Providing physicians with feedback on medication adherence for people with chronic diseases taking long‐term medication

Vincent Zaugg; Virginie Korb‐Savoldelli; Pierre Durieux; Brigitte Sabatier

doi:10.1002/14651858.CD012042.pub2

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Figure 1

Flow diagram for study selection.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Summary of findings for the main comparison. Summary of findings: feedback on medication adherence to physicians versus usual care

Feedback on medication adherence to physicians versus usual care
Patient or population: any physician, and any patient treated for chronic diseases with long‐term medication use Settings: hospitals or community, USA and Canada Intervention: feedback on medication adherence to physicians Comparison: usual care
Outcomes	Effect of providing feedback on medication adherence to physicians	No of patients (studies)	Certainty of the evidence (GRADE)
Medication adherence Percentage of 'days covered' by medication (medication possession ratio), percentage of 'time covered', percentage of non‐adherent patients, 'time‐to‐refill' (i.e. the number of days between the date where the patient was declared 7 days overdue, and the date of the next refill)	Intervention may lead to little or no difference to medication adherence	22,924 (7 studies)	⊕⊕⊝⊝ Low^a,b
Patient outcomes Lipid levels, HbA1C level, HIV viral load, number of major atherosclerosis disease events	Intervention may lead to little or no difference to patient outcomes	1292 (2 studies)	⊕⊕⊝⊝ Low^a,b
Health resource use Rate of hospitalisations, rate of emergency department encounters, rate of outpatient encounters, rate of oral steroid use	Intervention may lead to little or no difference to health resource use	4181 (2 studies)	⊕⊕⊝⊝ Low^a,b
Processes of care Rate of medication change (medication discontinued, added, replaced), proportion of visits with appropriate management of uncontrolled hypertension, patient rating (quality of care, duration of the visit, communication with physician), patient‐physician dialogue (utterance related to treatment, medication adherence, side effects)	Intervention may improve processes of care.	2780 (4 studies)	⊕⊕⊝⊝ Low^b,c
Adverse events	None of the 9 studies reported an adverse event due to the intervention.	—	—
GRADE Working Group grades of evidence High quality: this research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different* is low. Moderate quality: this research provides a good indication of the likely effect. The likelihood that the effect will be substantially different* is moderate. Low quality: this research provides some indication of the likely effect. However, the likelihood that it will be substantially different* is high. Very low quality: this research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different* is very high. *Substantially different = a large enough difference that it might affect a decision.
^aEvidence downgraded one level due to limitations in the design and implementation: high risk of contamination bias. ^bEvidence downgraded one level due to indirectness of evidence: most studies used pharmacy refill data to measure adherence, while other methods could be used in other settings. ^cEvidence downgraded one level due to unexplained heterogeneity or inconsistency of results.

Summary of findings for the main comparison. Summary of findings: feedback on medication adherence to physicians versus usual care

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Table 1. Details of the interventions implemented

Study/country	Study type	Medication	Feedback type/delivery approach	Data source	Intervention description	Intervention received by control group of physicians group	N patients (N physicians)^a
Bambauer 2006 USA	ITS analysis	Antidepressants	Alert/faxed	Pharmacy refill data	Physicians were alerted via fax in real‐time when their patient had a gap of more than 10 days in refilling antidepressant prescription.	No intervention	13,128 (NR)
Bieszk 2003 USA	Cluster‐RT	Any medication	Systematic/printed report	Pharmacy refill data	A printed medication refill history report was provided to physicians before the patient's encounter.	No intervention	231 (32)
Kronish 2016 USA	Cluster‐RT	Antihypertensive drugs	Systematic/printed report	Electronic device	A printed adherence report was provided to physicians before the patient's encounter. The report also provided clinical decision support by listing suggested clinical actions according to adherence status.	No intervention	100 (49)
Nietert 2009 USA	RT	Medication used to treat diabetes, hypertension, hyperlipidaemia, heart failure, depression, or psychosis.	Alert/faxed	Pharmacy refill data	Physicians were alerted via fax once per week about patients with a gap of more than 7 days in refilling medication. Fax included patient adherence data and prompts to assist the patient.	No intervention	2030 (175)
Pladevall 2015 USA	RT	Oral diabetes medication and a lipid‐lowering medication	Systematic/electronic prescription software	Pharmacy refill data	Physicians were provided, via electronic prescription software, with medication adherence of their patients, along with HbA1C (glycated haemoglobin) and LDL‐C (low‐density lipoprotein cholesterol) measurements. Physicians could also view trends in a patient's medication adherence over time by drug class. Physicians were given instruction on how to interpret and discuss this information with patients.	No intervention	1136 (NR)
Tamblyn 2010 Canada	RT	Lipid‐lowering or antihypertensive drugs	Systematic/Electronic prescription software	Pharmacy refill data	Physicians were provided, via electronic prescription software, with the list of prescribed and dispensed drugs; medication adherence for each drug; drug costs; out‐of‐pocket expenses; and received an alert for non‐adherent patients.	List of prescribed and dispensed drugs in the electronic prescription software.	2293 (NR)
Williams 2010 USA	Cluster‐RT	Anti‐asthma drugs	Systematic/electronic prescription software	Pharmacy refill data	Physicians were provided, via electronic prescription software, with adherence data for inhaled corticosteroid (ICS) use; the frequency of short‐acting beta‐agonist use; and the strength of each patient's current ICS prescription. In addition, the physician received asthma guidelines and methods for discussing non‐adherence with patients.	The physician received asthma guidelines and methods for discussing non‐adherence with patients.	2698 (193)
Willis 2013 USA	RT	Medication used to treat asthma, diabetes, hypertension, congestive heart failure, ischemic heart disease or stroke	Systematic/Printed report	Pharmacy refill data	A printed report was provided to physicians before the patient's encounter. The report contained a list of dispensed drugs with a calculation and a graphical depiction of adherence, and recommendations addressing possible deficiencies relative to pharmacotherapy guidelines.	No intervention	1483 (NR)
Wilson 2010 USA	Cross‐over‐RT	Antiretroviral drugs	Systematic/Printed report	Electronic device + self report	A printed report was provided to physicians before the patient's encounter. The report included electronic adherence data and patient survey data (self‐reported adherence, reminder use, beliefs about antiretroviral drugs, reasons for missed doses, alcohol and drug use, and depression).	No intervention	156 (41)
ITS: Interrupted time series; MPR: medication possession ratio; NR: not reported; RT: randomised (controlled) trial. ^aNumbers of participants refer to those included in the statistical analyses.

Table 1. Details of the interventions implemented

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Table 2. Principal results of studies for the outcome 'medication adherence'

Study	Definitions of the outcome 'medication adherence'	Result
Bambauer 2006	Rate of patients more than 30 days overdue for prescription refill^a	Immediate decrease of 2% (P = 0.15) then increase of 0.3% (P = 0.22) each month during the intervention. Over the entire study period, constant average of 75% (95% CI 72.7% to 77.3%)
Bambauer 2006	Proportion of days without treatment ('days uncovered')^a	Immediate decrease of 2% (P = 0.15) then increase of 0.4% (P = 0.04) each month during the intervention. Over the entire study period, constant average of 40% (95% CI 38.4% to 41.6%)
Nietert 2009	Median number of days from alert date to the next date of refill for any medication indicated for the patient's index disease (time‐to‐refill)^a	Intervention group: 116 days; control group: 106 days HR 0.87 (98.3% CI 0.76 to 1.00; P > 0.05)
	Within 30 days of index date, filled prescription for any medication indicated for the patient's index disease	Intervention group: N = 213 (21.0%); control group: N = 243 (24.0%) OR 0.83 (97.5% CI 0.65 to 1.06; P > 0.05)
	Within 60 days of index date, filled prescription for any medication indicated for the patient's index disease	Intervention group: N = 342 (33.7%); control group: N = 373 (36.8%) OR 0.83 (98.3% CI 0.65 to 1.07; P > 0.05)
	Within 30 days of index date, filled prescription for any medication	Intervention group: N = 484 (47.6%); control group: N = 490 (48.3%) OR 0.99 (95% CI 0.81 to 1.19; P > 0.05)
Pladevall 2015	Adherence to oral diabetes medications at 6 months (MPR)	Intervention group: 0.74 ± 0.36; control group: 0.75 ± 0.35 Postintervention MD −0.01 (95% CI −0.72 to 0.70; P = 0.67)
	Adherence to oral diabetes medications at 12 months (MPR)	Intervention group: 0.74 ± 0.36; control group: 0.75 ± 0.35. Postintervention MD −0.01 (95% CI −0.72 to 0.70; P = 0.57)
	Adherence to oral diabetes medications at 18 months (MPR)	Intervention group: 0.73 ± 0.37; control group: 0.75 ± 0.36 Postintervention MD −0.02 (95% CI −0.75 to 0.71; P = 0.47)
	Adherence to lipid lowing medications at 6 months (MPR)	Intervention group: 0.69 ± 0.36; control group: 0.70 ± 0.37 Postintervention MD −0.01 (95% CI −0.74 to 0.72; P = 0.88)
	Adherence to lipid lowing medications at 12 months (MPR)	Intervention group: 0.69 ± 0.37; control group: 0.70 ± 0.36 Postintervention MD −0.01 (95% CI −0.74 to 0.72; P = 0.78)
	Adherence to lipid lowing medications at 18 months (MPR)	Intervention group: 0.70 ± 0.37; control group: 0.70 ± 0.37 Postintervention MD 0.00 (95% CI −0.74 to 0.74; P = 0.95)
Tamblyn 2010	Change in medication adherence (MPR)	Difference between postintervention and preintervention periods, intervention group: −6.2% (95% CI 79.7% to 73.5%); control group: −6.4% (95% CI −79.2% to 72.9%). Adjusted postintervention MD 0.11% (95% CI −1.8 to 2.1; P = 0.90)
Williams 2010	Inhaled corticosteroid adherence at the end of the study (MPR)^a	Intervention group: 23.3% ± 2.2; control group: 21.3 % ± 2.5 (P = 0.55) Difference between study end and preintervention period, intervention group: −4.4% ± 1.2; control group: −4.4% ± 0.7. Postintervention MD 0.0% (95% CI −1.9 to 1.9; P = 0.99)
Willis 2013	Overall medication adherence (MPR)^a	Data not provided
	Medication adherence by drug class (MPR)	'All medication classes': intervention group: 41.2%; control group: 41.3% Postintervention MD −0.01% (P = 0.82)
	Medication adherence by disease condition (MPR)	'All diseases': intervention group: 40.6%; control group: 39.3% Postintervention MD 1.3% (P = 0.77)
Wilson 2010	Antiretroviral adherence, electronic data (percentage of 'time covered') between the first physician visit and the crossover physician visit^a	Postintervention MD 2.0% (95% CI −5.1 to 9.1; P = 0.57)
Wilson 2010	Medication adherence, self‐report data	No significant difference, i.e. P > 0.05 (data not shown in study)
CI: confidence interval; HR: hazard ratio; MD: mean difference; MPR: medication possession ratio; OR: odds ratio. ^aStudy's primary outcome.

Table 2. Principal results of studies for the outcome 'medication adherence'

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Table 3. Principal results of studies on patient outcomes

Study	Definitions of the patient outcome	Result
Pladevall 2015	HbA1C at 18 months (%)^a	Intervention group: 7.91 ± 1.53; control group: 7.88 ± 1.53 Postintervention MD 0.03% (95% CI −3.03 to 3.09; P = 0.76)
	LDL‐C at 18 months (%)^a	Intervention group: 87.27 ± 35.67; control group: 89.02 ± 32.11 Postintervention MD −1.75% (95% CI −69.53 to 66.03; P = 0.38)
	HbA1C at 6 months (%)	Intervention group: 7.90 ± 1.44; control group: 7.81 ± 1.42 Postintervention MD 0.09% (95% CI −2.77 to 2.95; P = 0.29)
	HbA1C at 12 months (%)	Intervention group: 7.96 ± 1.54; control group: 7.94 ± 1.60 Postintervention MD 0.02% (95% CI −3.12 to 3.16; P = 0.83)
	LDL‐C at 6 months (%)	Intervention group: 92.07 ± 36.68; control group: 92.92 ± 32.33 Postintervention MD ‐0.85% (95% CI −69.86 to 68.16; P = 0.67)
	LDL‐C at 12 months (%)	Intervention group: 90.70 ± 36.90; control group: 90.63 ± 32.41 Postintervention MD 0.07% (95% CI −69.24 to 69.38; P = 0.97)
	Number of major atherosclerosis disease event by 18 months	Intervention group: 43 (7.6%); control group: 29 (5.1%) Postintervention MD 1.49% (P = 0.091)
	Number of major atherosclerosis disease event by 24 months	Intervention group: 80 (14.1%); control group: 63 (11.1%) Postintervention MD 1.27% (P = 0.13)
	Number of major atherosclerosis disease event by 36 months	Intervention group: 112 (19.7%); control group: 101 (17.8%) Postintervention MD 1.11% (P = 0.42)
Wilson 2010	Plasma HIV RNA viral loads	No significant difference between the intervention and control groups, i.e. P > 0.05 (data not shown)
CI: confidence interval; HbA1C: glycated haemoglobin; LDL‐C: low density lipoprotein cholesterol; MD: mean difference; RNA: ribonucleic acid. ^aStudy's primary outcome.

Table 3. Principal results of studies on patient outcomes

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Table 4. Principal results of studies for the outcome "health resource use"

Study	Definitions of the outcome 'health resource use'	Result
Williams 2010	Rate of asthma‐related emergency room visits	RR 1.13 (95% CI 0.71 to 1.80; P = 0.61)
	Rate of asthma‐related hospitalisations	RR 0.93 (95% CI 0.34 to 2.56; P = 0.89)
	Rate of oral steroid use	RR 1.07 (95% CI 0.89 to 1.29; P = 0.45)
Willis 2013	Rate of outpatient encounters (per 100 participants during 6 months)	Intervention group: 46.6%; control group: 46.0% RR 1.01 (P = 0.42)
	Rate of emergency department encounters (per 100 participants during 6 months)	Intervention group: 0.84%; control group: 0.87% RR 0.97 (P = 0.77)
	Rate of hospitalisations (per 100 participants during 6 months)	Intervention group: 0.21%; control group: 0.19% RR 1.11 (P = 0.96)
CI: confidence interval; RR: relative rate.

Table 4. Principal results of studies for the outcome "health resource use"

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Table 5. Principal results of studies for the outcome 'processes of care'

Study	Definitions of the outcome 'processes of care'	Result
Bieszk 2003	Rate of patients with medication change	Intervention group: 70.5%; control group: 22.2% RR 3.18 (P = 0.001)
	Rate of patients with dosage change	Intervention group: 21.0%; control group: 7.1% RR 2.96 (P = 0.002)
	Rate of patients with change in medication usage directions	Intervention group: 1.9%; control group: 0% RR not calculable (P = 0.16)
	Rate of patient with medication added	Intervention group: 41.9%; control group: 13.5% RR 3.10 (P = 0.001)
	Rate of patients with medication discontinued	Intervention group: 15.2%; control group: 4% RR 3.8 (P = 0.008)
	Rate of patients with a non‐formulary medication replaced with a formulary agent	Intervention group: 18.1%; control group: 0% RR not calculable (P = 0.001)
Kronish 2016	Proportion of visits with appropriate management of uncontrolled hypertension^a	Intervention group: 69%; control group: 34% RR 2.03 (P = 0.001)
	Patient rating: quality of care during the visit	Intervention group: 71%; control group: 53% RR 1.34 (P = 0.05)
	Patient rating: satisfaction with the amount of time spent during the visit	Intervention group: 92%; control group: 80% RR 1.15 (P = 0.11)
	Patient rating: perceptions of patient‐centred communication	Intervention group: 59%; control group: 37% RR 1.59 (P = 0.001)
	Patient rating: perceptions of collaborative communication	Intervention group: 49%; control group: 29% RR 1.69 (P = 0.02)
Tamblyn 2010	Rate of access to the list of prescribed and dispensed drugs ('drug profile review')^a	Intervention group: 44.5%; control group: 35.5% OR 1.46 (95% CI 1.21 to 1.76; P < 0.001)
	Change in therapy: rate of increase in therapy^a	Intervention group: 28.5%; control group: 29.1% OR: 0.98 (95% CI 0.80 to 1.21; P = 0.86)
	Change in therapy: rate of discontinuation due to adverse effects^a	Intervention group: 2.3%; control group: 2.0% OR: 1.18 (95% CI 0.63 to 2.19; P = 0.61)
Wilson 2010	Median number of ART‐related utterances in patient‐physician dialogue	Intervention group: 76 (IQR 52 to 127); control group: 49.5 (IQR 28 to 113) (P = 0.07)
	Median number of utterances about adherence to the ART regimen	Intervention group: 51.5 (IQR 37 to 77); control group: 32.5 (IQR 17 to 52) (P < 0.001)
	Median number of utterances about ART side effects	Intervention group: 0 (IQR 0 to 11); control group: 0 (IQR 0 to 8) (P = 0.96)
	Median number of utterances about ART prescription	Intervention group: 0 (IQR 0 to 15); control group: 0 (IQR 0 to 17) (P = 1.00)
	Median number of utterances classified as 'ART problem solving'	Intervention group: 0 (IQR 0 to 12); control group: 0 (IQR 0 to 2) (P = 0.05)
ART: antiretroviral therapy; CI: confidence interval;IQR: interquartile range; OR: odds ratio; RR: relative rate. ^aStudy's primary outcome

Table 5. Principal results of studies for the outcome 'processes of care'

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