Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States (original) (raw)

2012, Annals of Internal Medicine

This review concluded that case management, patient education with behavioural support, and reducing out-of-pocket expenses each improved medication adherence for more than one condition. Whether they could be applied to or improve long-term adherence and health outcomes was uncertain. This was a well-conducted review, and the conclusions are likely to be reliable. Authors' objectives To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the USA. Searching MEDLINE and The Cochrane Library were searched for studies published in English and included from 1994 to June 2012. Reference lists of relevant reviews were searched. Study selection Randomised controlled trials (RCTs) and observational studies conducted in outpatient primary and specialty care, and community-based and home-based settings were eligible for inclusion if they assessed the effectiveness of interventions to improve adherence to self-administered medication for the secondary or tertiary prevention of chronic diseases in adults. Studies conducted in institutional settings or in patients with acute conditions were excluded, as were studies that evaluated interventions to improve adherence to antiretroviral therapy or medications for mental illness or substance abuse. Studies had to be conducted in the USA. Nearly 40% of the interventions evaluated were for patients only, and just over half were for more than one target (patient, provider, systems, or policy). About half of the interventions were delivered by a pharmacist, physician, or nurse and about half involved at least some face-to-face contact. The medical condition varied considerably across studies, but most patients had cardiovascular disease, diabetes, hypertension, depression or hyperlipidaemia. Two reviewers independently selected studies for the review; disagreements were resolved by consensus or consultation with a third reviewer. Assessment of study quality Two reviewers independently assessed the risk of bias, in the included studies, for the randomisation method, adequacy of allocation concealment, strategies to recruit patients, similarity at baseline, blinding, contamination, attrition, prespecification of outcome measures, confounders (where appropriate), justification of medication adherence thresholds, and the validity, consistency and reliability of outcome measures. Studies considered to be at a high risk of bias (serious errors in their design or analysis) were excluded. The strength of the evidence was graded based on the risk of bias, and the consistency, directness, and precision of the results. Disagreements were resolved by consensus or consultation with a third reviewer. Data extraction One reviewer extracted the proportion of patients with improved adherence and/or summary estimates, such as risk ratios, hazard ratios or odds ratios, with a measure of variance, for relevant outcomes; data were checked by a second reviewer. Methods of synthesis Studies were combined in a narrative synthesis, organised by clinical condition and intervention type. Study details were available in the full report (see Other Publications of Related Interest). Differences between studies were discussed in