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European Journal of Clinical Pharmacology

, Volume 74, Issue 3, pp 357–364 | Cite as

Measuring medication adherence in older community-dwelling patients with multimorbidity

  • San Kim
  • Kathleen Bennett
  • Emma Wallace
  • Tom Fahey
  • Caitriona CahirEmail author
Pharmacoepidemiology and Prescription

Abstract

Purpose

Older people with several chronic conditions require multiple drugs from different classes to be adequately treated. This study aims to: (i) measure medication adherence across multiple conditions and therapeutic drug groups in older community-dwelling patients, and (ii) examine the effect of multimorbidity on adherence.

Methods

This is a retrospective cohort study of medication adherence in 855 community-dwelling patients aged ≥ 70 years from 15 practices in Ireland using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. Multimorbidity was measured using the RxRisk-V and by the number of different drug classes. The RxRisk-V algorithm classifies prescription drug fills into 45 chronic disease classes for older populations based on the WHO Anatomical Therapeutic Chemical classification system. Adherence to medications was assessed by: (i) calculating the average medication possession ratio (MPR) per patient and (ii) an MPR< 80%.

Results

The overall median MPR for the cohort was 0.83 (IQR 0.69, 0.91). The conditions with the highest MPRs were hypothyroidism (mean MPR = 0.88, SD = 0.20) and type 2 diabetes (mean MPR = 0.83, SD = 0.19), followed by heart disease. On average, 20–40% of patients were non-adherent (MPR < 80%) across all conditions. There was an inverted U-shaped relationship between the mean MPR and number of morbidities and drug classes. Adherence varied per patients’ morbidity burden, with higher adherence for certain combinations of chronic conditions.

Conclusion

In total, 31% of older patients with multimorbidity were non-adherent to their medication but adherence levels varied across treatment categories and chronic conditions.

Keywords

Medication adherence Older people Multimorbidity MPR 

Notes

Acknowledgements

We wish to thank all the study participants and the 15 general practices who kindly gave their time to take part in this study.

Funding

This study was funded by the HRB Research Leader award (RL-2015-1579) and HRB Centre for Primary Care Research (HRC/1/2007).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Sabate E (2003) Adherence to long-term therapies: evidence for action. World Health Organization, GenevaGoogle Scholar
  2. 2.
    Giardini A, Martin MT, Cahir C, Lehane E, Menditto E, Strano M, Pecorelli S, Monaco A, Marengoni A (2016) Toward appropriate criteria in medication adherence assessment in older persons: position paper. Aging Clin Exp Res 28(3):371–381.  https://doi.org/10.1007/s40520-015-0435-z CrossRefPubMedGoogle Scholar
  3. 3.
    Melis R, Marengoni A, Angleman S, Fratiglioni L (2014) Incidence and predictors of multimorbidity in the elderly: a population-based longitudinal study. PLoS One 9(7):e103120.  https://doi.org/10.1371/journal.pone.0103120 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380(9836):37–43.  https://doi.org/10.1016/S0140-6736(12)60240-2 CrossRefPubMedGoogle Scholar
  5. 5.
    Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW (2005) Clinical Practice Guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 294(6):716–724.  https://doi.org/10.1001/jama.294.6.716 CrossRefPubMedGoogle Scholar
  6. 6.
    Gottlieb H (2000) Medication nonadherence: finding solutions to a costly medical problem. Drug Benefit Trends 12(6):57–62Google Scholar
  7. 7.
    Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, Pirmohamed M (2007) Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 63(2):136–147.  https://doi.org/10.1111/j.1365-2125.2006.02698.x CrossRefPubMedGoogle Scholar
  8. 8.
    Chisholm-Burns MA, Spivey CA (2012) The ‘cost’ of medication nonadherence: consequences we cannot afford to accept. J Am Pharm Assoc 52(6):823–826.  https://doi.org/10.1331/JAPhA.2012.11088 CrossRefGoogle Scholar
  9. 9.
    Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW (2003) Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289(9):1107–1116.  https://doi.org/10.1001/jama.289.9.1107
  10. 10.
    Gautério-Abreu DP, Santos SSC, da Silva BT, Gomes GC, Cruz VD, Tier CG (2016) Prevalence of medication therapy adherence in the elderly and related factors. Rev Bras Enferm 69(2):335–342.  https://doi.org/10.1590/0034-7167.2016690217i CrossRefPubMedGoogle Scholar
  11. 11.
    Choudhry NK, Shrank WH, Levin RL, Lee JL, Jan SA, Brookhart MA, Solomon DH (2009) Measuring concurrent adherence to multiple related medications. Am J Manag Care 15(7):457–464Google Scholar
  12. 12.
    Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J Med 353(5):487–497.  https://doi.org/10.1056/NEJMra050100
  13. 13.
    Claxton AJ, Cramer J, Pierce C (2001) A systematic review of the associations between dose regimens and medication compliance. Clin Ther 23(8):1296–1310.  https://doi.org/10.1016/S0149-2918(01)80109-0 CrossRefPubMedGoogle Scholar
  14. 14.
    Marcum ZA, Gellad WF (2012) Medication adherence to multi-drug regimens. Clin Geriatr Med 28(2):287–300.  https://doi.org/10.1016/j.cger.2012.01.008 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    International Society of Pharmacoeconomics (2017) Methods of measuring multiple medication adherence: A systematic review. On line publication https://www.ispor.org/sigs/medication.asp
  16. 16.
    Cahir C, Bennett K, Teljeur C, Fahey T (2014) Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. Br J Clin Pharmacol 77(1):201–210.  https://doi.org/10.1111/bcp.12161 CrossRefPubMedGoogle Scholar
  17. 17.
    Central Statistics Office (2013) Women and Men in Ireland 2013: Persons with a medical card. Available at http://www.cso.ie/en/releasesandpublications/ep/pwamii/womenandmeninireland2013/healthlist/health/#d.en.65619
  18. 18.
    Sinnott S-J, Bennett K, Cahir C (2017) Pharmacoepidemiology resources in Ireland—an introduction to pharmacy claims data. Eur J Clin Pharmacol 73(11):1457.  https://doi.org/10.1007/s00228-017-2358-4
  19. 19.
    Sloan KL, Sales AE, Liu CF, Fishman P, Nichol P, Suzuki NT, Sharp ND (2003) Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument. Med Care 41(6):761–774.  https://doi.org/10.1097/01.MLR.0000064641.84967.B7
  20. 20.
    Johnson ML, El-Serag HB, Tran TT, Hartman C, Richardson P, Abraham NS (2006) Adapting the Rx-Risk-V for mortality prediction in outpatient populations. Med Care 44(8):793–797.  https://doi.org/10.1097/01.mlr.0000218804.41758.ef
  21. 21.
    Vitry A, Wong SA, Roughead EE, Ramsay E, Barratt J (2009) Validity of medication-based co-morbidity indices in the Australian elderly population. Aust N Z J Public Health 33(2):126–130.  https://doi.org/10.1111/j.1753-6405.2009.00357.x CrossRefPubMedGoogle Scholar
  22. 22.
    Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K (2010) Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol 69(5):543–552.  https://doi.org/10.1111/j.1365-2125.2010.03628.x
  23. 23.
    Carey IM, De Wilde S, Harris T, Victor C, Richards N, Hilton SR et al (2008) What factors predict potentially inappropriate primary care prescribing in older people? Drugs Aging 25(8):639–706Google Scholar
  24. 24.
    Peterson AM, Nau DP, Cramer JA, Benner J, Gwadry-Sridhar F, Nichol M (2007) A Checklist for medication compliance and persistence studies using retrospective databases. Value Health 10(1):3–12.  https://doi.org/10.1111/j.1524-4733.2006.00139.x CrossRefPubMedGoogle Scholar
  25. 25.
    Steiner JF, Prochazka AV (1997) The assessment of refill compliance using pharmacy records: methods, validity, and applications. J Clin Epidemiol 50(1):105–116.  https://doi.org/10.1016/S0895-4356(96)00268-5 CrossRefPubMedGoogle Scholar
  26. 26.
    Andrade SE, Kahler KH, Frech F, Chan KA (2006) Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol Drug Saf 15(8):565–574.  https://doi.org/10.1002/pds.1230 CrossRefPubMedGoogle Scholar
  27. 27.
    Joint Formulary Committee (2015) British National Formulary. BMJ Group and Pharmaceutical Press, LondonGoogle Scholar
  28. 28.
    Briesacher BA, Andrade SE, Fouayzi H, Chan KA (2008) Comparison of drug adherence rates among patients with seven different medical conditions. Pharmacotherapy 28(4):437–443.  https://doi.org/10.1592/phco.28.4.437
  29. 29.
    Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ (2013) Patient characteristics associated with medication adherence. J Clin Med Res 11(2):54–65.  https://doi.org/10.3121/cmr.2013.1113
  30. 30.
    Gallagher P, O’Mahony D (2008) STOPP (Screening Tool of Older Persons’ potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing 37(6):673–679.  https://doi.org/10.1093/ageing/afn197 CrossRefPubMedGoogle Scholar
  31. 31.
    Lader M (2014) Benzodiazepine harm: how can it be reduced? Br J Clin Pharmacol 77(2):295–301.  https://doi.org/10.1111/j.1365-2125.2012.04418.x CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA (2009) Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169(21):1952–1960.  https://doi.org/10.1001/archinternmed.2009.357
  33. 33.
    Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J, Brennan TA, Shrank WH (2011) The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med 171(9):814–822Google Scholar
  34. 34.
    Grant RW, O'Leary KM, Weilburg JB, Singer DE, Meigs JB (2004) Impact of concurrent medication use on statin adherence and refill persistence. Arch Intern Med 164(21):2343–2348.  https://doi.org/10.1001/archinte.164.21.2343
  35. 35.
    DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW (2002) Patient adherence and medical treatment outcomes: a meta-analysis. Med Care 40(1):794–811.  https://doi.org/10.1097/00005650-200209000-00009 CrossRefPubMedGoogle Scholar
  36. 36.
    Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C (2006) ‘Justifiable depression’: how primary care professionals and patients view late-life depression? A qualitative study. Fam Pract 23(3):369–377.  https://doi.org/10.1093/fampra/cmi115
  37. 37.
    Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P (2011) Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 343–352:d6553.  https://doi.org/10.1136/bmj.d6553
  38. 38.
    Yeaw J, Benner JS, Walt JG, Sian S, Smith DB (2009) Comparing adherence and persistence across 6 chronic medication classes. J Manag Care Pharm 15(9):728–740.  10.18553/jmcp.2009.15.9.728 PubMedGoogle Scholar
  39. 39.
    National Institute for Clinical Excellence (2016) Multimorbidity: clinical assessment and management. This is a report https://www.nice.org.uk/guidance/ng56
  40. 40.
    Moriarty F, Hardy C, Bennett K, Smith SM, Fahey T (2015) Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study. BMJ Open 5(9):e008656.  https://doi.org/10.1136/bmjopen-2015-008656
  41. 41.
    Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al (2014) Interventions for enhancing medication adherence. Cochrane Database Syst Rev (11):Cd000011Google Scholar
  42. 42.
    Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, Stroupe KT, Wu J, Clark D, Smith F, Gradus-Pizlo I, Weinberger M, Brater DC (2007) Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med 146(10):714–725Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
  2. 2.HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland

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