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      Improvement in medication adherence and self-management of diabetes with a clinical pharmacy program: a randomized controlled trial in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital

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          Abstract

          OBJECTIVE:

          To evaluate the impact of a clinical pharmacy program on health outcomes in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital in Brazil.

          METHOD:

          A randomized controlled trial with a 6-month follow-up period was performed in 70 adults, aged 45 years or older, with type 2 diabetes who were taking insulin and who had an HbA1c level ≥8%. Patients in the control group (CG) (n = 36) received standard care, patients in the intervention group (IG) (n = 34) received an individualized pharmacotherapeutic care plan and diabetes education. The primary outcome measure was change in HbA1c. Secondary outcomes included diabetes and medication knowledge, adherence to medication, insulin injection and home blood glucose monitoring techniques and diabetes-related quality of life. Outcomes were evaluated at baseline and 6 months using questionnaires.

          RESULTS:

          Diabetes knowledge, medication knowledge, adherence to medication and correct insulin injection and home blood glucose monitoring techniques significantly improved in the intervention group but remained unchanged in the control group. At the end of the study, mean HbA1c values in the control group remained unchanged but were significantly reduced in the intervention group. Diabetes-related quality of life significantly improved in the intervention group but worsened significantly in the control group.

          CONCLUSION:

          The program improved health outcomes and resulted in better glycemic control in patients with type 2 diabetes undergoing insulin therapy.

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          Concurrent and predictive validity of a self-reported measure of medication adherence.

          D E Morisky, L Green, D Levine (1986)
          Adherence to the medical regimen continues to rank as a major clinical problem in the management of patients with essential hypertension, as in other conditions treated with drugs and life-style modification. This article reviews the psychometric properties and tests the concurrent and predictive validity of a structured four-item self-reported adherence measure (alpha reliability = 0.61), which can be easily integrated into the medical visit. Items in the scale address barriers to medication-taking and permit the health care provider to reinforce positive adherence behaviors. Data on patient adherence to the medical regimen were collected at the end of a formalized 18-month educational program. Blood pressure measurements were recorded throughout a 3-year follow-up period. Results showed the scale to demonstrate both concurrent and predictive validity with regard to blood pressure control at 2 years and 5 years, respectively. Seventy-five percent of the patients who scored high on the four-item scale at year 2 had their blood pressure under adequate control at year 5, compared with 47% under control at year 5 for those patients scoring low (P less than 0.01).
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            Patient adherence improves glycemic control.

            Mary K. Rhee, Wrenn Slocum, David C. Ziemer … (2015)
            The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.
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              Medication taking and diabetes: a systematic review of the literature.

              Peggy Soule Odegard, Kam Capoccia (2015)
              The purpose of this systematic review is to evaluate the evidence of the challenges and barriers to medication taking (adherence) and to summarize the interventions that improve medication taking in type 1 and type 2 diabetes mellitus. PubMed, the Cochrane Collaborative, and the Health and Psychosocial Instruments databases were used to obtain articles identified by using the MeSH headings of diabetes, medication, oral hypoglycemic agents, oral antihyperglycemic agents, oral antidiabetic agents, insulin, adherence, medication taking, compliance, fears, treatment, and electronic monitoring. Only articles published in English between 1990 and May 7, 2007, and including individuals of all ages with type 1 or type 2 diabetes mellitus were included. Retrospective and prospective studies reporting adherence to medications using self-report, pill counts, medication possession ratios, and electronic monitoring devices were included. Database analyses of prescription records from various organizations or countries were included only if adherence to pharmacologic therapy was stated. Surveys and questionnaires assessing medication taking were also included. The data from the selected literature was abstracted independently. The various studies were grouped together based on the type of study conducted. Studies were not included if a specific measure of adherence to medication was not used or stated. The studies are presented in 3 tables according to design. Several barriers to medication taking have been suggested for those with diabetes mellitus, although well-controlled trials to confirm and resolve these barriers are limited. Diabetes educators should be aware of the common barriers to medication taking (regimen complexity of more than 1 diabetes mellitus drug or more than 1 dose daily, depression, and remembering doses and refills) and provide screening and support to their patients to resolve barriers if they exist. Further studies are needed to test specific interventions to improve medication taking in diabetes.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clinics (Sao Paulo)
                Journal ID (iso-abbrev): Clinics (Sao Paulo)
                Title: Clinics
                Publisher: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
                ISSN (Print): 1807-5932
                ISSN (Electronic): 1980-5322
                Publication date (Print): February 2015
                Volume: 70
                Issue: 2
                Pages: 102-106
                Affiliations
                Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Serviço de Endocrinologia e Metabologia, Unidade de Diabetes, São Paulo, SP/Brazil.
                Author notes

                This article presents the results of a Master's project developed by Cani CG. She is a pharmacist and she performed the patient consultations and orientations and wrote the manuscript. Lopes LS is a physician and member of the team and she was also responsible for some of the statistical analysis and the manuscript review. Queiroz M is a physician and member of the team. She participated in the development of the study and also revised the manuscript. Nery M is the physician in charge of the Diabetes Unit of the Hospital, she supervised the student and the project, and revised the final version of the manuscript.

                *corresponding author
                Article
                Publisher ID: cln_70p102
                DOI: 10.6061/clinics/2015(02)06
                PMC ID: 4351311
                PubMed ID: 25789518
                SO-VID: 59aba10a-1037-4a76-a603-d62fa06c28eb
                Copyright © Copyright © 2015 Hospital das Clínicas da FMUSP
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 14 September 2014
                Date revision received : 5 December 2014
                Date accepted : 5 December 2014
                Page count
                Pages: 5
                Categories
                Subject: Clinical Science

                ScienceOpen disciplines: Medicine
                Keywords: diabetes mellitus type 2,medication adherence,clinical pharmacy services,self-management,outpatient care
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: diabetes mellitus type 2, medication adherence, clinical pharmacy services, self-management, outpatient care

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