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Ethnic Differences in 90-Day Poststroke Medication Adherence.
Lank, RJ, Lisabeth, LD, Levine, DA, Zahuranec, DB, Kerber, KA, Shafie-Khorassani, F, Case, E, Zuniga, BG, Cooper, GM, Brown, DL, et al
Stroke. 2019;(6):1519-1524
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Background and Purpose- We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods- Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ2 tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results- Mexican Americans (n=692) were younger (median 65 years versus 68 years, P<0.001), had more diabetes mellitus ( P<0.001) and hypertension ( P<0.001) and less atrial fibrillation ( P=0.003), smoking ( P=0.003), and education ( P<0.001) than non-Hispanic whites (n=422). Sex, insurance status, high cholesterol, previous stroke/transient ischemic attack history, excessive alcohol use, tPA (tissue-type plasminogen activator) treatment, National Institutes of Health Stroke Scale score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the 5 drug classes between Mexican Americans and non-Hispanic whites. Conclusions- This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.
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A smartphone application supporting patients with psoriasis improves adherence to topical treatment: a randomized controlled trial.
Svendsen, MT, Andersen, F, Andersen, KH, Pottegård, A, Johannessen, H, Möller, S, August, B, Feldman, SR, Andersen, KE
The British journal of dermatology. 2018;(5):1062-1071
Abstract
BACKGROUND Adherence to topical psoriasis treatments is low, which leads to unsatisfactory treatment results. Smartphone applications (apps) for patient support exist but their potential to improve adherence has not been systematically evaluated. OBJECTIVES To evaluate whether a study-specific app improves adherence and reduces psoriasis symptoms compared with standard treatment. METHODS We conducted a randomized controlled trial (RCT, clinicaltrials.gov registration: NCT02858713). Patients received once-daily medication [calcipotriol/betamethasone dipropionate (Cal/BD) cutaneous foam] and were randomized to no app (n = 66) or app intervention (n = 68) groups. In total, 122 patients (91%) completed the 22-week follow-up. The primary outcome was adherence, which was defined as medication applied ≥ 80% of days during the treatment period and assessed by a chip integrated into the medication dispenser. Secondary outcomes were psoriasis severity measured by the Lattice System Physician's Global Assessment (LS-PGA) and quality of life, measured using the Dermatology Life Quality Index (DLQI) at all visits. RESULTS Intention-to-treat analyses using regression was performed. More patients in the intervention group were adherent to Cal/BD cutaneous foam than those in the nonintervention group at week 4 (65% vs. 38%, P = 0·004). The intervention group showed a greater LS-PGA reduction than the nonintervention group at week 4 (mean 1·86 vs. 1·46, P = 0·047). A similar effect was seen at weeks 8 and 26, although it did not reach statistical significance. CONCLUSIONS This RCT demonstrates that the app improved short-term adherence to Cal/BD cutaneous foam treatment and psoriasis severity.
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Six-month adherence to Statin use and subsequent risk of major adverse cardiovascular events (MACE) in patients discharged with acute coronary syndromes.
Xie, G, Sun, Y, Myint, PK, Patel, A, Yang, X, Li, M, Li, X, Wu, T, Li, S, Gao, R, et al
Lipids in health and disease. 2017;(1):155
Abstract
BACKGROUND The evidence of adherence to statin decreasing risk of major adverse cardiovascular events (MACEs) is still lack among patients discharged with acute coronary syndrome (ACS). Our objective is to determine the relationship between six-month adherence to statins and subsequent risk of MACEs in patients discharged with ACS. METHODS Using two prospective registry cohorts (CPACS-1 and -2), we analyzed data from 12,516 consecutive patients with ACS who were prescribed statin at hospital discharge and survived beyond 6 months without recurrent myocardial infarction (MI) or stroke. Adherence to statin was defined as good (using statin at discharge and 6 months without declined dosage) and poor adherence groups (using statin at discharge but declining dosage or stopping at 6 months). We compared the hazard ratios of all-cause mortality and MACE in subsequent 6 months between groups, using Cox-regression models, adjusting for multiple potential confounders. RESULTS Seventy two percent of patients adhered to statin therapy at 6 months. The incident MACE in the poor adherence group was significantly higher than in good adherence group (2.7% vs. 1.8%, p = 0.002). Compared with poor adherence group, the good adherence group showed a 27% lower relative risk of MACE during the 6 month follow up (fully-adjusted hazard ratio (HR) = 0.73; 95%CI: 0.56-0.97). The protective effects of good adherence were similar in groups with different statin dose as well as groups by other baseline clinical characteristics and treatments (p > 0.05 for interaction). CONCLUSION Our study highlights the importance of adherence to statin therapy in prevention of MACE and clinicians should aim to achieve higher dosage if tolerable. CLINICAL TRIAL REGISTRATION CPACS2 was registered on URL: http://www.anzctr.org.au/default.aspx and unique identifier is ACTRN12609000491268 . CPACS1 was not a clinical trial and thus not registered.
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A Quality Improvement Initiative to Improve Patient Adherence to Vitamin Supplementation in Cystic Fibrosis.
Garavaglia, L, Duncan, C, Toucheque, M, Farley, A, Moffett, KS
Journal of pediatric gastroenterology and nutrition. 2017;(2):292-295
Abstract
OBJECTIVES Patients with cystic fibrosis (CF) and pancreatic insufficiency are prescribed fat-soluble vitamins, although compliance remains low. Our objective was to identify patient and caregiver knowledge deficits regarding vitamin supplementation, provide targeted education, and examine serum vitamin levels pre-and posteducation. METHODS This prospective quality improvement study involved 118 patients. A vitamin knowledge survey was given to patients/caregivers during a clinic visit, education was provided targeting knowledge deficits, and the survey was re-administered at the next clinic visit. Serum vitamin levels were collected at pre- and postsurvey. RESULTS Results showed significant pre-post increases for patient and caregiver knowledge scores, and significant decreases in self-reported nonadherence to vitamin use and number of reported barriers affecting adherence. A significant change in vitamin E level to therapeutic range post-education was demonstrated. CONCLUSIONS Our brief, targeted educational interventions regarding vitamin supplementation showed utility in a routine clinic setting.
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A phase IV, two-armed, randomized, cross-over study comparing compliance with once-a-month administration of vitamin D3 to compliance with daily administration of a fixed-dose combination of vitamin D3 and calcium during two 6-month periods.
Bruyère, O, Deroisy, R, Dardenne, N, Cavalier, E, Coffiner, M, Da Silva, S, De Niet, S, Reginster, JY
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2015;(12):2863-8
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UNLABELLED In a randomized, cross-over study, once monthly administration of vitamin D3 was preferred over a once daily administration of a fixed-dose combination of vitamin D3 and calcium, with a better compliance but without any significant difference in the increase in vitamin D levels. INTRODUCTION The aim of the present study was to compare a once-monthly administration of vitamin D3 to a daily administration of a fixed-dose combination of vitamin D3 and calcium during two treatment periods of 6 months. METHODS One hundred volunteers aged 50 years old or older were randomized to receive either one drinkable ampoule containing 25,000 IU vitamin D3 (D-Cure®, SMB) once monthly (group VD) or one chewable tablet containing 1000 mg calcium carbonate + 800 IU vitamin D3 (Steovit Forte®, Takeda) once daily (group VDCa) during 6 months. After the first 6 months of treatment, the groups were reversed according to the randomized cross-over design. Treatment compliance (i.e. the primary outcome), preference, acceptability and vitamin D levels and adverse events were all collected. RESULTS For the two periods, the patients had a significantly higher compliance in the VD group than in the VDCa group (p < 0.0001). During the study, 50 (56.8 %) patients preferred the VD treatment, 16 (18.2 %) patients preferred the VDCa, and for 22 (25.0 %) patients, neither treatment was preferred. At the end of the first 6 months of treatment, the mean (SD) increase of 25(OH)D was 6.57 ng/mL (8.19) in the VD group and 3.88 ng/mL (10.0) in the VDCa group (p = 0.16 between groups). CONCLUSION In this study, a once-monthly administration of vitamin D3 was preferred over a once-daily administration of a fixed-dose combination of vitamin D3 and calcium, with a better compliance but without any significant difference in the increase in vitamin D levels.
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Raltegravir-emtricitabine-tenofovir as HIV nonoccupational post-exposure prophylaxis in men who have sex with men: safety, tolerability and adherence.
McAllister, J, Read, P, McNulty, A, Tong, WW, Ingersoll, A, Carr, A
HIV medicine. 2014;(1):13-22
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OBJECTIVES Three-drug nonoccupational post-exposure prophylaxis (NPEP) typically includes co-formulated emtricitabine-tenofovir (FTC-TDF) and a protease inhibitor. However, protease inhibitors can cause significant toxicities, can interact with prescribed and illicit drugs, and work late in the viral cycle. Agents that act before viral integration into host DNA may have efficacy advantages. Raltegravir (RAL) is a good candidate for NPEP as it has few side effects or drug interactions and acts prior to HIV integration. The objective of this study was to investigate the use of RAL in 3-drug NPEP in terms of safety, adherence and tolerability. METHODS We evaluated 28 days of RAL-FTC-TDF treatment in 86 men and FTC-TDF treatment in 34 men eligible for three- and two-drug NPEP, respectively. We assessed adherence (compared between groups and with nonstudy controls) and clinical and adverse events at weeks 1, 2 and 4, and efficacy at week 12. Analyses were by intention to treat, excluding from the adherence analysis subjects who ceased NPEP because their source was HIV-uninfected. RESULTS No participant became infected with HIV. For RAL-FTC-TDF and FTC-TDF, regimen completion rates were 92% and 91% and medication adherence rates were 89% and 90%, respectively. Eight (9%) RAL recipients developed mild myalgias, with four developing transient grade 4 elevations in creatine kinase (two developed both), all of which improved to grade 2 or less by week 4 without RAL discontinuation. Eight prescribed and 37 potential illicit drug interactions with a protease inhibitor were avoided by use of RAL. CONCLUSIONS RAL-FTC-TDF is well tolerated as NPEP, results in high levels of adherence and avoids potential drug-drug interactions. Patients and clinicians should be aware of the potential for acute muscle toxicity when RAL is used as NPEP.
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[Adherence to and satisfaction with oral outpatient thromboembolism prophylaxis compared to parenteral: SALTO study].
Peidro-Garcés, L, Otero-Fernandez, R, Lozano-Lizarraga, L
Revista espanola de cirugia ortopedica y traumatologia. 2013;(1):53-60
Abstract
INTRODUCTION Prolongation of drug-based thromboembolism prophylaxis after discharge from hospital is clearly recommended following total hip and knee replacement. The aim of this study was to evaluate and compare adherence to and satisfaction with outpatient thromboembolism prophylaxis (by injection and oral) under routine clinical practice conditions. MATERIAL AND METHOD We analysed two consecutive cohorts of patients (480 and 366, respectively) who had undergone total hip or knee replacement surgery in 120 Spanish hospitals, and were prescribed outpatient thromboembolism prophylaxis, by injection and orally, respectively. Information on adherence to and satisfaction with both treatments, sociodemographic data and treatment compliance was collected using specific questionnaires. RESULTS The drop-out rate (9.49 vs. 4.14%), general satisfaction (37 vs. 83.38%), and the TSQM satisfaction scale were better in the oral prophylaxis cohort and, although the differences between the two routes of administration were not significant, treatment compliance was also better in the oral cohort (Morisky-Green test: 53.49 vs. 59.05%). CONCLUSIONS Adherence to and satisfaction with the oral thromboembolism prophylaxis were better than for prophylaxis by injection in the context of outpatient prolongation. Nevertheless, suboptimal treatment compliance was found in both cohorts, which could result in lack of efficacy of the prophylaxis. Both patients and doctors have to be made aware of the importance of post-discharge extension of thromboprophylaxis in orthopaedic surgery with high thrombotic risk. Moreover, strategies should be developed to encourage compliance.
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HIV disease progression in the first year after delivery among African women followed in the HPTN 046 clinical trial.
Watts, DH, Brown, ER, Maldonado, Y, Herron, C, Chipato, T, Reddy, L, Moodley, D, Nakabiito, C, Manji, K, Fawzi, W, et al
Journal of acquired immune deficiency syndromes (1999). 2013;(3):299-306
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BACKGROUND Starting lifelong antiretroviral therapy (ART) in HIV-infected pregnant women may decrease HIV progression and transmission, but adherence after delivery may be difficult, especially for asymptomatic women. We evaluated disease progression among HIV-infected women not on ART with CD4⁺ lymphocyte counts above 200 cells per microliter at delivery. METHODS We analyzed risk of death, progression to AIDS (stage IV or CD4 < 200 cells per microliter), or to CD4⁺ count <350 1 year after delivery among postpartum women enrolled to a prevention of breastfeeding transmission trial using the Kaplan-Meier method. In the primary analysis, women were censored if ART was initiated. RESULTS Among 1285 women who were not WHO stage IV or less at 6 weeks postpartum, 49 (4.3%) progressed to stage IV/CD4 <200 cells per microliter or death by 1 year. Progression to CD4 <200 cells per microliter or death occurred among 16 (4.3%) of 441 women with CD4 count of 350-549 cells per microliter and 10 (1.6%) of 713 with CD4 counts >550 cells per microliter at delivery. CD4 <350 cells per microliter by 12 months postpartum occurred among 116 (37.0%) of 350 women with CD4 count 400-549 cells per microliter and 48 (7.4%) of 713 with CD4 count >550 cells per microliter at delivery. CONCLUSIONS Progression to AIDS or CD4 count <350 cells per microliter is uncommon through 1 year postpartum for women with CD4 counts over 550 cells per microliter at delivery, but occurred in over one third of those with CD4 counts under 550 cells per microliter. ART should be continued after delivery or breastfeeding among women with CD4 counts <550 cells per microliter if follow-up and antiretroviral adherence can be maintained.
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Computerized community cholesterol control (4C): meeting the challenge of secondary prevention.
Gilutz, H, Novack, L, Shvartzman, P, Zelingher, J, Bonneh, DY, Henkin, Y, Maislos, M, Peleg, R, Liss, Z, Rabinowitz, G, et al
The Israel Medical Association journal : IMAJ. 2009;(1):23-9
Abstract
BACKGROUND Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity t close these gaps. OBJECTIVES To study the impact of computerized intervention on secondary prevention of CAD. METHODS The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization. RESULTS Follow-up was available for 7448 patients (median 19.8 months, range 6-36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment to lower lipid level. In patients with initial low density lipoprotein >120 mg/dl, a significant decrease in LDL levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 +/- 34.2 vs. 124.3 +/- 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001). CONCLUSIONS This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.