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PubMed2003

Meta-analysis of trials of interventions to improve medication adherence.

The effect of tools and methods designed to enhance medication adherence that have been evaluated in randomized controlled trials was studied. A literature search was performed with MEDLINE, International Pharmaceutical Abstracts, PsychLIT, ERIC, and EMBASE for the period from 1966 to December 2000. Only randomized, controlled trials with at least 10 subjects per intervention group were included. Of 484 articles evaluated, only 61 met the criteria for the meta-analysis. Multiple interventions or study samples were identified in 23 of the articles. Each intervention was counted as a separate study, yielding 95 cohorts totaling 18,922 subjects. Of these subjects, 9,604 (51%) received interventions and 9,318 served as controls. Cohorts reported between 1990 and 1999 accounted for 53% of the sample; 56% of all cohorts were based in physician offices and 26% involved hypertensive patients. Behavioral interventions accounted for 41 cohorts (8,885 subjects), educational interventions for 22 cohorts (6,392 subjects), and combined interventions for 32 cohorts (3,645 subjects). Homogeneity of groupings and effect sizes (ESs) were calculated for each type of intervention. Overall, the data were not homogeneous, so conclusions could not be derived from the entire body of data. The educational intervention and combined intervention cohorts were nonhomogeneous (p < 0.001 and p < 0.01, respectively); however, the behavioral intervention cohort was homogeneous (Q = 42.48, d.f. = 40, p = 0.36). The overall ES for behavioral interventions was 0.07 (95% confidence interval [CI] = 0.04-0.09). There were no significant differences among the behavioral interventions. Educational interventions had an overall ES of 0.11 (95% CI = 0.06-0.15); there were no significant differences among the educational interventions. The overall ES of the combined interventions was 0.08 (95% CI = 0.04-0.12). When stratifying the combined intervention group by type of behavioral intervention, mail reminders had the largest impact (ES = 0.38). Meta-analysis of studies of interventions to improve medication adherence revealed an increase in adherence of 4-11%. No single strategy appeared to be best.

Adult↗
PubMed2001

Barriers to the effectiveness of any intervention in OA.

One of the main barriers to the effectiveness of interventions in osteoarthritis (OA) is adherence to treatment interventions and advice. Estimates suggest that adherence to any intervention in OA is between 50 and 95% but many of these estimates are derived from clinical trials and the real levels in clinical practice may be much lower. The factors influencing adherence are complex and multifactorial and, although information is available from other diseases, little is known about the relative contribution of these factors in adherence to treatment in OA. Few interventions to improve adherence have been evaluated in OA, and such studies would be limited by the lack of an accurate method for assessing adherence.

Health Knowledge, Attitudes, Practice↗
PubMedDate not supplied

[Systemic review of clinical interventions for reducing treatment non-adherence in psychosis].

AIMS: Studies investigating the efficacy of clinical interventions for reducing treatment non-adherence have generated contrasting findings, and treatment non-adherence remains very common in clinical practice. This systematic review was carried out to investigate the efficacy of clinical interventions that community psychiatric services can implement to reduce non-adherence in patients with psychosis. METHOD: Systematic review of randomised clinical trials, controlled clinical trials and observational studies assessing the efficacy of adherence enhancing interventions. RESULTS: Forty-seven studies met the inclusion criteria and were included in this systematic review. Data suitable for re-analysis were reported in 24 studies; from the remaining 23 studies, with no data suitable for re-analysis, outcome data were extracted according to what study authors reported. In the group of studies included in the meta-analysis educational and psychotherapeutic interventions were more effective than usual care in reducing patient non-adherence. The remaining 23 studies reported contrasting findings regarding the efficacy of educational strategies. Case management models improved the adherence in half of studies, while other interventions were effective in the majority of studies reported. CONCLUSIONS: Community psychiatric services can arrange effective clinical interventions, backed by scientific evidence, for reducing patient non-adherence.

Antipsychotic Agents↗
PubMed2004

The economic implications of non-adherence after renal transplantation.

BACKGROUND: The economic impact of therapeutic non-adherence in chronic diseases has rarely been examined using qualitative standards for economic evaluation. This study illustrates the impact of non-adherence on the cost utility of renal transplantation versus haemodialysis from the societal perspective and examines the scope for adherence-enhancing interventions. METHODS: Long-term costs and outcomes in adherent and non-adherent renal transplant patients were simulated in a Markov model. The cost (euros, year 2000 values) and outcome data that were imputed in the model were derived from a prospective study in renal transplantation candidates performed in 2002. Probabilities of adverse events, graft rejection, graft loss and death in adherent and non-adherent renal transplant patients were derived from literature. RESULTS: Compared with dialysis, renal transplantation offers a better outcome in both adherent and non-adherent patients. Lifetime costs after transplantation in the adherent patient group are higher than lifetime dialysis costs and lifetime costs in the non-adherent patient group, mainly because adherent patients live longer after transplantation. Long-term outcomes after transplantation are better for adherent than for non-adherent patients. The mean cost per QALY gained in adherent patients relative to non-adherent patients was euro 35 021 per QALY (95% CI 26 959, 46 620). CONCLUSION: Compared with established healthcare interventions, such as haemodialysis, renal transplantation can be considered a cost-effective therapy for patients with end-stage renal disease, even if patients are non-adherent after transplantation. The low incremental cost per QALY calculated in this model for adherent renal transplant patients, suggests there may be scope for adherence-enhancing interventions (provided that such interventions with a sufficiently high effectiveness exist or can be developed). As the findings are based on simulated long-term costs and outcomes, they should not be considered as precise estimates of the impact of non-adherence. This study is rather meant as an illustration of how non-adherence may impact on the results of cost-effectiveness analyses.

Cost-Benefit Analysis↗
PubMed2003

Interventions to improve antipsychotic medication adherence: review of recent literature.

Antipsychotic nonadherence is an important barrier to the successful treatment of schizophrenia and can lead to clinical and economic burdens. Interventions capable of significantly improving medication adherence in patients with schizophrenia would be beneficial in maximizing treatment outcomes with antipsychotics. This article reviews recent literature reporting interventions designed to improve antipsychotic adherence in patients with schizophrenia. We searched the Medline, Healthstar, and PsycInfo electronic databases for articles published since 1980 on interventions to improve medication adherence in schizophrenia. Twenty-one studies met our selection criteria. In this review, educational, behavioral, affective, or a combination of these approaches to improve adherence were examined. A total of 23 interventions were tested, as 2 studies investigated more than 1 intervention. While study design and adherence measures varied across the trials reviewed, medication adherence was noted to moderately improve with 15 of the 23 interventions tested. Interventions of a purely educational nature were the least successful at improving antipsychotic adherence. The greatest improvement in adherence was seen with interventions employing combinations of educational, behavioral, and affective strategies with which improvements in adherence were noted in 8 out of 12 studies, with additional secondary gains such as: reduced relapse, decreased hospitalization, decreased psychopathology, improved social function, gains in medication knowledge, and improved insight into the need for treatment. Longer interventions and an alliance with therapists also appeared important for successful outcomes. The continuing development and study of successful interventions to improve medication adherence are necessary to maximize the usefulness of pharmacologic treatment of schizophrenia.

Adult↗
PubMed2004

[Strategies to optimize adherence to antiretroviral treatment. Interventions in the therapeutic regimen].

Within the first few years after the introduction of highly active antiretroviral therapy two facts became evident: the treatment was highly effective and proper compliance was essential to achieve the therapeutic objectives. Recently, the regimens containing these drugs have changed. Complex dosing with a large number of tablets taken three times daily together with dietary restrictions has given way to simpler treatments.The main advances include new formulations and new drugs that allow once-daily dosing, the use of ritonavir to enhance the bioavailability of the protease inhibitors and the coformulation of active ingredients in a single capsule. This review analyzes the impact of these interventions on the therapeutic regimen and it discusses the factors that facilitate and those that hinder optimal adherence to highly active antiviral treatment. Adherence is a complex, multidimensional problem. Simplification of the treatment is an important aspect, but it should be accompanied by other strategies focussed on the patient and the medical team in order to achieve effective long-term antiretroviral therapy in all patients.

Anti-HIV Agents↗
PubMedDate not supplied

Impact of antiretroviral regimen switches on adherence.

PURPOSE: An understanding of the situations in which adherence lapses occur is critical to the design of effective interventions to enhance adherence. We investigated whether a switch in antiretroviral medications affected adherence by examining a prospective observational cohort of 128 patients who began a new antiretroviral regimen. METHOD: Adherence was measured using electronic devices, pill counts, and self-reports, which were combined into a composite adherence measure and expressed as the proportion of prescribed medication taken. RESULTS: During 1,056 person-months of follow-up, 129 medication regimen changes occurred among 84 patients (66% of participants). Among the 89 analyzable switches (representing 66 patients), the most common reasons for switch included pill to liquid ritonavir (n = 26), gastrointestinal intolerance (n = 11), virologic failure (n = 8), and peripheral neuropathy (n = 7). Overall, mean adherence prior to regimen switch exceeded mean adherence after regimen switch (0.75 vs. 0.70; p =.035). Among subgroups of switches, adherence decreased significantly after switching from pill to liquid ritonavir (0.83 vs. 0.68; p <.001). When this group was excluded, there was no change in adherence after switches (0.72 vs. 0.71; p =.74). CONCLUSION: Antiretroviral regimen changes are not associated with adherence improvement and may be associated with declining adherence when a new regimen is unpalatable. Antiretroviral regimen changes should trigger reassessment of adherence and, when appropriate, adherence intervention.

Adult↗
PubMed1995

Factors associated with adherence to the dietary protein intervention in the Modification of Diet in Renal Disease Study.

OBJECTIVE: To determine the characteristics and behaviors associated with adherence to dietary protein interventions among participants with chronic renal disease in the Modification of Diet in Renal Disease (MDRD) Study. DESIGN: Participants were categorized as consistent adherers or nonadherers on the basis of urinary urea nitrogen excretion and dietary protein intake data from self-reports. Psychosocial and behavioral factors were compared between groups. SUBJECTS: Subgroups of consistently adherent and non-adherent participants in the MDRD Study. SETTING: 15 clinical centers in the United States. INTERVENTION: In the nutrition intervention program, participants were assigned randomly to a usual-, low-, or very-low-protein diet group. Each eating pattern also specified a phosphorus goal. STATISTICAL ANALYSIS: Analysis of variance. RESULT: Psychosocial factors significantly related to adherence included participant knowledge, attitude, support, satisfaction, and self-perception of success. Behavioral strategies including participant self-monitoring of protein intake and the provision of feedback by the dietitian were also significantly related to adherence. APPLICATION: Nutrition interventions for patients with renal disease should focus on psychosocial factors and behavioral approaches. Such approaches can be successfully incorporated into treatment programs and will assist the dietitian in promoting adherence to usual-, low-, and very-low-protein eating patterns.

Adult↗
PubMed2003

Impact of a patient education program on adherence to HIV medication: a randomized clinical trial.

Patients' knowledge of their HIV condition and its treatment, which has been recognized as a factor that influences adherence to antiretroviral therapy, can be improved through educational programs. This prospective, randomized, controlled trial compared an experimental group that participated in an educational program and a control group with standard care. The study evaluated the impact of an educational intervention on adherence to antiretroviral therapy, patients' knowledge, quality of life, and therapeutic response in patients treated with highly active antiretroviral therapy. Three hundred twenty-six patients were analyzed at inclusion. A higher level of adherence was associated with patients who were older, had higher incomes, and did not smoke. CD4 cell count and plasma viral load were correlated with adherence at entry. The educational intervention had an impact on adherence and knowledge in the experimental group at 6 months, which was maintained at 12 and 18 months. A delayed increase in adherence was observed in the control group at 12 months. No significant impact on quality of life was observed over time. The patients' health status improved in 56% of the experimental group subjects and 50% of the control subjects. However, no significant impact was shown on CD4 cell count and plasma viral load. This study shows that an educational intervention improves adherence to antiretroviral regimens and health status and suggests that it should be initiated early in therapy.

Adult↗
PubMed2001

Adherence assessment to highly active antiretroviral therapy.

Adherence to highly active antiretroviral therapy (HAART) is the outcome of a dynamic process of clinical and behavioral interactions. This article reviews factors influencing this process and provides suggestions to enhance adherence to HAART. Interventions to improve adherence to HAART should combine efficacy of treatments with a strong patient-provider alliance and cognitive behavioral interventions.

Anti-HIV Agents↗
PubMed2004

Medication non-adherence among older adults: a review of strategies and interventions for improvement.

Medication non-adherence among older adults is a prevalent and costly problem; approximately one half have problems following their prescribed medication regimen, and more than 10% of hospital admissions are the result of medication non-adherence. In this literature review, medication non-adherence is defined and described among adults age 50 and older. Factors associated with medication non-adherence are presented, interventions to improve medication non-adherence are discussed, and methods for assessing medication non-adherence are reviewed. In addition, nursing assessment and intervention to improve medication non-adherence are described.

Activities of Daily Living↗
PubMed1999

Genetic and environmental influences on eating patterns of twins aged >/=50 y.

BACKGROUND: Clinicians and researchers could benefit from a greater understanding of the role of genetic and environmental factors in human eating behavior. OBJECTIVE: Our aim was to estimate the relative influence of genetic and environmental factors on habitual eating patterns in middle-aged and elderly men and women. DESIGN: Male and female twins (n = 4640) aged >/=50 y completed a mailed version of the National Cancer Institute food-frequency questionnaire. Factor analysis was performed to identify eating patterns among respondents. Estimates of genetic, common environmental (shared by family members), and specific environmental (unique to an individual) influences were obtained for food use, serving size, and consumption frequency by comparing monozygotic and dizygotic twin-pair groups with structural equation analysis. RESULTS: Two independent eating patterns were identified: the first consisted of items high in fat, salt, and sugar, and the second reflected healthful eating habits. Although the influence of environmental factors was larger, between 15% and 38% of the total variation in pattern 1 and between 33% and 40% in pattern 2 were explained by genetic influences. Models accounting for sex differences in genetic and environmental estimates fit the data significantly better for food use and serving size of foods in eating pattern 1 and for food use in eating pattern 2. CONCLUSION: Although 60-85% of the variability in eating patterns was associated with environmental factors, genetic influences were also apparent and there was some evidence of sex specificity. These findings may be important in crafting dietary interventions and predicting adherence to these interventions.

Aged↗
PubMed2006

Defining and assessing adherence to oral antipsychotics: a review of the literature.

The definition and assessment of adherence vary considerably across studies. Increasing consensus regarding these issues is necessary to improve our understanding of adherence and the development of more effective treatments. We review the adherence literature over the past 3 decades to explore the definitions and assessment of adherence to oral antipsychotics in schizophrenia patients. A total of 161 articles were identified through MEDLINE and PsycINFO searches. The most common method used to assess adherence was the report of the patient. Subjective and indirect methods including self-report, provider report, significant other report, and chart review were the only methods used to assess adherence in over 77% (124/161) of studies reviewed. Direct or objective measures including pill count, blood or urine analysis, electronic monitoring, and electronic refill records were used in less than 23% (37/161) of studies. Even in studies utilizing the same methodology to assess adherence, definitions of an adherent subject varied broadly from agreeing to take any medication to taking at least 90% of medication as prescribed. We make suggestions for consensus development, including the use of recommended terminology for different subject samples, the increased use of objective or direct measures, and the inclusion in all studies of an estimate of the percentage of medication taken as prescribed in an effort to increase comparability among studies. The suggestions are designed to advance the field with respect to both understanding predictors of adherence and developing interventions to improve adherence to oral antipsychotic medications.

Antipsychotic Agents↗
PubMed2003

The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial.

BACKGROUND: The impact of adherence on outcome for a nonpharmacologic intervention strategy has not been previously examined. OBJECTIVE: To examine the impact of level of adherence on effectiveness of the intervention strategy in a large clinical trial of nonpharmacologic interventions to prevent delirium. METHODS: The subjects included 422 consecutive patients 70 years or older admitted to the medicine service at a university hospital. The intervention protocols were targeted toward 6 delirium risk factors. The primary outcome was new-onset delirium during hospitalization. RESULTS: During 9882 patient-days, complete adherence rates for individual intervention protocols ranged from 10% for the sleep protocol to 86% for the orientation protocol. The rate of complete adherence with all protocols was 57%, and combined partial and complete adherence was 87%. Higher levels of adherence resulted in lower delirium rates, with a significant graded effect, for orientation, mobility, and therapeutic activities protocols, and for the composite adherence measure. After controlling for potential confounding variables, such as illness severity, comorbidity, baseline delirium risk, and functional status, adherence continued to demonstrate a consistently strong and significant protective effect against delirium (adjusted odds ratio, 0.69; 95% confidence interval, 0.56-0.87). Patients in the highest adherence group demonstrated an 89% reduction in delirium risk compared with patients in the lowest group. CONCLUSIONS: Adherence played an important independent role in the effectiveness of a nonpharmacologic multicomponent intervention strategy. Higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group. Thus, adherence must be ensured in nonpharmacologic interventions to optimize effectiveness.

Aged↗
PubMed2002

Adherence to therapy with oral antineoplastic agents.

With the rise in availability and increasing use of oral anticancer agents, concerns about adherence to prescribed regimens will become an increasingly important issue in oncology. Few published studies have focused on adherence to oral antineoplastic therapy, in part because the vast majority of chemotherapy is delivered intravenously in physicians' offices or hospitals. In this article, we review current knowledge of adherence behavior with regard to oral medications in general, including factors associated with adherence and methods for measuring adherence. We also review published studies of adherence to oral antineoplastic agents in adult and pediatric populations and adherence issues in cancer prevention. The available evidence reveals that patient adherence to oral chemotherapy recommendations is variable and not easily predicted. Adherence rates ranging from less than 20% to 100% have been reported, and certain populations, such as adolescents, pose particular challenges. Future efforts should focus on improving measurement and prediction of adherence and on developing interventions to improve adherence for both patients in clinical trials and patients being treated outside of the research setting. Assessment of adherence among individuals with cancer and implementation of interventions in situations of poor adherence should improve clinical outcomes.

Administration, Oral↗
PubMedDate not supplied

Cardiopulmonary responses and adherence to exercise in women newly diagnosed with breast cancer undergoing adjuvant therapy.

Cardiopulmonary responses to an 8-week moderate-intensity aerobic exercise intervention and adherence to exercise during and after intervention were assessed in 41 women newly diagnosed with breast cancer undergoing adjuvant therapy. The intervention was primarily aimed at minimizing deconditioning. Women were randomly assigned to the intervention or control group, completed graded exercise tests before and after intervention, and encouraged to continue their exercise postintervention. Over time, only the intervention group showed significant decreases in resting heart rate, resting systolic blood pressure (SBP), P <.05 each, and maximum SBP, P <.02, and an increase in VO2 peak, P <.001, although resting SBP was higher in the intervention group at both timepoints, P <.05. The adherence rate to 8-week exercise intervention was 78.3% with average weekly attendance of 2.4 sessions and 42.7 minutes (27.8 minutes within target heart rate) exercise per session. Overall physical activity levels over 16 weeks postintervention did not differ between 2 groups. However, the within-group analysis indicated that only the intervention group showed a significant increase in voluntary activity, P < .02, and energy expenditure, P < .02, and a decrease in sedentary activity, P < .02. These findings indicate that moderate-intensity aerobic exercise is beneficial in reducing deconditioning of cardiopulmonary responses in newly diagnosed breast cancer women undergoing adjuvant therapy.

Adult↗
PubMed1985

The effects of motivational interventions upon the exercise adherence of high and low self-motivated adults.

Two studies were carried out to investigate the utility of an interactionist approach to motivating involvement in an exercise program. In both studies the Self-Motivation Scale (Dishman, Ickes and Morgan, 1980) was used to classify program participants according to their level of self-motivation. Participants for each category were then assigned to experimental or control conditions. A decision balance-sheet technique was the treatment intervention in the first study while a structured social support intervention was implemented in the second study. In both cases, the motivational treatment resulted in an improvement in program attendance but there was no effect due to level of self-motivation nor its interaction with the treatment. The results are interpreted as being consistent with a situationist perspective of behavior; however, the need for further research using an interactionist approach is emphasized. Implications for exercise practice are discussed.

Female↗