Adherence to long-term therapies: evidence for action

This report is based on an exhaustive review of the published literature on the definitions, measurements, epidemiology, economics and interventions applied to nine chronic conditions and risk factors. These are asthma, cancer (palliative care), depression, diabetes, epilepsy, HIV/AIDS, hypertension, tobacco smoking and tuberculosis.

Intended for policy-makers, health managers, and clinical practitioners, this report provides a concise summary of the consequences of poor adherence for health and economics. It also discusses the options available for improving adherence, and demonstrates the potential impact on desired health outcomes and health care budgets. It is hoped that this report will lead to new thinking on policy development and action on adherence to long-term therapies.

The impact of innovative packaging on adherence and treatment outcomes in elderly patients with hypertension

This study compares compliance rates of an antihypertensive drug administered to some elderly patients in a bottle and others in a blister. The results of this study continue to prove the point that calendarized blister packaging can provide increases in patient adherence. In the OSU research, 88 adults, all 65+ years of age, were included in the study. All had blood pressure readings of at least 140/90. Forty-eight participants received Prinivil in blister packs with compliance-prompting features. These partipants constituted the study group. Forty received Prinivil in traditional pharmacy vials and composed the control group. The patients were tracked for 12 months.
Over these months, the percent of on-time refills of the control group was only 66.1%, while the study group’s percent of on-time refills was 80.4%. Dramatic improvements in blood pressure were also measured in the study group. The change in DBP of the control group was -17% and SBP was -40%. For the study group , DBP was -50% and SBP was – 57%. The conclusions drawn by the researchers: “Patients in the study group had better adherence as
measured by: 1) Significantly more likely to refill prescriptions on time; and 2) Medication possession ratios significantly higher for study group (MRP = “proportion of days a patient has medication available to be taken”) and At 12 months, a significantly greater proportion of patients in the study group had lower diastolic blood pressure (compared to baseline) than patients in the control group.

Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients

Objective: To evaluate medication adherence and treatment outcomes in elderly outpatients using daily-dose blister packaging (Pill Calendar) compared with medications packaged in bottles of loose tablets.

Design: Randomized controlled trial.

Setting: Ambulatory care clinics at Ohio State University Medical Center, Columbus; University of Arizona Health Science Center, Tucson; and Riverside Methodist Hospital Family Medicine Clinic, Columbus, Ohio, from July 1, 2002, to December 31, 2004.

Patients: 85 individuals 65 years of age or older being treated with lisinopril for hypertension.

Intervention: Patients were randomly assigned to receive lisinopril in either daily-dose blister packaging (Pill Calendar) or traditional bottles of loose tablets.

Main outcome measures: Adherence was assessed by prescription refill regularity and medication possession ratio (MPR). Treatment outcome and use of medical services were assessed by medical record review of blood pressure and morbidity associated with poorly controlled hypertension.

Results: Patients receiving lisinopril in the daily-dose blister packaging (Pill Calendar) refilled their prescriptions on time more often (P = 0.01), had higher MPRs (P = 0.04), and had lower diastolic blood pressure (P = 0.01) than patients who had their medications packaged in traditional bottles of loose tablets.

Conclusion: Providing medications in a package that identifies the day each dose is intended to be taken and provides information on proper self-administration can improve treatment regimen adherence and treatment outcomes in elderly patients.

Electronic medication packaging devices and medication adherence: A systematic review

Importance  Medication nonadherence, which has been estimated to affect 28% to 31% of US patients with hypertension, hyperlipidemia, and diabetes, may be improved by electronic medication packaging (EMP) devices (adherence-monitoring devices incorporated into the packaging of a prescription medication).

Objectives  To investigate whether EMP devices are associated with improved adherence and to identify and describe common features of EMP devices.

Evidence Review  Systematic review of peer-reviewed studies testing the effectiveness of EMP systems in the MEDLINE, EMBASE, PsycINFO, CINAHL, International Pharmaceutical Abstracts, and Sociological Abstracts databases from searches conducted to June 13, 2014, with extraction of associations between the interventions and adherence, as well as other key findings. Each study was assessed for bias using the Cochrane Handbook for Systematic Reviews of Interventions; features of EMP devices and interventions were qualitatively assessed.

Findings  Thirty-seven studies (32 randomized and 5 nonrandomized) including 4326 patients met inclusion criteria (10 patient interface–only “simple” interventions and 29 “complex” interventions integrated into the health care system [2 qualified for both categories]). Overall, the effect estimates for differences in mean adherence ranged from a decrease of 2.9% to an increase of 34.0%, and the those for differences in the proportion of patients defined as adherent ranged from a decrease of 8.0% to an increase of 49.5%. We identified 5 common EMP characteristics: recorded dosing events and stored records of adherence, audiovisual reminders to cue dosing, digital displays, real-time monitoring, and feedback on adherence performance.

Conclusions and Relevance  Many varieties of EMP devices exist. However, data supporting their use are limited, with variability in the quality of studies testing EMP devices. Devices integrated into the care delivery system and designed to record dosing events are most frequently associated with improved adherence, compared with other devices. Higher-quality evidence is needed to determine the effect, if any, of these low-cost interventions on medication nonadherence and to identify their most useful components.

Targeting Improving Patient Outcomes in Europe through Community Pharmacists’ Intervention

Interventions for enhancing medication adherence

Adherence to long term therapy, evidence for action

This report provides a critical review of what is known about adherence to long-term therapies. This is achieved by looking beyond individual diseases. By including communicable diseases such as tuberculosis and human immunodeficiency virus/acquired immunodeficiency syndrome;mental and neurological conditions such as depression and epilepsy; substance dependence (exemplified by smoking cessation); as well as hypertension, asthma and palliative care for cancer, a broad range of policy options emerges. Furthermore, this broader focus highlights certain common issues that need to be addressed with respect to all chronic conditions regardless of their cause.These are primarily related to the way in which health systems are structured, financed and operated.

OECD Health Working Paper No. 105 (2018)

Despite  mounting  evidence, amassed  for more  than  four  decades, poor  adherence  to medications still affects approximately half of  the population that receives prescriptions, leading to severe  health  complications,  premature  deaths,  and  an  increased  use  of healthcare services. – – – – Poor  adherence is  estimated  to contribute to  nearly 200,000  premature  deaths  in Europe per year. Patients with chronic diseases are particularly vulnerable to poor health  outcomes  if  they  do  not  adhere  to  their  medications. Mortality  rates  for patients with diabetes and heart disease who don’t adhere are nearly twice as high as for those who do adhere.
– It  is  estimated  to  cost  EUR  125  billion in  Europe and USD  105  billion in  the United   States   per   year   in   avoidable   hospitalisations,   emergency   care,   and outpatient visits.
– The  three   most   prevalent   chronic   conditions – diabetes, hypertension, and hyperlipidaemia – stand  out  as  the  diseases  with  the  highest  avoidable  costs,  for which every  extra  USD  spent  on  medications  for  patients who  do  adhere can generate  between  USD  3  to  13 in  savings  on  avoidable emergency  department visits and inpatient hospitalisations alone.

The  prevalence  of medication non-adherence  varies  considerably  across  conditions  and patient groups. Most of the studies used different assessment methods making it difficult to compare adherence rates across health systems. Overall, among patients with diabetes, hypertension, and hyperlipidaemia:
– 4 to 31% of patients never fill their first prescription;
– of  those  who  do  fill  their first  prescription,  only  50  to  70%  are  taking  their medications regularly (i.e. at least 80% of the time); and
– less than half of these patients are still continuing to take their medications within two years of the initial prescription.