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PubMed1999

Adherence to antipsychotic medications.

Taking antipsychotic medication as prescribed is one of the best means patients have of managing psychotic symptoms and preventing relapse. Yet, for various reasons, patients may discontinue taking their medication or skip doses, either occasionally or frequently. Among patients treated with conventional neuroleptics, approximately 40% stop taking their antipsychotic medication within 1 year, and about 75% stop taking the medication within 2 years. Although adverse effects play a large role in a patient's decision to discontinue antipsychotic therapy, other factors also have an effect. Using the health belief model, clinicians can assess the relative impact of various factors on medication adherence. This model posits that adherence to treatment is determined by the patient's assessment of the perceived benefits of treatment and risks of illness versus the costs of treatment (including adverse effects such as weight gain). Other factors in the decision are barriers to adherence and cues to act (i.e., reminders to take medication). Patients who believe the risks of treatment outweigh the benefits are likely to discontinue their medication and are candidates for intervention to increase adherence.

Adult↗
PubMed1999

Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice.

Researchers and clinicians have used numerous methods in their attempts to adequately assess patient compliance (adherence) with medication regimens and to identify noncompliant patients. Large variations have been reported in the extent of noncompliance in individual patients and large populations. In addition, nonadherence has often been poorly defined. Direct measures of adherence include drug assays of blood or urine, use of drug markers with the target medication, and direct observation of the patient receiving the medication. Indirect measures of adherence imply that the medication has been used by the patient; these measures include various forms of self-reporting by the patient, medication measurement (pill count), use of electronic monitoring devices, and review of prescription records and claims. Compliance measures should be assessed on the basis of their validity (sensitivity and specificity or statistical correlation) and the reference standard used. Many early studies used pill counts as a reference standard, but electronic monitoring devices such as the Medication Event Monitoring System have replaced pill counts as the reference standard. The choice of a method for measuring adherence to a medication regimen should be based on the usefulness and reliability of the method in light of the researcher's or clinician's goals. Specific methods may be more applicable to certain situations, depending on the type of adherence being assessed, the precision required, and the intended application of the results.

Clinical Trials as Topic↗
PubMed2002

The role of the inpatient mental health nurse in facilitating patient adherence to medication regimes.

Non-adherence to antipsychotic medication is associated with relapse of psychiatric symptoms and readmission to inpatient mental health services. The important role of the mental health nurse in facilitating adherence has been acknowledged, however, there has been little exploration of how nurses themselves perceive this aspect of their role. A qualitative study was conducted to explore the perceptions of mental health nurses employed in inpatient settings regarding their role in facilitating medication adherence. Focus groups were conducted with 22 nurses from three inpatient settings in metropolitan Melbourne. The main themes to emerge from the data were: nurses' responsibilities in medication management; ways in which nurses are educated about antipsychotic medication; barriers to the provision of medication management, and barriers to effective patient adherence. Recommendations for more effective practice are discussed.

Antipsychotic Agents↗
PubMed2006

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy.

BACKGROUND: The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence. OBJECTIVES: To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549). MEASURES: Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%. RESULTS: Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64). CONCLUSIONS: The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

Aged↗
PubMed2003

Longitudinal study of mental health and psychosocial predictors of medical treatment adherence in mothers living with HIV disease.

Cross-sectional studies to date that examine psychosocial correlates of antiretroviral adherence have insufficiently addressed the challenges of long-term adherence. This longitudinal study examined mental health, substance abuse, and psychosocial predictors of long-term adherence to antiretroviral medications and medical appointments among HIV-seropositive mothers recruited from an infectious disease clinic of a large urban medical center. Individual interviews were conducted at baseline and two follow-up points, 8 to 18 months after enrollment. Based on a model of health behavior, we examined psychiatric and psychosocial predictors of adherence to antiretroviral medications and medical appointments over time. Presence of a psychiatric disorder, negative stressful life events, more household members, and parenting stress were significantly associated with both missed pills and missed medical appointments at follow-up. Baseline substance abuse was associated with missed pills at follow-up and lack of disclosure to family members at baseline was associated with missed medical appointments at follow-up. These findings suggest that interventions that integrate mental health, substance abuse and medical care may be important to improving the medical adherence and health of HIV-seropositive women, particularly in multistressed populations with substantial caregiving and other life demands.

Adult↗
PubMed1997

Non-adherence with medications in organ transplant patients: a literature review.

The problems of non-adherence with treatment in health care in general, and with medication adherence in particular, is an area with a voluminous and burgeoning literature. However, there appears to be no review of the literature on non-adherence with medications in organ transplant patients. This comprehensive review therefore considers literature on adherence in adult kidney, heart and liver transplantation. The particular problem of adherence in paediatric transplant patients is also addressed. This transplant research literature is then evaluated within the broader context of social science research on medication adherence. From the review it is apparent that there is an urgent need for research which examines the patient's beliefs about their illness and medicines. Such research is a precursor for rigorous nursing intervention studies which aim to promote adherence by being tailored to the patient's perceptions.

Adult↗
PubMed2006

Randomized trial of a telephone care management program for outpatients starting antidepressant treatment.

OBJECTIVE: This study evaluated the effectiveness of a structured telephone-based care management program for patients in a prepaid health plan receiving new antidepressant prescriptions from psychiatrists. METHODS: Potential participants were identified with computerized medical records and contacted by telephone. Eligible and consenting participants were randomly assigned to continued usual care (N=104) or to a three-session telephone care management program (N=103). Care management contacts included assessment of depressive symptoms, medication adherence, and medication side effects with structured feedback to treating psychiatrists. Effectiveness was assessed three and six months after randomization by blinded telephone assessments (depression scale on the Hopkins Symptom Checklist [SCL] and patient-rated global improvement). Computerized records were used to assess medication adherence and frequency of in-person follow-up visits. RESULTS: Compared with usual care, the care management intervention had no significant effect on the mean score of the SCL depression scale at six months, on the probability of 50 percent improvement in depressive symptoms (41 percent for care management and 37 percent for usual care), or on the probability of patient-rated improvement (57 percent for care management and 52 percent for usual care). Patients assigned to care management made significantly more medication management visits over six months (2.4 visits compared with 2.0 visits; p=.035), but there were no significant differences in rates of adequate medication treatment. CONCLUSIONS: This study found that a low-intensity telephone care management program did not appear to significantly improve clinical outcomes for patients starting antidepressant treatment. Compared with findings from earlier primary care studies, this study found that patients receiving care from a psychiatrist received more intensive treatment, although many still experienced poor outcomes.

Adult↗
PubMed1997

Verbal memory impairment in COPD: its mechanisms and clinical relevance.

STUDY OBJECTIVES: Identification of mechanisms accounting for verbal memory impairment in patients with severe COPD; assessing the relationship between verbal memory and the overall cognitive performance; verifying if verbal memory impairment affects medication adherence. DESIGN: Case-comparison study. SETTING: Outpatient Departments of Pneumology and Neurology, Day Hospital of General Surgery. PATIENTS: Forty-two COPD ambulatory patients, age 70+/-9.7 years, with hypoxemia and hypercarbia (group A); 27 normal subjects of comparable age and educational level (group B); 31 patients with Alzheimer's disease (group C); and 26 older normal subjects (group D). MEASUREMENTS AND RESULTS: The overall cognitive function and verbal memory were evaluated by the Mental Deterioration Battery and 14 indexes of verbal memory. Defective retrieval and recognition mechanisms distinguished group A from group B. According to discriminant analysis, verbal memory profile of COPD patients was group specific in 38.1% of cases and conformed to that of group B, C, and D in 19%, 16.7%, and 26.2% of cases, respectively. In COPD patients, both immediate and delayed recall, the strongest determinants of the discriminant function, were significantly correlated with the overall cognitive performance (rho=0.64, p=0.001; rho=0.61, p=0.001, respectively). Poor adherence to medication regimen was significantly associated with abnormal delayed recall score (82.3% vs 36% in subjects with normal delayed recall, p<0.008). CONCLUSIONS: Decline of verbal memory parallels that of the overall cognitive function in COPD patients and is due to the impairment of both active recall and passive recognition of learned material. It could be an important determinant of the level of medication adherence.

Aged↗
PubMed2002

Enhancing transplant patients' adherence to medication therapy.

Despite the importance of proper medication use, many transplant patients do not take their medications correctly. Non-adherence to medication therapy leads to adverse consequences, and practitioners should encourage adherence by transplant patients. This manuscript discusses several aspects of medication taking behavior including: (1) methods of identifying medication non-adherence; (2) models used to identify possible determinants of medication taking behavior; (3) strategies to educate patients concerning their therapy; (4) factors promoting adherence and non-adherence; and (5) practical interventions that we, as practitioners, can employ to enhance adult and pediatric transplant patients' adherence to therapy. By using the strategies suggested, transplant patients' adherence to medication therapy may be enhanced and patients' quality of life improved.

Drug Therapy↗
PubMed2002

Interventions to enhance patient adherence to medication prescriptions: scientific review.

CONTEXT: Low adherence with prescribed treatments is ubiquitous and undermines treatment benefits. OBJECTIVE: To systematically review published randomized controlled trials (RCTs) of interventions to assist patients' adherence to prescribed medications. DATA SOURCES: A search of MEDLINE, CINAHL, PSYCHLIT, SOCIOFILE, IPA, EMBASE, The Cochrane Library databases, and bibliographies was performed for records from 1967 through August 2001 to identify relevant articles of all RCTs of interventions intended to improve adherence to self-administered medications. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications for a medical or psychiatric disorder; both adherence and treatment outcome were measured; follow-up of at least 80% of each study group was reported; and the duration of follow-up for studies with positive initial findings was at least 6 months. Information on study design features, interventions, controls, and findings (adherence rates and patient outcomes) were extracted for each article. DATA SYNTHESIS: Studies were too disparate to warrant meta-analysis. Forty-nine percent of the interventions tested (19 of 39 in 33 studies) were associated with statistically significant increases in medication adherence and only 17 reported statistically significant improvements in treatment outcomes. Almost all the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family therapy, and other forms of additional supervision or attention. Even the most effective interventions had modest effects. CONCLUSIONS: Current methods of improving medication adherence for chronic health problems are mostly complex, labor-intensive, and not predictably effective. The full benefits of medications cannot be realized at currently achievable levels of adherence; therefore, more studies of innovative approaches to assist patients to follow prescriptions for medications are needed.

Acute Disease↗
PubMed2005

The relationship of guideline-concordant depression treatment and patient adherence to oral diabetes medications.

BACKGROUND: Many patients with diabetes experience depression, yet it is unclear if the treatment of depression in diabetic patients is concordant with national guidelines, and whether appropriate antidepressant use is associated with better diabetes self-care behaviors. OBJECTIVES: The purpose of this study was to (1) determine whether antidepressant medication use for managed care enrollees with type 2 diabetes was concordant with The Agency for Healthcare Research and Quality depression treatment guidelines; and (2) examine the relationship between guideline concordance and oral diabetes medication adherence. METHODS: Retrospective analyses were conducted using medical/pharmacy claims for 2001 from a managed care organization in the midwestern United States. Subjects were adults with type 2 diabetes treated with oral medications only. The subjects were divided into 3 groups: (1) guideline-concordant users of antidepressants; (2) those who received antidepressants not in concordance with the guidelines; and (3) nonusers of antidepressants. Antidepressant users were determined to be in concordance with the acute phase treatment guidelines if they filled at least 90 days supply of antidepressant drugs within 118 days of the first fill. Adherence to diabetes medications was measured by the medication possession ratio. A 1-way analysis of variance with Scheffe's test was used to compare the antihyperglycemic medication possession ratio across the three groups. RESULTS: One hundred eighty-two (12.5%) of the 1454 subjects initiated treatment with antidepressants. Eighty-nine (48.9%) of the 182 antidepressant users were in concordance with the acute phase treatment guidelines. Subjects with subconcordant antidepressant use had a lower mean diabetes medication possession ratio than those with either guideline-concordant use or no use (F=14.3, P<.01). CONCLUSION: Over half of the diabetic patients initiating treatment for depression did not receive therapy in concordance with the Agency for Healthcare Research and Quality guidelines. Patients whose antidepressant use was not concordant with the guidelines were also less adherent to diabetes medications.

Antidepressive Agents↗
PubMedDate not supplied

Patient factors and medication guideline adherence among older women with asthma.

BACKGROUND: Asthma guidelines are well established but often followed poorly. Determinants of adherence among older persons may differ from younger persons and have not been well characterized. OBJECTIVES: To assess adherence to asthma medication guidelines among older women with asthma and evaluate predictors of adherence with emphasis on asthma characteristics, comorbid medical conditions, work-related factors, social supports, caregiving, and emotional well-being. METHODS: We assessed adherence to the National Asthma Education and Prevention Program medication guidelines among participants in the Nurses' Health Study who reported a physician diagnosis of asthma and reconfirmed the diagnosis on a separate questionnaire, excluding those with chronic obstructive pulmonary disease. RESULTS: Among 121 700 participants in the Nurses' Health Study, 5107 reported physician-diagnosed asthma meeting inclusion criteria. Mean +/- SD age was 63 +/- 7 years in 1998. Adherence with asthma medication guidelines was 57% for mild persistent, 55% for moderate persistent, and 32% for severe persistent asthma (P =.001). In multivariate analysis, nonadherence was associated with severe asthma, increasing age, lower socioeconomic status, current smoking, earlier onset of asthma, and number of comorbid medical conditions. Measures of social isolation, caregiving, and emotional well-being were not associated with nonadherence. CONCLUSIONS: Asthma is undertreated among older women, even those who are health care professionals. Women with advanced age and severe asthma were particularly at risk. Given that the greatest increase in asthma mortality has occurred among older women, further research is needed to examine physician prescribing patterns and patient beliefs in this vulnerable population.

Adult↗
PubMed2004

A systematic review of the effectiveness of interventions to help older people adhere to medication regimes.

BACKGROUND: Non-adherence is a common cause of treatment failure. The causes and context of non-adherence may differ amongst older people and reviews of interventions to improve adherence have tended to focus on the younger adult population. OBJECTIVE: To conduct a systematic review of interventions to aid adherence to medication for older people over the age of 65. METHOD: Relevant papers identified by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Review of Effectiveness (Cochrane Library), Medline 1966-October 2002, Embase 1980-October 2002, Best Evidence, PsychINFO 1887-October 2002 and CINAHL 1982-October 2002. These were then hand-searched. The papers that fitted our inclusion criteria were selected. Two independent reviewers using an established tool assessed the studies for methodological quality. A non-statistical narrative approach was then taken to analyse the studies due to the heterogeneity of the outcome measures. RESULTS: 7 studies were identified. They used a variety of approaches involving external cognitive supports and/or educational interventions. Most studies were of poor methodological quality. Statistically significant effects, where present, tended to have small effects clinically. CONCLUSIONS: Currently there is no strong evidence to support the use of any one intervention type. Future research should use combinations of approaches, as there is some evidence that these are more likely to be successful.

Aged↗
PubMed2004

Non-adherence to medications following pediatric liver transplantation.

Non-adherence to medications is a leading cause of organ loss and morbidity in children and adolescents who had a liver transplant. Yet there are very few published studies about ways to detect whether patients are taking their medications or not, and about treatment options to improve adherence. The Pediatric Liver/Liver Transplant Program at Mount Sinai developed clinical and research programs that evaluate adherence. We review initial results from these programs. Clinic patients participate in an adherence-monitoring program that involves standardized assessments by patients, parents, clinicians, and routine examinations of medication blood levels. A research program adds an electronic monitoring device (MEMS-caps, AARDEX/APREX, Switzerland) and examines the use of azathioprine metabolites as predictors for non-adherence. Patients receive a thorough psychosocial evaluation to identify potential risk factors for non-adherence. Preliminary results indicate that an objective adherence detection method has to be incorporated into practice if non-adherence is to be reliably detected (clinicians' impressions and patients' reports are not sufficient). A risk factor for non-adherence, post-traumatic stress disorder, emerges as a potential target for intervention. It is possible to integrate a formal mechanism to assess adherence into the work of a liver/liver transplant clinic. We hope that the presented program will inspire clinicians in the community and other programs to regard the assessment and improvement of adherence to medications as an important goal in the management of children who had a transplant.

Azathioprine↗
PubMed2001

Gastrostomy tube placement in nonadherent HIV-infected children.

OBJECTIVE: To determine the benefits of gastrostomy tube (G-tube) placement in HIV-infected children receiving highly active antiretroviral therapy (HAART). METHODS: Children who had a G-tube placed due to medication adminsitration difficulties were followed to determine changes in medication adherence and changes in laboratory parameters. Medication adherence and laboratory parameters were reviewed for three months prior to G-tube placement and then were followed for six months after G-tube placement. Viral RNA and CD4+ counts were assessed between the two time periods. Medication adherence was followed by review of pharmacy refill records and pill counts. Parents were surveyed about their opinion regarding the G-tube placement and medication administration in their children. RESULTS: Six children had G-tubes placed due to medication administration difficulties. The G-tube was tolerated in all six cases, although one child developed a staphylococcal infection 13 months after G-tube placement. Before G-tube placement, the medication adherence to HAART averaged 47% +/- 20% SD, with a range of 15-90%. After G-tube placement, medication adherence improved to 90-100%. All parents were satisfied with the G-tube and all reported shorter medication administration times and fewer behavioral problems. Five of six patients had at least a 2-log10 decrease in viral load, and CD4+ percentages improved by an average of 6.4%. CONCLUSIONS: G-tubes were well tolerated by HIV-infected children. Although G-tube placement is not needed in most children with HIV, it may provide an option for parents and children where administration of antiretroviral medication poses extreme difficulty and all other avenues have been exhausted.

Anti-HIV Agents↗
PubMed2005

Factors associated with medication nonadherence in patients with COPD.

STUDY OBJECTIVES: To identify the predictors of medication adherence in patients with COPD and contrast the health beliefs, experiences, and behaviors of COPD patients self-reporting good adherence with those of patients reporting suboptimal adherence to their medications. DESIGN: Cross-sectional self-administered questionnaire. SETTING: Ambulatory care. PARTICIPANTS: Patients with chronic respiratory ailments identified through respiratory support groups and from a pulmonary rehabilitation database. MEASUREMENTS AND RESULTS: A 30-item questionnaire comprising items pertaining to health beliefs, experiences, and behaviors along with a valid self-reported measure of adherence-the medication adherence report scale (MARS)-was administered to 525 ambulatory patients with chronic lung conditions. A total of 276 usable responses were received (52.6%). The mean age of the respondents was 71 years, and there were slightly more male patients (54.4%). COPD was the underlying disease condition in 90.6% of the respondents; two thirds of the respondents had comorbid conditions. The respiratory condition was managed by both general practitioners and respiratory specialists in 61.2% of cases. One third of the respondents self-reported complementary and alternative medicine use. The mean score (+/- SD) on the MARS among the respondents was 23.37 +/- 2.09. One hundred two patients self-reported perfect adherence on the MARS. Differences in knowledge about the illness and treatment, faith in and satisfaction with the treatment and doctors, concerns about the treatment, and intentional and unintentional deviations from the recommended treatment were detected between the adherent and less adherent groups. In multivariate analysis, "I vary my recommended management based on how I am feeling" and "I get confused about my medications" were found to be significant independent predictors of nonadherence. CONCLUSIONS: Patients' acceptance of the disease process and recommended treatment, knowledge about and faith in the treatment, effective patient-clinician interaction, and routinization of drug therapy are critical for optimal medication adherence in patients with COPD.

Aged↗
PubMed2003

Relationship with health care provider and adherence to HIV medications.

Suboptimal adherence to antiretroviral medications was reported in a sample of 97 inner-city residents with HIV/AIDS. Most respondents had been seeing the same physician for several years. Those who perceived themselves to be more engaged with their health care provider also reported better treatment adherence. This finding, though, should be viewed with caution since self-reported measures were used. Interventions that target adherence could include patients' perceptions of providers.

Antiviral Agents↗