Table 3: Physician-Noninvolved Adherence Interventions: Reminder/Reinforcement, Behavioral
Table 3: Physician-Noninvolved Adherence Interventions: Reminder/Reinforcement, Behavioral and Educational
Author,Year, Site / Participants, Duration / Intervention / Adherence Measures / Outcomes,
Cohen’s D Effect Size
(95% Confidence Interval)
Reminder/Reinforcement and Behavioral interventions
Barrios, 200746
Category: R
Spain / 1523 HTN patients on lercanidipine.
12 weeks / Use of MEMS caps. / Used MPR (expressed as %); defined adherent as >80%.
pill count, MEMS. / % adherent patients
I: 92%
C: 91%
Comparison: NS
ES 0.04, (-0.07, 0.14)
Becker, 198647
Category: R
Oklahoma, Pennsylvania / 180 HTN patients.
3 months / Special unit dose-reminder packaging. / Nonadherent if admitted any such behavior or if taking <80% of medications; pill count, self report. / Adherent
I: 84.0%
C: 75.3%
Comparison: NS
ES 0.22 (-0.09, 0.53)
Fulmer, 199948
Category: R
New York, New York / 60 elderly CHF patients.
.
10 weeks / 1- Regular daily phone reminders.
2-daily videophone reminders
vs. Usual care. / MPR, expressed as %; MEMS. / Phone: 74%
Videophone: 84%
C: 57%
P<0.04 for Δ C (drop in adherence).
P=NS for Δ phone, videophone interventions
ES: Unable to calculate
Guthrie, 200149
Category: R
Ohio / 13,100 patients with elevated total cholesterol.
6 months / Postal, phone reminders about coronary risk reduction and medication adherence. / Taking pravastatin as prescribed per self-report: yes/no. / Taking as prescribed
I: 79.7% , C: 77.4%
Authors conclude: “no meaningful difference”
ES 0.06 (-0.02, 0.13)
Hagstrom,200450
Category: R
Sweden / 399 patients using 1 pharmacy.
1 week / 1 week after prescription issued,
nurse made standardized phone call. / Pharmacy claims:
Filled prescription yes/no. / Filled prescription:
I: 95%, C: 87%
P=0.023
ES 0.28 (0.08, 0.48)
Johnson, 200651
Category: B
Massachusetts and Rhode Island / 404 adults with hyperlipidemia.
18 months / Population-based, computer-generated individualized intervention; report mailed to patient. / Responses to 5 questions (on Likert scale) summed to create a continuous measure.
Calculated Odds of appropriate adherence; Self-report. / Adherence as continuous measure:
6 months OR 2.03 p>0.05
18 months OR 2.86 p<0.05
ES 0.18 (-0.08,0.45)
Marquez-Contreras, 200652
Category: R
Spain / 250 HTN patients from primary care centers.
6 months / Home automatic BP monitoring. / Used MPR expressed as %;
Adherent is >80%; MEMS. / % of adherent patients
I: 92 (SD 14.2)
C: 74 (SD 18.1)
P = 0.0007
ES 0.29 (0.00, 0.58)
McKenney,
199253
Category: R
Richmond, Virginia / 70 HTN patients age ≥50.
12 weeks / 1.Timepiece cap (displays time opened)
2.Cap and pocket cards
3. Cap, cards, home BP cuffs
C: standard vials. / MPR expressed as %; pill count. / Mean (SD)
Cap: 93.6%(8.67%) p=0.003*
Cap + card: 98.7% (11.28%) p<0.0001*
Cap, card, cuff: 100.2% (7.02%) P<0.0001*
C:79.0% (22.61)
*comparison to control
ES 0.85 (0.14, 1.56)
Saunders,199154
Category: R
Soweto, S Africa / 115 HTN patients.
6 months / Appointment reminders sent; patient-retained BP
and medication records. / MPR based on clinic instructions
Adherent: ≥80% consumed. / I: 31%
C: 15%; p= 0.19
ES 0.39 (-0.20, 0.97)
Schneider,
200855
Category: R
Ohio and Arizona / 112 HTN patients.
12 months / Lisinopril in daily-dose blister packaging. / MPR; pharmacy data. / Mean (SD)
I: 0.93 (11.4)
C: 0.87 (14.2); p=0.039
ES 0.45 (0.01, 0.89)
Simkins, 198656
Category: R / 311 patients on cardiovascular medications for > 3 months.
3 months / 1. Postcard reminder for refill
2. Phone reminder vs.
Usual care. / Number of refills divided by possible number of refills; pharmacy data. / Mean (SD)
Postcard: 0.65 (0.52)
Phone: 0.64 (0.46)
C: 0.58 (0.50)
C compared to interventions: p<0.05
ES 0.12 (-0.19, 0.44)
Table 3 continued
Author,Year, Site / Participants, Duration / Intervention / Adherence Measures / Outcomes
Reminder/Reinforcement and Behavioral interventions, continued
Skaer, 199357
Category: R
Florida / 304 HTN patients on Medicaid, started on verapamil.
1 year / 1. Mail reminder 10 days before refill date
2. Unit-of-use packaging
3. Reminder and Unit pack
Control: Usual care. / MPR; pharmacy data. / Mean (SD)
Reminder 0.64 (0.08)*,
Packaging 0.67 (0.06)*,
Reminder + Packaging 0.79+-0.09*
Control 0.56 (0.07)
p≤0.05
ES 2.85 (2.38, 3.33)
Skaer, 199358
Category: R
South Carolina / 258 DM patients on Medicaid, started on glyburide.
1 year / Reminder 0.73 (0.09)*
Packaging 0.71 (0.09)*
Reminder + Packaging 0.87 (0.08)*,
Control 0.58 (0.07)
p≤0.05
ES 3.86 (3.23, 4.48)
Stewart, 200559
Category: B
Johannesburg, S. Africa. / 83 HTN patients, majority indigent.
36 weeks / Support of physiotherapist and family member by phone. / Self-described as adherent to medications. / I: 82.4%
C: 86.7%
P = 0.56
ES -0.12 (-0.85, 0.61)
Marquez Contreras, 200560
Category: R / 636 HTN patients newly diagnosed or uncontrolled, on 1 drug.
4 months / Education and adherence reinforcement via:
1. 3 mailings
2. 3 calls with visit reminder
vs. Usual care. / Used MPR expressed as %,
Adherent is ≥80%; Pill Count. / % adherent patients
Mail: 91.3% (CI 87.1,95.5) Phone: 96.2% (CI 93.5 -98.9%)
C: 69.2% (CI 62.5 -75.9%)
p=0.0001
ES 0.44 (0.22, 0.65)
Santschi, 200761
Category: R
Lausanne, Switzerland / 25 HTN patients HTN on irbesartan.
4 months / Crossover study.
I: Intelligent Drug Administration System (electronic adherence monitor)
C: MEMS. / % of doses taken: calculated as # of times the MEMS/IDAS had been opened divided by # of times device should have been opened. / Median (range)
I: 100.0 (40.3,100.0)
C: 100.0 (50.0,101.8)
P = NS
ES unable to calculate
Ogedegbe, 200862
Category: B
New York, NY. / 190 HTN patients, African-Americans, most women.
12 months / Motivational interviewing with patient-centered counseling. / MPR, expressed as %; MEMS. / I: 60% C: 47% p=0.054
intent-to-treat analysis showed model-predicted rates:
I:57% C:43% p=0.027
ES 0.13 (-0.01, 0.27)
Eshelman, 197663
Category: R / 100 HTN patients presenting to an outpatient pharmacy taking chlorthalidone.
Outcome measured at next visit; time not specified. / Chlorthalidone in reminder packaging. / “number of times adhered divided by the total number of times prescribed".
Adherent is ≥ 80%; pill count. / % of adherent patients
I: 63%
C: 61%
p>0.05
ES 0.04 (-0.48, 0.56)
Educational Interventions
Emmett, 200564
Category: E
Bristol, England. / 217 newly diagnosed HTN patients, primary care practices.
3 years / 1.Decision analysis (DA)
2.Video and leaflet
3.DA and video, leaflet
vs.Usual care. / Proportion of patients who report taking all their medications. / DA: 90%
Adjusted OR 1.56,
CI 0.49-4.96, p=0.45
Video plus leaflet: 94%
Adjusted OR 0.53,
CI 0.15 -1.84, p=0.32
ES 0.15 (-0.12, 0.42)
Takala, 198365
Category: E
Southwest Finland / 147 untreated HTN patients.
2 years / Written education on HTN. / 2 years after intervention, asked if "still under treatment after 2 years." / Adherent:
I: 90%
C: 79%
P=NS
ES 0.28 (-0.14, 0.69)
Morisky, 198566
Category: E
Baltimore, Maryland. / 290 HTN patients.
18 months / Family support: Home interview, training with family member. / Scale: 0-4 (1 pt per yes answer)
(4 = lower compliance); self-report. / Intervention group had improved scores (0.876 vs 1.932, p<0.01)
ES 0.87 (0.63, 1.11)
Author,
Year, Site / Participants, Duration / Intervention / Adherence Measures / Outcomes,
Cohen’s D Effect Size
(95% Confidence Interval)
Educational Interventions, Continued
Powell, 199567
Category: E / 4246 patients on benzapril, metoprolol, simvastatin or estrogen.
9 months / Mailed 1 of 4 educational videotapes. / MPR; pharmacy claims. / No significant between-group differences in mean MPRs.
ES 0.04 (-0.02, 0.10)
Polack, 200868
Category: E
Saskatoon, Saskatchewan. Canada, / 15 patients hospitalized for MI, followed after discharge.
6 weeks / 1. Hospital pharmacist pre-discharge education
2. Pharmacist education 1-2 weeks post discharge vs. Usual care. / Morisky scale. Patients with score <4 defined as being nonadherent. Phone survey, self-report. / % nonadherent patients
pre-discharge education: 20%
post-discharge: 25%
C: 40%
P=NS
ES 0.45 (-0.82, 1.71)
In Methods and Outcomes columns, I = Intervention; C = Control; Controls received usual care unless otherwise specified.
Duration indicates time until last follow up in which adherence is measured. Confidence interval (CI) is 95% unless otherwise specified.
First column: Categories: R= Remind/Reinforce; C = combination OR Health professional; E=Education; B= Behavioral;
HTN = hypertension; BP = Blood pressure; CHF = Congestive heart failure; MI = Myocardial Infarct; MEMS = Medication Electronic Monitoring System; PCP = Primary Care Practitioner;
MPR = Medication Possession Ratio, medication doses taken divided by doses prescribed.
"Morisky scale" has 4 questions: 1 pt for every 'yes" response. 1.Do you ever forget to take your medication? 2.Are you careless at times about taking your medication? 3. When you feel better, do you sometimes stop taking your medication? 4. Sometimes if you feel worse when you take your medication, do you stop taking it?
For all studies where means and standard deviations for adherence outcomes were available, Cohen’s D statistics were calculated. The effect sizes compare the difference in effect between the study groups divided by the standard deviation of this difference. We considered an effect < 0.2 to be very small, an effect size of 0.2 to 0.5 to be small, an effect size of 0.5 to 0.8 to be medium, and an effect size of >0.8 to be large.