Susan J. Blalock

Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review

BACKGROUND Suboptimum medication adherence is common in the United States and leads to serious negative health consequences but may respond to intervention. PURPOSE To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the United States. DATA SOURCES Eligible peer-reviewed publications from MEDLINE and the Cochrane Library indexed through 4 June 2012 and additional studies from reference lists and technical experts. STUDY SELECTION Randomized, controlled trials of patient, provider, or systems interventions to improve adherence to long-term medications and nonrandomized studies of policy interventions to improve medication adherence. DATA EXTRACTION Two investigators independently selected, extracted data from, and rated the risk of bias of relevant studies. DATA SYNTHESIS The evidence was synthesized separately for each clinical condition; within each condition, the type of intervention was synthesized. Two reviewers graded the strength of evidence by using established criteria. From 4124 eligible abstracts, 62 trials of patient-, provider-, or systems-level interventions evaluated 18 types of interventions; another 4 observational studies and 1 trial of policy interventions evaluated the effect of reduced medication copayments or improved prescription drug coverage. Clinical conditions amenable to multiple approaches to improving adherence include hypertension, heart failure, depression, and asthma. Interventions that improve adherence across multiple clinical conditions include policy interventions to reduce copayments or improve prescription drug coverage, systems interventions to offer case management, and patient-level educational interventions with behavioral support. LIMITATIONS Studies were limited to adults with chronic conditions (excluding HIV, AIDS, severe mental illness, and substance abuse) in the United States. Clinical and methodological heterogeneity hindered quantitative data pooling. CONCLUSION Reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Evidence is limited on whether these approaches are broadly applicable or affect longterm medication adherence and health outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Arthritis and perceptions of quality of life: an examination of positive and negative affect in rheumatoid arthritis patients.

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity

OBJECTIVE The purpose of the study was to examine (1) how patient adherence and eye drop technique were associated with visual field defect severity and (2) how general glaucoma adherence self-efficacy and eye drop technique self-efficacy were related to visual field defect severity. DESIGN Cross-sectional study conducted at a single private practice site. PARTICIPANTS Patients using eye drops for their glaucoma. METHODS Subject adherence to glaucoma medications through Medication Events Monitoring System (MEMS) devices were measured, and eye drop instillation technique was assessed by video recording. General glaucoma medication adherence self-efficacy was measured using a 10-item scale, and eye drop technique self-efficacy was measured using a 6-item scale. Multivariate logistic regression was used to analyze the data. MAIN OUTCOME MEASURES Visual field defect severity. RESULTS Patients who were less than 80% adherent according to the MEMS devices were significantly more likely to have worse defect severity. Patients with lower scores on the general glaucoma medication adherence self-efficacy scale also were significantly more likely to have worse defect severity. Eye drop technique and eye drop technique self-efficacy were not related significantly to visual field defect severity. CONCLUSIONS Eye care providers need to assess patient adherence and to work with those patients with poor adherence to find ways to improve their ability and self-efficacy in using their glaucoma medications. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Medication Therapy Management Interventions in Outpatient Settings A Systematic Review and Meta-analysis

IMPORTANCE Medication therapy management (MTM) services (also called clinical pharmacy services) aim to reduce medication-related problems and their downstream outcomes. OBJECTIVE To assess the effect of MTM interventions among outpatients with chronic illnesses. DATA SOURCES MEDLINE, Cochrane Library, and International Pharmaceutical Abstracts through January 9, 2014. STUDY SELECTION Two reviewers selected studies with comparators and eligible outcomes of ambulatory adults. DATA EXTRACTION AND SYNTHESIS Dual review of titles, abstracts, full-text, extractions, risk of bias, and strength of evidence grading. We conducted meta-analyses using random-effects models. MAIN OUTCOMES AND MEASURES Medication-related problems, morbidity, mortality, quality of life, health care use, costs, and harms. RESULTS Forty-four studies met the inclusion criteria. The evidence was insufficient to determine the effect of MTM interventions on most evaluated outcomes (eg, drug therapy problems, adverse drug events, disease-specific morbidity, disease-specific or all-cause mortality, and harms). The interventions improved a few measures of medication-related problems and health care use and costs (low strength of evidence) when compared with usual care. Specifically, MTM interventions improved medication appropriateness (4.9 vs 0.9 points on the medication appropriateness index, P < .001), adherence (approximately 4.6%), and percentage of patients achieving a threshold adherence level (odds ratios [ORs] ranged from 0.99 to 5.98) and reduced medication dosing (mean difference, -2.2 doses; 95% CI, -3.738 to -0.662). Medication therapy management interventions reduced health plan expenditures on medication costs, although the studies reported wide CIs. For patients with diabetes mellitus or heart failure, MTM interventions lowered the odds of hospitalization (diabetes: OR, 0.91 to 0.93 based on type of insurance; adjusted hazard rate for heart failure: 0.55; 95% CI, 0.39 to 0.77) and hospitalization costs (mean differences ranged from -

Risk perceptions and participation in colorectal cancer screening.

363.45 to -

Measuring health status among survivors of burn injury: Revisions of the burn specific health scale

398.98). The interventions conferred no benefit for patient satisfaction and most measures of health-related quality of life (low strength). CONCLUSIONS AND RELEVANCE We graded the evidence as insufficient for most outcomes because of inconsistency and imprecision that stem in part from underlying heterogeneity in populations and interventions. Medication therapy management interventions may reduce the frequency of some medication-related problems, including nonadherence, and lower some health care use and costs, but the evidence is insufficient with respect to improvement in health outcomes.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior.

Compared individuals at high versus average risk for colorectal cancer (CRC) with respect to factors they cited as affecting their risk of developing CRC. We also examined the relationship of these risk-factor perceptions to perceived susceptibility and participation in a CRC screening test. All individuals in the high-risk group were informed that, as a sibling of someone with CRC, they were more likely to get this cancer themselves. We found minimal differences among siblings with respect to perceived susceptibility. Further, although high-risk siblings were more likely to participate in screening, only 20.2% cited heredity as a risk-increasing factor, and, among these siblings, there was no relationship between screening participation and the citation of any specific risk factors, including heredity. These findings demonstrate the need for more research examining how high-risk individuals process risk-relevant information and the effect of this information on health behavior.

Evaluation of a Problem-Solving Intervention for Patients With Arthritis*

This study examined the reliability of a revised version of the Burn Specific Health Scale (BSHS). Two hundred fifty-four former patients recruited from eight burn centers in the southeastern United States participated in the study. Data were collected via chart review and mailed questionnaire. Factor analyses were used to identify seven subscales containing a total of 31 items. Subsequent analyses provided strong support for the reliability and validity of the revised measure. Each subscale exhibited a high level of reliability (Cronbachs alpha ranged from 0.82 to 0.94). Each subscale also correlated in a predictable manner with measures used for validation. The revised measure should improve the ability of both researchers and clinicians to assess the impact of non-fatal burn injury accurately and comprehensively.

Illness attributions and hopelessness depression: the role of hopelessness expectancy.

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Factors associated with potentially inappropriate drug utilization in a sample of rural community-dwelling older adults.

A pretest-posttest control group design was used to evaluate a patient education program designed to help people with rheumatoid arthritis (RA) cope with problems posed by their disease. One hundred and one patients were randomly assigned to an intervention or control group. All patients participated in a psychosocial interview in which problems arthritis had caused in their lives were assessed and actual and potential resources patients had for dealing with those problems were identified. In addition, individuals in the intervention group received a problem-solving intervention based, in part, on information collected during the psychosocial interview. Posttest measures showed that the problem-solving intervention helped patients solve their compliance problems and their lifestyle problems, although support for the latter finding was marginal (P < 0.10). All patients who participated in the study, regardless of group assignment, improved on a number of global measures of physical and psychological functioning. This unexpected finding is attributed to unintended positive effects of the psychosocial interview, although regression to the mean can not be definitively ruled out as a competing explanation.