Search

The World Health Organization (WHO) considers medication safety as one of the main areas for improvement in patient safety. Treatment adherence, as a dynamic process that evolves through time or life circumstances, is of paramount importance, since it depends on a number of factors that health care professionals need to approach comprehensively during patient follow-up. In this article, we describe the tools available to general practitioners or specialist physicians, in collaboration with pharmacists and home care nurses, to optimize medication adherence in an ambulatory setting. An interprofessional approach between providers allows adequate support to patients by empowerment, treatment adjustments and optimization, based on shared common goals.La problématique de la sécurité des médicaments est l’une des thématiques prioritaires pour l’OMS en matière d’amélioration de la sécurité des patients. L’adhésion au traitement est un processus dynamique qui est au centre de cette problématique, en raison de nombreux éléments qui doivent être pris en compte par les professionnels de la santé durant le suivi d’un patient. Cet article décrit des outils qui s’offrent au médecin généraliste ou spécialiste, en collaboration avec le pharmacien et l’infirmier exerçant au domicile du patient, pour optimiser l’adhésion médicamenteuse. Une approche interprofessionnelle entre prestataires de soins permet un soutien adéquat aux patients via l’empowerment, les adaptations du traitement et l’optimisation, sur la base des objectifs communs partagés.

Non-adherence behaviors are very common in chronic hemodialysis patients, it is estimated that only one patient out of two complies with medical prescriptions, these behaviors are associated with a higher risk of morbidity and adverse events as well as increased expenses for health systems. The aim of our study was to assess adherence to long-term prescribed medications in chronic hemodialysis patients, using a mobile application named TestObs, as well as to determine the main factors influencing medication adherence.We conducted a prospective descriptive study, between January and June 2019. We developed a mobile application named TestObs, downloadable on playstore for android devices, which assesses with the Girerd questionnaire, the adherence to the main medications taken by chronic hemodialysis patients. We included adult patients, with a duration of dialysis of more than 6 months, all patients who downloaded TestObs, tested their adherence to their medication by answering the questionnaire. We created a web-based platform, where data was collected from the application and then analyzed and tabulated. Regarding the statistical analysis, the normal distribution of the variables was studied by the Kolmogorov-Smirnov test, the analysis of the qualitative variables used the Pearson's ChiWe collected 90 adult chronic hemodialysis patients, 51 of them (56%) were selected to enter the study. We found good compliance in 46.15% of patients, minor noncompliance in 32.87%, and noncompliance in 20.98%. In multivariate analysis, the factors influencing adherence were the presence of other comorbidities (diabetes and vision problems) and the number of pills per day.In this study, we report treatment adherence problems in 53.85% of patients, our results are close to the data reported in hemodialysis patients in the literature, different factors influence the quality of treatment adherence, in our study poly-medication and the presence of other comorbidities were the statistically significant determinants. The new technology assessment instruments were used in hemodialysis patients and were able to provide real-time monitoring of adherence behaviors.We believe that mobile health technologies hold promise for assessing and improving medication adherence in hemodialysis patients, so we suggest that TestObs represents an accessible and free of charge tool, based on a validated questionnaire, that can allow patients to benefit from new technologies for medical monitoring, and may eventually constitute an interventional program to improve medication adherence; however, this technological tool should not replace traditional therapeutic education; prior targeting of non-adherent patients and an optimal combination of several tools can help improve adherence in these patients.

The aims of this study were to assess medication adherence to immunosuppressive treatment in kidney transplanted patients, to identify predictive factors of medication non-adherence and to analyse its impact on the development of Donor Specific Antibodies (DSA) de novo, biomarkers of rejection in transplant recipients.A cross-sectional single-centre study was conducted to assess medication adherence to immunosuppressive treatment with the BAASIS (Basel Assessment of Adherence Scale for Immunosuppressives) self-report questionnaire. Univariate and multivariate analyses were performed to determine non-adherence predictive factors and its role in the development of DSA de novo.A total of 212 renal transplanted patients completed the BAASIS questionnaire: 36,3 % were non-adherent to their immunosuppressive treatment. Patient's age and taking azathioprine were independent predictors of non-adherence and "married or living together" family status was a protective factor in the multivariate analysis. Medication non-adherence was associated with DSA de novo development in the multivariate model and it multiplied their risk of development by 3.This study, which detected a large proportion of patients who did not adhere to immunosuppressive treatment, highlighted non-adherence predictors and showed the association between non-adherence and development of DSA de novo. In case of non-adherent behavior, it is crucial to set up a personalised support for patients with a multidisciplinary approach of therapeutic education, in which the clinical pharmacist has a role.

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

This work analyses the use of an adherence scale (EGOMAC) in a population of 334 subjects with a chronic psychiatric disorder, followed by a psychiatric center. The aim is to study the trait characteristics associated with adherence behaviors. These characteristics include personality traits. These personality traits have been studied from the broadest General Factor of Personality, then at the level of the five dimensions of the Five-Factor Model and, at the more specific level, traits of impulsivity measured by the UPPS-P scale. The patients answered two scales assessing adherence (EGOMAC and MARS), two scales assessing personality (BFI-Fr and HEXACO-60), two scales assessing impulsivity (UPPS-P and IS-12), and a shortened scale of social desirability (BIDR). The main results are the psychometric sound characteristics of the EGOMAC scale with a four factors solution: 1. Voluntary adherence to medical advice, 2. Involuntary forgetting of drugs, 3. Following of hygiene-dietetic advice, 4. Adherence to medical appointments. In a bifactorial model, a general adherence dimension appears with three first-level factors. These factorials scores correlated well with scores at the MARS. The general factor of the EGOMAC scale correlated significantly with plasmatic lithium dosage in a subgroup of patients taking oral lithium. The General Factor of Personality correlated significantly with adherence factorial scores, as the stability factor of the Big Two Model. The factorial score of Consciousness, obtained in factorial models with a social desirability factor and an acquiescence factor, correlated significantly with adherence factorial scores. We conclude that the markers of behavioral management abilities, as Consciousness or stability factors from the personality scale or the level of perseverance from the UPPS-P scale are the most strongly related to adherence assessed both by self-report questionnaire and by plasma level. This study allows to better understand why these patients have difficulty with adherence, they present chronic affective lability, even in euthymic phase. This tells us that psychoeducation should not be the only way to help the patient take his treatment better, but that helping the patient to increase his behavioral management capacities (psychotherapy, cognitive remediation) could increase his adherence., Ce travail porte sur l’utilisation d’une échelle d’observance : l’Echelle Générale d’Observance dans les Maladies Chroniques (EGOMAC). Cette échelle a été utilisé avec 334 patients suivis en psychiatrie. L’objectif était d’étudier l’observance et ses déterminants, ici les traits de personnalités. Ces traits de personnalités ont été analysés du plus général, le facteur général de personnalité, puis au niveau des cinq facteurs qui constituent le Five Factor Model, jusqu’à des traits spécifiques de la personnalité telle que l’impulsivité. Nous avons fait passer une série de questionnaires évaluant l’observance (MARS et EGOMAC), la personnalité (avec le BFI-Fr et HEXACO-60), l’impulsivité (avec les échelles UPPS-P et Impulsivity Scale 12) et la désirabilité sociale (BIDR). Les résultats principaux sont une confirmation de la validité de l’échelle EGOMAC avec une version en 4 facteurs principaux qui sont : 1. le suivi régulier et volontaire global des consignes médicales ; 2. l’oubli involontaire, 3. les règles hygiéno-diététiques et 4. le respect des rendez-vous. Dans un modèle bifactoriel, une dimension générale d’observance apparaît avec 3 facteurs secondaires. Ces scores factoriels corrèlent bien avec le score de l’échelle MARS. Le facteur général d’observance corrèle avec le taux de lithium plasmatique mesuré chez un sous-groupe de patients sous lithium. Nous montrons que la dimension générale de personnalité Stabilité, le caractère consciencieux du modèle FFM ou HEXACO et la bonne maîtrise de son comportement se manifestant par une faible impulsivité et de fortes capacités de persévérance sont associés très significativement à l’observance médicamenteuse, que celle-ci soit mesurée par des questionnaires ou par le dosage dans le sang du traitement. On comprend mieux pourquoi l’observance est aussi importante et perturbée dans le trouble bipolaire, puisque ce sont des patients qui présentent une forte instabilité comportementale chronique. La psychoéducation ne devrait donc pas être le seul moyen d’aider le patient à mieux prendre son traitement, mais aider le patient à augmenter ses capacités de gestions comportementales (psychothérapie, remédiation cognitive) pourrait également augmenter son observance.

For many people living with HIV (PLWH), treatment simplification is possible, while for others treatment forgiving missed doses is necessary, and sometimes with interventions to avoid medical care interruption (MCI).We sought to identify HIV-infected patients at risk for MCI in two hospital cohorts ; to study the forgiveness of dolutegravir (DTG)-based therapy compared to older antiretroviral (ARV) ; to determine the risk factors of virological failure (VF) under DTG in monotherapy (DTG-m) and to explore the heterogeneity of the risk as compared to a combined ARV therapy (cART), according to the identified risk factors.We estimated the incidence of MCI in 4,796 PLWH followed at Bichat University Hospital in Paris and in 989 PLWH followed at Caen University Hospital, between January 2010 and May 2016. MCI was defined as patients not seeking care in or outside the clinic for at least 18 months.Average adherence (Av-Adh) and treatment interruption (TI) to ARV were prospectively measured over 6 months using electronic drug monitoring in a multicentric prospective cohort of 399 PLWH.We performed an individual participant data meta-analysis of randomized clinical trials evaluating DTG-m. The study population were virologically controlled for at least 6 months, and followed for 48 weeks. Definition of VF was a confirmed viral load > 50 copies/ml before W48.The incidence rate of MCI in the Bichat cohort was 2.5 per 100 person-years (pa; 95% confidence interval [95% CI] = 2.3-2.7) and in the Caen cohort 3.0 per 100 pa (95% CI = 2.6-3.5). In the two cohorts, MCI was more likely in patients who accessed care >6 months after diagnosis, and who were not on ART. In the Bichat cohort, MCI was also more likely in patients who did not report a primary care physician and when the last CD4 count was ≤ 350 / mm3 during follow-up. In the Caen cohort, not having a mailing address reported and a hepatitis C coinfection were independent risk factors for MCI while being older than 45 years was a protective factor. Finally, being born in sub-Saharan Africa was a risk factor for MCI in Caen and a protective factor in Bichat vs. born in France.In our second study, 399 PLWH were analyzed with different ARV: DTG (n=102), raltegravir (n=90), boosted protease inhibitor (bPI, n=107), and non-nucleoside reverse transcriptase inhibitor (NNRTI, n=100). In the DTG group, the influence of adherence pattern measures on viral replication (R2) for HIV-RNA levels was marginal (+2%). Av-Adh, TI and Av-Adh x TI increased the R2 by 54% and 40% in the raltegravir and bPI treatment groups, respectively. TI increased the R2 by 36% in the NNRTI treatment group. Compared to the DTG group, the risk of VF was significantly increased for the raltegravir, NNRTI and IPb groups in PLWH with m-Adh ≤ 95%.In our third study, 416 PLWH were included, 101 from the Swiss EARLY-SIMPLIFIED trial, 95 from the Dutch DOMONO trial, 62 from the Spanish DOLAM trial and 158 from the French MONCAY trial. Sixteen failures occured, all in the experimental group DTG-m. Among 272 participants under DTG-m, VF were more likely in participants who presented a time before first ART ≥ 90 days, a nadir of CD4 T cells < 350, a detected plasma HIV RNA signal at baseline and a HIV DNA level at baseline ≥2.7/10⁶ PBMCs. The highest risk difference between DTG-m and cART group was found when HIV DNA level was ≥2.7 / 10⁶ PBMCs (32%). The VF risk difference could be explained by HIV DNA level (I2=80.2%).The socio-demographic context, the history of HIV infection, the previous and current immuno-virological status associated with the level of adherence of PLWH should guide the therapeutic choice and interventions to improve virological success. Thus, PLWH care, reinforced or simplified, must be adapted to individual characteristics., Nos objectifs étaient de déterminer l’incidence et les facteurs de risque (FDR) d’interruption de soins médicaux (ISM) dans deux cohortes de PVVIH ; d’étudier la pardonnance de la trithérapie à base de dolutégravir (DTG) par rapport aux régimes antirétroviraux (ARV) plus anciens ; de déterminer les FDR d’échec virologique (EV) sous DTG en monothérapie (DTG-m) et d’explorer l’hétérogénéité du risque comparé à une trithérapie classique, en fonction des FDR identifiés.Nous avons estimé l’incidence d’ISM chez 4 796 PVVIH suivies au centre hospitalier universitaire (CHU) Bichat à Paris et chez 989 PVVIH suivies au CHU de Caen, entre janvier 2010 et mai 2016. Les patients furent considérés en ISM s’ils ne recevaient aucuns soins médicaux pendant 18 mois ou plus. Nous avons constitué une cohorte prospective multicentrique des modèles d’adhésion aux ARV. L’adhésion moyenne (Adh-m) et la durée maximale d’interruption de traitement (ITmax) ont été mesurées prospectivement sur 6 mois à l’aide de piluliers électroniques. Nous avons réalisé une méta-analyse sur données individuelles des essais cliniques évaluant le DTG-m. La population d’étude était constituée de PVVIH contrôlées sur le plan virologique depuis plus de 6 mois, et suivies pendant 48 semaines. L’EV était défini par deux charges virales > 50 copies/mL avant la semaine 48.Le premier travail retrouva un taux d’incidence d’ISM dans la cohorte de Bichat à 2,5 pour 100 personnes-années (p-a ; intervalle de confiance à 95% [IC95%]=2,3-2,7) et dans la cohorte de Caen à 3,0 pour 100 p-a (IC95%=2,6-3,5). Les FDR indépendamment associés à l’ISM similaires entre les cohortes de Bichat et Caen étaient un délai avant la prise en charge du VIH > 6 mois, et l’absence de traitement ARV. Dans la cohorte de Bichat, ne pas avoir de médecin traitant et avoir un taux de CD4 ≤ 350/mm3 au cours du suivi étaient associés à un plus grand risque d’ISM. Dans la cohorte de Caen, les FDR étaient : ne pas avoir renseigné d’adresse postale et être co-infecté avec le virus de l’hépatite C. Être âgé de plus de 45 ans était associé à un moindre risque d’ISM vs. ≤ 30 ans. Enfin, être né en Afrique sub-saharienne était un FDR d’ISM à Caen vs. né en France, et un facteur protecteur à Bichat.Le deuxième travail regroupa 399 PVVIH avec différents ARV en 3e agent : DTG (n=102), raltégravir (n=90), inhibiteur de protéase boosté (IPb ; n=107) et inhibiteur non nucléosidique de la transcriptase inverse (INNTI ; n=100). Dans le groupe DTG, l’effet des mesures d’adhésion sur la réplication virale (R2) était marginal (+2 %). Adh-m, ITmax et Adh-m x ITmax augmentaient le R2 de 54 % et 40 % dans les groupes raltégravir et IPb, respectivement. ITmax augmentait le R2 de 36 % dans le groupe INNTI. Comparé au groupe DTG, le risque d’EV était significativement augmenté pour les groupes raltégravir, INNTI et IPb chez les PVVIH avec une Adh-m ≤ 95 %.Le troisième travail inclut 416 PVVIH, 101 de l’essai suisse EARLY-SIMPLIFIED, 95 de l’essai hollandais DOMONO, 62 de l’essai espagnol DOLAM et 158 de l’essai français MONCAY. Seize échecs furent retrouvés, tous dans le groupe sous DTG-m. Parmi 272 PVVIH traitées par DTG-m, les facteurs indépendants d’EV étaient le nadir de CD4 < 350 cellules/mmᶟ; un délai entre le diagnostic de l’infection VIH et le premier ARV > 90 jours ; un taux d’ADN proviral à l’inclusion ≥ 2,7log/106 PBMCs et la présence d’un signal PCR positif d’ARN VIH plasmatique. Nous avons trouvé que l’EV était expliqué en majeure partie par le niveau d’ADN proviral à l’inclusion (I2=80,2%) avec une différence de risque de 32% entre le groupe DTG-m et le groupe contrôle, parmi les PVVIH avec un taux d’ADN proviral ≥ 2,7 log/106 PBMCs.Le contexte socio-démographique, l’histoire de l’infection VIH, le statut immuno-virologique antérieur et actuel associés à la connaissance du niveau d’observance des PVVIH permettraient de guider le choix thérapeutique et les efforts nécessaires pour améliorer le succès virologique.

Objectives Consolidation of supported housing policies is a primary source of solutions aimed at addressing the problem of homelessness. Transitional housing (TH) offers a sequential housing trajectory from emergency shelters, to TH, to permanent housing with or without supports. Post-TH follow-up may improve residential stability and community integration. Yet little information is available on successful conditions and effectiveness related to post-TH follow-up for improving residential stability and community integration among homeless people, and especially homeless women. This pilot case study aimed to identify the needs of women who were previous TH residents before acquiring permanent housing with supports, the implementation process for post-TH follow-up activities and intensity of services offered and conditions for success of the follow-up, as well as the outcomes of post-TH follow-up in meeting the needs of these homeless women. Methods Two non-profit organizations for housing reintegration in the Montreal area were selected for study. Mixed methods based on a case study approach were used, triangulating the data collected from homeless women, case managers, and housing managers. Two interviews were conducted at 6-month intervals with homeless women (n=10), whose needs and outcomes related to post-TH follow-up were identified through a questionnaire with open and closed questions. To document implementation of the post-TH follow-up, case managers (n=2) recorded information on follow-up activities and intensity of services offered for the 6-month period using contact sheets. Factors facilitating and hindering post-TH follow-up were also identified in a group interview with case managers (n=2) and resource managers (n=4). Results Users identified health maintenance, support for daily activities and improved socialization as their primary needs. Most women were satisfied with activities offered and the frequency of follow-up, ease of access to case managers, and the overall capacity of follow-up to meet their needs. The intensity of follow-up, user/case manager therapeutic alliance, and user motivation to recover were identified as facilitating factors that influenced effectiveness of post-TH follow-up. Factors that hindered effectiveness included: the limited duration of TH before post-TH follow-up particularly among users with major trauma; refractory behavior; reluctance to take medications and consumption of psychoactive substances; problems in accessing health services, particularly specialized mental health services; and for case managers: time constraints, logistical difficulties related to follow-up, and lack of affordable permanent housing adequate to user needs. After six months, 80% of users remained in their housing and no changes were identified in community integration. Conclusion Post-TH follow-up seems particularly adapted to promote residential stability among chronically homeless women with mental health or dependence issues, as the essential first step toward community integration. The study underlined the importance of offering multiple service modalities adapted to user needs and post-TH follow-up geared toward recovery. Better funding of post-TH follow-up, tighter collaboration with other public services, case manager training, and increase in affordable and adequate permanent housing would promote more effective deployment of post-TH follow-up.

Resume Introduction L’usage de cannabis, de cocaine ou d’heroine peut etre responsable de complications pulmonaires parmi lesquelles figure l’asthme. Objectifs L’objectif de cette revue systematique de la litterature est d’exposer les donnees concernant la relation entre la consommation de cannabis, de cocaine ou d’heroine et l’asthme. Resultats L’usage de cannabis, de cocaine ou d’heroine par voie inhalee peut etre responsable de symptomes respiratoires (toux, sifflements thoraciques), favoriser le developpement d’un asthme, augmenter le risque d’exacerbation aigue d’asthme (pouvant necessiter une intubation et une ventilation invasive), voire des deces par asthme et diminuer l’observance du traitement de l’asthme. Le cannabis a un effet bronchodilatateur rapide. En revanche, sa consommation chronique provoque une diminution de la conductance specifique des voies aeriennes. Les etudes portant sur la diminution ou le declin du volume expiratoire maximal par seconde (VEMS) sont discordantes. Conclusion Une consommation de cannabis, de cocaine ou d’heroine doit etre recherchee devant des symptomes respiratoires survenant chez des sujets jeunes et les praticiens doivent aider les usagers de ces substances illicites a arreter leur consommation.

Data on severe asthma in France are scarce. The aim of this study was to evaluate adherence to asthma treatments and its determinants in a population of severe asthmatics.From May 2016 to June 2017, the French Collège des Pneumologues des Hôpitaux Généraux organized a large-scale prospective, cross-sectional, multicenter study on this topic; 1502 patients with severe asthma were included.The average number of substantive treatments was 2.5±1.1. Assessed by self-questionnaire in 1289 patients, overall adherence was 64.8%, in good agreement with the findings of the pneumologist in charge (p0.0001). Control of asthma according to the GINA criteria was more successful in compliant patients (p0.01). In univariate analysis, the most compliant participants were frequent exacerbator patients (p=0.02), those with nasal polyposis (p=0.01) and those receiving an anticholinergic agent (p0.01), anti-IgE biotherapy (p0.0001) or oral corticosteroids (p0.01). The least compliant participants were younger (p0.0001), active smokers (p0.001), with shorter average disease duration (24.2±15.7 vs 29.1±18.7 years, p0.0001) and a lower number of substantive asthma treatments (2.2±1 vs 2.6±1, p0.0001). In multivariate analysis, age, length of disease and anti-IgE treatment were the only factors affecting therapeutic compliance.In this large-scale study of severe asthmatic patients, 64.8% were compliant according to the MMAS-4© self-administered questionnaire and appeared to be better monitored according to the criteria defined in our study. Overall, adherence was more satisfactory among older patients and those whose disease had been evolving over a long period of time or were receiving anti-IgE biotherapy.

Adherence to antiretroviral therapy is a major obstacle to achieving WHO target 3. In West Africa, however, there is a lack of evidence on the most feasible, acceptable and effective adherence reinforcement measures and users' perceptions of these measures. The purpose of this article is to analyze the perceptions of PLHIV (people living with HIV) on ART reinforcement measures in Burkina Faso.In Ouagadougou and Bobo-Dioulasso care centers, THILAO Research Project (ANRS 12269) enrolled PLHIV experiencing therapeutic failure on 2nd line antiretroviral treatment, and offered to them adherence reinforcement measures. We conducted a qualitative socio-anthropological study to explore their perceptions. Data were collected through repeated individual interviews with 37 PLHIV.The 31 participants who completed interviews were relatively satisfied with the measures to support adherence. Three measures (pill organizer, weekly phone calls by a member of the team, cellphone alarm reminders) were perceived as simple, effective, discreet, adapted to both illiterate and educated people. Three other measures (home visits, involvement of a member of the family and SMS) were not highly appreciated as they expose to the disclosure of HIV+ status and /or stigmatization. Two measures (support group, frequent visits to the care center) were less selected because considered tedious.PLHIV chosed and used the most appropriate adherence measures for their profile / context. The most feasible and acceptable measures identified could be offered to PLHIV at risk of non-compliance in West African ART programs.

Polypharmacy is common in patients with a chronic disease. It is appropriate when both the patient and the physician discuss the goal of each prescribed medication with a motivated patient capable of managing his/her medication. It can however be inappropriate when treatment becomes too complex for the frail patient. The risk is non-adherence to therapy, which often results in an intensification of treatment due to unmet therapeutic goals. Collaboration between physicians and pharmacists is therefore essential for the educational support of patients with polypharmacy. In this article, we review the studies examining the impact of a physician-pharmacist collaboration on the medication adherence of diabetic patients with renal impairment.La polypharmacie concerne de nombreux patients avec une maladie chronique. Elle est appropriée lorsque chaque médicament a été prescrit dans un but thérapeutique spécifique discuté avec un patient motivé et capable de gérer ses médicaments. Elle peut cependant être inappropriée lorsque le traitement devient trop complexe pour une personne fragile. Le risque est une non-adhésion au traitement, dont découle souvent une intensification de la thérapie en raison d’objectifs thérapeutiques non atteints. La collaboration médecin-pharmacien est donc primordiale pour l’accompagnement éducatif du patient complexe dans la gestion de ses médicaments. Dans cet article, nous revoyons les études examinant l’adhésion thérapeutique chez le patient diabétique avec une atteinte rénale lors d’une collaboration médecin-pharmacien.

Polypharmacy is common in patients with a chronic disease. It is appropriate when both the patient and the physician discuss the goal of each prescribed medication with a motivated patient capable of managing his/her medication. It can however be inappropriate when treatment becomes too complex for the frail patient. The risk is non-adherence to therapy, which often results in an intensification of treatment due to unmet therapeutic goals. Collaboration between physicians and pharmacists is therefore essential for the educational support of patients with polypharmacy. In this article, we review the studies examining the impact of a physician-pharmacist collaboration on the medication adherence of diabetic patients with renal impairment.

The consequences of non-adherence to prescribed cardiovascular drugs can be serious, with cardiovascular complications having been reported in both secondary and primary prevention. The objective of this study was to develop a new scale to assess medication adherence in patients with cardiovascular diseases during their hospitalization.A cohort of 219 high risk cardiovascular patients was evaluated for this study. Data on reasons for non-adherence were collected using the newly developed Medication Adherence Scale in Cardiovascular disorders (Mascard) and compared with physician assessment during medical consultations and the control of their cardiovascular risk factors.The Mascard consists of 5 items has good psychometric properties and validity and correlated with physician assessment and control of cardiovascular risk factors.This rapid and easy to use scale may be useful for health care practitioners in their assessment of medication adherence in inpatients with cardiovascular disorders.

Adjuvant endocrine therapy is highly effective and appropriate for all breast cancer patients with hormone receptor positive tumors, pre and post menopausal women. It's an oral daily pill for many years, after primary treatment. Although this medication dramatically reduces reccurrence rates and risk of death, many breast cancer survivors either fail to take pills with prescribed frequency (adherence) or discontinue therapy (persistence) or even never begin to take it. It's difficult to know exactly the prevalence of adherence and persistence but women age younger than 40 years had the highest risk of discontinuation. Medical literature of the last 15 years in this area has been carefully reviewed considering initiation treatment background, specificity of premenopausal young women population, healthcare provider and patient communication and respective views. It's highlighted that dedicated care, at first and after in follow up, is an essential part for better adherence. Guidelines processing are more and more complicated, expert medical assesment is required, shared decision must be provide. Patients need enhanced knowledge about mode of action, benefits but also potential side effects, and optimized patient provider relationship for empathy and better comprehension. Providers must believe in treatment relevance and convey their convictions.

The evolution of chronic diseases implies the consideration of the patient to be active and collaborative in the multidisciplinary healthcare team. Medication non-adherence is a silent epidemic that affects 50% of patients with chronic disease.A first publication reports on the work done using the Delphi method with French-speaking members of the International Society for Medication Adherence (ESPACOMP) for the translation of the 7 terms and definitions of the ABC taxonomy of medication adherence. The objective is to promote a standardized taxonomy of medication adherence among French-speaking researchers and clinicians. Medication adherence, which describes medication-taking behavior, is defined according to three operational and quantifiable parameters: A. initiation, B. implementation, and C. Persistence.A second publication reports a review on measures of medication adherence in chronic patients commonly used in current practice, in research projects, for epidemiological or interventional studies. For each method, the review presents descriptions of the measures and their strengths and limitations.A third publication presents the construction of a self-questionnaire to meet our needs for the provision of a clinical routine tool (simple, self-administered, feasible in current practice, including outpatient), to target patients in difficulty with their drug treatment and to identify levers that can be mobilized for educational support.The questionnaire was developed for a population of chronic patients with type 2 diabetes, heart failure or chronic obstructive pulmonary disease. After item generation and the item reduction phase, the QUILAM questionnaire contains a visual analogue scale and 14 likert type items. This is the first scale available in French to identify the barriers and levers of medication adherence in patients with chronic disease. Four dimensions are described: general representations, specific representations, organization and relationship with caregivers. It is relatively simple and easily integrated into the clinical routine with a good acceptability and a 5 to 10 minutes passation time. The test-retest reports a good intra-class correlation between J0 and J15 for each item.Further research is needed to finalize the psychometric validation of the questionnaire (structural validity, internal consistency, external consistency and sensitivity following an intervention).This tool will be used to open communication with the patient about the daily challenge of taking medication. After identification of patients at risk, several types of interventions integrated into care can be considered by multidisciplinary team working around the chronically ill patient according to the barriers and levers to medication adherence identified., La complexité de la pathologie chronique impose qu’on repense le modèle d’accompagnement pluriprofessionnel en intégrant le patient dans une démarche collaborative. La non-adhésion médicamenteuse est une épidémie silencieuse qui touche 50% des patients atteint de maladie chronique.Une première publication rapporte le travail réalisé en utilisant la méthode Delphi auprès des francophones membres de la société internationale de l’adhésion médicamenteuse (ESPACOMP) pour la traduction des 7 termes et définitions de la taxonomie ABC de l’adhésion médicamenteuse. L’objectif est de promouvoir une taxonomie standardisée de l’adhésion aux médicaments auprès des chercheurs et cliniciens francophones. L'adhésion aux médicaments, qui décrit le comportement de prise de médicaments, est définie selon trois paramètres opérationnels et quantifiables : A. l'initiation, B. l’implémentation et C. La persistance.Une deuxième publication rapporte une revue de la littérature sur les mesures d’adhésion aux médicaments des patients atteints de maladie chronique couramment utilisées en pratique courante, dans le cadre de projets de recherche, pour les études épidémiologiques ou pour les études interventionnelles. La revue présente, pour chaque méthode, les descriptions des mesures ainsi que leurs points forts et leurs limites.Une troisième publication présente la construction d’un autoquestionnaire pour répondre à nos besoins de mise à disposition d’un outillage de routine clinique (simple, auto-administré, réalisable en pratique courante, y compris en ambulatoire), pour cibler les patients en difficulté avec la prise de leur traitement médicamenteux et identifier des leviers mobilisables pour l’accompagnement éducatif. Le questionnaire a été développé pour une population de patients chroniques atteints de diabète de type 2, d’insuffisance cardiaque ou de bronchopneumopathie obstructive chronique. Après génération des items et la phase de réduction du nombre d’items, le questionnaire QUILAM contient une échelle visuelle analogique et 14 items de type likert. Il s’agit de la première échelle disponible en langue française visant à identifier les freins et les leviers de l’adhésion médicamenteuse des patients atteints de maladie chronique. Quatre dimensions sont décrites : les représentations générales, les représentations spécifiques, l’organisation et la relation avec les soignants. Le QUILAM est relativement simple et facilement intégrable à la routine clinique avec une bonne acceptabilité et une durée de passation de 5 à 10 minutes. Le test-retest rapporte une bonne corrélation intra-classe entre J0 et J15 pour chaque item.D’autres recherches sont nécessaires pour finaliser la validation psychométrique du questionnaire : (validité structurelle, cohérence interne, cohérence externe, sensibilité du questionnaire à la suite d’une intervention).Cet outil sera utilisé pour ouvrir la communication avec le patient sur ce défi quotidien qu’est la prise des médicaments. Nous proposons au final plusieurs types d’interventions intégrées aux soins qui pourront être envisagées par l’équipe pluriprofessionnellequi gravite autour du patient atteint de maladie chronique selon les freins et leviers à l’adhésion médicamenteuse identifiés.

High blood pressure is a major risk factor for cardiovascular disease, leading to a high and increasing rate of morbidity and mortality with our current lifestyle. This is therefore a real public health problem. About 20 % of refractory hypertension is caused by a poor drug intake. The new 2018 European recommendations for high blood pressure emphasize the importance of improving patients' therapeutic adherence. To achieve that, the general practitioner must promote a bio-psycho-social approach, targeted to patient empowerment and to develop multidisciplinarity with the other care providers. Concerning the medication, physicians are encouraged to use combination therapies in a single pill.L’hypertension artérielle est un facteur de risque cardiovasculaire majeur, conduisant à un taux de morbidité et mortalité important et croissant avec notre hygiène de vie actuelle. Il s’agit donc d’un réel problème de santé publique. Environ 20 % des hypertensions réfractaires sont le fait d’une observance médicamenteuse parcellaire. Les nouvelles recommandations européennes de 2018 pour la prise en charge de l’hypertension artérielle mettent l’accent sur l’importance d’améliorer l’adhésion thérapeutique du patient. Dans ce but, le médecin traitant est encouragé à appliquer une approche biopsychosociale et à apporter les connaissances nécessaires au patient pour le rendre actif dans sa propre prise en charge en collaborant avec les autres acteurs de soins. Au niveau médicamenteux, l’utilisation de traitements combinés dans un même comprimé est encouragée.

After numerous years of research and development of effective anti-hypertensive drugs, it is regrettable to note that less than half of hypertensive patients reach the blood pressure targets that are known to reduce their cardiovascular risks and mortality. Poor adherence to treatment is one of the main causes of insufficient blood pressure control. Furthermore, non-adherence to anti-hypertensive therapy correlates with higher risks of cardiovascular events. The objective of health professionals is to identify non adherent patients and to offer them appropriate solutions to support their treatment self-management. Innovative approaches like using electronic pillboxes combined with an interprofessional medication adherence support program should allow a more appropriate and effective care.Après tant d’années de recherche et de développement de médicaments efficaces pour faire baisser la tension artérielle, il est regrettable de constater que moins de la moitié des patients hypertendus atteignent les cibles tensionnelles, censées réduire leurs risques cardiovasculaires. L’adhésion thérapeutique sous-optimale des patients est l’une des causes principales de ce contrôle tensionnel insuffisant. De plus, la non-adhésion au traitement antihypertenseur est corrélée à un risque cardiovasculaire plus élevé. L’objectif du professionnel de santé est d’identifier les patients non adhérents et de leur proposer des solutions adaptées afin de soutenir leur autogestion du traitement. Des approches innovantes, comme l’utilisation des piluliers électroniques combinée à une consultation interprofessionnelle dédiée à l’adhésion thérapeutique, devraient nous permettre une prise en charge plus adaptée et efficace.

The aim of this study is to assess the impact of the "Drugs" workshop of a therapeutic education program for cardiac rehabilitation on the patients' knowledge in the short and long term.This observational study includes patients who participated in the workshops from June 2016 to June 2017 (10 workshops). The scores obtained on the knowledge assessment survey submitted before (S1), after (S2) and at a distance (S3) from the workshops were compared (total scores and scores per question). The existence of a link between the patients' characteristics and the overall progression was assessed.The mean total S1 (4.46/10) and S2 (7.98/10) scores were statistically different (n=62; P0.0001) as well as the S1 (4.46/10) and S3 (7.53/10) scores (n=46; P0.0001). A significant difference was observed for five out of six questions (P0,0001) in the first sequence and for four out of six in the second one (P0,0001). Initially, the best progress was made in terms of actions to be taken if a dose of medication has been missed; the worst one was the role of platelet inhibitors. Among the patients, 93.5% had a higher distance score than initially obtained. None of the chosen patient characteristics had a significant influence on the progression.The workshop significantly improved patients' knowledge in the short and long term, regardless of their profile. This study identified areas for improvement for future workshops.

Lack of recent data on asthma control in Algeria led to this study whose results were compared with those of the same study conducted in the Middle East and North Africa (MENA).This cross-sectional epidemiological study was performed in adults who had been diagnosed with asthma for at least one year and without exacerbation within the last 4 weeks. Asthma control was assessed using the 2012 Global Initiative for Asthma (GINA) criteria and the Asthma control test (ACT) questionnaire.We studied 984 patients mainly managed by specialist physicians; 61% female, mean age 45 years, body mass index 27kg/mPoor control of asthma is still observed in Algeria despite a high level of specialist involvement. Except for adherence, known predictive factors of poor asthma control have been observed. Quality improvement training of health care professionals and patient education are probably the main issues to be addressed.

National audience; Non-adherence to antihypertensive treatment is one of the critical contributors to sub-optimal blood pressure control. The French Society of Hypertension remembered that urine and serum biochemical detection of antihypertensive drugs could be useful in a patient with resistant hypertension. Talking to a patient with biochemically confirmed non-adherence to blood pressure-lowering therapy and repeating them improved adherence to drugs. Despite its usefulness, biochemical detection of antihypertensive drugs is not routinely effective in France as they are not reimbursed by French Medical Care, except in patients attending hospitals. The list of blood pressure-lowering drugs able to be biochemically detected in France and their modalities are recorded here.

The primary objective was to estimate the proportion of non-adherence to antihypertensive drugs in patients with an apparently resistant hypertension despite optimal medical treatment. The secondary objective was to identify related factors to poor adherence.Monocentric, prospective and observational study, including consecutive patients, managed for an apparently resistant hypertension between January 2014 and December 2017, with an ambulatory blood pressure measurement (ABP) in the past year and a thorough etiological work up in the 2 past years. Hypertension was considered resistant if the daytime ABP was ≥ 135/85mmHg and/or the 24hours ABP≥to 130/80mmHg, despite 4 antihypertensive medications at optimal doses. Adherence to treatment was assessed by the eight-item Morisky Scale (MMAS-8).We enrolled 386 patients, with a mean age of 64.6 years, and 48.2% of men. The mean office blood pressure, 24hours and daytime APB were 178.6/101.3mmHg, 164.4/97.2mmHg and 170.5/99.7mmHg respectively. The proportions of low, medium and high adherence were 24.5%, 47.6% and 27.9% respectively. Associated-factors with poor adherence were female sex, low education level, celibacy, polypharmacy and lack of home self-blood pressure monitoring.Over two out of three patients with an apparently resistant hypertension under optimal treatment were partially or fully nonadherent to treatment in our study. Assessment of adherence would be systematic in these patients before implementing complex investigations or non-pharmacologic invasive procedures.