Medication adherence to inflammatory bowel disease medications in Aotearoa New Zealand and correlation with health outcomes: A nationwide database analysis.

AIMS: Inflammatory bowel disease (IBD) management entails long-term medication therapy. Worse disease outcomes and reduced quality of life might arise from poor medication adherence (MA). This study is the first to investigate patients with IBD's adherence across Aotearoa New Zealand and its relationship with disease outcomes. METHODS: Dispensing claims data (Pharmaceutical Collection) were used to calculate (3- and 5-year) adherence, using daily polypharmacy possession ratio. Using hospitalization data (National Minimum Dataset), the relationship between adherence and the numbers of hospitalizations and corticosteroid dispensings was investigated. RESULTS: In total, 4654 patients (53% female; 55% Crohn's disease [CD], 45% ulcerative colitis [UC]; median age-at-first-dispensing, 43 years) and 3148 patients (54% female; 55% CD, 44% UC; median age-at-first-dispensing, 44 years) were in the 3- and 5-year cohorts, respectively. The 3- and 5-year cohorts had mean 4.6 and 4.2 IBD-related hospitalizations and 6.9 and 9.2 corticosteroid dispensings, respectively. Average adherence estimates were 77.4% (95% confidence interval: 76.9-78.0%) and 74.9% (95% confidence interval: 74.1-75.6%; 3 and 5 years), while 54% and 51% of patients, respectively, had good adherence (MA ≥ 80%). There was no correlation between adherence and the numbers of hospitalizations (Pearson's R = -.0007; P = .65 and R = -.04; P = .02 [3 and 5 years]) and corticosteroid dispensings (R = .08; P = <.0001 and R = .08; P = <.0001, respectively). CONCLUSION: MA of Aotearoa New Zealand patients with IBD is moderately high but just over half of patients meet the adherent threshold. There was no correlation between adherence and hospitalizations or corticosteroid dispensings; hence, research into longitudinal adherence patterns and associated factors is needed.

Improving Medication Adherence Levels in Inflammatory Bowel Disease (IBD) Patients: A Narrative Evidence-Based Review.

Inflammatory bowel disease (IBD) management is typified by a long-term medication regimen which can comprise multiple medications prescribed in different combinations, doses, frequencies, and with various administration routes. This complexity can make medication adherence (MA) - patients taking their medications per the prescription - for patients with IBD a challenge. The research corpus contains diverse interventions aimed at improving MA in patients with IBD. Therefore, to condense the evidenced strategies for ease of reference, this narrative evidence-based review broadly outlines the patient-level interventions reported. The interventions are grouped as educational, behavioural, cognitive-behavioural, and multicomponent. They, however, present mixed results as to their efficacy at improving MA, with those employing combined approaches being the most promising. This reflects the reality that MA is impacted by multiple factors encompassing those pertaining to the patient, disease, therapy, patients' socioeconomic status, and health system. Hence, the most ideal interventions would likely be multifaceted patient-level interventions alongside policy/system-level strategies, to maximise the potential for successfully improving patients' MA. These findings might have been impacted by the heterogeneity of the studies in terms of the method of MA assessment, duration of interventions, and more besides.

Using electronic health records in analysing medication adherence in southern New Zealand patients with inflammatory bowel diseases.

AIMS: Electronic health records (EHRs) are widely used in medication adherence (MA) assessment. Poor adherence in patients with inflammatory bowel diseases (IBD) can lead to worse disease outcomes and increased health costs. This study explores the suitability of southern New Zealand EHRs for estimating adherence, and the relationship between adherence and corticosteroid dispensings (indicating negative disease outcomes). METHODS: Medication dispensing EHR data of former Southern District Health Board IBD patients were analysed to estimate 3-year adherence, using daily polypharmacy possession ratio. The correlation with the number of corticosteroid dispensings was investigated. RESULTS: Of 248/1,290 (19%) consenting patients, only 108/248 (44%) had sufficient data available (46%/54% Crohn's disease/ulcerative colitis; 57% female; 89.8%/0.9% NZ European/Maori; mean 5.1 corticosteroid dispensings). Mean adherence was 83.2% (95% confidence interval [CI] 80.0-86.4; standard deviation [SD]:16.7), with 69% of patients having MA ≥80% (good adherence). Median adherence was 13% higher for males versus females (96% vs 83%; p=0.0001). There was no correlation between adherence and the number of corticosteroid dispensings (Pearson's r=0.11; p>0.05). These findings should be considered with caution as the data were not obtained from all pharmacies and the quantum/nature of missing data is unknown. CONCLUSIONS: The patients' adherence seems high, with no correlation with corticosteroid dispensings demonstrated. Useful EHR data are available but need optimisation for adherence assessments.

"It's just like putting your socks on": patients' perspectives on inflammatory bowel disease medication adherence.

Background: A careful, often life-long, medication regimen is central to therapy for Inflammatory Bowel Disease (IBD) - a chronic gut disorder. Hence, medication adherence (MA) - patients taking medications in line with prescription - is important. Previous research indicates that a third of patients with IBD in southern New Zealand have poor medication adherence (MA). Objective: This study investigated these patients' experiences to determine factors that influence their MA, for the first time. Methods: Two focus group discussions (FGDs) were held with IBD patients in Otago, New Zealand. Reflexive thematic analysis from a 'direct realist' viewpoint was used to analyse the data. Results: Data were analysed in three segments: perceptions, experiences and support. Participants perceived MA as a "duty" that was very important to their wellbeing. The participants' MA was centred around a routine requiring proactivity to maintain. MA was negatively impacted by side effects and regimen factors including (high) pill numbers/dose frequency, and getting refills was framed as challenging; whilst healthcare professionals were presented as major MA facilitators. Lastly, the support structures identified included family, friends and colleagues as well as targeted health system factors e.g. medication subsidies. Conclusions: Factors spanning those related to the patients, their socioeconomic status, the disease, IBD therapy and the health system were presented as influencing IBD patients' MA in southern NZ. Thus, multifaceted interventions are needed across the health system to overcome the inhibiting and promote the facilitating elements.

Constraints on medication-based inflammatory bowel disease therapy in Aotearoa New Zealand-why medication adherence is important.

The therapeutic landscape for treating Inflammatory Bowel Disease (IBD) in Aotearoa New Zealand had remained largely unchanged for about a decade; however, just this year, two further biologic medications became available. In an international context, these medications are not exactly new, and several other highly efficacious, modern medications and treatment paradigms are available overseas but not in New Zealand. Medication adherence (MA), alongside factors including (relaxation of) medicines funding criteria, specialist availability, IBD awareness in primary healthcare etc., contributes to good patient care. Hence, we contend that MA remains of particular importance for New Zealand patients with IBD to derive maximum benefits from the limited therapeutic options available. Moreover, increased research and interventions for promoting MA, in IBD especially, are crucial.

Estimating HIV pre-exposure prophylaxis need and impact in Malawi, Mozambique and Zambia: A geospatial and risk-based analysis.

BACKGROUND: Pre-exposure prophylaxis (PrEP), a WHO-recommended HIV prevention method for people at high risk for acquiring HIV, is being increasingly implemented in many countries. Setting programmatic targets, particularly in generalised epidemics, could incorporate estimates of the size of the population likely to be eligible for PrEP using incidence-based thresholds. We estimated the proportion of men and women who would be eligible for PrEP and the number of HIV infections that could be averted in Malawi, Mozambique, and Zambia using prioritisation based on age, sex, geography, and markers of risk. METHODS AND FINDINGS: We analysed the latest nationally representative Demographic and Health Surveys (DHS) of Malawi, Mozambique, and Zambia to determine the proportion of adults who report behavioural markers of risk for HIV infection. We used prevalence ratios (PRs) to quantify the association of these factors with HIV status. Using a multiplier method, we combined these proportions with the number of new HIV infections by district, derived from district-level modelled HIV estimates. Based on these numbers, different scenarios were analysed for the minimum number of person-years on PrEP needed to prevent 1 HIV infection (NNP). An estimated total of 38,000, 108,000, and 46,000 new infections occurred in Malawi, Mozambique, and Zambia in 2016, corresponding with incidence rates of 0.43, 0.63, and 0.57 per 100 person-years. In these countries, 9%-20% of new infections occurred among people with a sexually transmitted infection (STI) in the past 12 months and 40%-42% among people with either an STI or a non-regular sexual partner (NP) in the past 12 months (STINP). The models estimate that around 50% of new infections occurred in districts with incidence rates ≥1.0% in Mozambique and Zambia and ≥0.5% in Malawi. In Malawi, Mozambique, and Zambia, 35.1%, 21.9%, and 12.5% of the population live in these high-incidence districts. In the most parsimonious scenario, if women aged 15-34 years and men 20-34 years with an STI in the past 12 months living in high-incidence districts were to take PrEP, it would take a minimum of 65.8 person-years on PrEP to avert 1 HIV infection per year in Malawi, 35.2 in Mozambique, and 16.4 in Zambia. Our findings suggest that 3,300, 5,200, and 1,700 new infections could be averted per year in the 3 countries, respectively. Limitations of our study are that these values are based on modelled estimates of HIV incidence and self-reported behavioural risk factors from national surveys. CONCLUSIONS: A large proportion of new HIV infections in these 3 African countries were estimated to occur among people who had either an STI or an NP in the past year, providing a straightforward means to set PrEP targets. Greater prioritisation of PrEP by district, sex, age, and behavioural risk factors resulted in lower NNPs thereby increasing PrEP cost-effectiveness, but also diminished the overall impact on reducing new infections.

Adherence to Inflammatory Bowel Disease Medications in Southern New Zealand.

Background: Inflammatory bowel diseases (IBDs) require continuous clinical management; poor medication adherence may result in worse disease outcomes and increased healthcare costs. This study investigated medication adherence and associated risk factors in IBD patients. Methods: Otago (New Zealand) IBD patients were mailed questionnaires on demographics, medication-taking behavior, and a validated Probabilistic Medication Adherence Scale (ProMAS). Results: The response rate was 29.7% (n = 174/590). The study sample was mean (SD) 50.5 (16.9) years old, 57.9% female, 49.4% had Crohn's disease, and 43.9% ulcerative colitis, with median of 9.5 years (interquartile range: 5.0-22.0) of IBD duration. About 31.1% scored below medium adherence according to ProMAS. About 11.9%, 24.7%, and 23.1% reported failing to renew, purposely not taking, and stopping taking medications, respectively; 27.2% of those who reported having no issues taking medication scored below medium on the ProMAS. Older age was associated with higher ProMAS adherence score (Pearson's r = .25; P = .0014). There were no differences in medication adherence between the types of IBDs (P = .87), disease activity status (P = .70), or gender (P = .27). There was no correlation between the number of medications and level of adherence (Pearson's r = .09; P = .27). About 18.7%, 10.1%, and 5.0% of patients reported forgetting to take medications when traveling, when out of routine, and when busy, respectively. The most used strategies to remember medications included utilizing specific routines (40.1%) and keeping medications in specific locations (21.1%). Conclusions: A third of IBD patients had below medium medication adherence. There were discrepancies between self-reported and tool-assessed medication adherence scores with over one-third of patients underestimating/overestimating their adherence.

Longitudinal Effect of Stroke on Cognition: A Systematic Review.

BACKGROUND: Stroke is associated with an increased risk of dementia; however, the impact of stroke on cognition has been found to be variable, such that stroke survivors can show decline, remain stable, or revert to baseline cognitive functioning. Knowing the natural history of cognitive impairment after stroke is important for intervention. The aim of this systematic review is to investigate the longitudinal course of cognitive function in stroke survivors. METHODS AND RESULTS: Three electronic databases (Medline, Embase, PsycINFO) were searched using OvidSP from inception to July 15, 2016. Longitudinal studies with ≥2 time points of cognitive assessment after stroke were included. In total, 5952 articles were retrieved and 14 were included. There was a trend toward significant deterioration in cognitive test scores in stroke survivors (8 studies). Cognitive stability (3 studies) and improvement (3 studies) were also demonstrated, although follow-up time tended to be shorter in these studies. Variables associated with impairment included age, ethnicity, premorbid cognitive performance, depression, stroke location, and history of previous stroke. Associations with APOE*E4 (apolipoprotein E with the E4 allele) allele status and sex were mixed. CONCLUSIONS: Stroke is associated with an increased risk of cognitive decline, but cognitive decline is not a consequence. Factors associated with decline, such as sociodemographic status, health-related comorbidity, stroke history, and clinical features could be used in models to predict future risk of dementia after stroke. A risk model approach could identify patients at greatest risk for timely intervention to reduce the frequency or delay the onset of poststroke cognitive impairment and dementia.