Electronic monitoring of adherence to multiple medications in cancer patients: Promise and challenges (Preprint)

BACKGROUND An electronic pillbox can serve as a tracking device for adherence to a complex medication regimen. Blood cancer patients receiving an allogeneic hematopoietic cell transplant (alloHCT), typically prescribed with multiple pills, can benefit from it. Their medication adherence plays a critical role in post-transplant survival, as it can help limit severe side effects and toxic drug interactions. However, existing studies report a wide range of adherence rates. OBJECTIVE Adherence to multiple medications is an important issue for patients with chronic conditions such as cancer but it remains understudied. An electronic pillbox can serve as tracking device for adherence to a complex medication regimen. The current mixed methods study in cancer patients who had received an allogeneic hematopoietic cell transplant (alloHCT) had three aims: (1) to test the feasibility of using an electronic pillbox for tracking a multiple-medication regimen in the first 180 days at home, (2) to describe sensor use and adherence levels, and (3) to capture patient experiences using the electronic pillbox. METHODS Cancer patients after alloHCT (n = 33) received an electronic pillbox at first discharge from hospital and were followed for 180 days. Data to calculate adherence was available for 27 individuals, and 28 patients participated in interviews about their experiences using the electronic pillbox. RESULTS Most patients used their pillbox immediately after discharge and continued using it beyond 180 days, with large variability in signal transmission rates. The average adherence score was 2.2, significantly lower than the prescribed at least four medication doses each day (P<.001) and indicating 55% adherence. In the interviews, patients reported ease of use and benefits of the electronic pillbox, but also challenges, such as the large size and limited battery life of the pillbox. CONCLUSIONS It is feasible to use an electronic pillbox for cancer patients taking multiple medications, although there is room for improvement in the pillbox design. Overall, patients had a positive experience using the electronic pillbox. A user-friendly device would have great potential for a multi-faceted, real-time intervention to facilitate adherence to multiple medication regimens.

Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis

Introduction Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12 months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. Materials and methods This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010–2013 (n = 381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91 days) during the first-year postinjury. Results During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24–34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. Conclusions This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.

MULTIPLE MEDICATION USE AND RISK OF TREATED FALL INJURY: THE HEALTH ABC STUDY

Multiple medication use within one year is associated with increased fall injury risk in older adults. However, chronically using multiple medications and treated fall injury have rarely been explored, particularly in cohort studies linked with claims data. We examined using &gt;5 medications in 2 or more consecutive years (chronic medication use) as a risk factor for treated fall injury in 1,898 community-dwelling adults (age 73.6±2.9 years; 53% women; 37% black) with linked Medicare Fee-For-Service (FFS) claims from the Health, Aging and Body Composition Study since 1997/98 clinic visit. Incident fall injury (N=546) was the first claim from 1998/99 clinic visit to 12/31/08 with an ICD-9 fall code and non-fracture injury code, or fracture code with/without a fall code. Stepwise Cox models with a time-varying predictor of chronic medication use before fall injury or censoring (N=414) vs. not using &gt;5 medications at the same time (N=1008) were adjusted for baseline demographics, lifestyle factors, fall history, quadriceps strength, cardiovascular disease (CVD), diabetes, sensory nerve impairment, and kidney function. Fall injury risk increased for chronic medication users (37%) vs. non-users (29%) (HR=1.25[1.00-1.57]), though was attenuated after adjustment for CVD and diabetes (HR=1.18[0.93-1.51]). Sensitivity analyses excluding fall-risk-increasing drugs (FRIDs) from medication counts (HR=1.32[0.54-3.20]), or including those using &gt;5 medications non-chronically (N=365) in referent groups (HR=1.22[0.96-1.55]) had consistent findings. Unmeasured comorbidity differences may confound associations of chronic medication use and treated fall injury risk in older adults with Medicare FFS. Considering both chronic diseases and medication use in fall risk assessments is needed.

Variations of a Commonly Used Medication Adherence Assessment Scale: Do Changes in Scale Change Structure Results?

Background: Medication nonadherence is a major barrier to both patients and health care professionals when trying to manage medical conditions. An appropriate self-report adherence tool would be helpful in determining a patient’s medication adherence. Objectives: To observe variations in scale scores based on modifications to an Original Adherence Scale, with the hypothesis that making modifications to the Original Adherence Scale will create variations in the percentage of adherent patients. Methods: This cross-sectional study utilized mailed surveys to people identified in a prescription claims administrative dataset who had a pharmacy claim for at least 2 antihypertensive medications. One thousand people were equally divided and randomly placed in 1 of 4 groups: Original Adherence Scale Group, Time Reference Scale Group, 4-Point Likert-Type Scale Group, Multiple Medication Scales Group. Each scale underwent assessment of internal reliability using Cronbach’s α. Changes made to the Original 4-item scale included altering the time reference period from 3 months to 7 days, changing response options from Yes/No to a Likert-type scale, and incorporating multiple scales so that the respondent may report on up to 4 different options. Results: There were 437 surveys completed appropriately, yielding a 46.4% response rate. The overall scale scores indicating perfect adherence was 51.8% for the 4-Point Likert-Type Scale Group, 66.5% for the Multiple Medication Scales Group, 68.8% for the Original Adherence Scale Group, and 78.9% for the Time Reference Scale Group. Conclusion: When there are more selection options, a change in time reference, or more medications reported, the amount of adherent patients varied.