Adherence to cardiovascular pharmacotherapy by patients in Iraq: A mixed methods assessment using quantitative dried blood spot analysis and the 8-item Morisky Medication Adherence Scale

Abstract

This study evaluated the adherence to prescribed cardiovascular therapy medications among cardiovascular disease patients attending clinics in Misan, Amara, Iraq. Mixed methods were used to assess medication adherence comprising the Arabic version of the eight-item Morisky Medication Adherence Scale (MMAS-8) and determination of drug concentrations in patient dried blood spot (DBS) samples by liquid chromatography-high resolution mass spectrometry. Three hundred and three Iraqi patients (median age 53 years, 50.5% female) who had been taking one or more of the nine commonly prescribed cardiovascular medications (amlodipine, atenolol, atorvastatin, bisoprolol, diltiazem, lisinopril, losartan, simvastatin and valsartan) for at least six months were enrolled. For each patient MMAS-8 scores were determined alongside drug concentrations in their dried blood spot samples. Results from the standardized questionnaire showed that adherence was 81.8% in comparison with 50.8% obtained using the laboratory-based microsample analysis. The agreement between the indirect (MMAS-8) and direct (DBS analysis) assessment approaches to assessing medication adherence showed significantly poor agreement (kappa = 0.28, P = 0.001). The indirect and direct assessment approaches showed no significant correlation between nonadherence to prescribed cardiovascular pharmacotherapy and age and gender, but were significantly associated with the number of medications in the patient’s treatment regimen (MMAS-8: Odds Ratio (OR) 1.947, 95% CI, P = 0.001; DBS analysis: OR 2.164, 95% CI, P = 0.001). The MMAS-8 results highlighted reasons for nonadherence to prescribed cardiovascular pharmacotherapy in this patient population whilst the objective DBS analysis approach gave valuable information about nonadherence to each medication in the patient’s treatment regimen. DBS sampling, due its minimally invasive nature, convenience and ease of transport is a useful alternative matrix to monitor adherence objectively in Iraq to cardiovascular pharmacotherapy. This information combined with MMAS-8 can provide clinicians with an evidence-based novel approach to implement intervention strategies to optimise and personalise cardiovascular pharmacotherapy in the Iraqi population and thereby improve patient health outcomes.

Medication Adherence and Belief about Medication among Vietnamese Patients with Chronic Cardiovascular Diseases within the Context of Implementing Measures to Prevent COVID-19

“…In Ethiopia, a study by Shimels et al reported an even lower figure for diabetic and hypertensive patients during the COVID-19 epidemic with only 28% adherence [ 28 ]. In contrast, the percentage of patients’ adherence in our study was lower than in an earlier study in Iraq that determined adherence based on a questionnaire (81.8%) [ 29 ]. However, most published studies on medication adherence in CVD patients used the eight-item Morisky Medication Adherence Scale (MMAS-8) questionnaire, which is distinct from the GMAS questionnaire we used since it does not mention the economic factors affecting adherence.…”

Medication Adherence Among Geriatric Patients with Chronic Diseases in Riyadh, Saudi Arabia

“…The total score ranges from −0-33, a higher score indicating a high adherence level. The final score is stratified into five groups; high (30)(31)(32)(33), good (27)(28)(29), partial (17)(18)(19)(20)(21)(22)(23)(24)(25)(26), low (11)(12)(13)(14)(15)(16), and poor (≤10). Prior to conducting this study, permission to use the tool was obtained.…”

“…Self-reported medication adherence questionnaires are one of the acceptable tools. 11 In Saudi Arabia, Morisky's Medication Adherence Scale (MMAS) and General Medication Adherence Scale (GMAS) are common validated instruments used for assessing medication adherence. 12 GMAS is considered more sensitive, specific, and accurate than MMAS.…”

Utilizing quantitative dried blood spot analysis to objectively assess adherence to cardiovascular pharmacotherapy among patients at Kenyatta National Hospital, Nairobi, Kenya

“…For instance, pill counts simply confirm the number of tablets removed from their original container but cannot corroborate if these tablets have actually been consumed by the patient. Although questionnaire tools are widely used, they are subjective as the evaluation is dependent on the participant's belief and recall bias [18]. Furthermore, this indirect adherence assessment strategy provides no information about the time a dose was taken and is unable to take into consideration drug pharmacokinetics and pharmacodynamics which vary from patient to patient and which may be fundamental in establishing clinical outcomes [6].…”