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Patrick Adly-Gendi,1,2 Elizabeth Koltz,1 Dena Arumugam1,3 1Hackensack Meridian School of Medicine, Nutley, NJ, USA; 2Palisades Medical Center, North Bergen, NJ, USA; 3Department of Surgery, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ, USACorrespondence: Patrick Adly-Gendi, Email patrick.adlygendi@hmhn.orgAbstract: Patient nonadherence to healthcare follow-up appointments is an ever-growing problem leading to worsened health outcomes and increased morbidity and mortality. Social factors, namely lack of transportation, are commonly implicated as a cause for the lack of following up. Medical students make up a significant portion of the healthcare team but are mostly viewed as passive learners on clinical rotations and do not receive many active opportunities to engage in direct clinical care. Here, an elective for 4th year medical students where students operate a clinic and work alongside residents to hold virtual surgical follow-up appointments to assess for complications and monitor healing is proposed. This could potentially bypass many of the social barriers that patients face while giving students a more direct role in patient care and a focused educational experience while reducing stress on the physical healthcare clinic system.Keywords: student, clinic, follow-up

Abstract This study aimed to assess the prevalence and reasons for nonadherence to cotrimoxazole prophylaxis therapy. A cross-sectional study was conducted among people living with HIV attending Ayder Comprehensive Specialized Hospital. Data were collected through interviews and reviews of medical records. Binary logistic regression was employed to analyze factors associated with CPT nonadherence. Approximately two-thirds (65.5%) of the participants were non-adherent to co-trimoxazole prophylaxis therapy. The main reasons for non-adherence were side effects, pill fatigue and forgetfulness. Strategies to improve adherence to co-trimoxazole prophylaxis therapy should focus on the combined patient, clinical and medication related issues of people living with HIV.

BackgroundDespite the fact that 1-year graft and recipient survival rates are above 90% in most transplant centers, improving long-term graft survival remains an important challenge. Immunosuppressant nonadherence has been recognized as one of the important risk factors for long-term graft failure. Understanding the modifiable correlates and risk factors for medication non-adherence is essential to develop interventions to improve adherence and thus long-term transplantation outcomes.MethodsThis study conducted a questionnaire survey on 431 renal transplant recipients who were followed up in the outpatient clinic between January 2022 and January 2023, and 409 valid questionnaires were returned. The BAASIS questionnaire was used to assess the prevalence of nonadherence to immunosuppressive therapy (implementation phase) in Chinese renal transplant recipients and to explore the multilevel correlates of immunosuppressive nonadherence. The BAASIS questionnaire was used to categorize renal transplant recipients into adherent (n = 239) and non-adherent (n = 170) groups, and a prospective cohort study with a 1-year follow-up was conducted to explore the impact of immunosuppressant non-adherence on clinical outcomes.ResultsThe prevalence of nonadherence to immunosuppressant therapy in renal transplant recipients in this study was as high as 41.6%. The number of years post-transplant (OR: 1.240, 95% CI: 1.136–1.353, p < 0.001) and the frequency of twice-daily dosing (OR: 5.145, 95% CI: 2.690–9.840, p < 0.001) were positively correlated with immunosuppressive nonadherence. There was a significant difference in TAC IPV (Intra-individual Variability) between the adherent and nonadherent groups (22.7 ± 8.7 vs. 25.4 ± 11.6, p = 0.010). Renal function remained stable during the follow-up period in the recipients in the adherence group and tended to decrease in the recipients in the non-adherence group (F = 4.932, p = 0.001). The rates of graft loss (7.1% vs. 1.7%, p = 0.006) and rejection (12.4% vs. 4.2%, p = 0.002) were higher in the nonadherent group than in the adherent group.ConclusionLonger time post-transplant and higher frequency of immunosuppressive dosing were positively associated with nonadherence to immunosuppressives medication. Immunosuppressant nonadherence was associated with adverse graft outcomes.

Abstract Purpose Standard oral cancer chemotherapy (OCT) or targeted therapy (OTT) has expanded the treatment methods for hepatocellular carcinoma (HCC). However, its principal nonadherence causes a reduction in efficacy. We aimed to evaluate the status of nonadherence and influencing factors among outpatient patients with HCC. Patients and methods In 2021, a prospective observational study was conducted on 384 patients with either old or newly diagnosed HCC treated with OTT. Nonadherence to OCT was determined using the eight-item Morisky Medication Adherence Scale, with a score

ABSTRACT Background The coexistence of diabetes and hypertension is prevalent due to shared risk factors. Pharmacological treatment has been reported to be effective in managing both conditions. However, treatment effectiveness depends on the extent to which a patient adheres to their treatment. Poor adherence to long‐term treatment for chronic diseases is a growing global problem of significant magnitude. Several interventions have been developed to help improve medication adherence in patients with coexisting diabetes and hypertension. This review aimed to determine the characteristics of these interventions and their impact on medication adherence. Methods A systematic review of the literature was conducted using the PRISMA guidelines and registered in the PROSPERO International Registry of Systematic Reviews. Studies were searched in the databases CINAHL, Embase and Medline to identify relevant articles published during 2012–2023. The search concepts included ‘medication adherence’, ‘hypertension’, ‘diabetes’ and ‘intervention’. Studies were included if they were in English and evaluated the impact of an intervention aimed at promoting adherence to medications for both diabetes and hypertension. Results Seven studies met the inclusion criteria, with five demonstrating a statistically significant improvement in medication adherence. Of the five studies that improved medication adherence, four were multifaceted and one was a single‐component intervention. All successful interventions addressed at least two factors influencing non‐adherence. Patient education was the foundation of most of the successful interventions, supported by other strategies, such as follow‐ups and reminders. Conclusion Multifaceted interventions that also included patient education had a positive impact on medication adherence in patients with coexisting diabetes and hypertension. Improving adherence in patients with coexisting diabetes and hypertension requires a multipronged approach that considers the range of factors impacting medication‐taking. Patient or Public Contribution This systematic review provides comprehensive insights into the benefits of patient‐centred approaches in intervention development and strengthening. Such patient involvement ensures that medication adherence interventions are more relevant, acceptable and effective, ultimately leading to better health outcomes and more meaningful patient engagement in healthcare research.

Purpose: Adherence to glaucoma medical therapy is a key factor in achieving target intraocular pressure to prevent glaucoma progression. To determine factors affecting medication adherence in glaucoma patients in an urban population belonging to poor socioeconomic status. Methods: A cross-sectional study was conducted on 200 patients attending glaucoma services in a tertiary referral hospital of North India. Adherence to medication was determined subjectively by questionnaire and objectively by counting the number of used bottles at the end of a month or during refill, whichever was earlier. Patient-related parameters in adherence toward glaucoma medication were studied based on demography, knowledge, attitudes, and practices (KAP). The statistical techniques of bivariate and multivariate logistic regression were adopted to test the objective. Results: The population was statistically homogeneous based on gender and income in both groups. A large proportion of patients had bilateral disease (87%) and were on two or more medications (62.5%). Adherence to glaucoma medical therapy was seen in 68% of patients, with knowledge about glaucoma present in 58% of patients. Deterrents to drug adherence were identified as forgetfulness (71%), unavailability of drugs (19%) or funds to purchase the same (26%), polypharmacy (21%), and side effects (5%). Dependence on an escort by 44% and dependence on hospital supply of medications by 60% emerged as the contextual factors requiring scrutiny while prescribing lifelong glaucoma medications. Disease misconceptions (53%) were prevalent and drug instillation practices were unsatisfactory (57%). Conclusion: The study offers insight into patients' perspectives regarding the lifetime use of antiglaucoma medications and focuses on key issues linked to drug nonadherence.

Key Clinical Message Posterior reversible encephalopathy syndrome may occur secondary to abrupt cessation of antihypertensive therapy. A gradual reduction in blood pressure and counseling regarding medication adherence are crucial to prevent adverse consequences. Abstract Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical radiographic syndrome with headache, hypertensive encephalopathy, seizures, and visual disturbances as common modes of presentation. PRES can be attributed to several risk factors. We reported the case of a 66‐year‐old Asian female with PRES following nonadherence to antihypertensive treatment. Initially, her computed tomography scan of the head was normal. After 48 h, we again ordered a head CT scan, which showed lesions suggestive of hypertensive encephalopathy. We immediately reduced 20%–25% of mean arterial pressure, followed by a gradual blood pressure lowering to avoid adverse consequences. We did a follow‐up CT scan of the head at 2 weeks, showing the resolution of early lesions. Hence, we made a diagnosis of PRES. In these patients, it is crucial to ensure medication adherence to avoid complications.

Introduction To establish a prediction model to predict immunosuppressive medication (IM) nonadherence in kidney transplant recipients (KTRs) based on a combined theory framework.Methods This polycentric, cross-sectional study included 1191 KTRs from October 2020 to February 2021 in China, with 1011 KTRs enrolled in the derivation set and 180 in the external validation set. Variables selected based on the combined theory of planned behavior (TPB)/health belief model (HBM) theory were analyzed by the least absolute shrinkage and selection operator (LASSO). Internal 10 cross-validation was conducted to determine the optimal lambda value. The receiver operating characteristic (ROC) curve, specificity, and sensitivity were used to evaluate the prediction model, and further assessment was run by external validation.Results IM nonadherence rate was 38.48% in the derivation set and 37.22% in the validation set. The LASSO model was developed with eight predictors for IM nonadherence: age, preoperative drinking history, education, marital status, perceived barriers, social support, perceived behavioral control, and perceived susceptibility. The model demonstrated acceptable discrimination with the area under the ROC curve of 0.797 (95% CI: 0.745–0.850) in the internal validation set and 0.757 (95% CI: 0.684–0.829) in the external validation set. The specificity and sensitivity in the internal validation and external validation set were 0.741, 0.748, 0.673, and 0.716, respectively.Conclusions The LASSO model was developed to guide identifying high-risk nonadherent patients and timely and effective interventions to improve their prognosis and survival.

Dropout from psychological or pharmacological treatment for anxiety and depressive disorders is common. It is especially problematic in adolescents and young adults because of the adverse consequences for their development. Reasons for treatment dropout can be divided into therapy-process related factors, attitudinal aspects, and practical issues. Adjusting treatment to patient preferences and shared decision making, improving the therapeutic alliance, and interventions such as (family) psychoeducation, motivational interviewing, and help with practical issues are promising strategies to optimize engagement and adherence.

Abstract Background Adherence to antiretroviral treatment (ART) remains the cornerstone of optimal HIV outcomes, including viral suppression (VS), immune recovery, and decreased transmission risk. For many people with HIV (PWH), particularly those with early-acquired HIV, structural, behavioral, and cognitive barriers to adherence and competing priorities related to life events may be difficult to overcome, resulting in nonadherence. Long-acting injectable antiretroviral therapies (LAI-ART) may be a useful strategy to overcome some of these barriers. However, to date, the approved LAI-ART strategies (e.g., cabotegravir and rilpivirine (CAB/RPV)) have targeted those who have already attained viral suppression, precluding their use in the 40% of adolescents and young adults (AYA) that VS has eluded. Case presentation Ms. X is a 30-year-old woman with perinatally-acquired HIV and barriers to adherence. Despite many interventions, she remained persistently viremic, with resultant immune suppression and multiple comorbid opportunistic conditions, and viral load (VL) > 10,000,000 copies/ml. Given her longstanding history of poor adherence to an oral regimen, a switch to monthly intramuscular (IM) injections and biweekly infusions of ibalizumab were initiated leading to decreased viral load to 8,110 copies/ml within two weeks. Ms. H is a 33-year-old woman with cognitive limitations due to childhood lead poisoning. Her viral load trajectory took a downward turn, precipitated by various life events, remaining elevated despite intensive case management. Initiation of LAI-ART (CAB/RPV) in this patient led to an undetectable VL ( 5 years. She received a 1-month oral lead-in (OLI) of cabotegravir/rilpivirine, followed by the injectable loading dose. She has since adhered to all her monthly dosing appointments, sustained VS, and transitioned to a bi-monthly injection schedule. Conclusion These three individuals with HIV (perinatally and non-perinatally acquired) with longstanding nonadherence and persistent viremia were successfully initiated on LAI-ART through the process of care coordination and the collective efforts of the care team, highlighting the barriers, challenges, and the multidisciplinary coordination needed to assure successful implementation of this strategy for the most vulnerable of patients.

Pedro Pallangyo,1,2 Makrina Komba,1 Zabella S Mkojera,1 Peter R Kisenge,1,2 Smita Bhalia,2 Henry Mayala,3 Engerasiya Kifai,3 Mwinyipembe K Richard,2 Khuzeima Khanbhai,1,2 Salma Wibonela,4 Jalack Millinga,4 Robert Yeyeye,4 Nelson F Njau,3 Thadei K Odemary,3 Mohamed Janabi2 1Unit of Research and Training, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania; 2Directorate of Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania; 3Directorate of Clinical Support Services, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania; 4Directorate of Nursing, Jakaya Kikwete Cardiac Institute, Dar es Salaam, TanzaniaCorrespondence: Pedro Pallangyo, Unit of Research and Training, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania, Email pedro.pallangyo@gmail.comBackground: Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania.Methods: The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence.Results: A total of 849 outpatients taking antihypertensive drugs for ≥ 1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3– 0.7, p< 0.01), last BP measurement > 1 week (OR 0.6, 95% CI 0.4– 0.8, p< 0.01), last clinic attendance > 1 month (OR 0.4, 95% CI 0.3– 0.6, p< 0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3– 0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4– 0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4– 0.8, p< 0.001) to be independent associated factors for poor adherence.Conclusion: A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.Keywords: medication adherence, nonadherence, drug adherence, hypertension, blood pressure control

Objective: This study aimed to determine the predictive power of patient-related factors, socio-economic factors, condition-related factors, treatment-related factors, and health care system-related factors for nonadherence to planned coronary angiography (CAG). Material and Methods: A retrospective analysis was conducted on electronic medical records (EMR) of 665 patients appointed for elective CAG at Naradhiwas Rajanagarindra Heart Center from January 2018 to December 2019. One hundred and thirty-three patients with nonadherence to planned CAG were assigned to the study group; the control group consisted of 532 patients with adherence to planned CAG. Results: The retrospective data analysis revealed that divorced or widowed status (OR=3.07; 95% CI 1.54, 6.12), cerebrovascular disease comorbidity (OR=4.37; 95% CI 1.74, 10.96), prescribed diuretics (OR=2.24; 95% CI 1.26, 3.97), CAG wait time three months or longer (OR=3.34; 95% CI 1.46, 7.64) and history of parental cardiovascular disease or death from heart disease (OR=0.12; 95% CI 0.01, 0.95) were co-predictors of nonadherence to planned CAG. Socioeconomic- related factors had no predictive power for planned CAG nonadherence. Conclusion: The findings of this study may contribute to the improvement of nursing service by screening groups at high risk of nonadherence and developing appropriate interventions aimed at increasing adherence to planned CAG as well the rate of positive health outcomes.

Janet Prameela Dsouza,1 Jyothi Chakrabarty,1 Padmakumar Ramachandran,2 Vasudeva Guddattu,3 Baby S Nayak,4 Anice George4 1Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India; 2Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India; 4Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, IndiaCorrespondence: Jyothi Chakrabarty, Professor and Head, Department of Medical-Surgical Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9880078542, Email jyothi.r@manipal.edu Padmakumar Ramachandran, Professor and Unit Head, Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9900921428, Email padma.kumar@manipal.eduBackground: Cardiovascular diseases are one of the major causes of mortality at the global level. They account for approximately 17.9 million deaths per year. Warfarin and acenocoumarol are the commonly used oral anticoagulants to treat and prevent thromboembolic disorders in patients with cardiovascular diseases. In India, approximately 2– 2.5 million patients with rheumatic heart disease are receiving oral anticoagulation therapy. Additionally, this therapy is provided for stroke prevention in the case of atrial fibrillation and the treatment of valvular heart disease, stroke, and deep vein thrombosis. As the therapeutic range of these drugs is narrow and is affected by many factors, their use is challenging. This study aims to evaluate the effectiveness of a nursing intervention module in terms of adherence to therapy, knowledge, quality of life, and complications among patients receiving oral anticoagulation therapy. Furthermore, this study will address factors that affect adherence and the risk for bleeding by using a randomized controlled trial design.Methods: This single-blind, single-center, randomized controlled trial will focus on adherence to oral anticoagulation therapy. A total of 320 patients who are on oral anticoagulation therapy will be randomized into blocks and allocated to either the intervention or standard care group. The intervention will comprise the use of a nursing intervention module that includes a booklet, log sheet, and decision aid on oral anticoagulation therapy adherence. Outcome measures, that is, knowledge regarding oral anticoagulation therapy, adherence, complications, and quality of life, will be assessed at the baseline and during follow-ups.Discussion: Patient safety can be best achieved through patients’ adherence to medication dose and monitoring of blood test values. Thromboembolic and bleeding complications are likely to occur when either the patient does not adhere to the treatment or the therapeutic range of the international normalized ratio is not maintained. This study will assess the nonadherence behavior and the effectiveness of a nursing intervention module toward adherence behavior.Trial Registration: This research project is registered under the Clinical Trial Registry of India (CTRI/2019/06/019610).Keywords: nonadherence, warfarin, efficacy, awareness, well-being

Abstract Background Two-stage least square [2SLS] and two-stage residual inclusion [2SRI] are popularly used instrumental variable (IV) methods to address medication nonadherence in pragmatic trials with point treatment settings. These methods require assumptions, e.g., exclusion restriction, although they are known to handle unmeasured confounding. The newer IV-method, nonparametric causal bound [NPCB], showed promise in reducing uncertainty compared to usual IV-methods. The inverse probability-weighted per-protocol [IP-weighted PP] method is useful in the same setting but requires different assumptions, e.g., no unmeasured confounding. Although all of these methods are aimed to address the same nonadherence problem, comprehensive simulations to compare performances of them are absent in the literature. Methods We performed extensive simulations to compare the performances of the above methods in addressing nonadherence when: (1) exclusion restriction satisfied and no unmeasured confounding, (2) exclusion restriction is met but unmeasured confounding present, and (3) exclusion restriction is violated. Our simulations varied parameters such as, levels of adherence rates, unmeasured confounding, and exclusion restriction violations. Risk differences were estimated, and we compared performances in terms of bias, standard error (SE), mean squared error (MSE), and 95% confidence interval coverage probability. Results For setting (1), 2SLS and 2SRI have small bias and nominal coverage. IP-weighted PP outperforms these IV-methods in terms of smaller MSE but produces high MSE when nonadherence is very high. For setting (2), IP-weighted-PP generally performs poorly compared to 2SLS and 2SRI in term of bias, and both-stages adjusted IV-methods improve precision than naive IV-methods. For setting (3), IV-methods perform worst in all scenarios, and IP-weighted-PP produces unbiased estimates and small MSE when confounders are adjusted. NPCB produces larger uncertainty bound width in almost all scenarios. We also analyze a two-arm trial to estimate vitamin-A supplementation effect on childhood mortality after addressing nonadherence. Conclusions Understanding finite sample characteristics of these methods will guide future researchers in determining suitable analysis strategies. Since assumptions are different and often untestable for IP-weighted PP and IV methods, we suggest analyzing data using both IP-weighted PP and IV approaches in search of a robust conclusion.

Introduction: Hypertension is a chronic disease that needs to be treated adequately. Nonadherence to antihypertensive medicines can lead to coronary heart disease and stroke complications. The present study assessed the prevalence and predictors of medication nonadherence among hypertensive patients. Methodology: A cross-sectional study was conducted among hypertensive patients visiting the outdoor patient department of a tertiary care hospital in North India. Trained investigators interviewed the study participants after obtaining their written informed consent. A validated tool, namely the Brief Medication Questionnaire, was used to assess the medication nonadherence. Statistical analyses were performed using the Epi Info version for Windows. Results: A total of 400 hypertensive patients participated in the study. The mean age of study participants was 62.8 years (standard deviation = 11.0). Around half (55.0%) of the hypertensive patients suffered from comorbid disease conditions. The prevalence of antihypertensive medication nonadherence was 23.8%. The logistic regression model revealed that patients having a shorter duration of hypertension (odds ratio = 2.2 [1.2–3.9]) and those living in a joint family (odds ratio = 1.7 [1.1–2.8]) had higher medication nonadherence, as compared to their counterparts. Conclusion: Nearly one-fifth of the study participants were nonadherent to their antihypertension medication. There is a need for designing and implementing effective strategies by health-care providers for increasing antihypertensive medication adherence.

Background: Nonadherence to antihypertensive medications remains a persistent problem that leads to preventable morbidity and mortality. Behavioral economic strategies represent a novel way to improve antihypertensive medication adherence, but remain largely untested especially in vulnerable populations which stand to benefit the most. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) was designed in this context, to test whether a digitally-enabled incentive lottery improves antihypertensive adherence and reduces systolic blood pressure (SBP). Design: BETTER-BP is a pragmatic randomized trial conducted within 3 safety-net clinics in New York City: Bellevue Hospital Center, Gouveneur Hospital Center, and NYU Family Health Centers – Park Slope. The trial will randomize 435 patients with poorly controlled hypertension and poor adherence (

Background Measurement of serum concentrations of drugs is a novelty found useful in detecting poor drug adherence in patients taking ≥2 antihypertensive agents. Regarding patients with treatment‐resistant hypertension, we previously based our assessment on directly observed therapy. The present study aimed to investigate whether serum drug measurements in patients with resistant hypertension offer additional information regarding drug adherence, beyond that of initial assessment with directly observed therapy. Methods and Results Nineteen patients assumed to have true treatment‐resistant hypertension and adherence to antihypertensive drugs based on directly observed therapy were investigated repeatedly through 7 years. Serum concentrations of antihypertensive drugs were measured by ultra‐high‐performance liquid chromatography–tandem mass spectrometry from blood samples taken at baseline, 6‐month, 3‐year, and 7‐year visits. Cytochrome P450 polymorphisms, self‐reported adherence and beliefs about medicine were performed as supplement investigations. Seven patients (37%) were redefined as nonadherent based on their serum concentrations during follow‐up. All patients reported high adherence to medications. Nonadherent patients expressed lower necessity and higher concerns regarding intake of antihypertensive medication (P=0.003). Cytochrome P450 polymorphisms affecting metabolism of antihypertensive drugs were found in 16 patients (84%), 21% were poor metabolizers, and none were ultra‐rapid metabolizers. Six of 7 patients redefined as nonadherent had cytochrome P450 polymorphisms, however, not explaining the low serum drug concentrations measured in these patients. Conclusions Our data suggest that repeated measurements of serum concentrations of antihypertensive drugs revealed nonadherence in one‐third of patients previously evaluated as adherent and treatment resistant by directly observed therapy, thereby improving the accuracy of adherence evaluation. Registration URL: https://www.clinicaltrials.gov; unique identifier: NCT01673516.

Background: Long-acting injectable antipsychotics (LAI – APs) improve adherence to antipsychotics and decrease functional decline in schizophrenia. Yet they are prescribed late, in patients with established functional decline. Although LAI – APs are widely prescribed in South Africa, there is a paucity of research regarding the prescription profile for LAI – APs. Aim: This study aimed to describe prescribing practices for LAI – APs at psychiatric clinics. Setting: Community psychiatric clinics in South Africa. Methods: A retrospective review of the psychiatric files of all patients on LAI – APs attending the clinics over the study period was conducted. Sociodemographic, clinical and pharmacological information regarding the LAI – AP prescribed was extracted from the files. Results: A total of 206 charts were examined. The mean age of the study population was 46 (SD ± 12) years. Significantly more patients were male (n = 154; 74.8%), single (n = 184, 89.3%) and unemployed (n = 115; 55.8%) (p 0.001). Approximately half had a comorbid substance use disorder (47.6%). The most common indication for the prescription of a LAI – AP was non-adherence (66%). Only 9.7% of the patients were prescribed a LAI – AP alone. No significant socio-demographic or clinical characteristic was associated with this prescribing habit. A LAI – AP was prescribed in combination with an oral antipsychotic, mood stabiliser or antidepressant in 53.9%, 44.7% and 7.8% of patients, respectively. Conclusion: Long-acting injectable antipsychotics were prescribed mainly following noncompliance with oral antipsychotics and may represent a missed opportunity to prevent functional decline. The high prevalence of LAI – AP polypharmacy has been highlighted.

Aim and Objectives: In this study, the level of adherence to medications and factors influencing nonadherence to oral antidiabetic medications among patients with type 2 diabetes mellitus was assessed. This study also ascertained the clinical pharmacist role in improving medication adherence. Materials and Methods: This is a descriptive cross-sectional study based on prospective analysis of data collected from 150 cases in the general medicine department at the secondary care Government Headquarters Hospital, Tiruppur, Tamil Nadu state, India. The study was carried out over 6 months duration, from March 2019 to August 2019. Results: In the study, of 150 patients 60% were adherent, while 40% showed low adherence. Apparently, the subjects aged below 50 years showed 100% adherence and age group of 80–89 showed the least adherence of 12.5%. Out of 83 (55%) males and 67 (45%) females enrolled in the study, 50 (60.24%) of the former and 40 (59.70%) of the latter were found to be adherent. The rate of nonadherence in married and unmarried population was found to be 40.71% and 30%, respectively. Patients who had graduated from college/university showed 100% adherence whereas, the illiterate patients showed the least adherence of 32%. Moreover, the subjects who had their onset in the age between 20–29 years were 100% adherent and the least adherence of 33% were shown by subjects with onset age between 70–79. Patients with monotherapy were more adherent (77.8%) to the therapy when compared to the patients who were on polytherapy (43.6%) and the patients with diabetic complications showed 40% of adherence and the patients without any complications showed 86.15% of adherence. Eventually, the patients who did not experience any side effects showed good adherence (79.2%) compared to the ones with side effects who showed poor adherence (20.8%) to the therapy. Finally, the adherence among the patients who never consumed alcohol was found to be 69.9% whereas, patients who consumed alcohol everyday was found to be only 33.3%. Conclusion: Majority of the patients were found to be adherent towards oral antidiabetic agents; thus, influence of clinical pharmacist in adherence was evident in this study. The major barriers for medication adherence found were being older age, having low level of education, late onset of disease, presence of side effects and complications, polytherapy, and consumption of alcohol.

Abstract Introduction The treatment of schizophrenia aims to reduce symptoms, improve quality of life and promote recovery from debilitating effects. Nonadherence to treatment is related to several factors and may lead to persistence of symptoms and relapse. Worldwide, the rate of nonadherence to treatment in individuals with schizophrenia is around 50%. Objectives To compare the clinical profile of nonadherent and adherent patients among individuals diagnosed with schizophrenia receiving treatment at psychosocial care centers in a city in southern Brazil. Method The clinical-epidemiological profile of patients with schizophrenia was retrospectively analyzed based on medical records entered into the system between January and December 2016, evaluating data at one-year follow-up. Results 112 patients were included. The disease was more prevalent in men; mean age was 40.5 years, being lower among men. Most of the sample had a low level of education, was unemployed/retired, did not have children and resided with relatives. The highest rate of diagnosis was among young adults. Psychotic symptoms were most frequently described, and the most commonly prescribed antipsychotic was haloperidol. The nonadherence rate was 15.2%; only one patient required admission to a psychiatric hospital. Among nonadherent patients, the mean time of attendance was 6 months; there were more nonadherent women than men. The most prevalent age range of nonadherence was 41-64 years. Psychosocial and clinical data were similar across the whole sample. Conclusion A nonadherence rate of 15.2% was found among individuals receiving treatment for schizophrenia, suggesting that psychosocial care centers were effective in treating and monitoring these patients.

Abstract Background Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of mortality globally. Patient’s adherence to treatment is a cornerstone factor in controlling hypertension and its complications. This study assesses hypertension patients’ adherence to treatment and its associated factors. Methods This cross-sectional study conducted in Riyadh, Saudi Arabia. The study targeted outpatients aged ≥18 years who were diagnosed with hypertension. Participants were recruited using a systemic sampling technique. The two main measurements were assessing adherence rate of antihypertensive medications using Morisky scale and identifying predictors of poor medication adherence among hypertensive patients including socio-economic and demographic data, health status, clinic visits, medication side effects, medications availability, and knowledge. Descriptive and logistic regression analyses were performed to assess factors associated with poor adherence. Results A total of 306 hypertensive outpatients participated in this study. 42.2% of participants were adherent to antihypertensive medications. Almost half of participants (49%) who reported having no comorbidities were adherent to antihypertensive medications compared to participants with one or more than one comorbidities 41, 39% respectively. The presence of comorbid conditions and being on multiple medications were significantly associated with medication adherence (P-values, respectively,

Marianne Vie Ingersgaard,1 Tue Helms Andersen,2 Ole Norgaard,2 Dan Grabowski,1 Kasper Olesen1 1Health Promotion, Steno Diabetes Center Copenhagen, Gentofte, Denmark; 2Education Department, Steno Diabetes Center Copenhagen, Gentofte, DenmarkCorrespondence: Marianne Vie IngersgaardHealth Promotion, Steno Diabetes Center Copenhagen, Niels Steensens Vej 6, Gentofte 2820, DenmarkTel +45 91 17 48 35Email marianne.vie.ingersgaard.joergensen@regionh.dkPurpose: Lipid-lowering medications are often prescribed to decrease the risk of micro- and macro-cardiovascular complications related to dyslipidaemia. Despite widespread prescription of lipid-lowering drugs, including statins, adherence to therapy is a challenge worldwide. This systematic review of reviews aimed to conduct a critical appraisal and synthesis of review findings and to provide an overview of the factors that were found to affect adherence to lipid-lowering drugs, focusing on statins, in the reviews.Patients and Methods: A systematic review methodology was used. MEDLINE, Embase, and Epistemonikos databases were searched for relevant publications. AMSTAR 2 criteria were used to assess the quality of the selected publications.Results: From a total of 763 screened publications, 9 met all inclusion criteria and were included in this synthesis. Several factors were identified as being associated with adherence to lipid-lowering agents. Among them, high socio-economic and educational position, and middle age had a positive effect on adherence to lipid-lowering agents. Contrary, female sex, older and younger age, non-white race, low socio-economic position, high co-payments, being a new statin user, comorbidities, side effects, regimen complexity, type and intensity of statin dose, smoking, alcohol consumption, imperceptible benefits, and medical distrust contributed to non-adherence. The overall quality of the included reviews was considered critically low to moderate.Conclusion: This review of reviews has evaluated the impact of factors on adherence statins. Further research related to modifiable predictors for non-adherence is warranted.Keywords: nonadherence, adherence, statins, dyslipidaemia, lipid-lowering drugs, review

Abstract Objective Management of heart failure is complex and multifaceted but adherence to medications remains the cornerstone of preventing avoidable readmissions, premature deaths, and unnecessary healthcare expenses. Despite of evidence-based efficacy on anti-failure drugs, poor adherence is pervasive and remains a significant barrier to improving clinical outcomes in heart failure population. Results We enrolled 459 patients with diagnosis of heart failure admitted at a tertiary cardiovascular hospital in Dar es Salaam, Tanzania. The mean age was 46.4 years, there was a female predominance (56.5%), 67.5% resided in urban areas and 74.2% had primary education. Of the 419 participants eligible for assessment of medication adherence, 313 (74.7%) had poor adherence and 106 (25.3%) had good adherence. Possession of a health insurance was found to be the strongest associated factor for adherence (adjusted OR 8.7, 95% CI 4.7–16.0, p

Background Diabetes mellitus is a growing global health challenge and affects patients of all ages. Treatment aims to keep blood glucose levels close to normal and to prevent or delay complications. However, adherence to antidiabetic medicines is often unsatisfactory. Purpose Here, we established and internally validated a medication nonadherence risk nomogram for use in Chinese type 2 diabetes mellitus (T2DM) patients. Methods This cross-sectional study was carried out from July–December 2020 on randomly selected T2DM patients visiting a diabetes clinic and included 753 participants. Adherence was analyzed based on an eight-item Morisky Medication Adherence Scale (MMAS-8). Other data, including patient demographics, treatment, complications, and comorbidities, were also collected on questionnaires. Optimization of feature selection to develop the medication nonadherence risk model was achieved using the least absolute shrinkage and selection operator regression model (LASSO). A prediction model comprising features selected from LASSO model was designed by applying multivariable logistic regression analysis. The decision curve analysis, calibration plot, and C-index were utilized to assess the performance of the model in terms of discrimination, calibration, and clinical usefulness. Bootstrapping validation was applied for internal validation. Results The prediction nomogram comprised several factors including sex, marital status, education level, employment, distance, self-monitoringofbloodglucose, disease duration, and dosing frequency of daily hypoglycemics (pills, insulin, or glucagon-like peptide-1). The model exhibited good calibration and good discrimination (C-index = 0.79, 95% CI [0.75–0.83]). In the validation samples, a high C-index (0.75) was achieved. Results of the decision curve analysis revealed that the nonadherence nomogram could be applied in clinical practice in cases where the intervention is decided at a nonadherence possibility threshold of 12%. Conclusion The number of patients who adhere to anti-diabetes therapy was small. Being single male, having no formal education, employed, far from hospital, long disease duration, and taking antidiabetics twice or thrice daily, had significant negative correlation with medication adherence. Thus, strategies for improving adherence are urgently needed.

Objective: Uncontrolled chronic diseases such as hypertension and diabetes mellitus can lead to severe complications. Poor adherence to medication is one of the important reasons, leading to complications for chronically diseased patients. We aimed to assess the trend toward medication adherence and the reasons for medication nonadherence in chronic disease patients in Tabuk city in Saudi Arabia. Methods: A cross-sectional study was conducted at a tertiary care hospital in Tabuk, Saudi Arabia. Participants were selected and interviewed for information regarding their medication adherence. A medication adherence rating scale questionnaire was used to measure the level of adherence in study participants. The data were analyzed by the statistical package for the social sciences (SPSS) database 24. Findings: Overall, 208 participants were involved in this study. Among these, 134 (64.4%) were female, and 74 (35.6%) were male. This study showed that 159 (76.44%) participants were adherent to their medications and nearly one-quarter of patients were nonadherent to their medications. No statistically significant differences were found between male and female patients toward their medication adherence. The primary intentional and nonintentional reason for nonadherence was side effects and forgetfulness, respectively. Conclusion: Tailoring the therapy according to the individual need of the patients will maximize the patient's adherence toward medications.

Drug development is a tedious and expensive procedure and it takes roughly 10 to 15 years to take a potential treatment from bench to bedside and costs the pharmaceutical companies as much as USD ~2 billion for the process. Delay in investigator-initiated studies can cause financial loss to grant providers (either public or private) and investigator's reputation may also be at stake. Participant recruitment and retention are two major bottlenecks in conducting clinical trials and contribute vastly to the delays. They are essential for both scientific validity of the clinical study and economic reasons. Thus, issues in recruitment and retention should be addressed and minimized. A proper recruitment and retention plan incorporating adequate communication between all stakeholders will eventually avoid the delays in drug development and make treatments available to the consumer at an earlier date and at a more affordable price. Awareness of challenges and reviewing strategies that can optimise recruitment and retention will facilitate drug development. The article gives a first-person perspective on challenges and proposed solutions from an experienced clinical study centre in a tertiary care hospital.

Abstract Background Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany. Methods In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521). Results The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status. Conclusions Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity. Trial registration Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Talea Cornelius,1 Corrine I Voils,2,3 Redeana C Umland,1 Ian M Kronish1 1Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; 2William S Middleton Veterans Memorial Hospital, Madison, WI 53705, USA; 3Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI 53792, USACorrespondence: Talea CorneliusCenter for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, 622 West 168th Street PH9-319, New York, NY 10032, USATel +1212-304-5215Email tmc2184@cumc.columbia.eduBackground: Self-report measures are important tools for assessing adherence to medication. Many of these scales, however, combine the extent of and reasons for nonadherence in one instrument, and have limited reliability and validity. The present study was the first to assess the convergent validity of the self-reported Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) scale with electronically measured adherence to a single cardiovascular medication.Methods: English- and Spanish-speaking patients evaluated for acute coronary syndrome (N=165; n=68 and n= 97, respectively) were recruited from an urban academic emergency department. Post-hospital discharge, participants were mailed a medication bottle with an electronic cap (eCAP) that recorded bottle openings. At 1 month, participants completed the 3-item DOSE-Nonadherence scale, which assessed the extent to which patients missed, skipped, or did not take the eCAP-monitored medication over the past 7 days. Correlations, sensitivity, and specificity were calculated using eCAP-monitored correct dosing adherence over the same 7-day time period as the reference standard.Results: The most commonly assessed medication was aspirin (70.91%). Correlations between self-reported and electronically monitored adherence were low-to-moderate: English-speaking participants (n=68), r=0.24, p=0.046; Spanish-speaking participants (n=97), r=0.18, p=0.071. Sensitivity was low (0.47 English, 0.28 Spanish) and specificity was moderate (0.77 English, 0.88 Spanish).Conclusions: The DOSE-Nonadherence scale was associated with electronically monitored adherence to a single daily cardiovascular medication in English-speaking participants, but had weak diagnostic properties when using electronic adherence as the reference standard.Keywords: medication adherence, self-report, nonadherence, validity, electronic monitoring

Introduction. Given the prevalence and burden of arterial hypertension, it is necessary to obtain an optimal control of blood pressure in order to improve the prognosis of these patients. Adherence to antihypertensive therapy is poor, leading to non-optimal disease control. The objective of the study was to investigate the adherence to therapy in hypertensive patients and to assess the impact of health education and self‐action plan in improving the compliance to the therapy in primary care settings. Material and methods. A prospective study was conducted in 750 patients diagnosed with primary hypertension for 3 years. After inclusion in the study, patients were monitored for 24 weeks to evaluate treatment non-compliance. In patients without adherence to antihypertensive therapy, we used various health education strategies to improve compliance. Results. A total of 750 patients with essential hypertension who started therapy over duration of 3 years were included in the study. At the end of 24 weeks, it was observed that only 324 patients (43.2%) had regular compliance and 426 patients (56.8%) were noncompliant to antihypertensive treatment. The factors that were associated with poor compliance were: a low level of education, burdensome treatment, dislike of drugs, remote pharmacies, concerns about side effects, anger about the condition or its treatment, forgetfulness or complacency, as well as the patients’ poor attitude to health. After employing various strategies for improving the compliance in these patients, the compliance increased in 263 patients (61.7%) among the earlier defaulted patients, while the remaining 163 patients (38.3%) were found to be noncompliant even after various educational techniques. Conclusions. Failure to treat hypertension is a reality, and none of the strategies for improving compliance are likely to be as effective as a good doctor-patient relationship. Optimal self-management, which allows to optimize control of arterial hypertension by adjusting drugs, can be carried out by self-regulation using a written plan of action or by regular medical examination.

Abstract Background Poor adherence is a major issue and is associated with increased morbidity, mortality, and immense costs for the healthcare system. Due to demographic changes, the burden of neurological diseases is increasing with a crucial exacerbation of the problem of nonadherence. However, comprehensive data on geriatric patients with neurological disorders do not exist to date. In this cross-sectional observational study we aim to identify disease-specific adherence-modulating factors in neurogeriatric patients. Methods Patients 60 years or older with neurological disorders will receive an assessment of adherence (Stendal Adherence with Medication Score) and a comprehensive geriatric assessment during their stay in the Department of Neurology or Geriatrics at the Jena University Hospital (baseline data). In addition disease specific data will be derived from medical records. After one and twelve months a telephone interview will be conducted to evaluate if and why changes of medication occurred (follow up data). Discussion This study aims to explore disease-specific patterns of nonadherence in elderly patients with neurological disorders and characteristics of information transfer between a specialized center, practicing neurologists, general practitioners, and the patients and their caregivers. This comprehensive data may help to develop and apply complex and disease-specific interventions to enhance adherence. Trial registration German Clinical Trials Register DRKS00016774. Registered 19.02.2019.

Background: The use of oral antineoplastic agents has increased in cancer medicine. However, the convenience of oral medication carries the risk of nonadherence and dosing errors, which could jeopardize therapeutic benefits and patient safety. This is a quality improvement project to investigate reasons for nonadherence and medication errors in patients receiving oral investigational treatment at the Phase 1 Department at MD Anderson Cancer Center, Houston, Texas. Early-phase clinical trials have an enormous impact on drug development and patient safety, not much has been done to evaluate adherence in patients receiving investigational oral antineoplastic agents. Materials and Methods: We examined our clinic dynamic including the initial encounter, follow-up phone calls, medication administration, and patient adherence the following visit. Then we explored and classified the main possible reasons for nonadherence and medication error across the workflow. Results: When examining potential deficiencies in the clinic flow, which are actionable and carry high impact, we found the initial encounter had a significant room for improvement and errors happened when instructions provided were unclear, not correct, or contradicted with the prescription or the label. Furthermore, the follow-up calling was also an important step to monitor and improve compliance. However, it was not a consistent practice and lacked a standardized format. Lastly and although the multistep reconciliation process for oral medication is important to monitor compliance, it was complex, had multiple manual aspects, and added substantial burden on the research staff. Conclusion: In this project, our goal was to shed light on the possible causes of oral medication errors and nonadherence in clinical trials. We proposed feasible measures including educational, training, and adherence monitoring tools. We will continue to monitor and evaluate our data to see any positive or negative impact from our interventions.

Background: Despite a wealth of studies seeking to identify factors associated with nonadherence few consistent predictors have been determined, and several gaps still exist in the literature. Method: We assessed 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder according to ICD-10 criteria. Assessments were performed during hospitalization and at six-months follow-up. Evaluation included sociodemographic, clinical, psychopathologic and treatment-related variables. Prevalence of nonadherence, associated variables, reasons for nonadherence and possible subtypes were explored. Adherence was defined as the concurrence of adherence to antipsychotic treatment and adherence to outpatient follow-up, during the six-month period. Results: Nonadherence was detected in 58.2% of patients. An identifiable profile was found in nonadherent patients. After multivariate logistic regression analysis, low socio-economic level (OR = 3.68; 95% CI = 1.42–9.53), current cannabis use or abuse (OR = 2.79; 95% CI = 1.07–7.28), nonadherence as a reason for relapse and admission (OR = 5.46; 95% CI = 2.00–14.90), and greater overall severity of symptoms at six months follow-up (OR = 2.00; 95% CI = 1.02–3.95) remained independently associated with nonadherence. Believing that medication is unnecessary was the most reported reason for nonadherence. For nonadherent patients (N = 64), two distinguishable subtypes were found: intentional nonadherence (N = 32; 50%), and unintentional nonadherence (N = 32; 50%). Conclusions: A large percentage of patients with schizophrenia or schizoaffective disorder did not adhere to their treatment in the post-discharge follow-up period. The profile identified may enable better prevention of this problem. Specific reasons for nonadherence should also be explored to provide individualized strategies.

Introduction: Antihypertensive medication nonadherence is a prevalent issue but is very difficult to accurately assess. To clarify this problem among hypertensive patients attending a cardiovascular disease outpatient clinic, we utilized high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS) to assess antihypertensive medication adherence and identify trends by sex and drug class. Methods: Serum was extracted from blood samples obtained from patients with either drug-controlled or drug resistant hypertension (RHTN) and analyzed via HPLC-MS for antihypertensive drugs which were categorized by drug class as beta blockers, aldosterone antagonists, diuretics, ACE inhibitor/ARBs, or calcium channel blockers. Clinic blood pressure (BP), sex, and prescription regimens were extracted from medical records at or near the time of blood collection. “Adherence” or “nonadherence” was determined by comparison of the patient's prescribed drug regimen and the presence/absence of prescribed drug(s) in their serum. Results: Among 76 patients (47 women; mean age 63; 53% white), nonadherence was confirmed in 29%. RHTN was more frequently identified in women than men (55% vs 38%) and nonadherence was higher in women than men (34% vs 21%). BP in those who were adherent to prescribed antihypertensive drugs was significantly lower than in those who were nonadherent (129/75 vs 145/83 mmHg, p = 0.0015). Overall, ACE inhibitors/ARBs were associated with the least nonadherence. Among women, nonadherence was highest for aldosterone antagonists, whereas among men, nonadherence was highest for diuretics. Conclusion: We observed nonadherence was more frequent among older women in a cohort of HTN and RHTN patients with cardiovascular disease based on HPLC-MS confirmed drug levels.

Objectives: Most studies of long-acting injectable antipsychotic (LAI) drugs have been focused on the efficacy of second-generation antipsychotic (SGA) LAIs through observation of the various outcomes of shifting from first-generation antipsychotic (FGA) LAIs to SGA LAIs. Rare studies have assessed the effectiveness of shifting from SGA LAIs to FGA LAIs. In this study, we intended to investigate the effectiveness of shifting from risperidone LAI to FGA LAIs in patients with schizophrenia. Methods: We included patients with schizophrenia and with the ownership of catastrophic illness card in the study. All the study patients had received risperidone LAI at least two months with a minimal dose of 50 mg per month. The case group included the patients who had been shifting from risperidone LAI to FGA LAIs (fluphenazine, haloperidol, or flupentixol). The control group included the patients who were continuously maintaining on risperidone LAI. The primary outcome was the time to hospitalization. The secondary outcomes were the side effects requiring to receive the use of concomitant anticholinergics, propranolol, and benzodiazepines. Results: We had 15 patients in the case group and 98 patients in the control group. The primary outcomes showed no significant between-group difference in the time to hospitalization (hazard ratio = 3.676, 95% confidence interval = 0.833 - 16.222). The secondary outcomes also showed no significant differences between the case and control groups. Conclusion: This study showed no significant differences in the treatment effectiveness and side effects between FGA LAIs and risperidone LAI. The results are compatible with those from a previous LAI study from the National Institute of Mental Health of the United States. But the relatively small effect with inadequate statistical power is the major study limitation, which may produce no significant differences in side effects. We suggest that further large-sample study is needed to confirm the results of this study.

Introduction: Drug-related problem (DRP) is any undesirable event experienced by the patient, which is suspected to involve drug therapy and interferes with a desired patient outcome. Most of these DRPs are avoidable with little vigilant effort. DRP admissions need high attention as DRP-related admissions on an average accounted for 8.36%, of which 50% are avoidable. The aim of the study was to identify the risk factors associated with DRPs in tertiary care hospital. Materials and Methods: One year prospective observational study was conducted in the departments of general medicine, dermatology, pediatrics, and gastroenterology of a tertiary care teaching hospital. A total of 148 cases, where a correlation between past medication history and current complaints was established, were included in the study. Exclusion criteria of the study were no correlation between past medication history and current complaints, social habits causing hospitalization, and herbal medication use history. Results and Discussion: In this study, nonadherence (50.94%) and adverse drug reaction (ADR) (38.36%) were predominant among the identified DRPs. Children and geriatrics showed the higher incidence of nonadherence to the prescribed therapy. ADRs were the DRP with the higher incidence among adults followed by nonadherence to the prescribed therapy. Lack of knowledge about the disease, its complications, and possible adverse reactions with self-medication was identified to be the high incidence risk factor. Higher incidence of DRPs was observed in patients having a past medical history of cardiovascular system and central nervous system diseases, which require long-term management. Conclusion: In this study, nonadherence to prescribed therapy was found to be the DRP causing hospitalization at a higher incidence. The most commonly involved risk factors were lack of knowledge about the disease, need of adherence to the therapy as prescribed, and outcomes of the treatment provided.

Background: Detailed knowledge about nonadherence to medication could improve medical care in elderly patients. We aimed to explore patterns and reasons for nonadherence in people with Parkinson's disease (PD) aged 60 years and older.Methods: Detailed clinical data and adherence (German Stendal Adherence with Medication Score) were assessed in 230 patients with PD (without dementia). Descriptive statistics were used to study reasons for nonadherence in detail, and general linear models were used to study associations between clusters of nonadherence and clinical parameters.Results: Overall, 14.2% (n = 32) of the patients were fully adherent, 66.8% (n = 151) were moderately nonadherent, and 19.0% (n = 43) showed clinically meaningful nonadherence. In the multivariable analysis, nonadherence was associated with a lower education level, higher motor impairment in activities of daily living, higher number of medications per day, and motor complications of PD. Three clusters of nonadherence were observed: 59 (30.4%) patients reported intentional nonadherence by medication modification; in 72 (37.1%) patients, nonadherence was associated with forgetting to take medication; and 63 (32.5%) patients had poor knowledge about the prescribed medication. A lower education level was mainly associated with modification of medication and poorer knowledge about prescribed medication, but not with forgetting to take medication. Patients with motor complications, which frequently occur in those with advanced disease stages, tend to be intentionally nonadherent by modifying their prescribed medication. Increased motor problems and a higher total number of drugs per day were associated with less knowledge about the names, reasons, and dosages of their prescribed medication.Conclusions: Elderly patients with PD report many reasons for intentional and non-intentional nonadherence. Understanding the impact of clinical parameters on different patterns of nonadherence may facilitate tailoring of interventions and counseling to improve outcomes.

Background: An increasing number of valid and well-designed trials have demonstrated a positive correlation between visit-to-visit variability (VVV) in systolic blood pressure (SBP) and increased risk of stroke and coronary heart disease among hypertensive patients. Methods: A cross-sectional study was conducted that involved 74 patients who visited the outpatient clinic at the Tabanan III Primary Health Care Service during April to May 2017. Blood pressure was retrospectively obtained from medical records. VVV was classified as low or high on the basis of the standard deviation of SBP. Antihypertensive medication adherence was expressed as the percentage of days covered, and sodium intake was measured with 24-hour food recall. Bivariate analysis was performed, followed by multivariate analysis for significant variables. Results: Among the participants, 67.6% were female, with a mean (standard deviation [SD]) age of 62.70 (10.00) years. Blood pressure was measured 4.82±0.78 times during the period, and the mean (SD) SBP was 139.65 (10.57) mm Hg. Nonadherence and sodium intake were significantly higher in the high-VVV group than in the low-VVV group (nonadherence 13.5% vs. 37.8%, P=0.033; sodium intake 1278.44±43.02 mg vs. 1495.85±45.26 mg, P=0.038). After adjustment for other covariates, the differences remained significant only for nonadherence (model I exp β=3.89 [95.0% confidence interval 1.23–12.34, P

Leslie R Martin,1 Cheyenne Feig,1 Chloe R Maksoudian,1 Kenrick Wysong,1 Kate Faasse2 1Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, USA; 2School of Psychology, University of New South Wales, Sydney, NSW, Australia Abstract: Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized – indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model. Keywords: nonadherence, medication nonadherence, adherence barriers, improving adherence

BackgroundSexual dysfunctions are associated with multiple medical and psychiatric disorders, as well as pharmacotherapies used to treat these disorders. Although sexual dysfunctions negatively affect both quality of life and treatment adherence, patients infrequently volunteer these symptoms and clinicians do not pose directed questions to determine their presence or severity. This issue is especially important in psychiatric patients, for whom most common psychotropics may cause sexual dysfunctions (antidepressants, antipsychotics, anxiolytics and mood-stabilising agents). There is limited literature addressing benzodiazepines, and alprazolam in particular.AimsTo report dose-dependent alprazolam anorgasmia.MethodCase analysis with PubMed literature review.ResultsA 30-year-old male psychiatric patient presented with new-onset anorgasmia in the context of asymptomatic generalised anxiety disorder, social anxiety, panic disorder with agoraphobia, obsessive–compulsive disorder, major depression in remission, and attention-deficit hyperactivity disorder treated with escitalopram 10 mg q.a.m., gabapentin 1000 mg total daily dose, lisdexamfetamine dimesylate 70 mg q.a.m., nortriptyline 60 mg q.h.s. and alprazolam extended-release 2.5 mg total daily dose. All psychotropic doses had been constant for >6 months excluding alprazolam, which was titrated from 1 mg to 2.5 mg total daily dose. The patient denied any sexual dysfunction with alprazolam at 1 mg q.d. and 1 mg b.i.d. Within 1 week of increasing alprazolam to 2.5 mg total daily dose, the patient reported anorgasmia. Anorgasmia was alprazolam dose-dependent, as anorgasmia resolved with reduced weekend dosing (1 mg b.i.d. Saturday/1.5 mg total daily dose Sunday).ConclusionsSexual dysfunction is an important adverse effect negatively influencing therapeutic outcome. This case reports alprazolam-induced dose-dependent anorgasmia. Clinicians/patients should be aware of this adverse effect. Routine sexual histories are indicated.Declaration of interestNone.

Abstract In Japan, because the most common site of drowning among patients with epilepsy is the bathtub, showering is generally recommended as an alternative to bathing. We herein report a case involving a female patient with epilepsy who drowned while showering. She had been diagnosed with epilepsy approximately 25 years previously, and her condition had progressed to refractory epilepsy. Carbamazepine, levetiracetam, lamotrigine, clobazam, and perampanel were prescribed daily. One day while showering, the patient was found lying with her face immersed in water that had accumulated on the floor of the bathtub. A forensic autopsy revealed water in the stomach, trachea, and proximal regions of both lung bronchi as well as white and red foam on the pharynx and larynx. A total of 1.9 μg/mL of lamotrigine, 0.14 μg/mL of carbamazepine, and 0.069 μg/mL of perampanel were detected in the patient’s blood. The patient’s cause of death was determined to be drowning due to an epileptic seizure. Although the patient was prescribed five types of antiepileptic medication, only three were detected in her blood. The current case demonstrates that drowning can occur while showering, suggesting that it is unsafe for patients with medication nonadherence. To prevent unintentional deaths in the bathroom, we recommend that patients with epilepsy maintain high adherence to all prescriptions and are supervised by a family member, even when showering. The current case is the first autopsy report of a patient with epilepsy who drowned while showering.

Johanna Boretzki,1,2 Eva Wolf,3 Carmen Wiese,4 Sebastian Noe,4 Annamaria Balogh,3 Anja Meurer,5 Ivanka Krznaric,6 Alexander Zink,7 Christian Lersch,1 Christoph D Spinner1,2 1Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich, 2German Center for Infection Research, Partner Site Munich, 3MUC Research, Munich, 4MVZ Karlsplatz, HIV Clinical Care Center, Munich, 5Center for Infectiology and Internal Medicine, Munich, 6Center for Infectiology Prenzlauer Berg, Berlin, 7Department of Dermatology and Allergology, University Hospital Klinikum rechts der Isar, Munich, Germany Background: Reasons for and frequency of nonadherence to antiretroviral therapy (ART) may have changed due to pharmacological improvements. In addition, the importance of known non-pharmacologic reasons for nonadherence is unclear.Methods: We performed a cross-sectional, noninterventional, multicenter study to identify current reasons for nonadherence. Patients were categorized by physicians into the following adherence groups: good, unstable, or poor adherence. Co-variables of interest included age, sex, time since HIV diagnosis, ART duration, current ART regimen, HIV transmission route, comorbidity, HIV-1 RNA viral load (VL), and CD4 cell count. Patients self-reported the number of missed doses and provided their specific reasons for nonadherent behavior. Statistical analyses were performed using Fisher’s extended exact test, Kruskal–Wallis test, and logistic regression models.Results: Our study assessed 215 participants with good (n=162), unstable (n=36), and poor adherence (n=17). Compared to patients with good adherence, patients with unstable and poor adherence reported more often to have missed at least one dose during the last week (good 11% vs unstable 47% vs poor 63%, p

Abstract Background When a randomised trial is subject to deviations from randomised treatment, analysis according to intention-to-treat does not estimate two important quantities: relative treatment efficacy and effectiveness in a setting different from that in the trial. Even in trials of a predominantly pragmatic nature, there may be numerous reasons to consider the extent, and impact on analysis, of such deviations from protocol. Simple methods such as per-protocol or as-treated analyses, which exclude or censor patients on the basis of their adherence, usually introduce selection and confounding biases. However, there exist appropriate causal estimation methods which seek to overcome these inherent biases, but these methods remain relatively unfamiliar and are rarely implemented in trials. Methods This paper demonstrates when it may be of interest to look beyond intention-to-treat analysis for answers to alternative causal research questions through illustrative case studies. We seek to guide trialists on how to handle treatment changes in the design, conduct and planning the analysis of a trial; these changes may be planned or unplanned, and may or may not be permitted in the protocol. We highlight issues that must be considered at the trial planning stage relating to: the definition of nonadherence and the causal research question of interest, trial design, data collection, monitoring, statistical analysis and sample size. Results and conclusions During trial planning, trialists should define their causal research questions of interest, anticipate the likely extent of treatment changes and use these to inform trial design, including the extent of data collection and data monitoring. A series of concise recommendations is presented to guide trialists when considering undertaking causal analyses.

Olga Z Rosen,1 Rachel Fridman,2 Bradley T Rosen,3,4 Rita Shane,1 Joshua M Pevnick4,5 1Department of Pharmacy Services, Cedars-Sinai Medical Center, 2Resources & Outcomes Management, Cedars-Sinai Health System, 3Department of Medicine, ISP Hospitalist Service, Cedars-Sinai Medical Center, 4University of California, Los Angeles School of Medicine, 5Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA Purpose: The aim of this study was to test whether patient medication adherence, a modifiable risk factor obtainable at hospital admission, predicts readmission within 30 days. Patients and methods: We used a retrospective cohort study design to test whether patient medication adherence to all chronic medications, as determined by the 4-item Morisky Medication Adherence Scale (MMAS-4) administered by a pharmacist at the time of hospital admission, predicts 30-day readmissions. We compared readmission rates among 385 inpatients who had their adherence assessed from February 1, 2013, to January 31, 2014. Multiple logistic regression was used to examine the benefit of adding medication adherence to previously published variables that have been shown to predict 30-day readmissions. Results: Patients with low and intermediate adherence (combined) had readmission rates of 20.0% compared to a readmission rate of 9.3% for patients with high adherence (P=0.005). By adding MMAS-4 data to previously published variables that have been shown to predict 30-day readmissions, we found that patients with low and intermediate medication adherence had an adjusted 2.54-fold higher odds of readmission compared to those in patients with high adherence (95% confidence interval [CI]: 1.32–4.90, P=0.005). The model’s predictive power, as measured by the c-statistic, improved from 0.65 to 0.70 after adding adherence. Conclusion: Because medication adherence assessed at hospital admission was independently associated with 30-day readmission risk, it offers potential for targeting interventions to improve adherence. Keywords: rehospitalization, predictive model, transition of care, care transitions, nonadherence, MMAS-4

Allison J Gardner,1 Alice L Gray,2 Staci Self,3 Jeffrey S Wagener4 1Med-IQ, LLC, Baltimore, MD, 2Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, 3Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, AL, 4Department of Pediatrics, University of Colorado Medical School, Aurora, CO, USA Background: Treatment regimens for patients with cystic fibrosis (CF) are complex, time consuming, and burdensome, and adherence to CF treatment is suboptimal. CF care teams play a critical role in supporting patients’ chronic self-management skills, but there is no uniform method for assessing patients’ adherence to treatment or standard interventions to help patients improve when necessary.Methods: Between May 2015 and March 2016, care team members from 10 CF centers in the USA participated in a practice assessment and quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, personalized continuing medical education (CME)-certified Webconferences with expert study faculty, targeted reinforcement of key practice points, and follow-up online survey and telephone interviews to evaluate the benefits and limitations of the intervention.Results: Responses to the baseline practice assessment survey were received from 50 multidisciplinary care team members representing 10 CF centers. Primary barriers to adherence-related aspects of care in their clinics were motivating patients and caregivers to improve adherence and obtaining accurate information about adherence from patients. At the conclusion of the initiative, participants reported improvements in communication within their care team, implementation of new approaches to asking about adherence, and a renewed commitment to asking patients and caregivers about adherence at each clinic visit.Conclusion: Structured QI interventions that bring multidisciplinary care teams together to reflect on clinic processes and elicit objective insights from outside faculty have the potential to improve practice patterns related to the assessment and improvement of patient adherence in CF. Keywords: nonadherence, treatment burden, communication, team-based care

To assess the prevalence of nonadherence to antihypertensive medications among adults attending Primary Healthcare Clinics (PHCs) in Al-Hasa Region. This cross-sectional study included participants from a variety of clinics in the region and each of them had been interviewed to complete the questionnaire. The participants were selected by random sampling from eight different PHCs. Data were collected by a structured questionnaire that was adopted from two different scales to determine the association between adherence and socioeconomic and health status characteristics. We included 372 participants with a mean (±standard deviation) age of 53 ± 12.4 years and most of them were male (62%, n = 231). The overall mean adherence based on our adapted scale was 5.3 ± 2.3. Among participants taking more than six medications, the percentage of nonadherent participants was significantly higher than the percentage of adherent participants (85% vs. 15%, p = 0.016). Participants with single comorbidity were more likely to be adherent than patients with multiple comorbidities (odds ratio = 1.52, p = 0.049). In conclusion, we found a high prevalence of nonadherence to antihypertensive medications in the Al-Hasa community and the main association factor was found to be the presence of comorbidity. Such high rate sends alarming messages for the need of potential interventions to improve adherence outcome.

Nonadherence is a growing issue in the treatment of Parkinson’s disease (PD). Many factors are known to influence nonadherence, but little is known about the influence of quality of life (QoL). Detailed clinical data were obtained from 164 patients with PD using the Parkinson’s Disease Questionnaire-39 (PDQ-39) and the German Stendal Adherence with Medication Score (SAMS). Descriptive statistics were used to identify reasons for nonadherence, and multivariable linear models were used to study associations between QoL and clinical parameters as well as nonadherence. Multivariate analysis of variance (MANOVA) and multivariate analysis of covariance (MANCOVA) were used to study the effect of the SAMS on PDQ domains and other medical covariates. The results showed that 10.4% (n = 17) of patients were fully adherent, 66.4% (n = 109) were moderately nonadherent, and 23.2% (n = 38) were nonadherent. Nonadherence was associated with male gender, lower Montreal Cognitive Assessment (MoCA) score, higher non-motor symptoms questionnaire (NMS-Quest) score, greater number of medications per day (an indicator of comorbidity), and higher Beck Depression Inventory (BDI) score. QoL was correlated with male gender, lower MoCA score, higher NMS-Quest score, more comorbidities, and higher BDI score, but was not correlated with nonadherence.

Marie-Luise Lemberg,1 Till Berk,2 Kija Shah-Hosseini,1 Elena-Manja Kasche,1,3 Ralph Mösges1 1Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany; 2Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland; 3Center for Dermatology, Specific Allergology and Environmental Medicine, Hamburg, Germany Background: Many placebo-controlled studies have demonstrated that allergen immunotherapy (AIT) is an effective therapy for treating allergies. Both commonly used routes, subcutaneous (SCIT) and sublingual immunotherapy (SLIT), require high patient adherence to be successful. In the literature, numbers describing adherence vary widely; this investigation compares these two routes of therapy directly.Methods: All data were retrieved from the patient data management system of a center for dermatology, specific allergology, and environmental medicine in Germany. All 330 patients (aged 13–89 years) included in this study had commenced AIT between 2003 and 2011, thus allowing a full 3-year AIT cycle to be considered for each investigated patient.Results: In this specific center, SCIT was prescribed to 62.7% and SLIT to 37.3% of all included patients. The total dropout rate of the whole patient cohort was 34.8%. Overall, SLIT patients showed a higher dropout rate (39.0%) than did SCIT patients (32.4%); however, the difference between these groups was not significant. Also, no significant difference between the overall dropout rates for men and for women was observed. A Kaplan–Meier curve of the patient collective showed a remarkably high dropout rate for the first year of therapy.Conclusion: The analysis presented in this single-center study shows that most patients who discontinue AIT do so during the first year of therapy. Patients seem likely to finish the 3-year therapy cycle if they manage to adhere to treatment throughout the first year. Strategies for preventing nonadherence in AIT, therefore, need to be developed and standardized in future investigations. Keywords: adherence, dropout, nonadherence, SCIT, SLIT, allergic rhinitis, allergy, allergen immunotherapy

Background: In this study, we investigated several socioeconomic, clinical, and psychological factors associated with medication adherence in a sample of Iranian patients with inflammatory bowel disease (IBD). Materials and Methods: This study was conducted on 110 IBD patients from 2013 to 2014 in Isfahan, Iran. The patients were invited to complete three anonymous questionnaires including the Hospital and Anxiety Depression Scale (HADS) for assessing the levels of anxiety and depression; IBD Questionnaire-Short Form (IBDQ-9) for the quality of life; and a visual analog scale assessing the medication adherence. A self-assessment adherence rate of more than 80% was considered “appropriate adherence.” Results: Overall, 99 patients completed the questionnaires. Among them, 77.8% reportedly adhered to their medications. There was no statistical difference between adherence and nonadherence rates in terms of gender, educational status, disease type, disease severity, and family history of IBD. Conversely, single patients (100% vs. 74.1%; P = 0.03), nonsmokers (79.4% vs. 0.0%; P = 0.04), patients receiving immunosuppressive drugs (100% vs. 71.9%; P = 0.01), and corticosteroids (95.1% vs. 65.5%; P = 0.01) were more likely to be adhered than their counterparts. No differences emerged in terms of the mean HADS scores in either of the sexes. The mean IBDQ-9 score was significantly higher in adhered patients only in females (31.08 ± 11.6 vs. 24.7 ± 9.1; P = 0.04) but not in males. Conclusion: The adherence rate in our study is almost similar to developed countries. Single marital status, not smoking, receiving corticosteroids and immunosuppressive drugs, and higher IBDQ-9 score in females are associated with higher adherence rate.

Introduction: Adherence to antiretroviral therapy is a principal predictor for the success of human immunodeficiency virus (HIV) treatment. It remains as a challenge to acquired immunodeficiency syndrome (AIDS) treatment and care with the widespread of the associated risks. Therefore, study aims to assess nonadherence level and factors associated with nonadherence to ART among people living with HIV/AIDS (PLHA). Materials and Methods: A hospital-based, cross-sectional study was conducted at two tertiary care hospital of Lucknow. A total of 322 adult HIV-positive patients registered in the ART center were included. Systematic random sampling was used to recruit patients. Nonadherence was assessed on the basis of pill count method. Results: A total of 10.9% of patients were found to be nonadherent to ART. Principal causes cited were being busy with other work (40.0%), felt sick or ill (28.5%), not having money (14.2%), and being away from home (11.4). Multivariate logistic regression analysis revealed that nonadherence was significantly associated with nonbeneficial perceptions towards ART (odds ratio (OR) 18.5; 95% confidence interval (CI) 3.2-106.6; P = 0.001), being counseled for adherence for more than 3 months (OR 13.9; 95% CI 1.6-118.9; P = 0.01), presence of depression (OR 2.6; 95% CI 1.0-6.7; P = 0.04), and those who were not satisfied with healthcare facilities (OR 5.63; 95% CI 1.88-16.84; P = 0.00). Conclusion: Although adherence to ART varies between individuals and over time, the factors that affect nonadherence can be addressed with proper periodic counseling and motivation of patients and their family members. Adherence to highly active antiretroviral therapy (HAART) could delay the progression of this lethal disease and minimize the risk of developing drug resistance.