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.

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.

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.

Physical Activity Interventions Among American Indian and Alaska Native Persons: A Systematic Review.

OBJECTIVE: The purpose of this review was to identify and describe physical activity (PA) interventions that have been implemented with American Indian and Alaska Natives (AIANs) in the U.S. and Canada since 2006. DATA SOURCE: Searches were conducted in 8 databases plus grey literature sources. STUDY INCLUSION AND EXCLUSION CRITERIA: Eligible studies: (a) described an intervention designed to increase PA; (b) targeted AIANs residing in the U.S. or Canada, or if a multiethnic population, contained an AIAN subanalysis; (c) were published in 2006 or later; and (d) reported a PA outcome. DATA EXTRACTION: Two reviewers independently extracted data, with conflicts resolved through discussion. DATA SYNTHESIS: Data were synthesized by participant characteristics, intervention strategies, PA outcomes, and impact. RESULTS: We identified 25 eligible studies, most targeting children and youth. Intergenerational, environmental policy, cultural adaptation, and curriculum-based approaches were used. Twenty studies used self-reported PA measures. 80% of studies used an element of cultural adaptation, mostly considering cultural needs in design, not program or outcome evaluation. Sedentary behavior and leisure-time PA were rarely assessed. Significant changes in PA outcomes were achieved post-intervention in 13 studies (52%). CONCLUSION: Future interventions should target AIAN adults to evaluate sedentary behavior and leisure-time PA. Interventions should incorporate psychometrically tested objective measures and prioritize the Native perspective from intervention design through project evaluation.

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.].

Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis.

BACKGROUND/OBJECTIVE: As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years). DESIGN/SETTING/PARTICIPANTS: Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance. MEASUREMENTS: Medication adherence using any method of measurement. RESULTS: Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70). CONCLUSION: This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.

High Blood Pressure Medication Adherence Among Urban, African Americans in the Midwest United States.

Hypertension is a chronic condition that disproportionately affects African Americans. Managing high blood pressure (HBP) requires adherence to daily medication. However, many patients with hypertension take their HBP medication inconsistently, putting them at heightened risk of heart disease. Researchers have shown that these health risks are greater for African Americans than for Caucasians. In this article, we examine barriers and facilitators of medication adherence among urban African Americans with hypertension. We interviewed 24 African Americans with hypertension (58.5% women, average age 59.5 years) and conducted a comprehensive thematic analysis. Twenty-two barriers and 32 facilitators to medication adherence emerged. Barriers included side effects and forgetting while facilitators included reminders, routines, and social support. Using this data, we developed a diagram of theme connectedness of factors that affect medication adherence. This diagram can guide multi-level HBP intervention research that targets African Americans to promote medication adherence, prevent heart disease, and reduce ethnic and racial health disparities.

Self-Reported Nonadherence Associated with Pharmacy and Home Medication Management Inconvenience Factors in a US Adult Population.

PURPOSE: Medication nonadherence is a significant and multidimensional problem contributing to an increased risk of morbidity and mortality. Inconveniences in pharmacy and home contexts may increase nonadherence. This research examined inconveniences in pharmacy and home contexts associated with self-reported nonadherence, controlling for demographic and medication-taking covariates. METHODS: Data from 4682 individuals who reported self-managing medications in an online marketing survey between October and December 2017 were analyzed in this secondary analysis. Nonadherence was dichotomized using a single question about likelihood to take medications as prescribed (adherence=always; nonadherence=most of the time, some of the time, never). Multivariable logistic regression with backwards elimination was used to examine the pharmacy (use of home delivery, number prescriptions picked up and visits to pharmacy) and home context (method used to organize/manage medications, satisfaction, and bother with management) variables and the demographic (age, sex, race/ethnicity, education, income, insurance) and medication (number of oral medications, medication changes and frequency of taking) covariates associated with nonadherence. RESULTS: Overall, 25.8% of the responses indicated nonadherence. Nonadherence was more likely for individuals making fewer separate pharmacy trips (OR 0.98; 95% CI 0.97-0.99); picking up fewer prescriptions (OR 0.96; 95% CI 0.93-0.99); never, rarely or sometimes using mail order compared with always (OR 1.71; 95% CI 1.30-2.26); not satisfied with managing medications (OR 2.13; 95% CI 1.42-3.19); and using pill pouches and being bothered by them (OR 8.28; 95% CI 1.83-37.31). Using pill pouches or a pillbox and not being bothered by them significantly decreased nonadherence likelihood. Younger and female respondents and those reporting medication changes in the last year were also more likely to report nonadherence. CONCLUSION: Though reasons for nonadherence are multidimensional, this study suggests that inconveniences in both the pharmacy and home context are important. Improving adherence requires addressing issues of inconvenience across the care continuum.

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.