Scalability of effective adherence interventions for patients using cardiovascular disease medication: A realist synthesis-inspired systematic review.

Upscaling of medication adherence interventions to routine care is still challenging. This realist theory-inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains: (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system, and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: (1) Complexity of the intervention; (2) training; (3) customization of the intervention; (4) drivers of the intervention; (5) technical interventions; and (6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development.

Implementing medication adherence interventions in four Dutch living labs; context matters.

BACKGROUND: Despite the abundant availability of effective medication adherence interventions, uptake of these interventions into routine care often lacks. Examples of effective medication adherence interventions include telephone counseling, consult preparation and the teach-back method. Assessing context is an important step in understanding implementation success of interventions, but context is often not reported or only moderately described. This study aims to describe context-specific characteristics in four living labs prior to the implementation of evidence-based interventions aiming to improve medication adherence. METHODS: A qualitative study was conducted within four living labs using individual interviews (n = 12) and focus groups (n = 4) with project leaders and involved healthcare providers. The four living labs are multidisciplinary collaboratives that are early adopters of medication adherence interventions in the Dutch primary care system. Context is defined as the environment or setting in which the proposed change is to be implemented. Interview topics to assess context were formulated based on the 'inner setting' and 'outer setting' domains of the Consolidated Framework for Implementation Research (CFIR). Interviews were recorded and transcribed verbatim. Transcripts were deductively analyzed. RESULTS: A total of 39 community pharmacists, pharmacy technicians, general practitioners and a home care employee participated in the (focus group) interviews. All four living labs proved to be pharmacy-driven and characterized by a high regard for innovation by staff members, a positive implementation climate, high levels of leadership engagement and high compatibility between the living labs and the interventions. Two living labs were larger in size and characterized by more formal communication. Two living labs were characterized by higher levels of cosmopolitanism which resulted in more adaptable interventions. Worries about external policy, most notably lack of reimbursement for sustainment and upscaling of the interventions, were shared among all living labs. CONCLUSIONS: Contextual characteristics of four living labs that are early adopters of medication adherence interventions provide detailed examples of a positive implementation setting. These can be used to inform dissemination of medication adherence interventions in settings less experienced in implementing medication adherence interventions.

Feasibility study of a digitalized nurse practitioner-led intervention to improve medication adherence in type 2 diabetes patients in Dutch primary care.

PURPOSE: The purpose of this feasibility study was to improve and implement an intervention aimed at enhancing medication adherence in sub-optimally controlled and non-adherent type 2 diabetes (T2DM) patients in primary care. METHODS: Four phases were completed: (1) context analysis, (2) collaboration protocol development, (3) digitalization, and (4) process evaluation. Two community pharmacies and seven general practices participated. In phase 1, two focus groups were conducted, of which one with healthcare providers (HCP, N = 5) and one with patients (N = 11). In phase 4, four semi-structured interviews and one focus group (N = 6) were conducted with healthcare providers. The goal of these focus groups and interviews was to obtain insights into current care to support medication adherence (phase 1), opportunities for collaboration (phase 2) and process evaluation (phase 4). Data were analyzed in Atlas.ti using thematic analyses. RESULTS: Both T2DM patients and HCPs considered medication adherence vital. Suboptimal collaboration between HCPs and unreliable ways to monitor medication non-adherence appeared important barriers for adequate care to support medication adherence (phase 1). The nurse practitioner (NP) was chosen as the interventionist with supportive roles for other HCPs (phase 2). All components of the intervention were digitalized (phase 3). The implementation of the digitalized intervention was reported to be suboptimal (phase 4). Main reasons were that pharmacy refill data were unreliable, NPs experienced difficulties addressing medication non-adherence adequately and collaboration between HCPs was suboptimal. CONCLUSIONS: The medication adherence enhancing intervention was successfully digitalized, but implementation of the digitalized intervention appeared not feasible as of yet.

Medication Intake, Perceived Barriers, and Their Correlates Among Adults With Type 1 and Type 2 Diabetes: Results From Diabetes MILES - The Netherlands.

Purpose: The purpose of this study is to investigate medication intake, perceived barriers and their correlates in adults with type 1 or type 2 diabetes. Methods: In this cross-sectional study, 3,383 Dutch adults with diabetes (42% type 1; 58% type 2) completed the 12-item 'Adherence Starts with Knowledge' questionnaire (ASK-12; total score range: 12-60) and reported socio-demographics, clinical and psychological characteristics and health behaviors. Univariable and multivariable logistic regression analyses were used. Results: Adults with type 1 diabetes had a slightly lower mean ASK-12 score (i.e. more optimal medication intake and fewer perceived barriers) than adults with non-insulin-treated type 2 diabetes. After adjustment for covariates, correlates with suboptimal intake and barriers were fewer severe hypoglycemic events and more depressive symptoms and diabetes-specific distress. In type 2 diabetes, correlates were longer diabetes duration, more depressive symptoms and diabetes-specific distress. Conclusions: Adults with type 1 diabetes showed slightly more optimal medication intake and fewer perceived barriers than adults with non-insulin treated type 2 diabetes. Correlates differed only slightly between diabetes types. The strong association with depressive symptoms and diabetes-specific distress in both diabetes types warrants attention, as improving these outcomes in some people with diabetes might indirectly improve medication intake.