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Interventions for enhancing medication adherence (Review)

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Background People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications. Objectives The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes. Search methods We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles. Selection criteria We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points. Data collection and analysis Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome. Main results The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes. Authors' conclusions Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.
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... The high prevalence and consequences of medication non-adherence have attracted considerable attention over the past 30 years. Researchers, clinicians and policymakers search for improved methods to assess this phenomenon and its determinants, along with effective MA-enhancing multifaceted interventions tailored to patients' needs [4]. ...
... Internationally, research evidence underscores the value of multilevel interventions, monitoring and equipping HCPs to address MA [1,4]. However, in Switzerland, implementation of MA interventions in clinical practice is limited. ...
... After half a century of research in this area, several medication adherence-enhancing interventions (MAEIs) have been designed, addressing individual or multiple of these factors. A single MAEI does not solve the non-adherence problem, however, currently available interventions targeting chronic conditions may improve both adherence and clinical outcomes (Nieuwlaat et al., 2014). ...
... In particular, reimbursement of MAEIs has not received much attention until now. Interestingly enough, this issue was neither tackled in the extensive Cochrane review on interventions for enhancing medication adherence (Nieuwlaat et al., 2014) nor in the WHO report on chronic diseases management in Europe (Nolte et al., 2014). ...
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Background: Medication non-adherence jeopardises the effectiveness of chronic therapies and negatively affects financial sustainability of healthcare systems. Available medication adherence-enhancing interventions (MAEIs) are utilised infrequently, and even more rarely reimbursed. The aim of this paper was to review reimbursed MAEIs across selected European countries. Methods: Data on reimbursed MAEIs were collected from European countries at the ENABLE Cost Action expert meeting in September 2021. The identified MAEIs were analysed and clustered according to their characteristics, direct vs. indirect relation to adherence, and the targeted adherence phase. Results: Out of 12 contributing countries, 10 reported reimbursed MAEIs, 28 in total, of which 20 were identified as MAEIs targeting adherence directly. Reimbursed MAEIs were most often performed by either doctors ( n = 6), nurses ( n = 6), or pharmacists ( n = 3). The most common types of MAEIs were education ( n = 6), medication regimen management ( n = 5), and adherence monitoring feedback ( n = 4). Only seven reimbursed MAEIs were technology-mediated, whereas 11 addressed two interlinked phases of medication adherence, i.e. , implementation and persistence. Conclusion: Our review highlights the scarcity of reimbursed MAEIs across the selected European countries, and calls for their more frequent use and reimbursement.
... A heterogeneous evidence level was shown for the use of SMS (Short Message Service) for preventive health measures (i.e., smoking, overweight and obesity, attendance of medical appointments, etc.) [20,[22][23][24][25][26][27]. More broadly, there is not enough evidence to conclude that ICT interventions improve patients' adherence [28][29][30][31][32]. However, ICT effectiveness has been shown in several chronic diseases, such as asthma, diabetes, or human immunodeficiency virus infection [32][33][34]. ...
... However, ICT effectiveness has been shown in several chronic diseases, such as asthma, diabetes, or human immunodeficiency virus infection [32][33][34]. Few studies were conducted in transplantation to assess the relevance of ICT use in patients' management [30]. To our knowledge, only one study was conducted in LT, assessing the acceptance and use of a smartphone application for daily health self-monitoring in a randomized controlled trial [35]. ...
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Optimal therapeutic management is a major determinant of patient prognosis and healthcare costs. Information and communication technologies (ICTs) represent an opportunity to enhance therapeutic management in complex chronic diseases, such as lung transplantation (LT). The objective of this study was to assess the preferences of LT patients and healthcare professionals regarding ICTs in LT therapeutic management. A cross-sectional opinion survey was conducted among lung transplant patients and healthcare professionals from the French lung transplantation centers. Five ICTs were defined (SMS, email, phone, internet, and smartphone application) in addition to face-to-face communication. An unsupervised approach by Principal Component Analysis (PCA) identified lung transplant patient profiles according to their preferences for ICTs. Fifty-three lung transplant patients and 15 healthcare professionals of the French LT centers were included. Both expected ICTs for treatment management and communication. Phone call, face-to-face, and emails were the most preferred communication tools for treatment changes and initiation. PCA identified four ICTs-related profiles (“no ICT”, “email”, “SMS”, and “oral communication”). “Email” and “oral communication” profiles are mainly concerned with treatment changes and transmission of new prescriptions. The “SMS” profile expected reminders for healthcare appointments and optimizing therapeutic management. This study provides practical guidance to enhance LT therapeutic management by ICT intervention. The type of ICT used should take into account patient profiles to improve adherence and thereby the prognosis. A combination of strategies including information, education by a multidisciplinary team, and reminders is a promising approach to ensure an optimal management of our patients.
... There is a need for practical and effective interventions to improve HTN medication adherence, particularly in patients that face challenges to their medication adherence due to mental health comorbidity. Two recent reviews of adherence interventions indicate that there is no single intervention that has strong evidence for improving antihypertensive drug adherence [31,32]. For many patients, poor adherence is a matter of "can't" rather than "won't" due to forgetting to take medications or having lifestyles that make it hard to incorporate medication-taking into daily routines. ...
... Furthermore, for individuals with BD, medication regimens may be relatively complex, involving treatments for HTN as well as mood stabilizing or antidepressant drugs. Yet, there are few effective interventions to enhance adherence and improve outcomes in BD [21,32] and those that do exist do not simultaneously target non-psychotropic non-adherence. ...
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Background Cardiovascular disease in individuals with mental health conditions such as bipolar disorder is highly prevalent and often poorly managed. Individuals with bipolar disorder face significant medication adherence barriers, especially when they are prescribed multiple medications for other health conditions including hypertension. Poor adherence puts them at a disproportionate risk for poor health outcomes. As such, there is a need for effective interventions to improve hypertension medication adherence, particularly in patients that struggle with adherence due to mental health comorbidity. Methods This 5-year project uses a 2-stage randomized controlled trial design to evaluate a brief, practical adherence intervention delivered via interactive text messaging (iTAB-CV) along with self-monitoring of medication taking, mood, and home blood pressure (N = 100) compared to self-monitoring alone (N = 100). Prior to randomization, all participants will view an educational video that emphasizes the importance of medication for the treatment of hypertension and bipolar disorder. Those randomized to the texting intervention will receive daily text messages with predetermined content to address 11 salient domains as well as targeted customized messages for 2 months. This group will then be re-randomized to receive either a high (gradual taper from daily to weekly texts) or low booster (weekly texts) phase for an additional 2 months. All participants will be monitored for 52 weeks. The primary outcomes are systolic blood pressure and adherence to antihypertensive medication as determined by a self-reported questionnaire and validated with an automated pill-monitoring device. Secondary outcomes include adherence to bipolar disorder medications, psychiatric symptoms, health status, self-efficacy for medication-taking behavior, illness beliefs, medication attitudes, and habit strength. Discussion This study specifically targets blood pressure and mental health symptom control in people with bipolar and includes implementation elements in the study design intended to inform future scale-up. Promising pilot data and a theoretical model, which views sustained medication-taking behavior in the context of habit formation, suggests that this remotely delivered intervention may help advance care for this high-risk population and is amenable to both scale up and easy adaptation for other groups with poor medication adherence. Trial registration The study was registered at ClinicalTrials.gov (NCT04675593) on December 19, 2020.
... Ensuring adherence to therapy -the extent to which a person's behaviors correspond with agreed recommendations from their health-care provider -is one of the most challenging aspects in the management of patients with chronic diseases [116], including those with EoE. Once disease activity and symptom remission have been achieved, loss of adherence to any type of therapy has been repeatedly documented in EoE [91,[117][118][119], leading to recurrence of inflammation (with its consequent risk of fibrotic progression) and symptoms. ...
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Introduction: Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. Areas covered: Since eosinophilic esophagitis is chronic, clinical, endoscopic and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. Expert opinion: Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.
... 179 When considering patients' adherence to prescribed medication, current intervention methods seem to be not very effective, but are likely to be more successful when repeated. 180,181 This suggests that information delivered to these affected patients should be multimedial, using various supports, and repeated over time. ...
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The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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Background Improving medication adherence represents one of the greatest behavioral challenges in medicine. Personal values are an under-examined source of motivation for adhering to medication. This secondary analysis leverages a mixed-method approach to understanding a novel, online, values-based intervention (‘REACH’) for promoting endocrine therapy (ET) adherence among breast cancer survivors, using data from a randomized trial. Methods Breast cancer survivors with challenges taking ET (n = 88) were randomized 1:1 to ET Education + Values (REACH) or Education-only online interventions. This report focuses on the three values strategies used in REACH to promote ET adherence: affirming health-related values, using values-based perspective-taking to motivate adherence, and creating a personalized cue-to-action values sticker for participants’ ET pillbox. Immediate responses to these values strategies were analyzed using Linguistic Inquiry and Word Count (LIWC) and in both conditions, using repeated assessment of positive and negative affective states. Long-term responses to these strategies were evaluated using structured study exit interviews. Affective responses to REACH were used to predict objective ET adherence. Results Compared to Education, REACH led to less tense and sad. And more loving states in the immediate term. Convergently, during REACH values exercises, LIWC identified greater use of positive emotion words than negative emotion words. Thematic coding of exit interviews identified generally positive responses to values content in the longer-term with a small minority of negative responses. Conclusions Distinct approaches to linking domain-relevant values directly to ET adherence were associated with generally positive affective responses, informing theory and practice.
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Non-compliance with treatment is a major problem, especially in psychiatric patients receiving a long-term medication. The aim of this study was to detect the extent of non-compliance with treatment of schizophrenic patients and assess the effectiveness of the intervention program. Compliance with treatment of 225 relapsed cases of Malay schizophrenia was assessed. About 73% of the patients were found to have poor compliance. Poor insight of the illness is the most common reason of poor compliance. Patients with poor compliance who were prescribed drug dosage of not more than twice per day throughout follow-up and underwent counseling to enhance treatment compliance had a significantly lower relapse rate than the controlled group at the end of 1 year of follow-up. The importance of family support and the role of pharmacists in health education and drug counseling was highlighted.
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This study was prospectively planned to compare the efficiacy of azithromycin which is a new antibacterial agent and cefuroxine axetile which is commonly used second-generation cephalosporin for the treatment of acute otitis media. Patients diagnosed with acute otitis media received three days of azithromycin (10 mg/kg/day in children, 500 mg/day in adults in single daily dose) or ten days of cefuroxime axetile (40 mg/kg/day in children, 500 mg/day in two divided doses). Clinical efficiacy was evaluated at the beginning and on days 4-6, 10-14 and 30 of the treatment. Microbiologic assessments were performed in patients provided informed consent. Fifty-six patients were enrolled in the study. Thirty-one patients received azithromycin and twenty-five cefuroxime axetile. There were no significant differences in symptoms and signs between the patient groups with acute otitis media (p>0.05). Microbiologic assessments were performed in thirty- seven ear samples and the primary pathogen was found to be Streptococcus pneumoniae. Four patients in azithromycin-treated group and three patients in cefuroxime axetile-treated group were excluded for lack of efficiacy. Moreover, nine patients in each group were excluded for inadequate follow- up; thus, the study which was started with fifty-six patients could be finished with thirty patients. Satisfactory clinical outcome observed in 82% of azithromycin-treated group and in 81% of cefuroxime axetile-treated group. The gastrointestinal complaints were the most common side effects. No patient discontinued treatment because of adverse events. Statistically significant difference between clinical responses in azithromycin-treated and in cefuroxime axetile-treated groups was not found. Compliance was better in azithromycin-treated patients than in cefuroxime axetile-treated patients.
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The broad-spectrum antibiotic clarithromycin has been shown to be safe and effective in the treatment of lower respiratory tract infections, including acute exacerbations of chronic bronchitis (AECB), when dosed at 250 or 500 mg twice daily. Because a once-daily schedule may improve compliance, a modified-release formulation of clarithromycin was developed. This prospective, double-blind, parallel-group, multicenter study randomized 239 patients to receive either clarithromycin modified-release tablets 500 mg once daily (CL MR) or clarithromycin tablets 250 mg twice daily (CL) for 7 to 14 days. At the end of treatment, 93% of evaluable and 91% of intent-to- treat (ITT) patients in the once-daily group and 95% and 90% of patients, respectively, in the twice-daily group achieved clinical success. At 21 days posttreatment, clinical success rates were 86% (evaluable) and 82% (ITT) with the once-daily formulation and 91% and 83% with the twice-daily formulation. Resolution or improvement of all symptoms occurred in 75% to 100% of patients in both groups. As measured by pill count, 96% and 94% of patients in the once- and twice-daily groups, respectively, were more than 90% compliant with their prescribed regimens. The most commonly reported adverse events were abdominal pain (9%) and diarrhea (4%) in the once-daily group and abdominal pain and headache (4% each) in the twice-daily group. CL MR is as effective as standard 250 mg CL given twice daily in the treatment of AECB. Both formulations were safe and well tolerated, and compliance with CL MR was slightly higher than with CL.