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PubMed1979

Medication packaging: simple solutions to nonadherence problems?

Medication nonadherence represents a well-documented, highly prevalent obstacle to successful long-term management of chronic illnesses. Recent research has focused on predictors of nonadherence, interventions for improving adherence, and measurement of medication adherence. Better medication packaging has received little attention as a partial solution to nonadherence complexities. Packaging has the obvious advantages of being continuous, inexpensive, and patient-oriented, while demanding little physician extra involvement. The ideal packaging solution should include six component functions: storage, education, cueing, monitoring, dispensing, and reinforcement. Practically, all six functions are highly interrelated necessitating tradeoffs. Combining several functions usually results in increased cost and decreased portability. A number of proposed devices for specific adherence-improving function are described, ranging from complex to simple. The need for more and better research to define and validate interventions is more critical, now that we recognize the consequences of nonadherence.

Cues↗

PubMed1982

Compliance with medication regimens among chronically ill, inner city patients.

Patient adherence to medication regimens in explored as a function of (1) patient beliefs, perceptions, and knowledge of the illness, (2) extent of social support for health actions, (3) complexity of and specific knowledge about the regimen, and (4) satisfaction with clinical encounters and the health care facility. One hundred and ninety patients receiving care on an outpatient basis at a municipal teaching hospital were interviewed. The patients' medical records provided an additional data source. Path analysis generally supported the stated hypotheses. The only variables that had a significant effect opposite to that hypothesized were perceived severity about and susceptibility to the illness. The factors with the greatest predictive power in regard to patient compliance were (1) patients' ability to state the names of or accurately describe their medicines, (2) patients' ability to state the functions of their drugs, and (3) the complexity of the medication regimen as measured by the number of drugs prescribed for the patient.

Chronic Disease↗

PubMed2003

A family group approach to increasing adherence to therapy in HIV-infected youths: results of a pilot project.

This paper describes the development of a novel, pilot program in which a combined family group and peer approach were used to increase adherence to antiretroviral therapy in HIV-infected youths. Twenty-three HIV-positive youths, 15-22 years of age and 23 family members or "treatment buddies" participated in one of three 12-week programs. The intervention had six biweekly family and youth education sessions and six biweekly youth-only education sessions. Devices to increase adherence to antiretroviral therapy such as pill boxes, calendars, and watch alarms were introduced at youth-only sessions. Eighteen of the 23 youths completed a group. Ninety-one percent of youths self-reported increased adherence to medications after completion of a group. Four participants experienced a one-log reduction in viral loads to undetectable levels during the intervention. Two participants continued to decline antiretroviral medications at the end of the intervention and demonstrated no decrease in viral load. Participants tested five devices and rated the multiple alarm watch as the best aid for improving adherence to medication. Family/treatment buddies rated the overall program as highly helpful, citing social support as most valuable. An unanticipated benefit was an increase in other health behaviors, including medical and dental appointments, hepatitis B and influenza immunizations, and referrals to mental health and substance abuse treatment.

Adolescent↗

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↗

PubMedDate not supplied

Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication.

PURPOSE: This study aimed to identify the demographic, psychiatric, and attitudinal predictors of treatment adherence during the maintenance phase of antidepressant treatment, ie, after symptoms and regimen are stabilized. METHODS: We surveyed 81 primary care patients given maintenance antidepressant medications regarding general adherence, recent missed doses, depression and treatment features, medication beliefs (necessity, concerns, harmfulness, and overprescription), and other variables. Additional data were collected from medical and payer records. RESULTS: Median treatment duration was 75 weeks. Adherence and beliefs were broadly dispersed and unrelated to treatment duration and type, physical functioning, and demographics. Multivariate analysis adjusting for social desirability, depression severity, and treatment duration indicated that an antidepressant-specific "necessity-minus-concerns" composite was strongly associated with both adherence outcomes. Specifically, adherence was highest when necessity exceeded concerns and lowest when concerns exceeded necessity. We crossed these 2 dimensions to characterize 4 patient attitudes toward antidepressants: skepticism, indifference, ambivalence, and acceptance. CONCLUSIONS: Patients given maintenance antidepressants vary widely in adherence. This variation is primarily explained by the balance between their perceptions of need and harmfulness of antidepressant medication, in that adherence is lowest when perceived harm exceeds perceived need, and highest when perceived need exceeds perceived harm. We speculate on ways to tailor adherence strategies to patient beliefs. Subsequent research should determine whether patients' perceptions about medication predict depression outcomes, can be used to improve clinical management, and respond to behavioral intervention.

Adult↗

PubMed2005

Integrating non-drug treatments in early schizophrenia.

There is a range of psychological interventions for established schizophrenia. These include family interventions, motivational interventions for substance misuse and for non-adherence to medication, cognitive remediation for neurocognitive deficits and cognitive-behavioural therapy for symptoms. Psychological interventions may explicitly target risk factors for poor outcome, such as substance use, or protective factors, such as adherence to medication, or be directed at specific symptoms or deficits. There is emerging evidence for efficacy of psychological treatments during, following and even prior to the first episode. Important areas for further study are how different treatment modalities can interact productively, and patient and carer preferences for treatment. Many trials of psychological treatments have design flaws and this tends to overestimate the treatment effect.

Antipsychotic Agents↗

PubMed2006

A qualitative study of persons who are 100% adherent to antiretroviral therapy.

This qualitative study examined the medication-taking behaviors and attitudes of participants determined to be 100% adherers to antiretroviral therapy from a NIH-funded study testing a 12-week telephone adherence intervention. Using open-ended questions, interviewers collected data on a sample of 13 informants, whose medication adherence to a randomly selected antiretroviral medication was 100%, based on a 30-day data collection using electronic event monitoring (EEM). The analysis revealed 'successful medication management' as the core category or main theme. The participants achieved success with medication adherence through managing specific areas (regimen, self and environment). By adopting realistic expectations and pragmatic attitudes, adherence is fostered when medication taking is a priority, when patients believe in the efficacy of their medications and when there is a strong patient/provider relationship. Future research is needed to develop tailored interventions using strategies identified by this population. Further in-depth examination of medication-taking behaviors in 100% adherers may be useful in developing individualized programs to maximize adherence to antiretroviral therapy in the clinical setting.

Adult↗

PubMed2006

Adherence in adolescents and young adults following heart or heart-lung transplantation.

To assess the prevalence and some potential correlates of non-adherence to medications in adolescent and young adult transplant patients. Fifty patients who had undergone heart or heart-lung transplantation 1.4-14.9 yr (mean 8.8 yr) previously completed the Beliefs about Medication Questionnaire (BMQ), Perceived Illness Experience (PIE) scale and a demographics questionnaire. Medical notes were reviewed for information regarding previous psychiatric referral, rejection episodes and complications and noted concerns about adherence. Forty (80%) completed questionnaires were received. Non-adherence determined from the questionnaires was associated with forgetting to take medication and was classified as unintentional non-adherence. Such non-adherence was reported by 11 (28%) patients. Seven patients (18%) showed evidence from their records of deliberate non-adherence, which was classified as intentional. Whilst intentional non-adherence was associated with depression and transplant-related lymphoma, unintentional non-adherence and perceived difficulties with medications were associated with high scores on the PIE preoccupation with illness and BMQ concerns subscale and with drinking alcohol. Future research is required to determine whether unintentional non-adherence results in significant medical complications in the longer term and how a reduction in the prevalence of non-adherence can be facilitated.

Adolescent↗

PubMed2003

Markers of loss of control of hypertension.

OBJECTIVE: To identify markers for loss of control of hypertension. DESIGN: Questionnaire administered to patients who had been monitored for 18 months and had had their blood pressure (BP) measured many times. SETTING: Fifty family practices in southeastern Ontario. PARTICIPANTS: Three hundred eighty-five adults with essential hypertension that was initially stable and controlled by medication. MAIN OUTCOME MEASURES: Change in BP (from baseline to mean of three measurements over 18 months) and proportion of patients with BP exceeding threshold values at most follow-up visits. RESULTS: Higher income was associated with an increase in diastolic BP; poor adherence to medication regimens and higher life stress were associated with increases in systolic BP Stress also led to a twofold increase in risk of exceeding BP thresholds. Other factors under study were not related to loss of control. CONCLUSION: Adherence to medication regimens, higher income, and life stress were the only factors associated with elevated BP or loss of control in previously controlled hypertension.

Antihypertensive Agents↗

PubMed1995

No symptoms, no problem? Patients' understandings of non-insulin dependent diabetes.

Depth interviews were carried out with 46 people with non-insulin dependent diabetes. In the course of narrative accounts, respondents displayed their thinking about the nature of diabetes and their understandings of how one ought to respond to it. Two variations in patients' interpretations of diabetes are discussed here: the extent to which patients primarily orientated themselves toward symptom control or toward prevention of complications, and their perceptions of the seriousness of the condition. Most patients believed diabetes to be a serious condition, which could cause complications. However, many were able to reconcile such beliefs with a less than whole-hearted adherence to medical advice about lifestyle. The analysis suggests a range of specific areas of diabetes care where patients could be more fully informed. Most importantly it describes a range of ways in which patients present their non-adherence to medical advice about lifestyle as entirely rational, given their perceptions of diabetes and its personal implications for each of them. Better understanding of such perceptions by health professionals may improve therapeutic alliances.

Adaptation, Psychological↗

PubMed2005

Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS.

Accurate self-administration of antiretroviral medication therapy for HIV/AIDS is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/AIDS as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals' medication-taking behaviour, speaks to the inherent power inequities in the patient-provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals' situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidiminsional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient-centred interventions.

Anti-HIV Agents↗

PubMed2004

Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection.

BACKGROUND: There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies. OBJECTIVE: To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection. DESIGN: Cross-sectional analysis. SETTING: Twenty-two outpatient HIV practices in a metropolitan area. PARTICIPANTS: Five hundred fifty-four patients with HIV infection taking antiretroviral medications. MEASUREMENTS: We measured adherence using a 4-item self-report scale (alpha= 0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; alpha > 0.70 for all) and 1 new scale, adherence dialogue (alpha= 0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens. RESULTS: Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians' practices, 6 of the 7 physician-patient relationship quality variables were significantly (P < .05) associated with adherence. In all 7 models worse adherence was independently associated (P < .05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health. CONCLUSIONS: This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients' medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients' belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.

Adult↗

PubMed1999

An intervention to increase physicians' use of adherence-enhancing strategies in managing hypercholesterolemic patients.

PURPOSE: Patients' lack of adherence to medical regimens frustrates many practicing physicians. This study was conducted to determine the effectiveness of a combined continuing medical education intervention in increasing physicians' adherence-enhancing skills and improving hypercholesterolemic patients' health. METHOD: A prospective, randomized, controlled trial was designed using a nested cohort of 28 community physicians throughout Alabama and 222 of their hypercholesterolemic outpatients. The intervention, carried out in 1998, consisted of three interactive case audio-conferences plus chart reminders. Physicians' learning was measured by unannounced standardized patients, and patients' health by serum cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary habits, and health status. RESULTS: No significant difference was found in the numbers of physician adherence-enhancing strategies, although the number did increase within the treatment group. There were significant differences in the intervention group's patients' knowledge of cholesterol management (p = .008) and significant reductions in their self-reported consumption of dietary fats (p = .002). A significant difference was found in the serum cholesterol level of men in the intervention group nine months after the intervention (p = .02). CONCLUSION: Combining a series of interactive case audio-conferences with chart reminders shows promise in increasing physicians' adherence-enhancing strategies. In chronic disease management, the problem of enhancing adherence remains complex.

Adult↗

PubMed2004

Methodology of an ongoing, randomized, controlled trial to improve drug use for elderly patients with chronic heart failure.

BACKGROUND: Medications can improve the functioning and health-related quality of life of patients with chronic heart failure (CHF) and reduce morbidity, mortality, and costs of treatment. However, patients may not adhere to therapy. Patients with complex medication regimens and low health literacy are at risk for nonadherence. OBJECTIVE: The primary goal of this project is to develop and assess a multilevel pharmacy-based program to improve patient medication adherence and health outcomes for elderly CHF patients with low health literacy. METHODS: In this 4-year, controlled trial, patients aged 50 years with a diagnosis of CHF who are being treated at Wishard Health Services (Indianapolis, Indiana) are randomly assigned to pharmacist intervention or usual care. Intervention patients receive 9 months of pharmacist support and 3 months of postintervention follow-up. The intervention involves a pharmacist providing verbal and written education, icon-based labeling of medication containers, and therapeutic monitoring. The pharmacist identifies patients' barriers to appropriate drug use, coaches them on overcoming these barriers, and coordinates medication use issues with their primary care providers. Daily updates of relevant monitoring data are delivered via an electronic medical record system and stored in a personal computer system designed to support pharmacist monitoring and facilitate documentation of interventions. To measure medication adherence objectively, electronic monitoring lids are used on all CHF medications for patients in both study groups. Other assessments include self-reported medication adherence, results of echocardiography (eg, ejection fraction), brain natriuretic peptide concentrations, and health-related quality of life. Health services utilization, refill adherence, and cost data derive from electronic medical records. After completion of this study, the data can be used to assess the effectiveness and cost-effectiveness of our intervention. RESULTS: One hundred twenty-two patients have been assigned to receive the intervention and 192 to receive usual care. CONCLUSIONS: Our study aims to improve patients' knowledge and self-management of their medication and to improve medication monitoring in a multilevel pharmacy-based intervention. By doing so, we intend that the intervention will improve the health outcomes of elderly patients with CHF.

Aged↗

PubMed2005

Medication use and prescribing considerations for elderly patients.

Older adults consume more medications than any other segment of the population. Increasing lifespan means that more people will live into old age, frequently with disabilities and conditions man-aged by medications. Age-associated physiologic changes, medication use patterns, and adverse drug effects and interactions place the older adult at high risk for medication-related problems. Older adults living in institutions, those with complex medical problems,and those who do not adhere to medication regimens are at highest risk for negative health outcomes from medication mishaps. Dentists must be able to identify older adults who are susceptible to adverse drug events and to recognize which medications are most likely to precipitate problems.

Aged↗

PubMed2006

Club drugs and HIV infection: a review.

Club drug use is common among populations with human immunodeficiency virus (HIV) and populations at high risk for HIV infection. Club drugs have a myriad of acute and chronic medical consequences. Club drug-related visits to the emergency department and admissions for treatment of substance use have increased dramatically over the past 15 years. Most epidemiological data support the role of club drugs in increasing sexual risk behavior, with some studies demonstrating an independent association between use of certain club drugs and HIV infection. The direct influence of club drugs on progression of HIV disease remains to be determined; however, club drugs may interact with certain retroviral medications and have been associated with decreased adherence to medication. Clinicians should ask all patients about patterns of club drug use, counsel patients about the risks associated with club drug use, and refer patients to appropriate behavioral treatment programs for substance use when clinically indicated.

Adolescent↗

PubMed2006

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures.

BACKGROUND: To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations. METHODS: Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP). RESULTS: In a notional population of 100,000 adults, going from current to 'best' practice for different interventions, the number of relapses prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 23 (family intervention), 43 (relapse prevention), and 44 (early intervention); and for depression the number of relapses prevented in the next year were 100 (increasing care management), 227 (continuing treatment with antidepressants), 279 (increasing rate of diagnosis), and 325 (Cognitive Behaviour Therapy). Hospital re-admissions prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 36 (relapse prevention) and 40 (early intervention). CONCLUSION: Population Impact measures provide the possibility for a policy-maker to see the impact of a new intervention on the population as a whole, and to compare alternative interventions to best improve psychiatric disease outcomes. The methods are much simpler than others, and have the advantage of being transparent.

Journal Article↗

PubMed2003

Detection of medication nonadherence through review of pharmacy claims data.

The utility of pharmacy claims data in detecting improper medication use, medication changes, and formulary adherence was assessed. Pharmacists provided six months of pharmacy claims data to primary care physicians for patients on the day of their scheduled clinic appointments. Similar data, not supplied to physicians, were generated for a matched population of patients on the day of their scheduled clinic appointments. A blinded pharmacist abstracter reviewed dictated office notes for both control and treatment groups. Medication adherence and medication changes were assessed by the abstracter as well as the difference in total medication costs for each of the groups before and after the pharmacy claims data were supplied. Surveys were distributed to physicians to determine whether pharmaceutical care was improved by the pharmacy claims data. In the treatment group, physicians detected medication nonadherence in 30.5% of their patients, while the abstracter noted nonadherence in 58.1% of patients. Physicians failed to detect any nonadherence in the control group, but the abstractor detected nonadherence in 57.1% of these patients. Changes in medication regimens occurred more often in the treatment group (p < 0.001). The mean percentage of patients switched to formulary agents significantly differed between the treatment and control groups (27.7% versus 0.0%, respectively) (p < 0.001). There were no differences in median drug costs for either group before or after the pharmacy claims data were provided. Provision of pharmacy claims data to physicians helped them detect medication nonadherence, evaluate therapeutic duplication or omissions, increase formulary use, and reduce the time required to obtain an accurate medication history.

Chi-Square Distribution↗