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      A Systematic Review of Adherence With Medications for Diabetes

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      Journal: Diabetes Care
      Publisher: American Diabetes Association

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          Abstract

          The purpose of this study was to determine the extent to which patients omit doses of medications prescribed for diabetes. A literature search (1966-2003) was performed to identify reports with quantitative data on adherence with oral hypoglycemic agents (OHAs) and insulin and correlations between adherence rates and glycemic control. Adequate documentation of adherence was found in 15 retrospective studies of OHA prescription refill rates, 5 prospective electronic monitoring OHA studies, and 3 retrospective insulin studies. Retrospective analyses showed that adherence to OHA therapy ranged from 36 to 93% in patients remaining on treatment for 6-24 months. Prospective electronic monitoring studies documented that patients took 67-85% of OHA doses as prescribed. Electronic monitoring identified poor compliers for interventions that improved adherence (61-79%; P < 0.05). Young patients filled prescriptions for one-third of prescribed insulin doses. Insulin adherence among patients with type 2 diabetes was 62-64%. This review confirms that many patients for whom diabetes medication was prescribed were poor compliers with treatment, including both OHAs and insulin. However, electronic monitoring systems were useful in improving adherence for individual patients. Similar electronic monitoring systems for insulin administration could help healthcare providers determine patients needing additional support.

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          A systematic review of the associations between dose regimens and medication compliance.

          Ami J Claxton, Joyce Cramer, Courtney Pierce (2001)
          Previous reviews of the literature on medication compliance have confirmed the inverse relationship between number of daily doses and rate of compliance. However, compliance in most of these studies was based on patient self-report, blood-level monitoring, prescription refills, or pill count data, none of which are as accurate as electronic monitoring (EM). In this paper, we review studies in which compliance was measured with an EM device to determine the associations between dose frequency and medication compliance. Articles included in this review were identified through literature searches of MEDLINE, PsychInfo, HealthStar, Health & Psychosocial Instruments, and the Cochrane Library using the search terms patient compliance, patient adherence, electronic monitoring, and MEMS (medication event monitoring systems). The review was limited to studies reporting compliance measured by EM devices, the most accurate compliance assessment method to date. Because EM was introduced only in 1986, the literature search was restricted to the years 1986 to 2000. In the identified studies, data were pooled to calculate mean compliance with once-daily, twice-daily, 3-times-daily, and 4-times-daily dosing regimens. Because of heterogeneity in definitions of compliance, 2 major categories of compliance rates were defined: dose-taking (taking the prescribed number of pills each day) and dose-timing (taking pills within the prescribed time frame). A total of 76 studies were identified. Mean dose-taking compliance was 71% +/- 17% (range, 34%-97%) and declined as the number of daily doses increased: 1 dose = 79% +/- 14%, 2 doses = 69% +/- 15%, 3 doses = 65% +/- 16%, 4 doses = 51% +/- 20% (P < 0.001 among dose schedules). Compliance was significantly higher for once-daily versus 3-times-daily (P = 0.008), once-daily versus 4-times-daily (P < 0.001), and twice-daily versus 4-times-daily regimens (P = 0.001); however, there were no significant differences in compliance between once-daily and twice-daily regimens or between twice-daily and 3-times-daily regimens. In the subset of 14 studies that reported dose-timing results, mean dose-timing compliance was 59% +/- 24%; more frequent dosing was associated with lower compliance rates. A review of studies that measured compliance using EM confirmed that the prescribed number of doses per day is inversely related to compliance. Simpler, less frequent dosing regimens resulted in better compliance across a variety of therapeutic classes.
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            Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control.

            S. Norris, J. Lau, S Smith … (2002)
            To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes. We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb. On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact. Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.
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              Adherence to prescribed oral hypoglycaemic medication in a population of patients with Type 2 diabetes: a retrospective cohort study.

              Thomas MacDonald, A.-B. Morris, P. T. Donnan (2002)
              To evaluate the patterns and predictors of adherence in all patients with Type 2 diabetes in the community receiving treatment with a single oral hypoglycaemic drug. In particular, to test the hypothesis that one tablet per day is associated with better adherence than more than one. The study design was a retrospective cohort study set in the Tayside region of Scotland (population approx. 400 000). Participants were residents of Tayside from 1 January 1993 until 31 December 1995 with at least 12 months of prescriptions of oral hypoglycaemic drugs (OHDs). The main outcome measures were adherence indices for sulphonylureas and metformin separately, adjusting for prescribing while hospitalized. Of the total 2920 subjects identified, adequate adherence (> or = 90%) was found in 31% of those prescribed sulphonylureas alone (n = 1329, median adherence = 300 days per year), and in 34% of those prescribed metformin alone (n = 528, median = 302 days per year). There were significant linear trends of poorer adherence with each increase in the daily number of tablets taken (p = 0.001) and increase in co-medication (p = 0.0001) for sulphonylureas alone after adjustment for other factors. In the community only one in three with Type 2 diabetes had adequate adherence to OHDs. One tablet per day administration was associated with greater adherence than multiple tablets. Poor adherence is a major obstacle to the benefit of complex drug regimens in the treatment of Type 2 diabetes.
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                Author and article information

                Journal
                Title: Diabetes Care
                Abbreviated Title: Diabetes Care
                Publisher: American Diabetes Association
                ISSN (Print): 0149-5992
                ISSN (Electronic): 1935-5548
                Publication date Created: April 26 2004
                Publication date Created: May 01 2004
                Publication date (Electronic): April 26 2004
                Publication date (Print): May 01 2004
                Volume: 27
                Issue: 5
                Pages: 1218-1224
                Article
                DOI: 10.2337/diacare.27.5.1218
                PubMed ID: 15111553
                SO-VID: ce7aeb74-e614-447b-ae97-5daae97f9043
                Copyright © © 2004
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