were aged 62 +/- 8 years. Mean DeltaCp(ave) and Cp(ave)/Cp'(ave) were 7.9 ng/mL (SD, 10.7) and 0.6 (SD, 0.3), respectively. Log-linear models adjusted for patient functional status indicated that greater deviation from the intended metoprolol exposure (DeltaCp(ave)) was associated with increased numbers of emergency department visits ( P < .0001) and hospital admissions (P < .0001). A higher proportion of intended exposure (Cp(ave) /Cp'(ave)) corresponded to a reduced number of emergency department visits (P = .0204) and hospital admissions (P = .0093). Taking adherence was univariately associated with both emergency department visits and hospital visits (P < .0001 and P = .0010, respectively). Scheduling adherence was associated with the number of emergency department visits (P = .0181) but not with the number of hospital admissions (P = .1602). Model selection procedures consistently chose the proposed measures over taking adherence and scheduling adherence. CONCLUSION: Deviation from the intended exposure and proportion of intended exposure achieved by the patient are valid adherence measures for immediate-release metoprolol and are associated with health care utilization. The potential utility of these measures for other beta-adrenergic antagonists and perhaps other cardiovascular drugs should be investigated.     

Advancing the role of nursing in the medical home model

The patient-centered primary care model has been positioned to improve patient outcomes, enhance patient satisfaction, and reduce health care costs. The role of nursing in this care transformation is evident in ProvenHealth Navigator-one of the organization's primary care models. ProvenHealth Navigator incorporates primary care practice redesign, including team-delivered care, as the foundation for its model. Case managers, as one of the components of the care team, have demonstrated their value in reducing fragmentation, enhancing care transitions, and coordinating care for the most complex patients.Combining the strengths of a clinical delivery system with the population management expertise of a health plan, ProvenHealth Navigator capitalizes on the strengths of an integrated health care system to stratify the population, enhance access, optimize outpatient treatment, provide near real-time reporting, and deploy additional disease/case management resources for those most in need of additional health care services. Operational since 2006, ProvenHealth Navigator has been associated with significant reductions in all-cause admissions, readmissions, and total cost of care. In addition, quality indicators for chronic conditions and preventive care improved and patient and clinician satisfaction is high. Optimizing the role of primary care teams and focusing on population management services provides one method of improving quality and reducing costs thus increasing health care value.     

Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial study design and sample characteristics

Pain is the most common physical symptom in primary care, accounting for an enormous burden in terms of patient suffering, quality of life, work and social disability, and health care and societal costs. Although collaborative care interventions are well-established for conditions such as depression, fewer systems-based interventions have been tested for chronic pain. This paper describes the study design and baseline characteristics of the enrolled sample for the Stepped Care to Optimize Pain care Effectiveness (SCOPE) study, a randomized clinical effectiveness trial conducted in five primary care clinics. SCOPE has enrolled 250 primary care veterans with persistent (3 months or longer) musculoskeletal pain of moderate severity and randomized them to either the stepped care intervention or usual care control group. Using a telemedicine collaborative care approach, the intervention couples automated symptom monitoring with a telephone-based, nurse care manager/physician pain specialist team to treat pain. The goal is to optimize analgesic management using a stepped care approach to drug selection, symptom monitoring, dose adjustment, and switching or adding medications. All subjects undergo comprehensive outcome assessments at baseline, 1, 3, 6 and 12 months by interviewers blinded to treatment group. The primary outcome is pain severity/disability, and secondary outcomes include pain beliefs and behaviors, psychological functioning, health-related quality of life and treatment satisfaction. Innovations of SCOPE include optimized analgesic management (including a stepped care approach, opioid risk stratification, and criteria-based medication adjustment), automated monitoring, and centralized care management that can cover multiple primary care practices.     

Factors that affect adherence to bipolar disorder treatments: a stated-preference approach

BACKGROUND: Medication nonadherence is high among patients with bipolar disorder, and may lead to poor clinical outcomes, decreased quality of life, and increased resource utilization. OBJECTIVE: To investigate the factors associated with nonadherence and to assess the effect of patient-stated preferences on stated adherence to hypothetical medications. RESEARCH DESIGN: A choice-format stated-preference Web survey was administered. In each choice question, patients were asked to choose among 2 or 3 different hypothetical medications. Each choice question was followed by a question asking patients about their likely adherence to the selected medication alternative. SUBJECTS: Patients (N = 469) with self-reported bipolar disorder completed the survey which was programmed and administered to members of a chronic-illness Web panel. MEASURES: Factors associated with stated adherence to current treatment were identified. The effects of socioeconomic characteristics and medication attributes on stated adherence to hypothetical medications were assessed. RESULTS: Patient socioeconomic characteristics affect patients' adherence. Being white and having more education has a significant positive effect on adherence. Self-reported current adherence is a strong factor in predicting adherence for better medications. Medication outcome attributes, especially severity of depressive episodes, strongly influence patients' stated adherence to treatment. Weight gain and cognitive effects of a medication most significantly affected patients' likely adherence to medications for bipolar disorder. CONCLUSIONS: Patients are the final health care decision makers; their satisfaction with a medication is likely to affect whether or not they adhere to the medication prescribed by their physician. In the case of bipolar disorder, this study suggests patients are likely to be more adherent to medications that reduce the severity of depressive episodes and do not cause weight gain or cognitive side effects. By understanding the factors that improve adherence, health care providers can optimize prescribing patterns, which may ultimately lead to more effective management and improvement in the patient's condition.     

Effects of once-daily and twice-daily dosing on adherence with prescribed glipizide oral therapy for type 2 diabetes

BACKGROUND: We evaluated differences in adherence and persistence with prescribed therapy of once-daily (OD) dosing compared with twice-daily (BID) dosing of glipizide in patients with type 2 diabetes. METHODS: The study cohort was derived from a pharmacy benefit manager claims database. Patients new to extended-release gastrointestinal therapeutic system (GITS) and immediate-release glipizide therapy were identified and followed for 1 year. Adherence indices (AIs) were calculated and persistence curves were constructed. RESULTS: Adherence indices rates were 60.5% in the GITS OD cohort and 52.0% in the BID cohort. Rates of persistence at 12 months were 44.4% in the GITS OD cohort vs 35.8% in the BID cohort. CONCLUSION: Initiation of OD pharmacotherapy results in better adherence and persistence compared with a BID regimen, despite a greater daily pill burden in the OD cohort. These data suggest that dosing frequency exerts a greater impact on patient adherence and persistence than number of tablets per dose.     

Advantages of extended-release metformin in patients with type 2 diabetes mellitus

Metformin is a first-line pharmacological treatment for patients with type 2 diabetes mellitus because of its favorable overall profile, including its glucose-lowering ability, weight-neutral effects, and low risk of hypoglycemia; however, gastrointestinal (GI) intolerance may limit use in some patients. Extended-release metformin improves GI tolerability, allows once-daily dosing, and is currently available in multiple branded and generic formulations; however, it is more expensive than immediate-release metformin. Maximum plasma metformin concentrations are reached more slowly with the extended-release formulation compared with conventional immediate-release metformin, although both provide similar exposure at a given total daily dose. Extended-release metformin is as effective as immediate-release metformin in patients newly started on metformin and those switched from the immediate-release formulation, with similar weight-neutral effects. Tolerability is generally comparable, although patients switched from the immediate-release formulation--even those switched due to GI intolerance--are often better able to tolerate the extended-release formulation. Based on studies of extended-release formulations in other disease states, metformin extended-release formulation has the potential to improve patient adherence with a simpler dosing regimen and increased tolerability. Increased adherence may result in greater glycemic control, and in turn, improve outcomes and lower health care usage and costs. Extended-release metformin provides an appropriate option for patients with type 2 diabetes mellitus who require several medications to achieve glycemic control or manage comorbid conditions, and for those who have GI intolerance with the immediate-release formulation.