A systemic review, published in the Journal of Patient Preference and Adherence, provides a general review of diabetes adherence interventions and highlights exemplar research studies that improved medication adherence and patient outcomes using strategies that could be effective if employed in real-world healthcare settings.
“We highlight that many interventions are found to effective in clinical trials, but fail to ensure similar results when scaled up into a larger model,” said Hayden B. Bosworth, PhD, associate director for health services research in primary care at Durham Veterans Affairs Medical Center. “Rather than ‘reinventing the wheel,’ we discussed how healthcare institutions or systems can adapt and implement existing proven strategies to promote medication adherence among patients with diabetes.”
Prior systematic reviews of medication adherence interventions, while comprehensive, offer little practical advice for clinicians, healthcare executives, and policymakers in terms of which interventions might be suitable for scale-up and what specific actions they can take to combat non-adherence in their specific settings, according to Bosworth.
“Our objective was to provide a general review of diabetes adherence interventions and highlight exemplar research studies that improved medication adherence and patient outcomes using strategies that could be effective if employed in real-world healthcare settings,” he told FormularyWatch.
Bosworth and colleagues reviewed existing literature for successful interventions, that: 1) addressed diabetes medication adherence; and 2) achieved an improvement in medication adherence. Their search was limited to studies indexed in PubMed that were written in English in the previous decade. Using this strategy, researchers identified 53 potential articles. Articles were subsequently omitted if they met any of the following exclusion criteria: did not address diabetes, did not report results of a randomized trial (e.g., protocol only or only information from a baseline assessment), did not significantly improve medication adherence, or medication adherence was not an outcome measure.
After applying exclusion criteria, 7 eligible studies remained.
“We described each intervention’s study design, effectiveness, and scalability—or potential for ‘scaling up’—and broad implementation,” Bosworth explains. “Of note, we initially intended that an assessment of cost be an inclusion criterion, but none of the seven identified articles contained a robust cost analysis.”
While medication non-adherence is a serious and costly challenge, many health service interventions have provided solutions to improve medication adherence in specific contexts and population groups.
“Because of its frequent reliance on intricate medication therapy, many of these programs have focused on patients with diabetes,” Bosworth says. “Thus, we used diabetes as a model to identify strategies that could promote medication adherence and be scaled to large healthcare systems.”
Strategies for formulary managers to improve diabetes medication adherence include:
1. Provide a team approach to facilitate medication adherence might be a scalable and sustainable solution.
Over half of the studies used pharmacists as interventionists, according to Bosworth.
“While these studies were effective at improving medication adherence and clinical outcomes, some resource-limited settings might not have additional staff to spare and/or may need to supplement with other skilled laborers such as certified health educators, social workers, licensed nurse practitioners, or other professionals who might be able to provide similar patient services at a reduced cost,” he said.
2. Offer e-learning through innovative applications available through smart-technologies that can be integrated into a patient’s day to help increase adherence.
3. Match patients with the right level and type of resources.
“All patients will not need a high-intensity pharmacist-driven intervention; a phone call might work just as well for highly motivated patients,” Bosworth says.
Several of these interventions relied on technologies, such as “smart” medication dispensers and text messaging, according to Bosworth.
“While mobile phone use is ubiquitous among many populations, use of these technologies may not be accessible or appealing to all patients,” he said. “Matching resources with patient needs is important and may ultimately reduce resource use.”
A key element of scalability and sustainability is resource use and cost or return on investment. “While many studies have shown an improvement in medication adherence, few provide evidence of an improvement in clinical outcome, and fewer still assess the return on investment or thoughtful economic analysis,” Bosworth said. “We have provided examples of programs that have the potential to be broadly applied to address this critical gap in the delivery of care.”