The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care.

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Adherence to Medication

Results On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations. Conclusions Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

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Emergency Hospitalizations for Adverse Drug Events in Older Americans

WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient's nonadherence whereas objective measures contribute to a more precise record of patient's medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently.

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Medication Adherence Measures: An Overview

Aims The aim of this study was to determine the extent to which adherence to individual vascular medications, assessed by different methods, influences the absolute and relative risks (RRs) of cardiovascular disease (CVD) and all-cause mortality.

Methods and results We performed a systematic review and meta-analysis of prospective epidemiological studies (cohort, nested case–control, or clinical trial) identified through electronic searches using MEDLINE, Web of Science, EMBASE, and Cochrane databases, involving adult populations (≥18 years old) and reporting risk estimates of cardiovascular medication adherence with any CVD (defined as any fatal or non-fatal coronary heart disease, stroke or sudden cardiac death) and/or all-cause mortality (defined as mortality from any cause) outcomes. Relative risks were combined using random-effects models.

Forty-four unique prospective studies comprising 1 978 919 non-overlapping participants, with 135 627 CVD events and 94 126 cases of all-cause mortality. Overall, 60% (95% CI: 52–68%) of included participants had good adherence (adherence ≥80%) to cardiovascular medications. The RRs (95% CI) of development of CVD in those with good vs. poor (<80%) adherence were 0.85 (0.81–0.89) and 0.81 (0.76–0.86) for statins and antihypertensive medications, respectively. Corresponding RRs of all-cause mortality were 0.55 (0.46–0.67) and 0.71 (0.64–0.78) for good adherence to statins and antihypertensive agents. These associations remained consistent across subgroups representing different study characteristics. Estimated absolute risk differences for any CVD associated with poor medication adherence were 13 cases for any vascular medication, 9 cases for statins and 13 cases for antihypertensive agents, per 100 000 individuals per year.

Conclusion A substantial proportion of people do not adhere adequately to cardiovascular medications, and the prevalence of suboptimal adherence is similar across all individual CVD medications. Absolute and relative risk assessments demonstrate that a considerable proportion of all CVD events (∼9% in Europe) could be attributed to poor adherence to vascular medications alone, and that the level of optimal adherence confers a significant inverse association with subsequent adverse outcomes. Measures to enhance adherence to help maximize the potentials of effective cardiac therapies in the clinical setting are urgently required.

Adherence to cardiovascular therapy: a meta-analysis of prevalence and clinical consequences

Objective:To determine the prevalence of hospital admissions associated with ADRs and examine differences in prevalence rates between population groups and methods of ADR detection.Data Sources:Studies were identified through electronic searches of Cumulative Index to Nursing and Allied Hearth Literature. EMBASE, and MEDLINE to August 2007. There were no language restrictions.Study Selection and Data Extraction:A systematic review was conducted of prospective observational studies that used the World Health Organization ADR definition. Subgroup analysis examined the influence of patient age groups and methods of ADR detection on reported ADR admission rates. All statistical analyses were performed using STATA v 9.0.Data Synthesis:Twenty-five studies were identified including 106, 586 patients who were hospitalized; 2143 of these patients had experienced ADRs. The prevalence rates of ADRs ranged from 0.16% to 15.7%, with an overall median of 5.3% (interquartile range [IQR] 2.7–9.0%). Median ADR prevalence ...

Hospital Admissions Associated with Adverse Drug Reactions: A Systematic Review of Prospective Observational Studies

BACKGROUND:Adverse drug reactions (ADRs) are a significant cause of hospital admissions. These events can lead to significant morbidity and mortality and financial costs. ADRs that may be preventable might be considered a form of medication error.OBJECTIVE:To assess the potential preventability of ADRs directly related to a patient's hospital admission.METHODS:A retrospective chart review of 437 ADRs occurring during an 11-month period was conducted at a university hospital. A subset of these events leading to hospital admissions was identified for further review. Those that resulted in admission were further examined to determine probability of causality, severity, and preventability.RESULTS:Over 11 months, 158 ADRs were directly related to hospital admission. The relationship of these admissions to drug exposure was determined to be probable or highly probable in 154 (97.4%) of these cases. From this group, 96 (62.3%) of these events were considered potentially preventable, with 23 (24%) considered seve...

Hospital Admissions Resulting from Preventable Adverse Drug Reactions

Comment: hospital admissions resulting from preventable adverse drug reactions. Authors' reply

OBJECTIVE:To report a case of anaphylaxis resulting from the use of a willow bark–containing dietary supplement in a patient with a history of an aspirin allergy.CASE SUMMARY:A 25-year-old white woman presented to the emergency department of a community teaching hospital with anaphylaxis requiring epinephrine, diphenhydramine, methylprednisolone, and volume resuscitation to which she responded favorably. Medication history revealed that she had ingested 2 capsules of Stacker 2 (NVE Pharmaceuticals, Newton, NJ), a dietary supplement promoted for weight loss, prior to experiencing her initial symptoms. Among other active ingredients, this product contains willow bark. Of significance is that this patient also reported a history of allergy to acetylsalicylic acid. No other causes for anaphylaxis were identified. She continued to receive routine supportive care and the remaining hospital course was uncomplicated.DISCUSSION:Dietary supplements, including herbal products, are used by many individuals who consid...

Anaphylactic Reaction to a Dietary Supplement Containing Willow Bark

Adverse drug events continue to have a negative impact on the delivery of health care in the United States.[1][1] A common approach to solve this problem has been the addition of medication-related clinical-decision-support (CDS) software to pharmacy information systems. For decades, pharmacy

Clinical decision support for drug-drug interactions: improvement needed.

This article reports the case of a 52-year-old male, status post-heart transplant, who was admitted to the hospital with profound pancytopenia. The cause was an adverse drug reaction, specifically the well-established drug interaction between allopurinol and azathioprine. This reaction was severe and costly, with total charges of $181,000 incurred during the patient's 31-day hospital stay. The annual cost of drug-related morbidity and mortality exceeds $136 billion. Adverse drug events can be classified variously; two common categories are adverse drug reactions and medication errors. If an adverse drug reaction is determined to be preventable, it can be classified as a medication error. Factors that determine preventability include whether a known drug-drug interaction was involved in the event and whether health care providers made efforts to avoid this interaction through increased monitoring or dose adjustments. Pharmacist intervention and increased vigilance can decrease the occurrence of such events. Furthermore, pharmacists who are aware of preventability factors involved in adverse drug events can become proactive leaders in the area of medication safety.

Patrick J McDonnell

Papers

Hospital Admissions Resulting from Preventable Adverse Drug Reactions

Comment: hospital admissions resulting from preventable adverse drug reactions. Authors' reply

Anaphylactic Reaction to a Dietary Supplement Containing Willow Bark

Clinical decision support for drug-drug interactions: improvement needed.

The $181,000 adverse drug reaction