Comparison of Interventions to Improve Long-Term Medication Adherence Across Different Clinical Conditions: A Systematic Review With Network Meta-Analysis

Abstract

Background: Medication non-adherence has a dynamic, temporal and multifactorial nature with a significant impact on economic and clinical outcomes. Interventions to improve adherence are complex and require adaptation to patients' needs, which may include patient's medical conditions. The aim of this study was to assess the comparative effectiveness of medication adherence interventions per type of clinical condition on adult patients.Methods: A systematic review with network meta-analysis was performed (PROSPERO registration number of CRD42018054598). An initial Pubmed search was conducted to select meta-analyses reporting results of interventions aiming to improve medication adherence. Primary studies were selected and those reporting results with a long-term follow up (≥10 months) on adult patients were included for data extraction. Study characteristics, description of interventions and adherence outcomes were extracted. Adherence interventions were classified in four groups: educational, attitudinal, technical, and rewards. Clinical conditions were classified in four groups: circulatory system and metabolic diseases, infectious diseases, musculoskeletal diseases, and mental, behavioral or neurodevelopmental disorders. Network meta-analyses with effect sizes expressed as odds ratio (OR) with a 95% credibility interval (CrI) were built. Ranking probabilities for each measure of adherence were calculated by using surface under the cumulative ranking analysis (SUCRA).Results: A total of 61 meta-analysis and 149 primary studies were included in the qualitative synthesis and 80 primary studies in the quantitative analysis. The most effective interventions were: educational + technical 79.6% [OR: 0.44 (CrI: 0.26, 0.73)] and 73.3% [OR: 0.56 (0.36, 0.84)] in circulatory system and metabolic diseases and infectious diseases respectively. Attitudinal intervention had the greatest probability for musculoskeletal diseases of 92.3% in SUCRA [OR: 0.30 (0.10, 0.86)]. Finally, educational + attitudinal interventions had the greatest effect (SUCRA 73.8%) for mental, behavioral or neurodevelopmental disorders, although this was not significant according to consistency analysis.Conclusion: Effectiveness of interventions seems to be related to the clinical condition. Educational and technical interventions resulted in a major effect on long-term management of medication adherence in patients with infectious diseases (HIV) and circulatory system and metabolic diseases whereas attitudinal components presented a higher effect on musculoskeletal and mental, behavioral or neurodevelopmental disorders.

Determinants of Primary Nonadherence to Medications Prescribed by General Practitioners Among Adults in Hungary: Cross-Sectional Evaluation of Health Insurance Data

“…Some interventions tested globally to enhance adherence included simple dose adjustment and reduction of the number of medications (Burke et al, 1997; Schedlbauer et al, 2010), reminders and improved scheduling (Claxton et al, 2001), and educational interventions (Kuntz et al, 2014; Torres-Robles et al, 2018). Other interventions included more comprehensive and complex strategies, such as expansion of the pharmacist role in health care, enhancement of patient–health care provider communication and trust, provision of services (Lu et al, 2008; Banning, 2009), proper description of disease and medications (Osterberg and Blaschke, 2005; Huang et al, 2017), habit analysis and management of side effects (Omran et al, 2012; Conn and Ruppar, 2017), patient follow-up, social and behavioral support and motivation (DiMatteo et al, 2012; Varshney, 2013; Kuntz et al, 2014; Ferdinand et al, 2017), and acting on patients’ feedback (Farris et al, 2016).…”

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services

“…Several simple and complex interventions have been tried to improve adherence. Some of the interventions that have been examined have entailed reducing the number of prescribed drugs and adjusting the dose [27,34], giving medication reminders and improving medication schedules [35], and employing educational strategies [8,36,37]. More complex and comprehensive strategies have also been implemented and tested.…”

Temporal effectiveness of interventions to improve medication adherence: A network meta-analysis

“…This was achieved by evaluating the patterns and changes of the effect of intervention components comprehensively across all clinical conditions over time, by not limiting our research to a clinical condition, a setting or a specific intervention type. Previous research demonstrated that the effectiveness of interventions may be related to the clinical condition [ 13 ]. Although including different clinical conditions in the network meta-analysis may be considered as a drawback due the potential heterogeneity induced, in our research, the four periods of evaluation contain an almost identical mix of medical conditions.…”

“…While patient population characteristics may have an effect on adherence, determinants and barriers for non-adherence are often comparable across different medications and clinical conditions. [ 11 – 13 ].…”