Factors Influencing Antihypertensive Medication Adherence Among Historically Underrepresented Adults: A Meta-analysis.

BACKGROUND: Addressing disparities in blood pressure control must include supporting antihypertensive medication adherence (MA). Developing effective MA interventions requires identifying the most important factors influencing MA. OBJECTIVE: In this review, the authors aimed to meta-analyze the results of research testing associations between factors potentially influencing antihypertensive MA and assessed antihypertensive MA in historically underrepresented populations. Additional exploratory analyses focused on system-level factors, which have been understudied and may particularly impact disparities in MA. METHODS: A health sciences librarian assisted with searching across 10 databases. Inclusion criteria included (1) published in English, (2) sample of adults with hypertension, (3) ≥50% of participants having self-identified as a race/ethnicity underrepresented in the country where the study was conducted, and (4) reporting sufficient data to calculate effect size(s). RESULTS: Fifty-eight studies were eligible for inclusion. Nine factors met criteria for planned analyses. Older age (r = 0.08, P < .01; k = 26 studies) and higher income (r = 0.11, P = .01; k = 15) were significantly correlated with better MA. Having depressive symptoms was significantly correlated with worse MA (r = -0.18, P < .01; k = 11). Effect sizes for sex, education level, marital status, number of medications, comorbidities, and perceived social support were not significant. System-level factors examined included insurance coverage, access to healthcare, perceived barriers, having a primary care provider, perceptions of their healthcare provider, and experiences of discrimination in healthcare. CONCLUSIONS: Understanding the impact of factors associated with antihypertensive MA in historically underrepresented adults can support development of targeted, culturally relevant MA interventions. Future research should examine the impact of system-level factors on antihypertensive MA among historically underrepresented populations.

Ketogenic therapies in Parkinson's disease, Alzheimer's disease, and mild cognitive impairment: An integrative review.

BACKGROUND: Ketogenic therapies have shown benefit for seizure reduction in epilepsy but their impact on other neurologic conditions is less known. In this literature review, the efficacy of ketogenic therapies were assessed in Parkinson's disease (PD), Alzheimer's disease (AD), and mild cognitive impairment (MCI). METHODS: A literature search was conducted using PubMed, Scopus, and Google Scholar focusing on ketogenic therapies in PD, AD, and MCI. RESULTS: A total of 2565 records were identified with a total of 15 studies (3 for PD and 12 for MCI/AD) meeting criteria for analysis. The ketogenic diet was used in all the PD studies and did show significant improvement in motor function either through vocal quality, gait, freezing, tremor, and/or balance. A variety of ketogenic therapies were utilized in the MCI and AD groups including a ketogenic diet, low-carbohydrate diet, modified Adkins diet, Mediterranean diet with coconut oil supplementation, a ketogenic diet with a ketogenic medium chain triglyceride (kMCT) supplement, as well as ketogenic supplements including a ketogenic drink with kMCT, oral ketogenic compounds (Axona and AC-1202), and MCT oil or emulsion. The ketogenic diet independently showed a non-significant trend towards improvement in cognition. The Mediterranean diet, modified Adkins diet, and low-carbohydrate diet showed statistically significant improvements in some, although not all, of their cognitive measures. Use of ketogenic supplements, drinks, or compounds showed variable results in the AD and MCI groups. The Axona and AC-1202 compounds showed no significant improvement in cognition at the end of their respective 90-day trials. Most MCT supplements did show cognitive improvements, although only after 6 months of adherence. Adherence to the intervention was problematic in most of the diet studies. CONCLUSION: Ketogenic therapies have promise in PD, AD, and MCI for symptom improvement although larger studies are needed to support their implementation in clinical practice.

Treatment Adherence in Adolescents With Histories of Adverse Childhood Experiences: A Systematic Review.

Adverse childhood experiences (ACEs) are associated with poor treatment adherence and worse health outcomes among adults, but evidence among adolescents is less clear. The current systematic review identified and synthesized results from studies examining associations between ACEs and treatment adherence among adolescents. An expert medical librarian conducted searches in seven databases. Results were analyzed using a narrative synthesis framework. A total of six studies were eligible for review. Assessment strategies for ACEs and treatment adherence varied across studies. Most studies assessed for histories of maltreatment and neglect. Treatment adherence was most often defined as some form of attendance in a treatment program. Results support a relationship between ACEs and treatment nonadherence in adolescents. ACEs related to maltreatment, particularly emotional abuse, may be more predictive of treatment nonadherence than other types of ACEs. Specific qualities of ACEs (e.g., timing, intensity, frequency) may influence the relationship between ACEs and treatment nonadherence. [Journal of Psychosocial Nursing and Mental Health Services, 60(6), 11-18.].

Self-care interventions for adults with heart failure: A systematic review and meta-analysis protocol.

AIM: To synthesize and compare outcomes from controlled trials of interventions to improve heart failure self-care among adults. BACKGROUND: Heart failure self-care interventions are recommended for preventing and detecting exacerbations, improving symptom management and preventing hospitalizations. Little is known about the overall effectiveness of heart failure self-care programmes and which types of interventions show the greatest improvement in outcomes. DESIGN: Systematic review and meta-analysis, including moderator analyses. METHODS: Multiple databases (including MEDLINE/PubMed, CINAHL, PsycINFO, Scopus and Cochrane Central Register of Controlled Trials) will be searched from inception through 2018 along with grey literature searches to identify trials testing interventions to improve self-care outcomes of adults with heart failure. Data will be extracted from eligible studies on sample, methodological and intervention characteristics and data to calculate effect sizes. Data will be analysed using random-effects models. Moderator variables will be analysed with meta-regression and sub-group analyses. Risk for bias will be assessed using the Cochrane Risk for Bias tool and by examining potential sources of bias as moderator variables. Funding for this project began in July 2017. DISCUSSION: We will analyse self-care behaviour outcomes and clinical outcomes including hospitalizations, mortality, disease severity and quality of life. This will be the most extensive meta-analysis of heart failure self-care interventions to date. IMPACT: Comparative effectiveness of existing self-care interventions is not yet known. This research will identify the most promising self-care intervention components for designing better interventions and guide targeting of interventions to specific sub-populations. PROSPERO Registration Number: CRD42017075831.

Medication adherence outcomes of 771 intervention trials: Systematic review and meta-analysis.

Excellent medication adherence contributes to decreases in morbidity, mortality, and health care costs. Although researchers have tested many interventions to increase adherence, results are sometimes conflicting and often unclear. This systematic review applied meta-analytic procedures to integrate primary research that tested medication adherence interventions. Comprehensive searching completed in 2015 located 771 published and unpublished intervention studies with adherence behavior outcomes. Random-effects model analysis calculated standardized mean difference effect sizes. Meta-analytic moderator analyses examined the association between adherence effect sizes and sample, design, and intervention characteristics. Analyses were conducted in 2016. A standardized mean difference effect size of 0.290 comparing treatment and control groups was calculated. Moderator analyses revealed larger effect sizes for habit-based and behavioral-targeted (vs. cognitive-focused) interventions. The most effective interventions were delivered face-to-face, by pharmacists, and administered directly to patients. Effect sizes were smaller in studies with older and homeless participants. Risks of bias were common; effect sizes were significantly lower among studies with masked data collectors and intention-to-treat analyses. The largest effect sizes were reported by studies using medication electronic event monitoring and pill count medication adherence measures. Publication bias was present. This most comprehensive review to date documented that, although interventions can increase adherence, much room remains for improvement. Findings suggest health care providers should focus intervention content on behavioral strategies, especially habit-based interventions, more so than cognitive strategies designed to change knowledge and beliefs.

Health Literacy in Older Latinos With Heart Failure: A Systematic Review.

BACKGROUND: By 2050, one-third of US residents will be Latino, with an incidence of heart failure (HF) higher than other ethnicities. Culturally linked risk factors and socioeconomic challenges result in cardiometabolic risks, healthcare disparities, and worsening health outcomes. Individuals with low health literacy (HL) and HF are less likely to possess tools for optimal self-care, disease management, or preventative health strategies. OBJECTIVE: In this systematic review, we analyzed the literature studying older Latinos with HF and limited HL. METHOD: We searched the literature and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an iterative process. Inclusion criteria were research studies, Latinos, HF, and HL. RESULTS: Eight quantitative studies were identified for final review. Inadequate HL was reported in 87.2% of elderly Latinos. Higher HL was associated with more HF knowledge. Clinics serving minorities reported lower HL levels and higher medical complexity. CONCLUSIONS: Nurses and advanced practice nurses serve a pivotal role improving access and understanding of health information. Before conducting intervention research affecting clinical outcomes, it is essential to describe elderly Latinos with HF and their HL and self-care levels. Barriers identified confirm the need to alter research protocols for older adults and ensure the availability of assistive devices. The need to examine HL in older Latinos with HF is confirmed by the medical complexity of ethnic minority patients with limited HL, limited HL in the elderly, and the relationship of HL with HF knowledge. In culturally diverse populations, HL levels alone may not be reliable predictors of a person's ability to self-manage, recognize symptoms, and develop, implement, and revise a self-care action plan to manage their health.

Patient-Centered Outcomes of Medication Adherence Interventions: Systematic Review and Meta-Analysis.

OBJECTIVE: Using meta-analytic procedures to synthesize changes in patient-centered outcomes after medication adherence interventions. METHODS: Strategies to locate studies included online searches of 13 databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches of all eligible studies. Search terms included patient compliance, medication adherence, and related terms. Searches were conducted for all studies published since 1960. Eligible published or unpublished primary studies tested medication adherence interventions and reported medication knowledge, quality of life, physical function, and symptom outcomes. Primary study attributes and outcome data were reliably coded. Overall standardized mean differences (SMDs) were analyzed using random-effects models. Dichotomous and continuous moderator analyses and funnel plots were used to explore risks of bias. RESULTS: Thorough searching located 141 eligible reports. The reports included 176 eligible comparisons between treatment and control subjects across 23,318 subjects. Synthesis across all comparisons yielded statistically significant SMDs for medication knowledge (d = 0.449), quality of life (d = 0.127), physical function (d = 0.142), and symptoms (d = 0.182). The overall SMDs for studies focusing on subsamples of patients with specific illnesses were more modest but also statistically significant. Of specific symptoms analyzed (depression, anxiety, pain, energy/vitality, cardiovascular, and respiratory), only anxiety failed to show a significant improvement after medication adherence interventions. Most SMDs were significantly heterogeneous, and risk of bias analyses suggested links between study quality and SMDs. CONCLUSIONS: Modest but significant improvements in patient-centered outcomes were observed after medication adherence interventions.

Blood pressure outcomes of medication adherence interventions: systematic review and meta-analysis.

This systematic review applied meta-analytic procedures to integrate primary research that examined blood pressure outcomes of medication adherence interventions. Random-effects model analysis calculated standardized mean difference effect sizes. Exploratory dichotomous and continuous moderator analyses using meta-analytic analogues of ANOVA and regression were performed. Codable data were extracted from 156 reports with 60,876 participants. The overall weighted mean difference systolic effect size was 0.235 across 161 treatment versus control comparisons. The diastolic effect size was 0.189 from 181 comparisons. Effect sizes were significantly heterogeneous. Common risks of bias included lack of allocation concealment, unmasked data collectors, and absent intention-to-treat analyses. Exploratory moderator analyses suggested that habit-based interventions may be most effective. The largest effect sizes were for interventions delivered by pharmacists. The modest magnitude effect sizes suggest future research should explore novel higher dose interventions that might address multiple levels of influence on adherence behavior.

The Effectiveness of Medication Adherence Interventions Among Patients With Coronary Artery Disease: A Meta-analysis.

BACKGROUND: Despite the known benefits of medication therapy for secondary prevention of coronary artery disease (CAD), many patients do not adhere to prescribed medication regimens. Medication nonadherence is associated with poor health outcomes and higher healthcare cost. OBJECTIVE: The purpose of this meta-analysis was to determine the overall effectiveness of interventions designed to improve medication adherence (MA) among adults with CAD. In addition, sample, study design, and intervention characteristics were explored as potential moderators to intervention effectiveness. METHODS: Comprehensive search strategies helped in facilitating the identification of 2-group, treatment-versus-control-design studies testing MA interventions among patients with CAD. Data were independently extracted by 2 trained research specialists. Standardized mean difference effect sizes were calculated for eligible primary studies, adjusted for bias, and then synthesized under a random-effects model. Homogeneity of variance was explored using a conventional heterogeneity statistic. Exploratory moderator analyses were conducted using meta-analytic analogs for analysis of variance and regression for dichotomous and continuous moderators, respectively. RESULTS: Twenty-four primary studies were included in this meta-analysis. The overall effect size of MA interventions, calculated from 18,839 participants, was 0.229 (P < .001). The most effective interventions used nurses as interventionists, initiated interventions in the inpatient setting, and informed providers of patients' MA behaviors. Medication adherence interventions tested among older patients were more effective than those among younger patients. The interventions were equally effective regardless of number of intervention sessions, targeting MA behavior alone or with other behaviors, and the use of written instructions only. CONCLUSIONS: Interventions to increase MA among patients with CAD were modestly effective. Nurses can be instrumental in improving MA among these patients. Future research is needed to investigate nurse-delivered MA interventions across varied clinical settings. In addition, more research testing MA interventions among younger populations and more racially diverse groups is needed.

Interventions to Improve Medication Adherence in Hypertensive Patients: Systematic Review and Meta-analysis.

This systematic review applied meta-analytic procedures to synthesize medication adherence interventions that focus on adults with hypertension. Comprehensive searching located trials with medication adherence behavior outcomes. Study sample, design, intervention characteristics, and outcomes were coded. Random-effects models were used in calculating standardized mean difference effect sizes. Moderator analyses were conducted using meta-analytic analogues of ANOVA and regression to explore associations between effect sizes and sample, design, and intervention characteristics. Effect sizes were calculated for 112 eligible treatment-vs.-control group outcome comparisons of 34,272 subjects. The overall standardized mean difference effect size between treatment and control subjects was 0.300. Exploratory moderator analyses revealed interventions were most effective among female, older, and moderate- or high-income participants. The most promising intervention components were those linking adherence behavior with habits, giving adherence feedback to patients, self-monitoring of blood pressure, using pill boxes and other special packaging, and motivational interviewing. The most effective interventions employed multiple components and were delivered over many days. Future research should strive for minimizing risks of bias common in this literature, especially avoiding self-report adherence measures.

Systematic Review of Clinical Practice Guidelines for the Improvement of Medication Adherence.

BACKGROUND: Poor adherence to medications is a significant problem that leads to increased morbidity, mortality, and health care costs. Recommended approaches to address medication adherence vary, and existing practice guidelines are unclear. PURPOSE: This review evaluated clinical practice guidelines designed to help health care providers address patients' medication adherence. METHOD: Multiple search methods were used to identify national or international guidelines addressing medication adherence. We included guidelines published in English, as well as guidelines with an English-language summary or translation. RESULTS: We identified 23 guidelines of varying detail and quality. Recommendations were categorized as assessment strategies (n = 20 guidelines); educational strategies (n = 18); behavioral strategies (n = 17); therapeutic relationship, communication, and provider factors (n = 19); and addressing outside influences/co-morbidities (n = 10). CONCLUSION: Future guidelines should be more clearly guided by research findings and comparative effectiveness methods. When implemented, guidelines will facilitate health care providers and health systems in supporting optimal adherence and improved health outcomes.

Cultural relevance in medication adherence interventions with underrepresented adults: systematic review and meta-analysis of outcomes.

OBJECTIVE: This meta-analysis systematically compiles intervention research designed to increase medication adherence among underrepresented adults. METHOD: Comprehensive searching located published and unpublished studies with medication adherence behavior outcomes. Studies were included if samples were adults living in North America who had any of the following backgrounds or identities: African American, Native American, Latino, Latino American, Asian, Asian American, Pacific Islander, Native Alaskan, or Native Hawaiian. Random-effect analyses synthesized data to calculate effect sizes as a standardized mean difference and variability measures. Exploratory moderator analyses examined the association between specific efforts to increase the cultural relevance of medication adherence studies and behavior outcomes. RESULTS: Data were synthesized across 5559 subjects in 55 eligible samples. Interventions significantly improved medication adherence behavior of treatment subjects compared to control subjects (standardized mean difference=0.211). Primary studies infrequently reported strategies to enhance cultural relevance. Exploratory moderator analyses found no evidence that associated cultural relevance strategies with better medication adherence outcomes. CONCLUSION: The modest magnitude of improvements in medication adherence behavior documents the need for further research with clear testing of cultural relevance features.

Impact of physical activity interventions on anthropometric outcomes: systematic review and meta-analysis.

Considerable research has tested physical activity (PA) interventions to prevent and treat overweight and obesity. This comprehensive meta-analysis synthesized the anthropometric effects of supervised exercise interventions and motivational interventions to increase PA. Eligible intervention studies included healthy participants with reported anthropometric outcomes [e.g., body mass index (BMI)]. Extensive searching located 54,642 potentially eligible studies. We included data from 535 supervised exercise and 283 motivational interventions in our syntheses, which used random-effects analyses. Exploratory moderator analyses used meta-analytic analogues of ANOVA and regression. We synthesized data from 20,494 participants in supervised exercise and 94,711 undergoing motivational interventions. The overall mean effect sizes (ES, d) for treatment versus control groups in supervised exercise interventions were 0.20 (treatment vs. control within-group comparison) and 0.22 (between-group comparison). The ES of 0.22 represents a post-intervention BMI of 26.7 kg/m(2) for treatment participants relative to 27.7 kg/m(2) for controls. The corresponding mean ES for motivational interventions was significantly smaller (d = 0.09 for between group, d = 0.10 for treatment vs. control within-group). Control group within-group comparisons revealed slightly worsening anthropometric outcomes during study participation (d = -0.03 to -0.04). Moderator analyses identified potential variables for future research. These findings document significant improvements in anthropometric effects from both supervised exercise and motivational interventions.

Important considerations when applying for a postdoctoral fellowship.

PURPOSE: To examine important decision points that graduates should consider before applying for a postdoctoral fellowship. METHODS: A literature review was performed. FINDINGS AND CONCLUSIONS: A synthesis of the present data on the postdoctoral fellowship, eligibility criteria, application process, and important considerations was provided. Experiential knowledge from four present postdoctoral fellows was included. The goals, advantages, and disadvantages of the fellowship were discussed. In conclusion, the postdoctoral fellowship was examined to offer important considerations in the decision to pursue this opportunity. CLINICAL RELEVANCE: The clinical relevance of this article is related to the training and education of nurses to become the next generation of independent, successful scholars and scientists. Postdoctoral training adds valuable contributions and quality to the field of nursing.

Understanding Processes, Outcomes, and Contexts in Medication Adherence: The Medication Adherence Context and Outcomes (MACO) Framework.

Poor medication adherence is a significant problem, yet interventions to improve it have been largely ineffective. Existing ecological models indicate that adherence is multi-dimensional; however, they do not reflect understanding of context-specific processes and how they lead to adherence outcomes. A framework that reflects context-specific processes is important because it could be used to inform context-specific intervention delivery and measure associated adherence outcomes. The purpose of this paper is to describe the Medication Adherence Context and Outcomes (MACO) framework, which includes contexts (ie, clinics, pharmacies, and home) and context-specific processes (ie, shared decision-making, prescription filling strategies, home medication management) that lead to adherence outcomes (initiation, implementation, discontinuation, and persistence). The Medication and Adherence Contexts and Outcomes (MACO) framework was iteratively developed between 2015 and 2018 based on theory, practice, and research and combining patient experience journey mapping to chronologically describe the environmental contexts and actions (processes) that occur within the contexts and how they contribute to medication adherence as outcome. The three distinct yet interrelated contexts described in the MACO framework are 1) clinical encounters, 2) pharmacy encounters, and 3) day-to-day home management. Within these contexts are specific medication management actions that occur (processes) in order to produce adherence-related outcomes (initiation, implementation, and discontinuation/persistence). The MACO framework distinguishes context-specific processes and outcomes. The MACO framework may be useful to understand at which point(s) along the continuum people experience problems with managing medications. This understanding is potentially useful for developing and delivering context-specific interventions that are based on processes that underlie nonadherence and selecting adherence measures appropriate for the contexts.

Managing Medications and Medication Adherence Among US Adults During the Early Phase of the COVID-19 Pandemic.

Purpose: Before the COVID-19 pandemic and the disruptions it brought, medication adherence was already a challenging and complex health behavior. The purpose of this study was to describe patients' interactions in clinic, pharmacy, and home contexts and associated medication management and adherence during the early phase of the COVID-19 pandemic. Patients and Methods: A survey questionnaire was developed using the Medication Adherence Context and Outcomes framework and distributed via social media between May and July 2020 targeting adults taking a daily prescribed medication. Survey questions assessed sociodemographics, interactions with healthcare providers, clinics, pharmacies, medication management experiences, habit strength, and life chaos perceptions during the pandemic. Medication adherence was assessed by the self-report BAASIS© scale to measure implementation, discontinuation, and overall nonadherence. Results: A total of 134 adults from the United States, mean age 50.0 (SD 16.1) years were included in this analysis. Respondents took a median of 3.50 (interquartile range 4) daily medications. Delays in seeing a provider were reported by 47 (35.1%). Pharmacy encounters were impacted; 25 (18.7%) indicated their method for obtaining medication changed. Medication nonadherence was reported among 62 (46.3%) and was significantly greater among those who delayed prescription refills (p=0.032), pillbox users (p=0.047), and those who experienced greater life chaos (p=0.040) and lower habit strength (p<0.001) in the early phase of the pandemic. Conclusion: Although the early phase of the pandemic affected access to care for nearly one-third of the sample, distance-accessible care options and strategies to obtain needed services without being in-person supported respondents medication management. Helpful strategies included provider accessibility, telehealth, home delivery/mail-order, drive-thru's, 90-day supplies, and online/automatic refills. Methods to develop and reestablish habits are critical. Care providers in clinic and pharmacy settings can educate and remind patients about services like distance-accessible technologies and online ordering of medications and establishing routines to support medication adherence.

Using meta-analyses for comparative effectiveness research.

Comparative effectiveness research seeks to identify the most effective interventions for particular patient populations. Meta-analysis is an especially valuable form of comparative effectiveness research because it emphasizes the magnitude of intervention effects rather than relying on tests of statistical significance among primary studies. Overall effects can be calculated for diverse clinical and patient-centered variables to determine the outcome patterns. Moderator analyses compare intervention characteristics among primary studies by determining whether effect sizes vary among studies with different intervention characteristics. Intervention effectiveness can be linked to patient characteristics to provide evidence for patient-centered care. Moderator analyses often answer questions never posed by primary studies because neither multiple intervention characteristics nor populations are compared in single primary studies. Thus, meta-analyses provide unique contributions to knowledge. Although meta-analysis is a powerful comparative effectiveness strategy, methodological challenges and limitations in primary research must be acknowledged to interpret findings.

Medication beliefs and antihypertensive adherence among older adults: a pilot study.

Older adults with hypertension are dependent on medication to control blood pressure and reduce risk for cardiovascular disease and renal impairment. Unfortunately, adherence to antihypertensive regimens remains low. This pilot study examines the relation among medication beliefs, demographic variables, and antihypertensive medication adherence in a sample of older adults (median age = 74 years). Medication beliefs were measured using the Beliefs About Medicines Questionnaire (BMQ), and medication adherence was measured by electronic monitoring. Among study participants (n = 33), concerns about medications were found to be related to poorer antihypertensive adherence. In particular, older adults with lower medication adherence were concerned about dependency and long-term effects from their medications. When controlling for other factors that may influence antihypertensive adherence, beliefs about medication necessity were related to adherence (odds ratio: 2.027, 95% confidence interval: 1.10-3.75).