Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care

BackgroundProviders are often unaware of poor adherence to prescribed medications for their patients with chronic diseases.ObjectiveTo develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers.Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH.Key resultsBehavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4–16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability.ConclusionMeasures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.     

Medication adherence and barriers among low-income,uninsured patients with multiple chronic conditions

BackgroundPoor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States.ObjectiveTo evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease.MethodsA cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization—social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence.ResultsA total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01–5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09–6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62–8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10–0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04–0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06–0.59).ConclusionsMedication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.     

The association of health literacy with illness perceptions,medication beliefs,and medication adherence among individuals with type 2 diabetes

Background

Beliefs in medications and illness perceptions is associated with medication adherence among individuals with diabetes and several adherence interventions focus on patients' beliefs in medicines and illnesses. Though health literacy is important in medication adherence, the relationship between health literacy and medication adherence remains inconclusive; thus raising the question as to whether health literacy has an amplifying or reducing effect on the relationship between beliefs and adherence.

Understanding of medications and associations with adherence,unmet needs,and perceived control of risk factors at two years post-stroke

BackgroundIt is unclear whether survivors of stroke or transient ischemic attack (TIA) routinely receive, and understand, education about secondary prevention medications.ObjectivesTo investigate whether survivors of stroke/TIA understand explanations about their prescribed prevention medications and associations with medication adherence, control of risk factors, and unmet needs.MethodsA survey was administered among survivors of stroke/TIA (random sample N = 1500) from the Australian Stroke Clinical Registry (Victoria and Queensland, 2016). Participants reported whether they understood explanations about each prescribed medication, as well as their unmet needs, perceived control of risk factors, and 30-day medication adherence. Linked pharmacy claims data were also used to determine medication adherence in the previous two years (proportion of days covered ≥80%). Outcomes were analyzed using multivariable logistic regression or multivariable negative binomial regression for frequency of unmet needs.ResultsOverall, 630/1455 eligible survivors completed the survey at ≈2.5 years post-admission (median age 69 years; 37% female). Most participants reported using prevention medications (76% antihypertensive; 84% antithrombotic; 76% lipid-lowering) but only 66–75% reported they understood explanations about their medication (75% antihypertensive; 66% antithrombotic; 74% lipid-lowering). Participants who understood explanations about their medication more often reported 30-day adherence for antihypertensive (adjusted odds ratios [aOR]: 1.96; 95% CI: 1.20–3.19), antithrombotic (aOR: 2.03; 95% CI: 1.31–3.14) and lipid-lowering medications (aOR: 1.73; 95% CI: 1.08–2.76). Similar associations were observed for antihypertensive and antithrombotic medications when pharmacy claims data were used to infer 2-year medication adherence. Understanding explanations about medications was also associated with perceived control of risk factors (hypertension: aOR: 11.08; 95% CI: 6.04–20.34; cholesterol aOR: 8.26; 95% CI: 4.72–14.47) and up to 33% fewer unmet needs related to secondary prevention.ConclusionsExpanded efforts are needed to improve the delivery of information about prevention medications to promote medication adherence, control of risk factors, and potentially prevent unmet needs following stroke/TIA.     

Medication adherence and healthcare costs among patients with diabetic peripheral neuropathic pain initiating duloxetine versus pregabalin

Abstract

Objective:

To examine the impact of medication choice between duloxetine or pregabalin on medication adherence and direct healthcare costs among patients with diabetic peripheral neuropathic pain (DPNP).     

The impact of medication adherence on health outcomes for chronic metabolic diseases: A retrospective cohort study

BackgroundHypertension, diabetes, and hyperlipidemia have a large influence on health outcomes due to their chronic nature and serious complications. Medication is a key factor in preventing disease advancement, and it is important to assess whether good medication adherence has any potential long-term impact on health outcomes and provides an international validation on the relationship.ObjectivesTo evaluate the impact of good medication adherence on health outcomes of complications and hospitalizations for hypertension, hyperlipidemia, and diabetes.MethodsPatients who had had outpatient pharmacy claims for drugs for hypertension, diabetes, or hyperlipidemia were separately identified from the Korean National Health Insurance Claims Database in year 2009. A 10% random sample was respectively drawn from the three disease groups, and all claims from years 2008–2011 were extracted for the sampled subjects. Medication adherence was measured by the medication possession ratio (MPR) during the 12-month after the index date, the initial date from when medication was counted, with poor adherence as <80% of MPR. Health outcomes were measured both at 2 and 3 years after the index date as any occurrence of disease-related complications, disease-specific hospitalizations, and all-cause hospitalizations.ResultsPoor medication adherence was associated with a higher occurrence of disease-specific hospitalizations for hypertension patients (+10.9%, only at 2 years). The likelihood of all-cause hospitalization was higher among patients who had poor medication adherence in hypertension (+32% and +29% at 2 and 3 years), hyperlipidemia (+16% and +14% at 2 and 3 years), and diabetes (+32% and +29% at 2 and 3 years). Poor medication adherence also increased the likelihood of complications for hypertension (+14% and +7% at 2 and 3 years) and hyperlipidemia patients (+8.1% at 2 years).ConclusionsTargeting good medication adherence could be a valuable policy strategy to effectively manage chronic diseases to improve health outcomes.     

Environmental and individual predictors of medication adherence among elderly patients with hypertension and chronic kidney disease: A geospatial approach

BackgroundFew studies have examined how adherence to antihypertensive medications varies across different regions or how neighborhood-level factors were related to individuals’ medication-taking behaviors in patients.ObjectiveTo explore local variation in medication adherence and examine environmental and individual influences on adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) among elderly hypertensive patients with chronic kidney disease (CKD) in the United States.MethodsThe Medicare 5% sample claim data (2006-2013), American Community Survey 5-Year Data (2005-2009) and the Health Resources and Services Administration Primary Care Service Area data (2007). The primary outcome was medication adherence, measured by Proportion of Days Covered (PDC). Geographically weighted regression (GWR) and linear mixed-effects models were used to investigate the relationship between environmental factors, individual risk factors and medication adherence.ResultsA total of 70,201 hypertensive CKD patients residing in 2,981 counties of the US were selected. Significant spatial autocorrelation was observed in ACEIs/ARBs PDC. The West North Central and New England regions demonstrated higher adherence compared to the East South Central and West South Central regions. Residing in Medically Underserved Areas, counties with high deprivation scores, and not receiving Part D Low-income Subsidy were associated with poor medication adherence.ConclusionsMedication adherence is geographically differentiated across the US. Environmental and individual factors identified may be helpful in the design of local interventions focused on improving patient outcomes from a population perspective.     

临床药师对稳定期慢性阻塞性肺疾病患者的用药指导

目的探讨临床药师在慢性阻塞性肺疾病(COPD)稳定期用药治疗中的作用。方法将我院2010年1月至2013年1月出院的COPD患者124例,完全随机分为对照组和干预组,于出院后1、3、6个月,应用BODE指数评价效果。结果第1个月,两组BODE指数比较差异无统计学意义(P>0.05);第3个月,干预组患者的BMI、FEV1%pred%等较对照组增加(P<0.05);第6个月,干预组的m MRC、6MWD较对照组降低(P<0.05)。结论临床药师参与稳定期COPD患者的药物指导,有利于提高患者的生活质量。     

哮喘/慢性阻塞性肺疾病患者吸入剂用药依从性调查

目的:了解哮喘及慢性阻塞性肺疾病(COPD)患者使用吸入剂用药依从性的现状,分析其影响因素,为对患者开展针对性的用药教育提供参考依据。方法:对121名使用吸入剂半年以上的患者采用统一的吸入剂依从性测试(TAI)问卷进行调查。结果:哮喘/COPD患者吸入剂用药依从性仅为19.83%,37.19%被调查者存在无意识的不依从;用药依从性主要受年龄、教育程度的影响。结论:哮喘及COPD患者吸入剂用药依从性较差,尤其是文化程度较低及老年患者,建议针对相应人群加强用药教育。     

Racial/ethnic disparities in measure calculations for Part D Star Ratings among Medicare beneficiaries with diabetes,hypertension, and/or hyperlipidemia

BackgroundPrevious literature reported racial/ethnic disparities in the measure assessment of diabetes medication adherence in the Medicare Part D Star Ratings program.ObjectiveThis study examined the likelihood of inclusion in measure calculation across racial/ethnic groups for adherence metrics in Part D Star Ratings among individuals with diabetes, hypertension, and/or hyperlipidemia.MethodsThis was a retrospective cross sectional analysis of a 10% random sample of 2017 Medicare claims linked to Area Health Resources Files. Inclusion in measure calculation was determined based on inclusion/exclusion criteria in adherence metrics for adherence medications for diabetes, hypertension, and hyperlipidemia in Part D Star Ratings developed by the Pharmacy Quality Alliance. Logistic regression and multinomial logistic regression were used to adjust for patient/community characteristics.ResultsThe study sample size was 2 707 216. Compared to Non-Hispanic White (White) beneficiaries, minorities were more likely to be excluded from measure calculation among individuals with 1 condition. For example, among individuals with hypertension, compared to White individuals, the adjusted odds ratios for exclusion for Black, Hispanic, Asian/Pacific Islander and other individuals were 1.46 (95% confidence interval, or CI = 1.42–1.50), 1.38 (95% CI = 1.33–1.43), 1.28 (95% CI = 1.21–1.35), and 1.08 (95% CI = 1.02–1.15), respectively. Among individuals with more than 1 chronic condition, minorities were more likely to be included in fewer calculations for medication adherence measures. For example, among individuals with all 3 conditions, the adjusted relative risk ratios for Black, compared to White, beneficiaries for being included in 0, 1, and 2 measures, versus all 3 measures, were 2.14 (95% CI = 1.99–2.30), 1.49 (95% CI = 1.41–1.56), 1.20 (95% CI = 1.18–1.23), respectively.ConclusionsCompared to White beneficiaries, racial/ethnic minorities are more likely to be excluded from the calculation for adherence measures among individuals with diabetes, hypertension, and/or hyperlipidemia. Future studies should examine whether such disparities exacerbate existing racial/ethnic disparities in health outcomes and devise solutions for these disparities.     

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。     

A systematic review of measures of medication adherence in consumers with unipolar depression

Objective

To identify and evaluate the range of adherence measures used to assess different phases of medication adherence (initiation, implementation, and discontinuation) to antidepressants, including the psychometric properties of the measures.

Obese versus non-obese patients with type 2 diabetes: patient-reported outcomes and utility of weight change

ABSTRACT

Introduction: This study (1) used patient-reported outcome measures to assess and compare the health status of type 2 diabetes patients with and without obesity and (2) assessed the value of weight change among obese and non-obese subgroups, using standard gamble (SG) utility methodology.

Methods: Among a sample with type 2 diabetes in the United Kingdom, individuals with obesity (BMI ≥ 30 kg/m²) were identified and compared to non-obese patients. Patients completed the EQ?5D, Psychological General Well-Being Index, Appraisal of Diabetes Symptoms, and Diabetes Symptom Checklist – Revised (DSC?R). SG interviews assessed the utility of the ‘basic’ type 2 diabetes health state anchored to respondents’ body weight, as well as health states with altered weight.

Results: A total of 129 patients (74 obese; 55 non-obese) completed interviews (mean age 55.9 years; 64.3% male). Obese patients reported lower health status (EQ?5D VAS; between-group difference: p < 0.001) and greater symptom impact (several DSC?R scales, p < 0.05). Utilities of the basic health state were 0.86 (obese) and 0.91 (non-obese; p = 0.02). Hypothetical health states with higher weight received lower utilities, whereas reduced weight was associated with increased utility. There was a between-group difference in the disutility associated with 5% higher weight (obese 0.068; non-obese 0.051; p = 0.03).

Discussion: Compared with non-obese patients, the obese group reported lower health status and greater symptom impact. SG interviews found an inverse relationship between weight and utility. Furthermore, obese patients with type 2 diabetes may value weight change differently than non-obese patients. Study limitations include the sample size and the use of a patient sample, rather than a sample selected from the general population. Overall, the results demonstrate that utilities can differ by patient subgroups, even among patients with the same diagnosis.     

Patient perspectives on primary care and oncology care coordination in the context of multiple chronic conditions: A systematic review

BackgroundPatients’ views on the optimal model for care coordination between primary care providers (PCPs) and oncologists in the context of cancer and multiple chronic conditions (MCC) are unclear. Thus, the purpose of this systematic review is to evaluate the perceptions of patients with both cancer and MCC regarding their care coordination needs.MethodsFollowing PRISMA guidelines, the literature was systematically searched through PubMed, CINAHL, and PsycINFO for articles pertaining to patients’ perspectives, experiences, and needs regarding care coordination between PCPs and oncologists during the cancer care continuum, in the context of patients with cancer and MCC. English-language articles were included if they met the following criteria: 1) published between 2008 and 2018; 2) peer-reviewed study; 3) patients aged 18 years or older diagnosed with any type or stage of cancer; 4) patients have one or more chronic comorbid condition; 5) inclusion of patient perceptions, experiences, or needs related to care coordination between PCPs and oncologists; and 6) ability to extract results. Data extraction was performed with a standardized form, and themes were developed through qualitative synthesis. A grounded theory approach was used to qualitatively evaluate data extracted from articles and create a framework for providers to consider when developing patient-centered care coordination strategies for these complex patients. Risk of bias within each study was assessed independently by two authors using the Mixed Methods Appraisal Tool.ResultsA total of 22 articles were retained, representing the perspectives of 8,114 patients with cancer and MCC. Studies were heterogeneous in the patients' respective phases of cancer care and study design. From qualitative synthesis, four themes emerged regarding patients’ needs for cancer care coordination and were included as constructs to develop the Patient-centered Care Coordination among Patients with Multiple Chronic Conditions and Cancer (PCP-MC) framework. Constructs included: 1) Communication; 2) Defining provider care roles; 3) Information access; and 4) Individualized patient care. Care navigators served as a communication bridge between providers and patients.ConclusionsFindings highlight the importance that patients with both cancer and MCC place on communication with and between providers, efficient access to understandable care information, defined provider care roles, and care tailored to their individual needs and circumstances. Providers and policymakers may consider the developed PCP-MC framework when designing, implementing, and evaluating patient-centered care coordination strategies for patients with both cancer and MCC.     

老年高血压患者自我感知老化对服药依从性的影响

目的 探讨老年高血压患者自我感知老化对服药依从性的影响.方法 对苏州市350例社区老年高血压患者进行问卷调查,采用Morisky服药依从性量表评估服药依从性,分析自我感知老化总分及其8个维度得分对服药依从性的影响.结果 350例中,服药依从性不良(＜6分)者222例(63.4％).服药依从性良好(≥6分)组自我感知老化总分低于不良组[(80.10±39.03)分vs.(91.64±28.83)分](P＜0.01).周期时间性维度、情感表征维度、积极控制维度、消极控制维度、积极结果维度及认同维度的高、中、低不同得分组之间患者服药依从性也有明显差异(P＜0.05).血压控制良好、积极控制维度与积极结果维度高得分是患者服药依从性的保护因素,周期时间性维度高得分与认同维度中、高得分是其危险因素.结论 老年高血压患者的服药依从性水平较低,自我感知老化是影响其服药依从性的重要因素.     

Health locus of control: Its relationship with medication adherence and medication wastage

Background

Non-adherence is a significant factor contributing to medication wastage. Whilst there is some evidence on the influence of patients' health locus of control in relation to adherence, there has been little inquiry into its relationship with mediation wastage.

The effect of visual interventions on illness beliefs and medication adherence for chronic conditions: A scoping review of the literature and mapping to behaviour change techniques (BCTs)

BackgroundMaintaining health with chronic conditions often involves taking multiple medications; however, approximately 50% of patients with chronic conditions are non-adherent to medication. Patients’ illness beliefs inform health behaviour, including medication-taking. Research has shown that visuals accompanying health information increased patient comprehension and the accuracy of illness perceptions. To date, the influence of visuals on illness beliefs and medication adherence has not been comprehensively reviewed.ObjectivesThe review aimed to collate available literature on visualisation interventions for illness beliefs and medication adherence in chronic conditions and identify key intervention characteristics.MethodsA scoping review was conducted according to recommended guidelines and the PRISMA-ScR statement. Searches used keywords relating to ‘illness’, ‘visual’, ‘adherence’, ‘illness perception’, ‘intervention’, and ‘medication’. Six databases were searched from inception to 2019; reference-list searching provided additional articles. Articles were included if the study population had a chronic health condition, the intervention included a visual element, had a measure of illness beliefs or medication adherence. Data regarding intervention characteristics and outcomes were extracted. Behaviour change techniques (BCTs) were identified to provide further insight into intervention characteristics.ResultsInitially, 18,012 articles were identified. Screening led to 293 full-text articles, ultimately resulting in 45 studies for final analysis. Forty-four were quantitative studies, 1 was qualitative. Studies were grouped into those using visuals to conceptualise a condition, medication reminders and educational interventions. Almost two-thirds of visual interventions were effective post-intervention, 3 sustained post-1-year, although many studies only assessed impact immediately post-intervention. BCTs from ‘Natural consequences’, ‘Social support’ and ‘Feedback and monitoring’ categories were prevalent in effective interventions for both outcomes, particularly the ‘Salience of consequences’ BCT.ConclusionsThis comprehensive scoping review found that visual interventions can positively influence illness beliefs and medication adherence. These findings highlight the need to further evaluate the impact and sustainability of visual interventions.     

Treatment adherence and persistence with duloxetine,venlafaxine XR,and escitalopram among patients with major depressive disorder and chronic pain-related diseases

Abstract

Objective:

Chronic pain is prevalent in patients with major depressive disorder (MDD). This study compared adherence and persistence rates among MDD patients with comorbid chronic pain-related diseases (CPD, including fibromyalgia, diabetes with neurological manifestations, osteoarthritis, low back pain, and headache) for three antidepressants: duloxetine, venlafaxine XR, and escitalopram.