Most Effective Adherence-Enhancing Interventions for Osteoporosis MedicationsMost Effective Adherence-Enhancing Interventions for Osteoporosis MedicationsMickaël Hiligsmann1-2, Maribel Salas 3,4, Dyfrig A. Hughes 5, Elizabeth Manias 6, Femida H. Gwadry-Sridhar 7, Pat Linck 5, Warren Cowell 8

1 Maastricht University, Netherlands. 2 University of Liège, Belgium. 3 AstraZeneca, USA. 4 CCEB, University of Pennsylvania, USA 5 Bangor University, United Kingdom. 6 University of Melbourne, Australia. 7 University of Western Ontario, Canada, 8 Bayer, United Kingdom

IntroductionIntroduction

Adherence to osteoporosis medications is suboptimal with persistence rates of between 25% and 35% at one year. This results in higher fracture rates with significant medical costs and hospitalizations. Over the past years, interventions have been proposed to improve medication adherence. The objective of this study was to critically appraise the literature and determine the most effective adherence-enhancing interventions for osteoporosis medications.

We conducted a literature search using Medline, EMBASE, Cochrane library and CINAHL using the following key words: osteoporosis, low bone density, low bone mineral density, low bone mass, low bone turnover, low bone mass density and bisphosphonates, calcium, colecalciferol, estrogens, hormone replacement therapy, raloxifene, vitamin D and patient compliance, adherence, concordance, persistence, and interventions, clinical trials, RCT. The search period was January 1st, 1999 to July 31st, 2010. We included studies on adult users of osteoporosis medications that evaluated an adherence-enhancing intervention (e.g. patient education, intensified patient care), and which reported quantitative results of adherence. Each article was reviewed independently by two investigators and disagreements were resolved by consensus. Downs’ checklist was modified to assess the quality of studies. Since the studies were too heterogeneous, we focused on a narrative systematic review.

The most effective adherence interventions with osteoporosis medications were in patients monitored by nursing staff and received education. There is a need to conduct additional research with interventions and to consider the impact of specific pharmacological treatments on medication adherence.

This work was conducted by the Medication Adherence and Persistence SIG from the International Society of Pharmacoeconomics and Outcomes Research

Identified abstracts = 27

Studies that fulfilled inclusion criteria = 8Education = 6Monitoring/supervision = 2

ExcludedReviews = 5Protocols = 1Lack of intervention = 7No quantitative data on adherence = 6

Flow diagram of Studies

Results of Included StudiesReference Outcomes Control Intervention

for StudyP value

Blalock et al, 2002 Adherence/Calcium (Ca) intake

Ca –not changes

↑ Ca intake 500mg/d

<0.05

Clowes et al, 2004 Adherence 42% 65% 0.04Robbins et al, 2004 Adherence 81% 87% <0.05Delmas et al, 2007 Persistence 77% 80% 0.016Cook et al, 2007 Adherence 40% 69% <0.001Shu et al, 2009 MPR 73% 74% 0.18Nielsen et al, 2010 Adherence 80% 92% 0.006Ojeda-Bruno et al, 2011 Adherence/Persistence 16% 71% / 76% --

ISPOR 16th Annual International Meeting, May 24, 2011, Baltimore, MD, USA

27 publications were identified including 8 studies which randomized more than 4,500 patients fulfilled the inclusion criteria. Articles on reviews (5), protocols (1), lack of intervention (7) or no quantitative data on adherence (6) were excluded. The most frequent intervention was education (6) followed by monitoring/supervision (2). Four studies used randomization, which was led by nurses (3), pharmacists (1), physicians (1) and

Table 1. Characteristics of Included Studies

Reference Type of intervention Study design Sample size Follow-up timeRandomization Use of

ComparatorStudy Group

Control Group

Blalock et al. 2002 Tailored educational program No Yes 714 0 12 mClowes et al. 2004 Monitoring Yes Yes 73 24 1 yRobbins et al. 2004 Educational information by nurses No No 109 0 1 yDelmas et al. 2007 Monitoring and feedback on results Yes Yes 2302 1113 1 yCook et al. 2007 Telehealth program No No 402 0 6 mShu et al. 2009 Physician’s directed education Yes Yes 1867 875 10 mNielsen et al. 2010 Group-based educational program Yes Yes 300 150 2 yOjeda-Bruno et al. 2011 Patient education by nurse/ physician No No 380 0 4 y

Table 2. Results of Included Studies

multidisciplinary teams (2). Follow-up ranged from 3 to 48 months. The average intervention effect ranged from 12% (education) to 24% (patients monitored by nursing staff). The average quality score was 65.7%.

Materials and MethodsMaterials and Methods

ResultsResults

ConclusionConclusion

AcknowledgementsAcknowledgements