Todd M. Ruppar

Interventions to Improve Medication Adherence Among Older Adults: Meta-Analysis of Adherence Outcomes Among Randomized Controlled Trials

PURPOSE This study investigated the effectiveness of interventions to improve medication adherence (MA) in older adults. DESIGN AND METHODS Meta-analysis was used to synthesize results of 33 published and unpublished randomized controlled trials. Random-effects models were used to estimate overall mean effect sizes (ESs) for MA, knowledge, health outcomes, and health services utilization. RESULTS Data were synthesized across 11,827 participants. Interventions significantly improved MA (ES = 0.33), knowledge (ES = 0.48), and diastolic blood pressure (ES = 0.19). Nonsignificant effects were found for systolic blood pressure (ES = 0.21), other health outcomes (ES = 0.04), and health services utilization (ES = 0.16). Moderator analyses showed larger adherence ESs for interventions employing special medication packaging, dose modification, participant monitoring of medication effects and side effects, succinct written instructions, and standardized (not tailored) interventions. Larger effects were found when a moderate proportion of participants were women, for participants taking 3-5 medications, and when pill count adherence was measured. IMPLICATIONS The findings document that interventions increase MA in older adults. The considerable heterogeneity in the magnitude of effects across studies and results of the moderator analyses demonstrate the need for additional empirical research to optimize interventions.

Searching for the Intervention in Intervention Research Reports

PURPOSE Precisely described interventions in nursing research reports are essential as a foundation for nursing practice and to facilitate future research. The purpose of this project was to characterize the intervention descriptions in nursing intervention research reports. DESIGN AND METHODS Quantitative content analysis was used to analyze intervention descriptions in reports published in English-language general nursing journals during 2005. Normative analysis was used to examine reports for details related to intervention content and delivery. Physical unit analysis was used to compare relative amounts of article space devoted to intervention description vs. other methodological details. FINDINGS Results were tabulated for 141 research articles published in 27 journals. Analysis indicated incomplete reporting of intervention details in many articles. Dose and dosing frequency were rarely completely defined. Delivery setting and interventionist were frequently not indicated, and the professional credentials of nurse interventionists were often unclear. While descriptions of interventions involving substances or devices were typically detailed, the specifics of psychological, educational, behavioral, and systems-level interventions were often lacking. Intervention descriptions averaged 7.27% of total article space, whereas nonintervention methodological descriptions averaged 20.74% of space. Of studies examined, only 38 (27.0%) reported enough detail to potentially replicate the study or translate the intervention into practice. CONCLUSIONS Intervention descriptions in general nursing journals lack sufficient detail to provide the evidence basis for practice.

Interventions to Improve Medication Adherence in Hypertensive Patients: Systematic Review and Meta-analysis

This systematic review applied meta-analytic procedures to synthesize medication adherence interventions that focus on adults with hypertension. Comprehensive searching located trials with medication adherence behavior outcomes. Study sample, design, intervention characteristics, and outcomes were coded. Random-effects models were used in calculating standardized mean difference effect sizes. Moderator analyses were conducted using meta-analytic analogues of ANOVA and regression to explore associations between effect sizes and sample, design, and intervention characteristics. Effect sizes were calculated for 112 eligible treatment-vs.-control group outcome comparisons of 34,272 subjects. The overall standardized mean difference effect size between treatment and control subjects was 0.300. Exploratory moderator analyses revealed interventions were most effective among female, older, and moderate- or high-income participants. The most promising intervention components were those linking adherence behavior with habits, giving adherence feedback to patients, self-monitoring of blood pressure, using pill boxes and other special packaging, and motivational interviewing. The most effective interventions employed multiple components and were delivered over many days. Future research should strive for minimizing risks of bias common in this literature, especially avoiding self-report adherence measures.

Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta‐Analysis of Controlled Trials

Background Poor adherence to medications is a common problem among heart failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function, and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown. Methods and Results We conducted a comprehensive search and systematic review of intervention studies testing interventions to improve adherence to HF medications. Mortality and readmission outcome effect sizes (ESs) were calculated from the reported data. ESs were combined using random‐effects model meta‐analysis methods, because differences in true between‐study effects were expected from variation in study populations and interventions. ES differences attributed to study design, sample, and intervention characteristics were assessed using moderator analyses when sufficient data were available. We assessed publication bias using funnel plots. Comprehensive searches yielded 6665 individual citations, which ultimately yielded 57 eligible studies. Overall, medication adherence interventions were found to significantly reduce mortality risk among HF patients (relative risk, 0.89; 95% CI, 0.81, 0.99), and decrease the odds for hospital readmission (odds ratio, 0.79; 95% CI, 0.71, 0.89). Heterogeneity was low. Moderator analyses did not detect differences in ES from common sources of potential study bias. Conclusions Interventions to improve medication adherence among HF patients have significant effects on reducing readmissions and decreasing mortality. Medication adherence should be addressed in regular follow‐up visits with HF patients, and interventions to improve adherence should be a key part of HF self‐care programs.

Medication adherence interventions that target subjects with adherence problems: Systematic review and meta-analysis

BACKGROUND Inadequate medication adherence is a pervasive, under-recognized cause of poor health outcomes. Many intervention trials designed to improve medication adherence have targeted adults with adherence problems. No previous reviews have synthesized the effectiveness of medication adherence interventions focused on subjects with medication adherence difficulties. OBJECTIVE This systematic review and meta-analysis synthesized findings from medication adherence intervention studies conducted among adults with medication adherence difficulties. METHODS Primary research studies were eligible for inclusion if they tested an intervention designed to increase medication adherence among adults with documented adherence difficulties and reported medication adherence behavior outcomes. Comprehensive search strategies of 13 computerized databases, author and ancestry searches, and hand searches of 57 journals were used to locate eligible primary research. Participant demographics, intervention characteristics, and methodological features were reliably coded from reports along with medication adherence outcomes. Effect sizes for outcomes were calculated as standardized mean differences, and random effects models were used to estimate overall mean effects. Exploratory dichotomous and continuous variable moderator analyses were employed to examine potential associations between medication adherence effect size and sample, intervention, and methodological characteristics. RESULTS Data were extracted from 53 reports of studies involving 8243 individual primary study participants. The overall standardized mean difference effect size for treatment vs. control subjects was 0.301. For treatment pre- vs. post-intervention comparisons, the overall effect size was 0.533. Significantly larger effect sizes were associated with interventions incorporating prompts to take medications than interventions lacking medication prompts (0.497 vs. 0.234). Larger effect sizes were also found for interventions that linked medication taking with existing habits compared to interventions that did not (0.574 vs. 0.222). Effect sizes were largest among studies that measured adherence by pill counts or electronic event monitoring systems. Analysis of study design features identified several potential risks of bias. Statistically significant publication bias was detected, but adherence effect sizes were not significantly associated with other risks of bias. CONCLUSIONS These findings document that interventions targeting individuals with medication adherence problems can have modest but significant effects on medication-taking behavior. The findings support the use of behavioral strategies such as prompts and linking medications to habits to increase medication adherence in adults with adherence challenges. Face-to-face interventions appear to be critical for patients who have experienced past problems with medication adherence.

Medication Beliefs and Antihypertensive Adherence Among Older Adults: A Pilot Study

Older adults with hypertension are dependent on medication to control blood pressure and reduce risk for cardiovascular disease and renal impairment. Unfortunately, adherence to antihypertensive regimens remains low. This pilot study examines the relation among medication beliefs, demographic variables, and antihypertensive medication adherence in a sample of older adults (median age = 74 years). Medication beliefs were measured using the Beliefs About Medicines Questionnaire (BMQ), and medication adherence was measured by electronic monitoring. Among study participants (n = 33), concerns about medications were found to be related to poorer antihypertensive adherence. In particular, older adults with lower medication adherence were concerned about dependency and long-term effects from their medications. When controlling for other factors that may influence antihypertensive adherence, beliefs about medication necessity were related to adherence (odds ratio: 2.027, 95% confidence interval: 1.10-3.75).

Packaging interventions to increase medication adherence: systematic review and meta-analysis

Abstract Objective: Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. Research design and methods: Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. Results: Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. Conclusions: Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.

Medication adherence in successful kidney transplant recipients

OBJECTIVE To explore the medication-taking behavior of successful kidney transplant recipients and determine what behaviors were common among this group. METHODS Open-ended interviews were conducted by telephone with 19 individuals who had successfully maintained a transplanted kidney for 25 years or more. Data were coded by using a grounded theory approach to explore patterns of phenomena, common descriptions, and relationships. RESULTS Four themes emerged as participants described the behaviors they developed to adhere successfully to the immunosuppressive medication required for maintaining their transplanted kidneys. The themes were reminder methods, obtaining medications, maintaining routines, and problem-solving strategies. Kidney transplant recipients identified the importance of developing and maintaining medication-taking skills and routines on medication adherence. Problem-solving abilities were also valuable during times of disruption of normal routines. CONCLUSIONS Interventions focusing on medication-taking skills, habit formation, and resources for problem solving may improve immunosuppressive medication adherence and clinical outcomes in kidney transplant recipients.

Insulin Sensitivity Following Exercise Interventions Systematic Review and Meta-Analysis of Outcomes Among Healthy Adults

Objective: Although exercise can improve insulin sensitivity, no adequate synthesis exists of exercise intervention studies with regard to their effect on insulin sensitivity. This comprehensive meta-analysis synthesized the insulin sensitivity outcomes of supervised exercise interventions. Method: Extensive literature searching located published and unpublished intervention studies that measured insulin sensitivity outcomes. Eligible studies tested supervised exercise interventions among healthy adults. Primary study characteristics and results were coded. Random-effects meta-analyses of standardized mean differences included moderator analyses. Results: Data were synthesized across 2509 subjects (115 samples, 78 reports). The overall mean effect size for 2-group postintervention comparisons was 0.38 (95% confidence interval [CI] = 0.25-0.51, I2 = 0%) and for 2-group pre–post comparisons was 0.43 (95% CI = 0.30-0.56, I2 = 52%; higher mean insulin sensitivity for treatment than control subjects). The postintervention mean of 0.38 is consistent with treatment subjects ending studies with a mean fasting insulin of 6.8 mU/L if control participants’ mean fasting insulin were 7.9 mU/L. Exploratory moderator analyses did not document different insulin sensitivity effect sizes across intervention characteristics or sample attributes. Conclusion: This study documented that exercise is a valuable primary care and community health strategy for healthy adults to improve insulin sensitivity and lower the risk for diabetes conferred by insulin resistance.

Improving Medication Adherence: Moving from Intention and Motivation to a Personal Systems Approach

Medication nonadherence is a challenging and prevalent problem in older adults. Effective medication management involves successfully completing a complex group of behaviors. Meta-analyses and narrative review findings support limited benefits to medication adherence with interventions preoccupied with personal characteristics, intention, and motivation. Evidence supports a paradigm shift toward changing personal systems in which the person lives to improve and maintain medication adherence behavior. Personal-systems change systematically improves individual systems through collaboratively shaping routines, involving supportive-others in routines, and using medication self-monitoring to improve and maintain behavior. Other advances that support personal systems change are also presented.