Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation

PLOS ONE, Dec 2019

Aims Poor adherence to medication therapy among type 2 diabetes patients is a clinical challenge. We aimed to determine which factors are associated with the three phases of long-term adherence to medication: initiation, implementation and discontinuation in a register-based study. Methods Adherence to six medicine groups (metformin, sulfonylureas, acetylsalicylic acid, thiazide diuretics, renin angiotensin system inhibitors, and statins) were analysed among 5,232 patients with type 2 diabetes at a tertiary referral hospital during 1998–2009. Rate-ratios of initiation of treatment, recurrent gaps in supply of medication, and discontinuation of treatment were analysed using Poisson regression. Results Poor initiation rather than poor implementation or discontinuation was the main contributor to medication nonadherence. Polypharmacy was a risk factor for slower initiation of treatment for all six medicine groups (rate ratio ranging 0.79 95%CI [0.72–0.87] to 0.89 95%CI [0.82–0.96] per already prescribed medicine), but once patients were in treatment, polypharmacy was not associated with recurrence of gaps in supply of medication, and polypharmacy was associated with lower risk of discontinuation (rate ratio ranging 0.93 95%CI [0.86–1.00] to 0.96 95%CI [0.93–0.99] per prescribed medicine). Other identified risk factors for slow initiation, poor implementation, and discontinuation were diabetes duration, younger age, and Turkish/Pakistani origin. Discussion This study showed that a risk factor does not necessarily have the same association with all three elements of adherence (initiation, implementation and discontinuation), and that efforts supporting patients introduced to more complex drug combinations should be prioritized.

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Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation

June Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation Majken Linnemann Jensen 0 1 2 Marit Eika Jørgensen 0 1 2 Ebba Holme Hansen 0 1 Lise Aagaard 0 1 Bendix Carstensen 0 1 2 0 Data Availability Statement: The data used in this paper was a combination of data obtained from the Steno Diabetes Center Electronic Patient Record and data from national Danish Registers at Denmark Statistics (DST). The Steno Diabetes Center Electronic Patient Record data were obtained after a written application to the Research and Innovation Office (michelle.anne 1 Editor: Ping-Hsun Wu, Kaohsiung Medical University Hospital , TAIWAN 2 Steno Diabetes Center Copenhagen, Gentofte, Denmark, 2 Faculty of Health and Medical Sciences, Department of Pharmacy, Section for Social and Clinical Pharmacy , Universitetsparken 2 , University of Copenhagen, Denmark, 3 Faculty of Health, University of Southern Denmark , Odense , Denmark Aims Methods Results Poor initiation rather than poor implementation or discontinuation was the main contributor to medication nonadherence. Polypharmacy was a risk factor for slower initiation of treatment for all six medicine groups (rate ratio ranging 0.79 95%CI [0.72±0.87] to 0.89 95%CI [0.82±0.96] per already prescribed medicine), but once patients were in treatment, polypharmacy was not associated with recurrence of gaps in supply of medication, and polypharmacy was associated with lower risk of discontinuation (rate ratio ranging 0.93 95%CI [0.86±1.00] to 0.96 95%CI [0.93±0.99] per prescribed medicine). Other identified risk factors for slow initiation, poor implementation, and discontinuation were diabetes duration, younger age, and Turkish/Pakistani origin. ). Data from Steno's Electronic Patient Records and DST were merged by DST and analyses were performed via a secure VPN connection. Due to the Danish Act of processing of personal data, future interested researchers have to perform the above-mentioned steps to obtain access to the data. Funding: This study received funding from The Danish Agency for Science, Technology and Innovation, Bredgade 40, DK-1260 Copenhagen K Grant number: 11-117460 www.http:// innovationsfonden.dk/en, ªdanmarkº sygeforsikring (a mutual health insurance company) www.sygeforsikring.dk M.L.J, M.E.J. and B.C. were employed at Steno Diabetes Center until 31 December 2016, a diabetes research hospital and a teaching center owned by Novo Nordisk A/S, associated with Copenhagen University Hospital, and working in partnership with the health authorities of the Capital Region of Denmark. Steno Diabetes Center A/S received part of its core funding from unrestricted grants from the Novo Nordisk Foundation and Novo Nordisk A/ S. M.L.J., M.E.J. and B.C. own shares in Novo Nordisk A/S. No one at the Novo Nordisk Foundation or at Novo Nordisk A/S had any role in study design, data collection and analysis, decisions to publish, or preparation of the manuscript. Steno Diabetes Center provided support in the form of salaries for authors [M.L.J, M.E.J. and B.C.], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the `author contributions' section. Competing interests: M.L.J, M.E.J. and B.C. are employed at Steno Diabetes Center, a diabetes research hospital and a teaching center owned by Novo Nordisk A/S, associated with Copenhagen University Hospital, and working in partnership with the health authorities of the Capital Region of Denmark. Steno Diabetes Center A/S receives part of its core funding from unrestricted grants from the Novo Nordisk Foundation and Novo Nordisk A/ S. M.L.J., M.E.J. and B.C. own shares in Novo Nordisk A/S. This study received part funding from "danmark" sygeforsikring, Palñgade 5, DK-1261 Copenhagen K, Denmark (a mutual health insurance company). Sygeforsikringen "danmark" is a mutual insurance company which specializes in health insurance. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors. Discussion This study showed that a risk factor does not necessarily have the same association with all three elements of adherence (initiation, implementation and discontinuation), and that efforts supporting patients introduced to more complex drug combinations should be prioritized. Introduction Poor adherence to medication therapy in chronic disease is associated with a worsening of clinical status/health[ 1, 2 ], higher risk of hospitalisation[3], risk of medicine-related hospital admissions[ 4 ] and higher mortality risk[ 5 ]. Losing adherence has been shown to be associated with more hospitalizations and emergency department visits[ 6 ]. Improving adherence (...truncated)


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Majken Linnemann Jensen, Marit Eika Jørgensen, Ebba Holme Hansen, Lise Aagaard, Bendix Carstensen. Long-term patterns of adherence to medication therapy among patients with type 2 diabetes mellitus in Denmark: The importance of initiation, PLOS ONE, 2017, Volume 12, Issue 6, DOI: 10.1371/journal.pone.0179546