Standardizing terminology and definitions of medication adherence and persistence in research employing electronic databases.
TL;DR: A unifying set of definitions for prescription adherence research utilizing electronic health record prescribing databases, prescription dispensing databases, and pharmacy claims databases are proposed and a conceptual framework to operationalize these definitions consistently across studies is provided.
Abstract: Objective:To propose a unifying set of definitions for prescription adherence research utilizing electronic health record prescribing databases, prescription dispensing databases, and pharmacy claims databases and to provide a conceptual framework to operationalize these definitions consistently acr
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TL;DR: In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence, and increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications.
Abstract: The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.
350 citations
Cites background from "Standardizing terminology and defin..."
...It is also possible to calculate the new prescription medication gap, a metric that starts with the date of prescription and includes the time until initiation, which is not the case with the medication possession ratio.(33) Suboptimal Adherence: Contributing and Associated Factors...
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TL;DR: Patients’ perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence, and interventions for healthcare providers and systems that foster shared decisions and trust might improve medication adherence.
Abstract: BACKGROUND
Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient–provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence.
128 citations
TL;DR: Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases, however, high-quality clinical trials of sufficient size and duration are needed to move the field forward and justify use in routine care.
Abstract: Cardiovascular disease is a leading cause of morbidity and mortality worldwide, and a key barrier to improved outcomes is medication non-adherence. The aim of this study is to review the role of mobile health (mHealth) tools for improving medication adherence in patients with cardiovascular disease. We performed a systematic search for randomized controlled trials that primarily investigated mHealth tools for improving adherence to cardiovascular disease medications in patients with hypertension, coronary artery disease, heart failure, peripheral arterial disease, and stroke. We extracted and reviewed data on the types of mHealth tools used, preferences of patients and healthcare providers, the effect of the mHealth interventions on medication adherence, and the limitations of trials. We identified 10 completed trials matching our selection criteria, mostly with <100 participants, and ranging in duration from 1 to 18 months. mHealth tools included text messages, Bluetooth-enabled electronic pill boxes, online messaging platforms, and interactive voice calls. Patients and healthcare providers generally preferred mHealth to other interventions. All 10 studies reported that mHealth interventions improved medication adherence, though the magnitude of benefit was not consistently large and in one study was not greater than a telehealth comparator. Limitations of trials included small sample sizes, short duration of follow-up, self-reported outcomes, and insufficient assessment of unintended harms and financial implications. Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases. However, high-quality clinical trials of sufficient size and duration are needed to move the field forward and justify use in routine care.
127 citations
Cites background from "Standardizing terminology and defin..."
...which a patient acts in accordance with the prescribed interval and dose of a dosing regimen) and persistence (the duration of time from initiation to discontinuation of therapy).(5) Various aetiologies are reported for medication non-adherence and nonpersistence....
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25 Apr 2019
TL;DR: An appropriate overview of the most common validated methods that can be used to identify non-adherent patients is given and concise information is presented that can help researchers and clinicians when choosing an appropriate method.
Abstract: Background and aims The success of a treatment depends on the effectiveness of the medication regimen, provided that patients take the medicines as prescribed. A low rate of adherence in chronic conditions is associated with poor outcome and decreased quality of life, which constitutes an additional burden for the healthcare systems. To correctly identify the dimension of this problem may be a challenge, as there are numerous methods, definitions, patient settings and factors, each with their specific roles. Our aim was to give an appropriate overview of the most common validated methods that can be used to identify non-adherent patients. Methods This overview is based on an online search of PubMed database and includes the relevant articles in this field. Results We included both direct and indirect methods for measuring treatment adherence and presented concise information that can help researchers and clinicians when choosing an appropriate method. Both subjective and objective methods have advantages and disadvantages that should be fully understood and taken into consideration. Conclusions Choosing a simple, accurate and inexpensive method that can give supplementary information about the patterns, beliefs and barriers of adherence would be desirable. But because this perfect method to measure treatment adherence does not exist, the best solution seems to be the combined use of at least two methods.
120 citations
Cites background or methods from "Standardizing terminology and defin..."
...This requires the existence of a centralized, electronic system with consistency among prescribers and dispensers, and can be a convenient and inexpensive method to measure adherence [14,15,20]....
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...By studying registries, we can obtain valuable data on causes of discontinuation (like ineffectiveness, suspected adverse drug reactions), since most registries give accurate information about different aspects of the patient treatment regimen [17-20]....
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TL;DR: After 2 years, the persistence with any anticoagulant treatment was high in patients with non-valvular AF, and results indicate better persistence with warfarin and apixaban than with dabigatran or rivaroxaban in regular care.
Abstract: Oral anticoagugulants (OACs) effectively reduce the risk for ischemic stroke in patients with atrial fibrillation (AF), but undertreatment and poor persistence with treatment are important problems. NOACs now provide alternatives to warfarin. This study compares the persistence with presently available antithrombotic treatments in AF patients with a CHA2DS2VASc score ≥2. All first claims of either warfarin (n = 9969), dabigatran (n = 2701), rivaroxaban (n = 2074), apixaban (n = 1352), or aspirin (n = 4540) from April 2011 until December 2014, in individuals with non-valvular AF and CHA2DS2VASc scores of 2–9, were identified in the administrative health data register (VAL) of the Stockholm region (2.1 million inhabitants). Prescription claims were analyzed with and without multivariate analysis in relation to age, sex, prescriber category, prior OAC treatment, number of drugs, and death. The overall persistence with any OAC was 88.2 % (CI 87.5–88.9) at 1 year and 82.9 % (CI 81.8–83.9) at 2 years. After 1 year, the crude persistence was 85.0 % (CI 84.2–85.9) with warfarin, 85.9 % (CI 81.8–90.1) with apixaban, 74.4 % (CI 72.3–76.5) with dabigatran, and 77.4 % (CI 74.6–80.2) with rivaroxaban. Multivariate analysis confirmed significantly higher persistence with warfarin and apixaban than with dabigatran or rivaroxaban. The adherence (proportion of days covered >80 %) was above 90 % for all NOACs; significantly higher with rivaroxaban compared to dabigatran (p < 0.001), but not compared to apixaban (p = 0.14). After 2 years, the persistence with any anticoagulant treatment was high in patients with non-valvular AF. Our results indicate better persistence with warfarin and apixaban than with dabigatran or rivaroxaban in regular care.
105 citations
Cites background from "Standardizing terminology and defin..."
...Methodological issues that need to be addressed include how to measure exposure (if data on therapeutic drug monitoring are not available) and durations of treatment gaps [24, 25]....
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References
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TL;DR: This report highlights the need for a multi-disciplinary approach to adherence, emphasizes system factors that need to be addressed in successfully implementing adherence-enhancing strategies, and provides illustrative examples of the ways in which professionals have contributed in their own fields of expertise including cardiovascular care among other fields.
4,899 citations
TL;DR: Providing specific definitions for compliance and persistence is important for sound quantitative expressions of patients' drug dosing histories and their explanatory power for clinical and economic events and adoption by health outcomes researchers will provide a consistent framework and lexicon for research.
1,920 citations
"Standardizing terminology and defin..." refers background or result in this paper
...Adherence connotes the degree or extent to which the patient conforms to the medication use recommendations specified by the prescriber (eg, frequency/interval of administration, time of day ingested, strength of dosage).(20) In contrast, persistence encompasses the time over which a patient continues treatment or continues to refill the prescription, from starting to stopping therapy....
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...In contrast, persistence encompasses the time over which a patient continues treatment or continues to refill the prescription, from starting to stopping therapy.(20,47) In this conceptual model (Fig....
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...Our conceptual model is specific to prescription-filling and has not been compared with frameworks for other prescription behaviors such as medication-taking.(20,25) Definitions are only part of the decision-making process in adherence research....
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...Further, existing definitions do not define terms consistently, do not address the issues of medications that are prescribed but not dispensed, and do not address behaviors such as medication discontinuation.(20,21) Finally, adherence-related publications sometimes neither define their terms carefully nor explain their choice of metrics, leaving readers to make assumptions about why metrics were chosen and how they were calculated....
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TL;DR: In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy, focused on promoting consistency and quantification in terminology and methods.
Abstract: Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines (‘Adherence to medications’, ‘Management of adherence’) and the discipline that studies those processes (‘Adherence-related sciences’). ‘Adherence to medications’ is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: ‘Initiation’, ‘Implementation’ and ‘Discontinuation’. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.
1,339 citations
"Standardizing terminology and defin..." refers result in this paper
...Our conceptual model is specific to prescription-filling and has not been compared with frameworks for other prescription behaviors such as medication-taking.(20,25) Definitions are only part of the decision-making process in adherence research....
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TL;DR: It is concluded that, though some methodologic problems require further study, RC measures can be a useful source of compliance information in population-based studies when direct measurement of medication consumption is not feasible.
1,212 citations
TL;DR: Despite slightly better persistence among patients who began treatment in recent years, long-term use remains low and interventions are needed early in treatment and among high-risk groups, including those who experience coronary heart disease events after initiating treatment.
Abstract: ContextKnowledge of long-term persistence with 3-hydroxy-3-methylglutaryl coenzyme
A reductase inhibitor (statin) therapy is limited because previous studies
have observed patients for short periods of time, in closely monitored clinical
trials, or in other unrepresentative settings.ObjectiveTo describe the patterns and predictors of long-term persistence with
statin therapy in an elderly US population.Design, Setting, and PatientsRetrospective cohort study including 34 501 enrollees in the New
Jersey Medicaid and Pharmaceutical Assistance to the Aged and Disabled programs
who were 65 years of age and older, initiated statin treatment between 1990
and 1998, and who were followed up until death, disenrollment, or December
31, 1999.Main Outcome MeasuresProportion of days covered (PDC) by a statin in each quarter during
the first year of therapy and every 6 months thereafter; predictors of suboptimal
persistence during each interval (PDC <80%) were identified using generalized
linear models for repeated measures.ResultsThe mean PDC was 79% in the first 3 months of treatment, 56% in the
second quarter, and 42% after 120 months. Only 1 patient in 4 maintained a
PDC of at least 80% after 5 years. The proportion of patients with a PDC less
than 80% increased in a log-linear manner, comprising 40%, 61%, and 68% of
the cohort after 3, 12, and 120 months, respectively. Independent predictors
of poor long-term persistence included nonwhite race, lower income, older
age, less cardiovascular morbidity at initiation of therapy, depression, dementia,
and occurrence of coronary heart disease events after starting treatment.
Patients who initiated therapy between 1996-1998 were 21% to 25% more likely
to have a PDC of at least 80% than those who started in 1990.ConclusionsPersistence with statin therapy in older patients declines substantially
over time, with the greatest drop occurring in the first 6 months of treatment.
Despite slightly better persistence among patients who began treatment in
recent years, long-term use remains low. Interventions are needed early in
treatment and among high-risk groups, including those who experience coronary
heart disease events after initiating treatment.
1,187 citations