Rheumatology
Rheumatol Int (2016) 36:1543–1548 DOI 10.1007/s00296-016-3558-4
INTERNATIONAL
HEALTH SERVICES RESEARCH
Use of medication reminders in patients with rheumatoid arthritis Sebastian Bruera1 · Andrea G. Barbo2 · Maria A. Lopez‑Olivo3
Received: 16 March 2016 / Accepted: 25 August 2016 / Published online: 2 September 2016 © Springer-Verlag Berlin Heidelberg 2016
Abstract Patients with rheumatoid arthritis (RA) often have difficulties adhering to their medical treatment plans. We determined the characteristics of patients with RA who used reminders and the association between reminders and adherence. A total of 201 patients with RA were asked the frequency of reminders use such as pill containers, calendars, or diaries. Patients completed self-reported adherence questionnaires, and their disease activity and functional ability were measured. Sixty-eight patients (34 %) reported using a reminder. Factors associated with reminder use were older age (yes-mean age 54 vs no-mean age 49, p = 0.004), race (Whites—54 % vs Blacks—30 % vs Hispanics—26 %, p = 0.003), and sex (males—50 % vs females 28 %, p = 0.005). Working patients were less likely to use reminders (employed—21 % vs unemployed—43 %, p = 0.006). Use of calendars was associated with adherence while away from home (ρ = 0.16, p = 0.03), when busy (ρ = 0.16, p = 0.03), and use of any reminder was associated with adherence when running out of pills (ρ = 0.15, p = 0.04). The use of calendar reminders was associated with fewer tender joints (ρ = −0.17, p = 0.02). Few patients with RA used reminders, and whites, males and patients of increasing age were most
* Maria A. Lopez‑Olivo
[email protected] 1
Department of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
2
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
3
Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1465, Houston, TX 77030, USA
likely to use reminders. Our findings show that reminders can assist patients with RA in taking medications, particularly when they are most prone to forgetting, such as when they are away from home or busy. Providers should encourage using reminders as a low-cost aid to enhance adherence. Keywords Reminders · Treatment adherence · Rheumatoid arthritis · Compliance · Compliance questionnaire rheumatology
Introduction Reminders are forms of individualized supervision that could encourage adherence by providing practical ways of coping with a treatment plan. A patient’s decision to use reminders may be influenced by several factors, including medication factors such as the number of medications, frequency of administration, route of administration, and dosage schedule [1]. Other factors that may also contribute include demographic characteristics, social support, disease severity, or coping mechanisms against disease stressors. Multiple reminder methods currently exist, but traditionally, patients most often rely on pill containers (plastic containers with daily dividers into which a patient inserts pills), calendars, medication diaries, and alarms. In this cross-sectional study, we examined the proportion of patients with RA who use reminders (including pill containers, calendars, and diaries) and the characteristics associated with the use of reminders (including age, sex, education, and occupation). We also determined whether the use of reminders was associated with treatment adherence, disease activity, or disability measures.
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Materials and methods
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Data for the current analysis were collected as part of a larger study on electronic monitoring of medication use [2]. Briefly, patients were eligible for the study if they met the following criteria: (1) age 18–80 years; (2) fulfillment of the 1987 American College of Rheumatology classification criteria for diagnosis of RA [3]; (3) disease duration of 15 years or less; (4) current treatment with steroids, disease-modifying drugs, or other immunosuppressants; (5) adequate cognitive status to understand researcher instructions; and (6) English or Spanish language proficiency. Consecutive patients were enrolled, with a bonvenience sampling scheme. The study was approved by each institution’s review board.
were not helping (responses ranged from 1 = “often” to 4 = “never”) [4]. Score ranges from 0 to 4 (higher score, higher adherence). II. Compliance Questionnaire Rheumatology (CQR) described by de Klerk et al. [5]. The CQR assessment is based on adherence statements made by patients, to assess the primary reason for missed doses. Patients respond by using a four-point Likert scale (“don’t agree at all” = 1 to “agree very much” = 4). Score ranges from 0 to 100 (higher score, higher adherence). III. Adult AIDS Clinical Trials Group (AACTG) adherence instrument [6]. The AACTG examines specific reasons non-adherent patients miss medication doses across seven individual domains (14 items) in self-reported adherence. Responses are “never,” “rarely,” “sometimes,” and “often.” Score ranges from 0 to 3 (higher score, lower adherence).
Data collection
Disease activity measures
All participants signed a consent form and completed a self-response questionnaire. We collected demographics including age, sex, race, ethnicity, marital status, education levels, and comorbidities and the following outcomes measures:
Board-certified rheumatologists conducted a clinical assessment of each patient, which included the number of tender and swollen joints, the patient’s global assessment of his or her disease, and the physician’s global assessment of the patient’s disease (i.e., overall health rating), measured with a visual analog scale (0–10 cm). Clinical assessments were done the same day after patients completed their surveys.
Participants
Use of reminders Participants were asked how frequently they used pill containers, calendars, or diaries to remember to take medications. Patients were allowed to list other methods and their frequency of use in conjunction with the aforementioned traditional methods. The list of other methods was categorized by one author and crosschecked by another. Possible responses were “never,” “sometimes,” “often,” and “always.” For patients who used more than one method, the response assigned was the maximum response for any of the methods. A patient was considered to have used a reminder method if the patient’s response was anything but “never.” Patient‑reported adherence and number of non‑RA medications taken Participants completed three adherence assessments: I. Self-reported adherence questionnaire. This questionnaire was developed in-house to assess how patients described their compliance, how often patients forgot to take their medications, how often patients discontinued their medications on their own because of side effects, and how often patients discontinued medications on their own because the medications
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Disability measure Patients completed a modified Health Assessment Questionnaire (M-HAQ) [7] to evaluate their functional ability. Statistical analysis Frequencies, percentages, means (±standard deviations), and medians (range) were calculated to describe the patient characteristics. Patients were compared in terms of how often they used at least one reminder. Differences between groups were assessed using independent two-sample t tests or Wilcoxon–Mann–Whitney test for numeric characteristics, and differences between proportions were assessed using a Chi-square or Fisher’s exact test. Spearman correlation was used to evaluate the association between the frequency of use of reminder methods and adherence to medications, disease activity, or disability. Multiple logistic and linear regressions were carried out to determine predictors of reminder use and adherence, respectively, with patient characteristics, gender, age, education level, employment, etc., considered as possible predictors. Statistical significance was set at p < 0.05 (two-sided). All statistical
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analyses were conducted using SAS 9.3 (SAS Institute, Cary, NC, USA).
Results Patient characteristics A total of 1700 patients were screened for the study. Among these, 347 were eligible and 201 were enrolled and completed the study questionnaires. The patient characteristics are summarized in Table 1. Frequency of use In our population, 68 of 201 patients (34 %) used at least one reminder. The most common reminder was pill containers (n = 53, 78 %), followed by calendars (n = 12, 18 %) and diaries (n = 3, 4 %). Six patients (9 %) reported the use of two or more reminders. Other reminders used in conjunction with the aforementioned included setting alarms (e.g., clocks, cell phones, apps, timers), relying on other people (e.g., receiving phone calls from relatives, friends, or health care providers), and carrying medications at all times. Three patients also listed the use of specific routine habits, such as keeping pill containers in the same place, taking medications on the same day (or time of the day), or sorting pills regularly (e.g., A–Z order, by groups), to decrease the likelihood of forgetting to take medications. For the purposes of this analysis, we did not consider the use of routine habits a reminder method. Among the patients using at least one reminder, a higher proportion reported uninterrupted use (“always”) of pill containers than of other types of reminders (Fig. 1).
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Reminder use and self‑reported adherence Table 2 shows correlations between the use of reminder methods and adherence to medications. The correlation coefficients were determined using the overall (composite) score for each questionnaire and the scores for reminder-related individual items. The use of at least one reminder had a weak but statistically significant correlation with three measures in the CQR: composite score (ρ = 0.21, p < 0.01), taking medication even when on vacation (ρ = 0.16, p = 0.02), and taking medication when away for the weekend (ρ = 0.15, p = 0.04). Similarly, the use of calendars also had weak correlations with two items of the AACTG: adherence while away from home (ρ = 0.16, p = 0.03) and when busy (ρ = 0.16, p = 0.03). Furthermore, the use of at least one reminder also had a weak correlation with not missing taking medications because of running out of pills (ρ = 0.15, p = 0.04). Linear regressions showed that the better adherence levels of the patients as reported with the Klerk adherence score were directly related to the use of at least one reminder. Characteristics and clinical measurements of reminder users and nonusers We observed a weak but significant correlation between use of calendars and number of tender joints (ρ = −0.17, p = 0.02) and age (ρ = 0.20, p = < 0.01). We also found pill containers also had weak associations with age (ρ = 0.20, p = < 0.01) and number of comorbidities (ρ = 0.22, p = < 0.01). There were no other correlations found between clinical outcomes (including M-HAQ, patient overall health rating, physician overall health rating, and number of swollen joints) and reminders.
Factors associated with reminder use Patients using at least one reminder were significantly older than those using no reminders (mean age 54 years compared with 49 years, p = 0.004). There was a higher proportion of those using at least one reminder among males compared to females (50 vs 28 % females, p = 0.005) and among whites (54 % compared with 26–30 %, p = 0.003) patients. Employed patients (full-time or part-time) were less likely to report the use of reminders. On the CQR scale adherence was significantly higher in users of reminders than in nonusers (Table 1). There were no differences in characteristics between patients who used special pill containers and those who used other reminder methods (data not shown). In the multivariate logistic regression, being male (OR 2.3, 95 % CI 1.1 to 4.9) and unemployed (OR 3.3, 95 % CI 1.3 to 8.5) was associated with the use of at least one reminder.
Discussion In the current study, we found that 34 % of patients with RA used reminders, most commonly pill containers. Factors associated with the use of reminders were increasing age, male sex, and white race, and patients who were working full-time or part-time were less likely to use reminders. The use of reminders had weak but statistically significant correlations with increased self-reported adherence to treatment as measured by the CRQ. Certain specific items from the CQR and AACTG questionnaire also had weak but significant positive correlations with self-reported adherence in patients who used reminders such as not missing medications while on vacation or away for the weekend. Regarding clinical measures, we found that the use of calendars had a weak but significant correlation with number
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Table 1 Patient characteristics (n = 201)* pb
Characteristic
Total, n = 201a
Patients using at least one reminder, n = 68a
Patients using no reminders, n = 133a
Age in years, mean (SD)c Disease duration in years, mean (SD) Gender Male Female Ethnicity Black Hispanic White Other Education Less than high school High school or higher education Occupation Homemaker Employed full-time or part-time Unemployed or disabled Other Annual income <$20,000 ≥$20,000 Partnered status Living with partner Living without partner Household members None/Live Alone One or more Self-reported adherence In-house-developed questionnaire, median (min–max)
50.9 (11.4) 7.5 (4.9)
54.1 (10.1) 7.9 (4.8)
49.3 (11.7) 7.3 (5.0)
0.004 0.4
50 (24.9) 151 (75.1)
25 (50.0) 43 (28.5)
25 (50.0) 108 (71.5)
0.005
43 (21.4) 106 (52.7) 50 (24.9) 2 (1.0)
13 (30.2) 27 (25.5) 27 (54.0) 1 (50.0)
30 (69.8) 79 (74.5) 23 (46.0) 1 (50.0)
0.003
81 (40.3) 119 (59.2)
22 (27.2) 46 (38.7)
59 (72.8) 74 (61.3)
0.1
56 (27.9) 38 (18.9) 72 (35.8) 33 (16.4)
12 (21.4) 8 (21.1) 31 (43.1) 16 (48.5)
44 (78.6) 30 (78.9) 41 (56.9) 17 (51.5)
0.006
125 (62.2) 40 (19.9)
43 (34.4) 17 (42.5)
82 (65.6) 23 (57.5)
0.4
103 (51.2) 98 (48.8)
36 (35.0) 32 (32.7)
67 (65.0) 66 (67.3)
0.7
30 (14.9) 168 (83.6)
14 (46.7) 53 (31.5)
16 (53.3) 115 (68.5)
0.1
3.5 (1.3–4.0)
3.5 (1.3–4.0)
3.5 (1.8–4.0)
0.3
CQR, mean [3] (SD)d AACTG, median [5] (min–max)d M-HAQ, mean [6] (SD)d VAS, mean (SD)d No. of comorbidities <2
69.9 (10.9) 0.5 (0–2.1) 0.9 (0.6) 5.5 (2.5)
≥2
73.4 (11.8) 0.4 (0–2.1) 0.8 (0.6) 5.4 (2.5)
68.1 (9.9) 0.5 (0–2.1) 0.9 (0.6) 5.6 (2.5)
<0.001 0.088 0.7 0.6 0.071
121 (60.2)
35 (28.9)
86 (71.1)
80 (39.8)
33 (41.3)
47 (58.8)
* Use of reminders was analyzed as binary variable, wherein if a patient answered either sometimes, often, or always in a specific reminder type, then that patient was considered as yes (uses reminders) and if a patient answered never, then that patient was a no (does not use reminders) a Cells contain n (row %) unless otherwise specified. Percentages may not add up to 100 % owing to missing values from incomplete questionnaire responses b
p values from independent two-sample sample t test, Wilcoxon–Mann–Whitney test, Chi-square test, or Fisher exact test where appropriate
c
SD standard deviation
d CQR de Klerk’s Compliance Questionnaire Rheumatology, AACTG Adults AIDS Clinical Trials Group, M-HAQ Modified Health Assessment Questionnaire, VAS Overall Health Rating on Visual Analog Scale
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Pill containers
67.6%
Calendars
Diary
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13.2%
2.9%
0%
10%
20%
30%
Sometimes
40% Often
50%
60%
70%
80%
Always
Fig. 1 Frequency of use of reminders among patients using at least one reminder (n = 68)
of tender joints, and pill containers were associated with greater number of comorbidities. We identified various patient characteristics associated with the use of reminders. Young patients, ethnic minorities, and female patients used reminders less frequently. Clinicians may be less likely to counsel young patients about reminders to improve adherence because Table 2 Correlations between the use of reminder methods and adherence to medication among patients with rheumatoid arthritis (n = 201), using the overall (composite) score for each adherence
young patients may not appear to be as much at risk for “forgetting” to take medications as elderly patients. This may also be why female patients are less likely to use reminders. Ethnic minorities may not use reminders as frequently as other populations because of communication barriers between the clinician and patient, or possibly because of socioeconomic barriers in obtaining reminders. Our results are consistent with those of other studies that have examined patient characteristics for non-adherence in RA [4, 8–10]. However, we offer a unique perspective because our patient population was predominantly ethnically diverse and of low socioeconomic status. Furthermore, we specifically examined the use of reminders, whereas other studies have examined total non-adherence without specifically considering forgetfulness and reminder methods. To the best of our knowledge, this is the first study to report patient characteristics and frequency of reminder use in a rheumatologic setting. Our study has certain limitations. We examined secondary outcomes from a preexisting cohort of patients [2]. Therefore, we did not include a large enough sample size to questionnaire and for reminder-related individual items on each questionnaire (significant values are shown in boldface)
Questionnaire
Four-item compliance questionnairec How often do you forget to take your meds? Overall, which of the following describes you best? CQRc [3] I store my meds in the same place to remember to take them When I’m on vacation, sometimes I don’t take my medicines I use a dose organizer for my medication Every now and then, I go away for the weekend and then miss my meds When my usual schedule changes, I am more likely to miss my meds AACTGd [5] Away from home Busy with other things Simply forgot Had too many pills to take Change in daily routine Fell asleep/slept through dose time Ran out of pills
ρa Used at least one reminder methodb
Pill container
Calendar
0.09 0.06 0.07 0.21 0.21 0.21 0.53 0.13 0.09 −0.13 −0.08 −0.10 −0.07 −0.04 −0.03 −0.05
0.08 0.04 0.07 0.19 0.20 0.16 0.59 0.15 0.07 −0.08 −0.04 −0.04 −0.05 −0.03 −0.03 −0.08
0.06 0.04 0.06 0.10 0.12 0.13 0.01 0.01 0.06 −0.15 −0.16 −0.16 −0.09 −0.02 −0.07 −0.06
−0.15
−0.11
−0.12
Use of reminders was treated as ordinal with four levels: never, sometimes, often, and always. Scores ranged from 0 (never) to 3 (always) a
ρ pertains to the Spearman correlation coefficient. Bolded values indicate p < 0.05
b
For patients who used more than one method, the score assigned was the maximum score for any of the methods
c
CQR = de Klerk’s Compliance Questionnaire Rheumatology. Higher score indicates higher adherence (less often forgetting medications)
d
AACTG = Adult Aids Clinical Trials Group. Higher score indicates lower adherence (more often forgetting medications)
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detect small improvements in self-reported adherence. This may also contribute to the lack of statistical significance between most clinical outcomes (except number of tender joints) and the use of reminders. More research is needed with larger sample sizes to identify the effects that reminders may have on adherence and clinical outcomes. In addition, we examined self-reported adherence, and although we analyzed three different questionnaires to evaluate adherence, each specific questionnaire is vulnerable to certain limitations in reliability. Self-reporting has the potential to overestimate adherence. A more objective measure of adherence would be the Medication Event Monitoring System [11, 2]. However, despite the opportunity for study participants to provide inflated adherence rates when selfreporting, other studies have reported that adherence rates between self-reporting and electronic tracking devices are similar [12]. In conclusion, we found that most patients do not use reminders. Specifically, female, young, and ethnic minorities were less likely to utilize reminders. We also found that reminders were weakly correlated with increased self-reported adherence. Therefore, it may be beneficial for clinicians to educate patients on the use of reminders to increase treatment adherence in patients with RA— especially those populations that are at risk of not using reminders. Acknowledgments We are grateful to Maria E. Suarez-Almazor, MD, PhD, from The University of Texas MD Anderson Cancer Center Department of General Internal Medicine for providing the data for analysis in this study. Author contributions Dr. Lopez-Olivo had full access to all of the data in the study and takes responsibility for the integrity and the accuracy of the data analysis. Lopez-Olivo contributed to study concept and design, and supervision of the study.; Suarez-Almazor acquired data; Bruera, Barbo, and Lopez-Olivo analyzed and interpreted the data, and drafted and critically revised the manuscript; Statistical analysis was performed by Barbo; Suarez-Almazor obtained funding and provided administrative, technical, or material support. Funding The data for this analysis are part of a study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS R01AR047858). Dr. Lopez-Olivo is the recipient of an investigator career award from the Rheumatology Research Foundation. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.
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Rheumatol Int (2016) 36:1543–1548 Compliance with ethical standards Conflict of interest S. Bruera declares that he has no conflict of interest. A. Barbo declares that she has no conflict of interest. M.A. LopezOlivo declares that she has no conflict of interest.
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