Littérature scientifique sur le sujet « DMARD adherence »

Scanty information on clustering longitudinal real-world data is available in the medical literature about the adherence implementation phase in rheumatoid arthritis (RA). To identify and characterize trajectories by analyzing the implementation phase of adherence to biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDs), we conducted a retrospective cohort drug-utilization study using Tuscan administrative databases. RA patients were identified by a validated algorithm, including the first biologic DMARD supply from 2010 to 2015, RA specialist visit in the year before or after the first supply date and RA diagnosis in the five years before or in the year after the first supply date. We observed users for three years or until death, neoplasia, or pregnancy. We evaluated adherence quarterly through the Medication Possession Ratio. Firstly, we identified adherence trajectories and described the baseline characteristics; then, we focused on the trajectory most populated to distinguish the related sub-trajectories. We identified 952 first ever-biologic DMARD users in RA (712 females, mean age 52.7 years old, standard deviation 18.8). The biologic DMARD mostly supplied was etanercept (387 users) followed by adalimumab (233). Among 935 users with at least 3 adherence values, we identified 49 fully-adherent users, 829 continuous users, and 57 early-discontinuing users. Significant differences were observed among the index drugs. After focusing on the continuous users, three sub-trajectories were identified: continuous-steady users (556), continuous-alternate users (207), and continuous-declining users (66). No relevant differences emerged at the baseline. The majority of first ever-biologic DMARD users showed a continuous adherence behavior in RA. The role of adherence potential predictors and the association with effectiveness and safety outcomes should be explored by further studies.

Objective.Rheumatoid arthritis (RA) patients’ adherence to disease-modifying antirheumatic drugs (DMARD) is often suboptimal. We examined associations among medication beliefs, self-efficacy, and adherence to medications in RA.Methods.Data were from a longitudinal observational cohort of persons with RA. Subjects completed telephone interviews on self-reported adherence, self-efficacy, demographics, and the Beliefs about Medicines Questionnaire (BMQ), which assesses beliefs in necessity and beliefs about taking medication. Bivariate and multivariate logistic regression identified correlates of poor adherence to synthetic DMARD and prednisone as well as to biologic therapy, including medication concerns and necessity.Results.There were 362 patients who reported taking a synthetic DMARD and/or prednisone. Of these, 14% and 21% reported poor adherence to oral DMARD or prednisone, and biologics, respectively. There were 64% who reported concern about taking medicines, 81% about longterm effects, and 47% about becoming too dependent on medicines. In multivariate analyses, the BMQ necessity score was independently associated with better adherence to oral DMARD or prednisone (adjusted OR 0.61, 95% CI 0.41–0.91), while self-efficacy was associated with greater odds of poor adherence to oral medications (adjusted OR 1.23, 95% CI 1.01–1.59). Beliefs in medicines and self-efficacy were not associated with adherence to biologics.Conclusion.In a diverse cohort of patients with RA, stronger beliefs in the necessity of medication were associated with better adherence to oral DMARD or prednisone, while higher self-efficacy was associated with poor adherence. Providers can play important roles in eliciting patient beliefs about medications to improve adherence and ultimately health outcomes.

Non-adherence challenges efficacy and costs of healthcare. Knowledge of the underlying factors is essential to design effective intervention strategies.ObjectivesTo estimate the prevalence of treatment adherence in rheumatoid arthritis (RA) and to evaluate its predictors.MethodsA 6-month prospective cohort study of patients with RA selected by systematic stratified sampling (33% on first disease-modifying rheumatic drug (DMARD), 33% on second-line DMARD and 33% on biologics). The outcome measure was treatment adherence, defined by a score greater than 80% both in the Compliance Questionnaire in Rheumatology and the Reported Adherence to Medication scale, and was estimated with 95% CIs. Predictive factors included sociodemographic, psychological, clinical, drug-related, patient–doctor relationship related and logistic. Their effect on 6-month adherence was examined by multilevel logistic models adjusted for baseline covariates.Results180 patients were recruited (77% women, mean age 60.8). The prevalence of adherence was 59.1% (95% CI 48.1% to 71.8%). Patients on biologics showed higher adherence and perceived a higher medication need than the others; patients on second-line DMARDs had experienced more adverse events than the others. The variables explaining adherence in the final multivariate model were the type of treatment prescribed (second-line DMARDs OR=5.22, and biologics OR=3.76), agreement on treatment (OR=4.57), having received information on treatment adaptation (OR=1.42) and the physician perception of patient trust (OR=1.58). These effects were independent of disease activity.ConclusionTreatment adherence in RA is far from complete. Psychological, communicational and logistic factors influence treatment adherence in RA to a greater extent than sociodemographic or clinical factors.

Objective.Nonadherence in patients with rheumatoid arthritis (RA) using disease modifying antirheumatic drugs (DMARD) may result in unnecessarily high levels of disease activity and function loss. The aim of this descriptive study was to assess adherence rates with self-report measures in a large random population, and to identify potential risk factors for nonadherence.Methods.A randomly selected sample of 228 patients with RA using DMARD was invited for a standardised interview. For each medicine, the patients were asked about adherence, consumption and perceived (side) effects. After the interview, the patients received self-report questionnaires to assess adherence [Compliance Questionnaire on Rheumatology (CQR) and the Medication Adherence Scale (MARS)], coping, beliefs about medicines, satisfaction about medicine information, and physical functioning. Subsequently, associations between adherence and demographics, clinical characteristics, and patient attitudes were examined.Results.Depending on the instrument used, 68% (CQR) and 60% (MARS) of the patients were adherent to DMARD. Nonadherence was not associated with demographic and clinical characteristics, satisfaction about information, medication concerns, and coping styles. The disease duration, the number of perceived side-effects, and beliefs about the necessity of the medicine were weakly associated with adherence.Conclusion.In this large study with a random RA population, 32%–40% of the patients did not adhere to their DMARD prescription. As none of the possible risk factors was strongly related to adherence, no general risk factor seems to be powerful enough as a possible screening tool or target for adherence-improving interventions. This implies that nonadherence barriers should be assessed on an individual basis.

BackgroundConsistent immunosuppressive treatment of rheumatoid arthritis (RA) with disease-modifying anti-rheumatic drugs (DMARDs) is crucial for reduced progression and improved long-term outcome of the disease. Therefore, drug adherence is a prerequisite, which is often insufficient according to literature.ObjectivesOur aim was to investigate the relationship between adherence and beliefs about medication in patients with RA.MethodsThe study included 137 RA patients (102 female, 35 male; age range 28-86 years, Ø 64.8 ± 12.6 yrs; SDAI Ø 9.9 ± 6.8; 61 % DMARD monotherapy, 31 % DMARD combination therapy, 9 % currently treated without DMARD). Medication adherence was measured with the Compliance-Questionnaire-Rheumatology (CQR). This is a self-report questionnaire with 19 items (4 response options each). The sum score is mapped to a scale from 0 to 100 % (CQR%), where 100 % corresponds to optimal adherence. A CQR% ≥ 80 % was defined as satisfactory adherence. In addition, the specific part of the Beliefs about Medicines Questionnaire (BMQ) was used to assess patients’ opinions about the necessity of their medication therapy and their concerns. Besides correlation analyses (Spearman-Rho) multiple linear regression was applied to determine factors influencing adherence (coefficient of determination: adjusted R2).ResultsAdherence was satisfactory in 93 RA patients (67.9 %) and insufficient in almost one-third (n = 44, 32.1 %). Analyses showed that adherence was significantly related to belief in necessity (r = 0.46; p < 0.001) and concerns about drug therapy (r = -0.27; p = 0.001). Furthermore, it became apparent that adherence is closely linked to the age of the patient (r = 0.30; p < 0.001). Younger RA patients (< 60 yrs) had significantly lower CQR%-scores than older RA patients (≥ 60 yrs; p < 0.01). Belief in the necessity of therapy, medication concerns and patient age accounted for almost half of the patient-specific variability in adherence (each p < 0.001; R2 = 42.9 %), suggesting a strong dependence of adherence on these three factors.ConclusionAdherence is insufficient in about one-third of RA patients. Additionally, adherence appears to be strongly dependent on the patient’s belief in the necessity of therapy, medication concerns and age. Physicians should strive for all RA patients to have sufficient knowledge about their medication, strengthen the belief in the necessity of the therapy and be mindful of adherence when talking to patients.Disclosure of InterestsNone declared

Objectives:The objective of this study was twofold: (1) to determine how best to measure adherence with time-dependent quality indicators (QIs) related to laboratory monitoring, and (2) to assess the accuracy and efficiency of gathering QI adherence information from an electronic medical record (EMR).Methods:A random sample of 100 patients were selected who had at least three visits with the diagnosis of rheumatoid arthritis (RA) at Brigham and Women’s Hospital Arthritis Center in 2005. Using the EMR, it was determined whether patients had been prescribed a disease-modifying antirheumatic drug (DMARD) (QI #1) and if patients starting therapy received appropriate baseline laboratory testing (QI #2). For patients consistently prescribed a DMARD, adherence with follow-up testing (QI #3) was calculated using three different methods, the Calendar, Interval and Rolling Interval Methods.Results:It was found that 97% of patients were prescribed a DMARD (QI #1) and baseline tests were completed in 50% of patients (QI #2). For follow-up testing (QI #3), mean adherence was 60% for the Calendar Method, 35% for the Interval Method, and 48% for the Rolling Interval Method. Using the Rolling Interval Method, adherence rates were similar across drug and laboratory testing type.Conclusions:Results for adherence with laboratory testing QIs for DMARD use differed depending on how the QIs were measured, suggesting that care must be taken in clearly defining methods. While EMRs will provide important opportunities for measuring adherence with QIs, they also present challenges that must be examined before widespread adoption of these data collection methods.

ObjectiveTo examine the effect on adherence to disease modifying anti-rheumatic drugs (DMARDs) in participants with rheumatoid arthritis (RA) of a serious game that targeted implicit attitudes toward medication.MethodsA multicentre randomised controlled trial (RCT) was performed with adults with RA that used DMARDs and possessed a smartphone/tablet. Control and intervention groups received care as usual. The intervention group played the serious game at will during 3 months. Game play data and online questionnaires Compliance Questionnaire on Rheumatology (CQR), Beliefs about Medicine Questionnaire (BMQ), Health Assessment Questionnaire (HAQ) and Rheumatoid Arthritis Disease Activity Index (RADAI) were collected. Primary outcome was DMARD implementation adherence operationalised as the difference in proportion of non-adherent participants (<80% taking adherence) between intervention and control group after 3 months using a Chi-squared test. Two sample t-tests and Wilcoxon rank-sum test were performed to test for differences on secondary outcomes.ResultsOf the 110 intervention participants that started the study, 87 participants (79%) installed the game and had a median playtime of 9.7 hours at 3 months. Overall, 186 participants completed the study. Adherence in intervention group (63%) and control group (54%) did not differ significantly (p=0.13) at 3 months. Neither were there differences oberved in CQR continuous score, beliefs about medication (BMQ) or clinical outcomes (HAQ and RADAI).ConclusionA serious game aimed at reinterpreting attitudes toward medication failed to show an effect on adherence to DMARDs or clinical outcomes in patients with RA. The game was played frequently indicating that it can be an effective channel for reaching patients.Trial registration numberNL7217.

Objective.To test the feasibility of reporting on 4 national performance measures for patients with rheumatoid arthritis (RA) in 5 different models of care.Methods.The following performance measures were evaluated in 5 models of care: waiting time (WT) to rheumatologist consultation, percentage of patients seen in yearly followup (FU), percentage taking disease-modifying antirheumatic drugs (DMARD), and time to starting DMARD. All models aimed to improve early access and care for patients with RA.Results.A number of feasibility issues were encountered in performance measure evaluation because of differences in site data collection and/or the duration of the model of care. For example, while 4/5 programs maintained clinical or research databases, chart reviews were still required to report on WT. Median WT for care in 2015 varied by site between 21 and 75 days. Yearly FU rates could only be calculated in 2 sites (combined owing to small numbers) and varied between 83% and 100%. Percentage of patients taking a DMARD and time to DMARD could be calculated in 3 models, and rates of DMARD use were between 90% and 100%, with median time to DMARD of 0 days in each.Conclusion.Our review has shown that even in models of care designed to improve access to care and early treatment, data to document improvements are often lacking. Where data were available for measuring, deficits in WT performance were noted for some centers. Our results highlight a need to improve reporting processes to drive quality improvement.

Objective.To explore themes associated with adherence in the initiation phase for first-time use of disease-modifying antirheumatic drugs (DMARD) in patients with inflammatory arthritis using focus groups and individual interviews.Methods.Thirty-three patients were interviewed in focus groups and individual interviews. Interviews were transcribed verbatim and imported into ATLAS.ti software (Scientific Software Development GmbH). Responses that included reasons for adherence or nonadherence in the initiation phase were extracted and coded by 2 coders separately. The 2 coders conferred until consensus on the codes was achieved. Codes were classified into overarching themes.Results.Five themes emerged: (1) symptom severity, (2) experiences with medication, (3) perceptions about medication and the illness, (4) information about medication, and (5) communication style and trust in the rheumatologist.Conclusion.Perceptions about medication and the communication style with, and trust in, the rheumatologist were mentioned the most in relation to starting DMARD. The rheumatologist plays a crucial role in influencing adherence behavior by addressing perceptions about medication, providing information, and establishing trust in the treatment plan.

L’artirite reumatoide (AR) è la più diffusa patologia autoimmune in Italia con elevati costi terapeutici e previdenziali associati. Questa patologia colpisce circa lo 0.5-1% della popolazione adulta, prevalentemente di genere femminile. Essendo una patologia degenerativa, i cui danni sono frequentemente irreversibili, una diagnosi precoce così come un adeguato trattamento ed un elevato livello di compliance del paziente allo stesso, potrebbero rallentare il peggioramento della malattia. Inoltre sono poco noti i possibili effetti della malattia e del suo trattamento sulle gravidanze e i successivi outcome gravidici. I principali obiettivi della tesi quindi sono: i) valutare l’aderenza alle linee guida per il trattamento dell’ AR da parte dei clinici, ii) valutare l’aderenza al trattamento per AR da parte del paziente, iii) stimare costo ed efficacia delle cure erogate nelle cliniche specializzate per il trattamento di pazienti con AR, iv) analizzare gli esiti gravidici e il raggiungimento della gravidanza in donne con AR trattate con metotrexate (MTX). La prima tematica ha riguardato la valutazione di come sono state implementate le linee guida della European Alliance of Associations for Rheumatology (EULAR) per il trattamento dell’AR e l’impatto dell’aderenza a queste linee guida sulla probabilità di ospedalizzazione. I principali risultati di questo studio hanno mostrato come i pazienti con un’ottima aderenza alle linee guida, se confrontati con quelli con bassa aderenza, abbiano un rischio del 24% inferiore di incorrere in ospedalizzazione. La seconda tematica ha riguardato la valutazione dell’impatto dell’aderenza al trattamento con Disease-Modifying Anti-Rheumatic Drugs (DMARDs), terapia suggerita dall’EULAR, sul raggiungimento della remissione clinica di malattia. I dati provengono dal database ELECTRA (con informazioni cliniche e provenienti da database amministrativi) di pazienti con AR trattati presso l’IRCCS Policlinico San Matteo (Pavia). Si è osservato che un incremento percentuale di 10 unità nella copertura al trattamento comporta un aumento della probabilità di remissione clinica del 10%. Da questi risultati sembra emergere l’importanza di riuscire a monitorare i pazienti nella pratica clinica per mantenere elevati standard di compliance. L’obiettivo della terza tematica si è focalizzato su una valutazione costo-efficacia del trattamento dei pazienti con AR erogato da cliniche specializzate (EAC), confrontandolo con quello dei pazienti trattati in cliniche non specializzate. Sono state quindi reclutate due coorti, la prima di pazienti trattati in una EAC e l’altra estratta dai database amministrativi di regione lombardia tra i soli soggetti con AR. I risultati principali di questa terza fase hanno mostrato come ad un incremento moderato dei costi si associ un incremento molto elevato dell’efficacia, specialmente se calcolata come durata di degenza e come aderenza alle linee guida EULAR. La quarta ed ultima tematica riguarda l’analisi dell’impatto del trattamento con MTX (DMARD suggerito dall’EULAR come prima linea di trattamento) nelle pazienti con AR sulla possibilità di raggiungere una gravidanza e sugli outcome gravidici conseguenti. Sono state definite tre coorti: donne con AR con esposizione incidente di MTX, donne con AR senza trattamento con MTX e donne senza AR. I risultati principali di questa analisi hanno mostrato che le donne con AR, specialmente se trattate con MTX, hanno una minor frequenza di gravidanze rispetto alle donne senza AR. Inoltre, le donne trattate con MTX sembrano avere un rischio più elevato di aborto spontaneo (circa due volte superiore) rispetto alle altre due coorti.
Rheumatoid arthritis (RA) is, in Italy, the most widespread autoimmune disease with high associated costs for the National Health Service. This disease affects about 0.5-1% of the adult population, mainly of the female gender. Being a degenerative disease, whose damages are frequently irreversible, an early diagnosis as well as an adequate treatment and a high level treatment compliance of the patient, could slow down the worsening of the disease. Furthermore, the possible effects of RA and its treatment on pregnancies and subsequent pregnancy outcomes are not well known. The main objectives of the thesis are therefore: i) to evaluate the adherence to guidelines for the treatment of RA, ii) to evaluate the patient's adherence to RA treatment, iii) to estimate the cost and effectiveness of care provided in specialized clinics for the treatment of RA patients, iv) to analyze pregnancy outcomes and the likelihood of achieving pregnancy in women with RA treated with methotrexate (MTX). The first issue concerned the assessment of how the guidelines of the European Alliance of Associations for Rheumatology (EULAR) for the treatment of RA have been implemented, and the impact of adherence to these guidelines on the probability of hospitalization. The main results of this study showed that patients with excellent adherence to guidelines, when compared with those with low adherence, have a 24% lower risk of hospitalization. The second topic concerned the evaluation of the impact of adherence to treatment with Disease-Modifying Anti-Rheumatic Drugs (DMARDs), the therapy suggested by EULAR, on the achievement of disease clinical remission (defined as a substantial decrease or absence of symptoms). The ELECTRA database, which contains clinical information and information from administrative databases of RA patients treated at the IRCCS Policlinico San Matteo (Pavia), was considered for the analysis. The main finding showed that a 10-unit percentage increase in proportion of days covered by DMARDs is associated with a 10% increase in the likelihood of clinical remission. These results show the importance of monitoring patients in clinical practice to maintain high levels of treatment compliance. The objective of the third theme focused on a cost-effectiveness evaluation, comparing RA patients treated in specialized clinics ("Early Arthritis Clinic" - EAC), with RA patients treated in non-specialized clinics. Two cohorts were recruited, the first one included patients treated in the EAC of the IRCCS Policlinico San Matteo and the other one with patients with RA extracted from the administrative databases of Lombardy region. The main results of this third phase showed that a moderate increase in costs is associated with a very high increase in effectiveness, especially if calculated as length of hospitalizations and as adherence to the EULAR guidelines. These findings could open up new scenarios in RA patient management. The fourth and final topic concerned the impact of treatment with MTX (DMARD suggested by EULAR as the first line of treatment) in RA women, on the likelihood of achieving pregnancy and on pregnancy outcomes. Three cohorts were recruited: women with RA with incident MTX exposure, women with RA without MTX treatment, and women without RA. The main results of this analysis showed that women with RA, especially when treated with MTX, have a lower frequency of pregnancies than women without RA. Furthermore, women treated with MTX have a higher risk of spontaneous abortion (about twice as high) than the other two cohorts.