Reimbursed Medication Adherence Enhancing Interventions in European Countries: Results of the EUREcA Study.

Introduction: Current literature lacks detailed understanding of the reimbursement framework of medication adherence enhancing interventions (MAEIs). As part of the ENABLE COST Action, the EUREcA ("EUropen REimbursement strategies for interventions targeting medication Adherence") study aimed to provide an in-depth overview of reimbursed MAEIs currently available in European countries at national and regional levels and to pave the way for further MAEIs to be implemented in the future. Methods: A web-based, cross-sectional survey was performed across 38 European countries and Israel. The survey questionnaire was developed as a result of an iterative process of discussion informed by a desk review. The survey was performed among invited ENABLE collaborators from June to July 2021. Besides descriptive analysis, association between country income and health care expenditure, and the availability of reimbursed MAEIs were also assessed. Results: The survey identified 13 reimbursed MAEIs in nine countries: multi-dose drug dispensing (n = 5), medication review (n = 4), smart device (n = 2), mobile application (n = 1), and patient education (n = 1). The median GDP per capita of countries having ≥1 reimbursed MAEI was significantly higher compared to countries having no reimbursed adherence intervention (33,888 EUR vs 16,620 EUR, respectively; p = 0.05). Conclusions: Our findings highlight that to date only a small number of MAEIs have been reimbursed in European countries. Comprehensive health technology assessment recommendations and multi-stakeholder collaboration could help removing barriers related to the implementation and reimbursement of MAEIs.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people.

BACKGROUND: Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. METHODS: Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. RESULTS: Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. CONCLUSION: Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments.

INTRODUCTION: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, 'Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY', which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter's eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

Type 2 Diabetes Patients Benefit from the COMODITY12 mHealth System: Results of a Randomised Trial.

Patient acceptance is one of the major barriers toward widespread use of mHealth systems. The aim of this study was to assess system operability and whole trial feasibility, including patients' experience with their use of COMMODITY12 mHealth system under. Secondary study aims included assessment of several metabolic parameters as well as patient adherence to the treatment. This was a prospective parallel-arm randomized controlled trial in outpatients diagnosed with DM2, being treated in the primary care settings in Lodz region, Poland, with 6 weeks period of follow-up. Patients opinions were collected with 7-item questionnaire, assessing different aspects of system use, as well as EuroQol-5D-5 L questionnaire, assessing health-related quality of life. Sixty patients (female, 24, male, 36, mean age +/- SD 59.5 +/- 6.8) completed study. All four layers of the COMMODITY12 system proved to work smooth under real-life conditions, without major problems. All dimensions of experience with system use were assessed well, with maximum values for clearness of instructions, and ease of use (4.80, and 4.63, respectively). Health related quality of life, as assessed with cumulative utility measure, improved significantly in COMMODITY12 system users (P < 0.05). mHealth system modestly improved glycaemic and blood pressure control, assuring high level of patient adherence with overall adherence reaching 92.9 %. Study proved that the COMODITY12 system is well accepted by type 2 diabetes patients taking part in clinical trial, leading to several clinical benefits, and improved quality of life. Nevertheless, before future commercialisation of the system, several minor problems identified during the study need to be addressed.

Adherence to treatment in asthma and COPD patients in their doctors' assessment.

INTRODUCTION: Adherence to therapy is one of the basic preconditions of successful treatment of asthma and COPD. Unfortunately, many patients take their medication incorrectly. The aim of this study was to assess doctors' knowledge of this phenomenon, including interventions able to improve patient adherence. MATERIAL AND METHODS: It was a questionnaire-based survey conducted among convenience sample of Polish physicians treating asthma and COPD. RESULTS: One hundred and sixty one physicians, mainly specialists in allergology (44.1%) and pulmonology (37.3%) took part in the study. According to participants, asthma patients took on average 65.4 ± 17.1% of doses of prescribed drugs, whereas COPD patients - 61.6 ± 24.2%. Over half of respondents claimed that during the first year of treatment, no more than 20% of asthma and COPD patients discontinue their therapy. Survey participants pointed at patients discourage (41.6%) and lack of knowledge about disease (19.3%) as the main reasons for discontinuation of therapy. Almost 2/3 of participants (65.8%) claimed that they could recognize non-adherence in their patients. Prescribing combination inhaled drugs (72.7%), drugs with infrequent dosing (63.4%), and affordable ones (53.4%) were the most common interventions aimed at improving adherence provided by respondents. CONCLUSIONS: Survey participants were aware of the phenomenon of non-adherence in patients with asthma and COPD, but underestimated the real prevalence and seriousness of it. They also overestimated their ability to recognise non-adherence in their patients. Therefore, not necessarily they may obtain better adherence in their asthma and COPD patients. These results point at the issues which should be addressed in pre- and postgraduate education of physicians treating chronic airways conditions.

Factors affecting the opinions of family physicians regarding generic drugs--a questionnaire based study.

A range of factors are believed to exert a negative influence on opinions of physicians about generic drugs.The aim of this study was to survey the opinions of primary care doctors on generics, and determine the factors which may affect them. A questionnaire comprising thirty eight questions was distributed among primary care doctors working in seventy out-patient clinics of the Lodzkie province, Poland, during the period of January 1, 2010 - December 31, 2010. A total of 170 of 183 participants completed the survey (average age 48.5; 70.0% women): a 92.9% response rate. While 38.8% of physicians claimed that generics were worse than brand name drugs, 54.1% considered them to be better. However, 36.5% of the doctors did not choose generics for their own use. Two key opinions were identified among the responses concerning the effectiveness of generic drugs: use of generic drugs by the physician (p<0.001), and their opinion that pharmacists do inform patients about generic drugs (p<0.05). Although existing evidence confirms that generic and brand name drugs are equally effective, many physicians doubt this, which prevents them from being used as cost effective drug therapy. In order to increase healthcare savings through the use of generics, these factors should be addressed: for example, convincing a physician to adopt generics for personal use may be an efficient way to support more cost effective treatment of his patients.

Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis.

BACKGROUND: Non-adherence to medications is prevalent across all medical conditions that include ambulatory pharmacotherapy and is thus a major barrier to achieving the benefits of otherwise effective medicines. OBJECTIVE: The objective of this systematic review was to identify and to compare the efficacy of strategies and components thereof that improve implementation of the prescribed drug dosing regimen and maintain long-term persistence, based on quantitative evaluation of effect sizes across the aggregated trials. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Library, and PsycINFO were systematically searched for randomized controlled trials that tested the efficacy of adherence-enhancing strategies with self-administered medications. The searches were limited to papers in the English language and were included from database inception to 31 December 2011. STUDY SELECTION: Our review included randomized controlled trials in which adherence was assessed by electronically compiled drug dosing histories. Five thousand four hundred studies were screened. Eligibility assessment was performed independently by two reviewers. A structured data collection sheet was developed to extract data from each study. STUDY APPRAISAL AND SYNTHESIS METHODS: The adherence-enhancing components were classified in eight categories. Quality of the papers was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions guidelines to assess potential bias. A combined adherence outcome was derived from the different adherence variables available in the studies by extracting from each paper the available adherence summary variables in a pre-defined order (correct dosing, taking adherence, timing adherence, percentage of adherent patients). To study the association between the adherence-enhancing components and their effect on adherence, a linear meta-regression model, based on mean adherence point estimates, and a meta-analysis were conducted. RESULTS: Seventy-nine clinical trials published between 1995 and December 2011 were included in the review. Patients randomized to an intervention group had an average combined adherence outcome of 74.3 %, which was 14.1 % higher than in patients randomized to the control group (60.2 %). The linear meta-regression analysis with stepwise variable selection estimated an 8.8 % increase in adherence when the intervention included feedback to the patients of their recent dosing history (EM-feedback) (p < 0.01) and a 5.0 % increase in adherence when the intervention included a cognitive-educational component (p = 0.02). In addition, the effect of interventions on adherence decreased by 1.1 % each month. Sensitivity analysis by selecting only high-quality papers confirmed the robustness of the model. The random effects model in the meta-analysis, conducted on 48 studies, confirmed the above findings and showed that the improvement in adherence was 19.8 % (95 % CI 10.7-28.9 %) among patients receiving EM-feedback, almost double the improvement in adherence for studies that did not include this type of feedback [10.3 % (95 % CI 7.5-13.1 %)] (p < 0.01). The improvement in adherence was 16.1 % (95 % CI 10.7-21.6 %) in studies that tested cognitive-educational components versus 10.1 % (95 % CI 6.6-13.6 %) in studies that did not include this type of intervention (p = 0.04). Among 57 studies measuring clinical outcomes, only 8 reported a significant improvement in clinical outcome. LIMITATIONS: Despite a common measurement, the meta-analysis was limited by the heterogeneity of the pooled data and the different measures of medication adherence. The funnel plot showed a possible publication bias in studies with high variability of the intervention effect. CONCLUSIONS: Notwithstanding the statistical heterogeneity among the studies identified, and potential publication bias, the evidence from our meta-analysis suggests that EM-feedback and cognitive-educational interventions are potentially effective approaches to enhance patient adherence to medications. The limitations of this research highlight the urgent need to define guidelines and study characteristics for research protocols that can guide researchers in designing studies to assess the effects of adherence-enhancing interventions.

Family physicians' perception of plastic surgery and its influence on referral. A survey from Poland.

BACKGROUND: Inadequate family physicians' knowledge of plastic surgery might be a barrier for patients to benefit from plastic surgery treatments reimbursed by the Polish National Health Service (NHS). OBJECTIVES: The aim of this study was to assess family physicians' awareness of the indications for plastic surgery, and their knowledge of conditions that are treated without extra costs for the patient in plastic surgery outpatient clinics (OCs). METHODS: An e-mail survey was carried out in a group of 100 out of 378 randomly selected primary care doctors currently practicing in Lodz, central Poland. Respondents were asked to fill in a questionnaire, which contained questions about conditions with reimbursed treatments in plastic surgery OCs. We also provided them with a list of diseases and asked them to which OC they would refer a patient in such case. RESULTS: 58 primary care physicians responded: 30 specialists in family medicine and 28 residents in the final year of their specialization in family medicine. Respondents had good knowledge of the range of conditions managed in plastic surgery OCs. They were also aware of most of the medical procedures not being reimbursed by the Polish NHS. However, some indications for plastic surgery as well as the free availability of relevant medical procedures were known by less than half of the respondents (e.g. lipoma 47%, gynaecomastia 28%, and xanthelasma palpebrarum 16%). CONCLUSION: To improve collaboration between plastic surgeons and family physicians basic information regarding plastic surgery might be included in residency programmes in family medicine.

Prevention and management of chronic obstructive pulmonary disease (COPD) in primary care: position paper of the European Forum for Primary Care.

Chronic obstructive pulmonary disease (COPD) is a smoking-related, progressive lung disease that represents a substantial individual, societal and economic burden. Primary care professionals have an important role in healthcare provision for patients with COPD. In this position paper we summarise the current knowledge about, and management of patients with COPD. Next, we describe the role general practitioners and other primary care disciplines (should) have to prevent, diagnose and treat COPD. Finally, we explore differences in the way particular aspects of primary care COPD disease management are available or organised in a number of European countries, in order to identify barriers and provide examples of 'best practices' for optimal primary care management of patients with COPD.

A noninvasive continence management system: development and evaluation of a novel toileting device for women.

PURPOSE: This paper describes a project to develop and clinically evaluate a novel toileting device for women called the Non-Invasive Continence Management System (NICMS). The NICMS device is designed to provide an alternative toileting facility that overcomes problems some women experience when using conventional female urinals. DESIGN: A single product evaluation was completed; participants used the same device with 1 or 2 interface variants. SUBJECTS AND SETTING: Eighty women from 6 countries who were either mobile or wheelchair dependent evaluated the product over a 15-month period. RESULTS: The device was found to be useful in some circumstances for women and their caregivers. CONCLUSION: Significant further development is required for it to work reliably and to provide an acceptable device in terms of reliability, size, weight, noise, and aesthetics.

Dilemma of an indigent country: Is academic medicine a good investment?

Academic medicine is a discipline which requires much financial expenditure and the profit is not always immediate. Therefore, an idea has been raised in some circles to limit the expenditures on it. The experience of Poland points out, however, that such a limitation will not bring benefit in the long run--just the opposite, it can bring about both social and economic loss. Even the countries that are not wealthy should invest in academic medicine, as this is a necessary condition for their harmonious growth.