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Catherine Girouard,1–3 Jean-Pierre Grégoire,1–3 Paul Poirier,2,4 Jocelyne Moisan1–3 1Chair on Adherence to Treatments, Université Laval, 2Faculty of Pharmacy, Université Laval, 3Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Center, 4Quebec Heart and Lung Institute-Université Laval, Quebec City, QC, Canada Purpose: β-Blockers (bisoprolol, carvedilol, and metoprolol) are the cornerstone of heart failure (HF) management. The incidence rate of β-blocker initiation and discontinuation and their associated factors among seniors with a first HF diagnosis were assessed.Methods: A population-based inception cohort study that included all individuals aged ≥65 years with a first HF diagnosis in Quebec was conducted. β-Blockers initiation among 91,131 patients who were not using β-blockers at the time of HF diagnosis and discontinuation among those who initiated a β-blocker after HF diagnosis were assessed. Stepwise Cox regression analyses were used to calculate hazard ratios (HR) and to identify factors associated with β-blocker initiation and discontinuation.Results: After HF diagnosis, 32,989 (36.2%) individuals initiated a β-blocker. Of these, 15,408 (46.7%) discontinued their β-blocker during the follow-up. Individuals more likely to initiate a β-blocker were those diagnosed in a recent calendar year (2009: HR, 2.11; 95% confidence interval [CI], 2.00–2.23) and diagnosed by a cardiologist (HR, 1.38; 95% CI, 1.34–1.42). Individuals less likely to initiate were those aged ≥90 years (HR, 0.65; 95% CI, 0.61–0.68) and those with chronic obstructive pulmonary disease (HR, 0.66; 95% CI, 0.64–0.68). Individuals more likely to discontinue were those with more than nine medical consultations (HR, 1.14; 95% CI, 1.10–1.18) and those with dementia (HR, 1.13; 95% CI, 1.01–1.27). Individuals less likely to discontinue were those diagnosed in a recent calendar year (2009: HR 0.74; 95% CI, 0.65–0.82) and those exposed to another β-blocker before HF diagnosis (HR, 0.88; 95% CI, 0.85–0.91).Conclusion: Quebec seniors seem to be underexposed to β-blocker following HF diagnosis. Among those who initiate β-blocker use, discontinuation is high. Better understanding of the underlying causes is needed to help target interventions to improve the management of HF. Keywords: heart failure, β-blocker initiation, β-blocker discontinuation, cohort study, drug use

Viet Thanh Truong,1,2 Jocelyne Moisan,1,2 Edeltraut Kröger,1–3 Serge Langlois,4 Jean-Pierre Grégoire1,2 1Faculty of Pharmacy, Laval University, 2Chair on Adherence to Treatments, Population Health and Optimal Practices in Health Research Unit, CHU de Québec Research Center, 3Center of Excellence on Aging of Québec, 4Faculty of Medicine, Laval University, Quebec, Canada Background: Patients with chronic kidney disease initiating an antihypertensive drug (AH) treatment must persist and comply with it to slow disease progression and benefit from the reduction of cardiovascular morbidity and mortality. Objectives: This study evaluates the persistence and compliance with AH treatment and identifies the associated factors among chronic kidney disease patients who initiated AH treatment. Methods: A population-based cohort study using Quebec administrative data was conducted. Patients who still take any AH 1 year after initiation were considered persistent. Of these patients, those who had ≥80% of days covered with an AH in the year after initiation were considered compliant. Factors associated with persistence and compliance were identified using a modified Poisson regression. Results: Of the 7,119 eligible patients, 78.8% were persistent, 87.7% of whom were compliant with their AH treatment. Compared with patients on diuretic monotherapy, those who initially used angiotensin-converting enzyme inhibitor monotherapy, angiotensin II receptor blocker monotherapy, calcium channel blocker monotherapy, β-blocker monotherapy, or multidrug therapy were more likely to be persistent. In contrast, individuals who visited their physicians ≥17 times were less likely to be persistent than those who visited between 0 and 8 times. The patients who were more likely to be compliant had initially used an angiotensin-converting enzyme inhibitor, β-blocker, calcium channel blocker, or multitherapy as opposed to a diuretic. Conclusion: A year after initiating AH treatment, nearly a third of chronic kidney disease patients were either not taking an AH or had not been compliant. Factors associated with persistence and compliance could help identify patients who need help in managing their AH treatment. Keywords: chronic kidney disease, adherence, factors, antihypertensive drug

Line Guénette,1–3 Sophie Lauzier,1–3 Laurence Guillaumie,2–4 Gabriel Giguère,1 Jean-Pierre Grégoire,1–3 Jocelyne Moisan1–3 1Faculty of Pharmacy, Laval University, Quebec City, QC, Canada; 2Chair on Adherence to Treatments, Laval University, Quebec City, QC, Canada; 3CHU de Québec Research Center, Population Health and Optimal Practices Research Unit, Quebec City, QC, Canada; 4Faculty of Nursing, Laval University, Quebec City, QC, Canada Purpose: The purpose of this study was to elicit patients’ beliefs about taking their oral antidiabetic drugs (OADs) as prescribed to inform the development of sound adherence-enhancing interventions.Methods: A qualitative study was performed. Adults with type 2 diabetes who had been taking an OAD for >3 months were solicited to participate in one of six focus groups. Discussions were facilitated using a structured guide designed to gather beliefs related to important constructs of the theory of planned behavior. Four coders using this theory as the theoretical framework analyzed the videotaped discussions.Results: Forty-five adults participated. The most frequently mentioned advantages for OAD-taking as prescribed were to avoid long-term complications and to control glycemia. Family members were perceived as positively influential. Carrying the OAD at all times, having the OAD in sight, and having a routine were important facilitating factors. Being away from home, not accepting the disease, and not having confidence in the physician’s prescription were major barriers to OAD-taking.Conclusion: This study elicited several beliefs regarding OAD-taking behavior. Awareness of these beliefs may help clinicians adjust their interventions in view of their patients’ beliefs. Moreover, this knowledge is crucial to the planning, development, and evaluation of interventions that aim to improve medication adherence. Keywords: type 2 diabetes, medication adherence, theory of planned behavior, focus groups

Guénette L, Lauzier S, Guillaumie L, Giguère G, Grégoire JP, Moisan J. Patient Prefer Adherence. 2015;9:413–420.On page 414, Data collection and variables section, 1st paragraph, “We used a modified version of the validated French version18 of the 4-item Morisky medication adherence scale (MMAS-4).19” should have been “We used a modified version of the validated French version18 of a 4-item self-report medication adherence scale (SR-4).19”Read the original article

Background: In Côte d'Ivoire, people living with HIV (PLHIV) have free access to antiretroviral therapy (ART) and cotrimoxazole. Yet, they may use other medications to treat non-HIV diseases. Scarce data are available regarding the use of non-HIV medications in Africa. This study describes the use of non-HIV medications and identifies the factors associated with their use by PLHIV on ART in Côte d'Ivoire., Methods: A cross-sectional study was conducted in six HIV clinics in 2016. HIV-1-infected adults receiving ART for at least one year were eligible. A standardized questionnaire was used to collect demographics, HIV characteristics and medication use data. Associated factors were identified using a multivariate adjusted Poisson regression., Results: A total of 1,458 participants (74% women) were enrolled. The median age was 44 years, and the median duration of ART was 81 months. A total of 696 (48%) participants reported having used at least one non-HIV medication. Among the 1,519 non-HIV medications used, 550 (36%) had not been prescribed and 397 (26%) were from the nervous system class. Individuals who were more likely to report the use of at least one non-HIV medication included those who had been treated in an Abidjan HIV clinic, had a high school education level, had a monthly income between 152 and 304 euros, had a poor perceived health status, had WHO advanced clinical stage, had used traditional medicine products and had not used cotrimoxazole., Conclusion: Almost half PLHIV on ART reported using non-HIV medication. Further research is needed to assess whether the use of non-HIV medication is appropriate given about a third of those medications are not being prescribed., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Ticagrelor is recommended following an acute coronary syndrome if used appropriately. Its use has not yet been well described in the context of ambulatory clinical practice. The objective of this study was to assess the proportion of ticagrelor new users who initiated this medication appropriately and explore associated factors., Methods: A retrospective population-based inception cohort study was conducted using Quebec administrative databases. The study population included all Quebec residents aged ≥18 years who had a first ticagrelor prescription claim between 1 January, 2012, and 31 March, 2015, and had been continuously eligible in the Quebec public drug plan during the 365 days preceding the first ticagrelor claim. The initial ticagrelor prescription was considered appropriate if:1) it met the indication for use criterion, 2) the prescribed daily dose was 90 mg twice a day, and 3) there was a concomitant use of acetylsalicylic acid (ASA) 80-81 mg daily. Factors potentially associated with the ticagrelor appropriateness of use were included in a logistic log-binomial regression model., Results: A total of 7,073 patients were included in the study, 6,013 (85.0%) had an appropriate indication, 6,895 (97.5%) were prescribed ticagrelor 90 mg twice a day, and 6,385 (90.3%) had a concomitant prescription of ASA. A total of 5,371 (75.9%) patients were prescribed ticagrelor in accordance with all criteria. Twelve factors were associated with prescription appropriateness., Conclusions: A large majority of patients initiated ticagrelor appropriately. Further improvement in appropriateness may come at targeting indication for use.

Background: Little is known about exposure to heart failure (HF) treatment among seniors with ischemic heart disease., Objectives: In a population of seniors, we: 1) estimated the association between age and exposure to HF drug therapy at 6, 12, 36 and 60 month intervals after HF diagnosis, and 2) determined the influence of the passage of time on exposure to drug therapy., Methods: Using the Quebec provincial administrative databases, we conducted a population-based inception cohort study that included all individuals aged ≥ 65 with a first HF diagnosis between 2000 and 2009 and an ischemic heart disease diagnosis in the year before HF diagnosis. We assessed exposure to HF drug therapy and to drug therapy at target doses at 6, 12, 36 and 60 month intervals after HF diagnosis. Adjusted prevalence ratios (aPR) between age at diagnosis and exposure to drug therapy and the influence of time (6-month periods) were assessed using multivariate modified Poisson regressions., Results: Among the 86,428 seniors, those who were older were less likely to be exposed to both HF drug therapy and drug therapy at target doses at each time point, than were the younger ones (aged 65-69). The aPRs for exposure to drug therapy for the 90+ age group were 0.64, 0.64, 0.56 and 0.53 at the 6, 12, 36 and 60 month intervals, respectively. After HF diagnosis, exposure increased by a maximum of 8% per 6-month period., Conclusion: Increasing age is associated with a decrease in exposure to drug therapy, with only slight improvement in exposure after HF diagnosis.

A third of breast cancers (BC) occur in women ≥65 years (seniors). Anti-estrogen therapy (AET) significantly reduces BC recurrence and death. This study characterizes determinants of adherence to AET in seniors with BC. Provincial cancer registry and administrative claims data were accessed for all non-metastatic BC diagnosed in Quebec (1998-2005) to identify seniors treated for 5 years with AET. Multivariate linear regression was used to assess the association with patient, disease, and physician characteristics and the 5-year medication possession ratio (MPR) for each patient. 4,715 women were included (mean age: 72.9). Mean MPR was 83.5%, 79% of patients reached a 5-year MPR of ≥80%, and 34% discontinued AET at some point during treatment. The cumulative probability of discontinuation was 33.8% (mean time to discontinuation 2.3 years). The MPR decreased with increasing age and non-BC related hospitalizations, p < 0.05. Each new medication added during the 5-years decreased the MPR by 0.3% (p < 0.05). Women with in situ disease, on antidepressants at baseline, or treated with Tamoxifen had a lower MPR by 6.5% (p = 0.0002), 4.7% (p = 0.003) and 6% (p = 0.001), respectively. Switching AET type was associated with a lower MPR by 5.3% (p = 0.002) if the switch occurred during the first year. Optimal 5-year adherence to AET in seniors with BC remained a challenge and medication discontinuation rates were high. Advanced age, increasing number of hospitalizations, in situ disease, baseline use of antidepressants, Tamoxifen (versus aromatase inhibitors), early switches of AET type, and newly added medications significantly reduced the MPR., (© 2014 Wiley Periodicals, Inc.)

Background and Purpose: To estimate the prevalence of insomnia symptoms and syndrome in the general population, describe the types of self-help treatments and consultations initiated for insomnia, and examine help-seeking determinants., Patients and Methods: A randomly selected sample of 2001 French-speaking adults from the province of Quebec (Canada) responded to a telephone survey about sleep, insomnia, and its treatments., Results: Of the total sample, 25.3% were dissatisfied with their sleep, 29.9% reported insomnia symptoms, and 9.5% met criteria for an insomnia syndrome. Thirteen percent of the respondents had consulted a healthcare provider specifically for insomnia in their lifetime, with general practitioners being the most frequently consulted. Daytime fatigue (48%), psychological distress (40%), and physical discomfort (22%) were the main determinants prompting individuals with insomnia to seek treatment. Of the total sample, 15% had used at least once herbal/dietary products to facilitate sleep and 11% had used prescribed sleep medications in the year preceding the survey. Other self-help strategies employed to facilitate sleep included reading, listening to music, and relaxation., Conclusions: These findings confirm the high prevalence of insomnia in the general population. While few insomnia sufferers seek professional consultations, many individuals initiate self-help treatments, particularly when daytime impairments such as fatigue become more noticeable. Improved knowledge of the determinants of help-seeking behaviors could guide the development of effective public health prevention and intervention programs to promote healthy sleep.

The gap between best care and usual care is large for many important diseases. In particular, poor adherence remains a significant, inadequately addressed, cause of the care gap. About half of all patients with chronic diseases stop refilling prescriptions by one year. Several effective interventions are available and adaptations of clinical trials practices offer promise for further improvement. Poor adherence is a remedial problem in healthcare quality and its improvement and accountability offer shared opportunities for providers and patients. There is a large gap between best care, defined as the optimal use of proven efficacious therapies in whole populations at risk from any disease, and usual care, the actual level of efficacious care being provided (Montague et al. 1997). This gap in patient care has four main causes: diseases may not be diagnosed, efficacious therapies may not be prescribed, access to therapy may be restricted or patients may not adhere to prescriptions. Irrespective of causation, the ultimate result of care gaps is the same--less than optimal clinical outcomes and associated lost opportunities for improved quality of life and productivity. Systematic approaches to improving prescribing practices are increasing, and there is much debate around improving patients' access to care. Poor diagnosis is judged to be relatively uncommon, leaving decayed adherence as the major under-addressed cause of care gaps and a major opportunity for improvement. This paper reviews the scope and causation of sub-optimal adherence, evaluates improvement strategies and explores a best-practice benchmark.

Broadly defined, disease, or health management, is a focused application of resources to improve patient outcomes; its premise: things can be better. In particular, the gap between what best care could be, and what usual care is, can be reduced and, consequently, care and outcomes can be improved. This paper reviews the evolution of the partnership/measurement paradigm of disease management and considers its value in sustaining Canadian healthcare. Lessons from ICONS (Improving Cardiovascular Outcomes in Nova Scotia), a major public-private health partnership of physicians, nurses, pharmacists, patients and their advocacy groups, government and industry, are highlighted. Launched in 1997, ICONS' proof-of-concept phase ended in 2002. Due to its positive impact on the cardiovascular health of the population and its integrated and accountable administrative processes, ICONS became an operational program of the Nova Scotia Department of Health. This successful community-based partnership represents a major achievement in organizational behaviour in the arena of primary healthcare. It supports optimal care as evidence-based and seamless, recognizing the patient as the nucleus. It should be considered for other disease states and constituencies where the goals are closing care gaps and delivering the best health to the most people at the best cost.

Sustainability of the Canadian health system is currently foremost in the minds of many stakeholders. Historically, health expenditures have been viewed as ever increasing and with little visible economic return. Recently, economists have recognized the health arena as an important growth area within the total economy and have begun quantitative analyses of the impact of health investments as drivers of innovation and the general economic advance of nations. In particular, evidence has focused on the discovery and diffusion of new drugs as practical reflections of the quality ladder model of innovation, largely through their provision of improved duration and quality of life and accompanying productivity. The rate of return on innovative drug therapy within the universe of patients who could benefit is, however, impeded by under-prescription of, restricted access to, and/or impaired compliance with, newer efficacious drugs. The authors support further research to assist in future health policy decisions, including wider testing of the partnership/measurement model of disease management as a feasible tool to optimize the social rate of return on already-proven drug therapy. They further recommend these partnerships be designed with enough breadth of vision to facilitate their transition to operational projects compatible with evolving public health policies.

The degree of agreement between implicit and explicit judgments made by a pharmacist in a drug-use review program in an ambulatory-care setting was studied. During a six-month period in 1980, all prescriptions for a group of 19 drugs were reviewed for appropriateness of indication, dosage, and length of therapy by a pharmacist using implicit judgment. The same prescriptions were then reevaluated according to explicit criteria that had been approved by the prescribing physicians. A sample of prescriptions that did not meet either implicit or explicit criteria for use was subjected to review by a committee of four physicians to validate whether these prescriptions were indeed inappropriate. Of the 935 prescriptions evaluated, 36.8% were judged inappropriate by the explicit criteria and 23.5% were judged inappropriate by implicit judgment. The explicit and implicit approaches yielded concordant results for 95.5% of the observations. The proportion of true deviations as validated by the review committee was estimated at 80% for the implicit method and 74.4% for the explicit method. The implicit judgments of a pharmacist appear to be as effective as explicit drug-use criteria for identifying inappropriate prescribing in a drug-use review program. These judgments could be used to increase the efficiency of a drug-use review program when explicit criteria are not available.