Multifactorial approach and adherence to prescribed oral medications in patients with type 2 diabetes

The aims of this study were to assess adherence to oral hypoglycaemic/cardiovascular drugs and determine non-adherence predictors in type 2 diabetes patients. It was designed as a population-based cross-sectional study in which 90 patients from a primary care setting were studied. Pill count and self-report methods were used to measure adherence. Logistic regression analysis was performed to predict factors related to non-adherence. Adequate adherence to all drugs was found in 29 patients (35.4%; 95% confidence interval (CI) 25.0-45.7). Variables associated with non-adherence were HbA1c odds ratio (OR) 2.32 (95% CI: 1.09-4.95), systolic blood pressure OR 1.68 (95% CI: 1.08-2.62), total cholesterol OR 1.34 (95% CI: 1.08-1.66), number of pills OR 1.80 (95% CI: 1.26-2.55) and duration of disease OR 0.44 (CI 95%: 0.24-0.83). In conclusion, one in three patients had adequate adherence. Factors associated with non-adherence were duration of disease, complexity of drug regimen and inadequate control of cardiovascular risk factors.     

Medication adherence and the associated health-economic impact among patients with type 2 diabetes mellitus converting to insulin pen therapy: an analysis of third-party managed care claims data

OBJECTIVE: This study evaluated the impact on adherence, hypoglycemic events, resource utilization, and the associated health care costs of converting from administration of insulin therapy by a vial/syringe to an insulin analogue pen device in patients with type 2 diabetes mellitus. METHODS: This pre-post analysis used an integrated medical and pharmacy claims database containing information for >40 million covered lives from 57 managed care health plans in the United States. Adults with a diagnosis of type 2 diabetes whose treatment was converted from conventional human or analogue insulin injection (vial/syringe) to a prefilled insulin analogue pen from July 2001 through December 2002, with no use of an insulin analogue pen device in the preceding 6 months, were identified and analyzed retrospectively. The primary end points were adherence (as measured by a medication possession ratio [MPR] > or =80%); the odds ratio (OR) for hypoglycemic events requiring health care resource utilization and resulting in a claim; the association between adherence and hypoglycemic events; and all-cause, hypoglycemia-attributable (HA), and diabetes-attributable (DA) health care costs. RESULTS: A total of 1156 subjects were identified and analyzed (mean [SD] age, 45.4 [13.7] years; 53.8% male; previous insulin vial use: 595 [51.5%] human, 561 [48.5%] analogue). Medication adherence was significantly improved after conversion to the insulin pen device (from 62% to 69%; P < 0.01). The proportion of subjects considered adherent was significantly higher in the period after the conversion compared with before the conversion (54.6% vs 36.1%, respectively; P < 0.01). The likelihood of experiencing a hypoglycemic event was significantly reduced after conversion (OR = 0.50; 95% CI, 0.37-0.68; P < 0.05), and the incidence of hypoglycemia in subjects with an MPR > or =80% decreased by nearly two thirds (incident rate ratio = 0.35; 95% CI, 0.11-0.81; P < 0.05). There were significant decreases in HA emergency department visits (OR = 0.44; 95% CI, 0.21-0.92; P < 0.05) and physician visits (OR = 0.39; 95% CI, 0.24-0.64; P < 0.05), whereas HA-related hospitalizations and outpatient visits remained similar after conversion. Total mean all-cause annual treatment costs were reduced by $1590 per patient (from $16,359 to $14,769; P < 0.01). Annual HA costs were reduced by $788 per patient (from $1415 to $627; P < 0.01), predominantly as a result of decreased hospitalization costs (from $857 to $288; P < 0.01). Annual DA costs were reduced by $600 per patient (from $8827 to $8227; P < 0.01). CONCLUSIONS: Among these patients with type 2 diabetes treated in a managed care setting, a switch from administration of insulin therapy by vial/syringe to a prefilled insulin analogue pen device was associated with improved medication adherence, fewer claims for hypoglycemic events, reduced emergency department and physician visits, and lower annual treatment costs.     

Adherence to antihypertensive medications among family practice patients with diabetes mellitus and hypertension

Objective

To measure adherence and to identify factors associated with adherence to antihypertensive medications in family practice patients with diabetes mellitus (DM) and hypertension.

Design

A cross-sectional study using a mailed patient self-report survey and clinical data.

Setting

Twenty-seven family physician and nurse practitioner clinics from Nova Scotia, New Brunswick, and Prince Edward Island (the Maritime Family Practice Research Network).

Participants

A total of 527 patients with type 2 DM and hypertension who had had their blood pressure measured with the BpTRU (an automated oscillometric instrument) at family practice clinic visits within the previous 6 months.

Main outcome measures

Level of adherence to antihypertension medications as measured by patients'' self-report on the Morisky scale; association between high adherence on the Morisky scale and 22 patient factors related to demographic characteristics, clinical variables, knowledge, beliefs, behaviour, health care provider relationships, and health system influences.

Results

The survey response rate was 89.6%. The average age of patients was 66 years, and 51.6% of participants were men. Forty-three percent of patients had had a diagnosis of DM for more than 10 years, and 49.7% had had a diagnosis of hypertension for more than 10 years. Eighty-nine percent of patients had some form of medical insurance. All patients had seen their family physician providers at least once within the past year. Seventy-seven percent of patients reported high adherence as measured by the Morisky scale. On multiple logistic regression, being older than 55, taking more than 7 prescribed medications, and having a lifestyle that included regular exercise or a healthy diet with low salt intake or both were significant independent predictors of high adherence scores on the Morisky scale (P ≤ .05).

Conclusion

More than three-quarters of patients with type 2 DM and hypertension from community family practice clinics in Maritime Canada reported high adherence to their antihypertensive medications. Family physicians and nurse practitioners can apply strategies to improve antihypertensive medication adherence among type 2 DM patients who are younger, taking fewer medications, or not maintaining a lifestyle that includes regular exercise or a healthy diet or both. Future studies will need to determine whether focusing adherence strategies on these patients will improve their cardiovascular outcomes.     

Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence

BACKGROUND: Adherence to medication is unacceptably low in both medical and psychiatric disorders. Explanatory models of illness beliefs and behaviors suggest that an individual's beliefs about a disorder and its treatment will influence their adherence. Given that beliefs about medications may influence adherence to antidepressants, we examined beliefs about medications in relation to antidepressant adherence in a primary care sample. OBJECTIVE: The purpose of this report is to 1) describe beliefs about medication in primary care patients prescribed antidepressants for depression; 2) examine the factor structure of the Beliefs about Medicines Questionnaire (BMQ) and compare it with the previously reported factor structure of the BMQ in medical conditions; and 3) examine the association of medication beliefs with self-reported medication adherence. RESULTS: Factor analysis indicates that the BMQ is valid in a sample of primary care patients receiving treatment for depression and has a similar factor structure to that obtained in samples of patients with chronic medical conditions. Beliefs about medications are significantly associated with self-reported adherence. Severity of depressive symptoms and specific concerns about antidepressants are significantly associated with self-reported medication-taking behavior. Findings suggest that in addition to telling patients how to take their medications, primary care physicians should also educate patients about the short- and long-term effects of the medication, how the medication works, and that antidepressants are not addictive.     

Improving adherence and reducing medication discrepancies in patients with diabetes

OBJECTIVE: To improve medication adherence by reducing self-reported adherence barriers, and to identify medication discrepancies by comparing physician-prescribed and patient-reported medical regimens. DESIGN: Prospective, randomized, controlled trial. SETTING AND PARTICIPANTS: A single academically affiliated community health center. Eligible patients had type 2 diabetes, had undergone laboratory testing in the year preceding the study, and had visited the clinic in the 6 months preceding the study. INTERVENTION: A pharmacist administered detailed questionnaires, provided tailored education regarding medication use and help with appointment referrals, and created a summary of adherence barriers and medication discrepancies that was entered into the medical record and electronically forwarded to the primary care provider. MEASUREMENTS: Changes in self-reported adherence rates and barriers were compared 3 months after the initial interview. Intervention patients with medication discrepancies at baseline were assessed for resolution of discrepancies at 3 months. RESULTS: Rates of self-reported medication adherence were very high and did not improve further at 3 months (6.9 of 7 d, with all medicines taken as prescribed; p = 0.3). Medical regimen discrepancies were identified in 44% of intervention patients, involving 45 doses of medicines. At 3-month follow-up, 60% of discrepancies were resolved by corrections in the medical record, while only 7% reflected corrections by patients. CONCLUSIONS: In this community cohort, patients reported few adherence barriers and very high medication adherence rates. Our patient-tailored intervention did not further reduce these barriers or improve self-reported adherence. The high prevalence of medication discrepancies appeared to mostly reflect inaccuracies in the medical record rather than patient errors.     

Polypharmacy and medication adherence in patients with type 2 diabetes

OBJECTIVE: To determine medication adherence and predictors of suboptimal adherence in a community cohort of patients with diabetes and to test the hypothesis that adherence decreases with increased number of medicines prescribed. RESEARCH DESIGN AND METHODS: A total of 128 randomly selected patients with type 2 diabetes from a single community health center responded to a pharmacist-administered questionnaire regarding medication use. Survey data were linked to clinical data available from the electronic medical record. We assessed self-reported adherence rates for each diabetes-related medicine, barriers and attitudes regarding medication use, and HbA(1c), total cholesterol, and blood pressure levels. RESULTS: Patients were taking a mean of 4.1 (+/-1.9) diabetes-related medicines. The average 7-day adherence was 6.7 +/- 1.1 days. Total number of medicines prescribed was not correlated with medication adherence. Adherence was significantly lower for medicines not felt to be improving current or future health (6.1 vs. 6.9 days out of 7, P < 0.001). Among patients on three or more medicines, 71% (15 of 21 patients) with suboptimal adherence were perfectly adherent with all but one medicine. Side effects were the most commonly reported problem with medication use. Of 29 medicines causing side effects that interfered with adherence, 24 (83%) did so for >1 month, and only 7 (24%) were reported to the patient's primary care physician. CONCLUSIONS: In this sample, patients reported very high medication adherence rates regardless of number of medicines prescribed. Among patients on multiple medicines, most patients with suboptimal adherence were perfectly adherent to all but one medicine. Unreported side effects and a lack of confidence in immediate or future benefits were significant predictors of suboptimal adherence. Physicians should not feel deterred from prescribing multiple agents in order to achieve adequate control of hyperglycemia, hypertension, and hyperlipidemia.     

Quality of care for diabetes patients using National Health Insurance claims data in Japan

Background Assessment of the quality of care is a key element in current diabetes care. However, the quality of care for diabetes patients in Japan has rarely been reported. Objectives To assess the quality of diabetes care in two communities in Japan by using National Health Insurance claims data. Methods We analysed claim data of 13 650 beneficiaries of National Health Insurance in two communities in Japan from May 2006 to April 2007. Diabetes cases were identified by using a case detection algorism. Our main outcome measures were three process quality indicators: (1) haemoglobin A1c (HbA1c) testing; (2) annual eye examination; and (3) annual nephropathy screening, recommended in the existing clinical guidelines. We calculated the performance rate of each quality indicator and examined the effects of demographic characteristics and co‐morbid conditions. Results We identified 636 diabetes cases. Of these, 97.0% had at least one HbA1c test, and 69.8% had ≥4 tests during the study period. The odds ratios (ORs) for ≥4 HbA1c tests were lower in subgroups aged 75–79 (OR 0.58, 95% confidence interval 0.35–0.96), and aged ≥80 (OR 0.54, 95% confidence interval 0.32–0.88) compared with the subgroup aged <70 after adjusting for other patient characteristics. The annual rate for eye examinations and nephropathy screenings were 20.8% and 5.8% respectively. Conclusions We found high performance rates for HbA1c testing, while the annual rates for eye examinations and nephropathy screenings were suboptimal. Using administrative data would facilitate more comprehensive assessment of the quality of care in Japan.     

2型糖尿病患者甲真菌病临床资料分析

目的了解糖尿病患者甲真菌病的临床分型、菌种构成及易感因素。方法分析2013年1月至2014年8月山西医科大学第二医院内分泌科2型糖尿病住院患者的临床资料,对合并甲真菌病者进行临床分型、菌种鉴定,对可能导致糖尿病患者甲真菌感染的因素进行Logistic回归分析。结果 1 125例2型糖尿病患者中合并有甲真菌病者153例,患病率为13.6%;临床分型为远端侧缘甲下型94例(58.39%),全甲毁损型43例(26.71%),白色浅表型18例(11.18%),近端甲下型6例(3.72%);菌种鉴定为皮肤癣菌属77例(67.54%),是主要的致病菌,酵母菌属(23.68%)和曲霉菌属(3.51%)相对要少;多因素分析结果表明年龄、男性、糖尿病病程、周围循环障碍、周围神经病变、视网膜病变与糖尿病患者患甲真菌病有关(P<0.05)。结论糖尿病患者甲真菌病的易感因素包括年龄、男性、糖尿病病程、周围循环障碍、周围神经病变、视网膜病变。     

Nonmydriatic teleretinal imaging improves adherence to annual eye examinations in patients with diabetes

We studied whether nonmydriatic digital retinal imaging with remote interpretation (teleretinal imaging) in the ambulatory care setting affected adherence to annual dilated eye examinations among patients with diabetes. We randomly assigned 448 patients to a teleretinal imaging group or a control group. We measured the number of patients who had dilated eye examinations within 12 months of group assignment and the agreement for level of diabetic retinopathy between teleretinal imaging and the eye examinations. The teleretinal imaging group (n = 223) had significantly more dilated eye examinations than the control group (n = 225). Teleretinal imaging and eye examination results showed significant correlation and moderate agreement. Cataract and smaller pupil size were significantly associated with ungradable retinal images. Two-thirds of patients with ungradable images had other ocular findings. Patients reported high satisfaction with nonmydriatic teleretinal imaging. Nonmydriatic teleretinal imaging improves diabetic retinopathy assessment rates.     

Clinical outcomes for low-income adults with hypertension and diabetes

BACKGROUND: Long-term management of hypertension and diabetes, which are more prevalent in minority and socioeconomically disadvantaged populations, presents challenges for healthcare providers in community health centers. OBJECTIVES: The purpose of the study was twofold: to examine health outcomes for persons with hypertension and diabetes and to compare these outcomes for disparities in patients who were Black, Hispanic, or White. METHODS: Medical records (N = 280) from an urban community health center that serves predominantly uninsured adults were reviewed for selected clinical outcomes of primary care. Measures included outcomes of hypertension and diabetes control, lifestyle behaviors, preventive care, and patient status. Chi-square tests, t tests, and one-way analysis of covariance were used to analyze racial/ethnic group differences. RESULTS: Data revealed significant differences in smoking status, influenza immunization, and blood pressure. Racial/ethnic group differences were minimal compared with the overall high prevalence of risk factors such as smoking and obesity. Regular access to primary care did not result in improved clinical outcomes. CONCLUSION: The findings support the need for more effective interventions that promote healthy lifestyle if health disparities in low-income populations with chronic conditions are to be reduced.