Meera Viswanathan, PhD; Carol E. Golin, MD; Christine D. Jones, MD, MS; Mahima Ashok, PhD; Susan J. Blalock, MPH, PhD; Roberta C.M. Wines, MPH; Emmanuel J.L. Coker-Schwimmer, MPH; David L. Rosen, MD, PhD; Priyanka Sista, BA; Kathleen N. Lohr, PhD
Note: RTI International is a trade name of Research Triangle Institute.
Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its contents; they do not necessarily represent the view of AHRQ or the Veterans Health Administration. Therefore, no statement in this report should be construed as an official position of these entities, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.
Acknowledgment: The authors thank the Evidence-based Practice Center (EPC) team staff at RTI International and the University of North Carolina at Chapel Hill for their considerable support, commitment, and contributions; Timothy S. Carey, MD, MPH, Director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina; Christiane Voisin, MSLS, EPC Librarian; Audrey R. Holland, MPH, and Elizabeth Harden, MPH, EPC Project Managers; Catherine A. Grodensky, MPH, and Andrea Yuen, BS, abstractors; Laura Small, BA, EPC editor; and Loraine Monroe, EPC publications specialist.
Financial Support: By AHRQ (contract 290200710056I). Dr. Jones is supported by an NIH/HRSA training grant (T32HP14001-25).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1030.
Requests for Single Reprints: Meera Viswanathan, PhD, Social, Statistical, and Environmental Sciences, RTI International, 3040 Cornwallis Road, Durham, NC 27709; e-mail, email@example.com.
Current Author Addresses: Drs. Viswanathan and Lohr: Social, Statistical, and Environmental Sciences, RTI International, 3040 Cornwallis Road, Durham, NC 27709.
Dr. Golin, Ms. Wines, and Mr. Coker-Schwimmer: Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, 725 Martin Luther King Jr. Boulevard, CB #7590, Chapel Hill, NC 27599-7590.
Dr. Jones: UNC General Medicine, 5034 Old Clinic Building, CB #7110, Chapel Hill, NC 27599-7110.
Dr. Ashok: Social, Statistical, and Environmental Sciences, RTI International, 1440 Main Street, Suite 310, Waltham, MA 02451.
Dr. Blalock: Eshelman School of Pharmacy, University of North Carolina, 2213 Kerr Hall, Chapel Hill, NC 27599-7573.
Dr. Rosen: University of North Carolina at Chapel Hill, 130 Mason Farm Road, CB #7215, Chapel Hill, NC 27599-7215.
Ms. Sista: UNC at Chapel Hill School of Medicine, 1001 Bondurant Hall, CB #9535, Chapel Hill, NC 27599-9535.
Author Contributions: Conception and design: M. Viswanathan, C.E. Golin, C.D. Jones, M. Ashok, S.J. Blalock.
Analysis and interpretation of the data: M. Viswanathan, C.E. Golin, C.D. Jones, M. Ashok, S.J. Blalock, E.J.L. Coker-Schwimmer, D.L. Rosen, K.N. Lohr.
Drafting of the article: M. Viswanathan, C.E. Golin, M. Ashok, S.J. Blalock, D.L. Rosen, K.N. Lohr.
Critical revision of the article for important intellectual content: M. Viswanathan, C.E. Golin, C.D. Jones, M. Ashok, S.J. Blalock, K.N. Lohr.
Final approval of the article: M. Viswanathan, C.E. Golin, C.D. Jones, M. Ashok, S.J. Blalock, D.L. Rosen, K.N. Lohr.
Statistical expertise: M. Viswanathan, D.L. Rosen.
Obtaining of funding: M. Viswanathan, C.E. Golin.
Administrative, technical, or logistic support: M. Viswanathan, C.E. Golin, R.C.M. Wines, E.J.L. Coker-Schwimmer, P. Sista, K.N. Lohr.
Collection and assembly of data: M. Viswanathan, C.E. Golin, C.D. Jones, M. Ashok, R.C.M. Wines, E.J.L. Coker-Schwimmer, D.L. Rosen, P. Sista.
Suboptimum medication adherence is common in the United States and leads to serious negative health consequences but may respond to intervention.
To assess the comparative effectiveness of patient, provider, systems, and policy interventions that aim to improve medication adherence for chronic health conditions in the United States.
Eligible peer-reviewed publications from MEDLINE and the Cochrane Library indexed through 4 June 2012 and additional studies from reference lists and technical experts.
Randomized, controlled trials of patient, provider, or systems interventions to improve adherence to long-term medications and nonrandomized studies of policy interventions to improve medication adherence.
Two investigators independently selected, extracted data from, and rated the risk of bias of relevant studies.
The evidence was synthesized separately for each clinical condition; within each condition, the type of intervention was synthesized. Two reviewers graded the strength of evidence by using established criteria. From 4124 eligible abstracts, 62 trials of patient-, provider-, or systems-level interventions evaluated 18 types of interventions; another 4 observational studies and 1 trial of policy interventions evaluated the effect of reduced medication copayments or improved prescription drug coverage. Clinical conditions amenable to multiple approaches to improving adherence include hypertension, heart failure, depression, and asthma. Interventions that improve adherence across multiple clinical conditions include policy interventions to reduce copayments or improve prescription drug coverage, systems interventions to offer case management, and patient-level educational interventions with behavioral support.
Studies were limited to adults with chronic conditions (excluding HIV, AIDS, severe mental illness, and substance abuse) in the United States. Clinical and methodological heterogeneity hindered quantitative data pooling.
Reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Evidence is limited on whether these approaches are broadly applicable or affect long-term medication adherence and health outcomes.
Agency for Healthcare Research and Quality.
Appendix Table 1.
Inclusion and Exclusion Criteria
Appendix Table 2.
Definitions of Grades of Overall Strength of Evidence
Appendix Table 3.
Summary of Strength of Evidence, by Intervention Type
Appendix Table 4.
Summary of Evidence for Policy Interventions
Summary of evidence search and selection.
NA = not applicable; PICOTS = population, intervention, comparators, outcomes, timing, setting.
Summary of Results for Patient, Provider, and Systems Interventions
Medication Adherence Intervention Characteristics
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Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review. Ann Intern Med. 2012;157:785-795. doi: 10.7326/0003-4819-157-11-201212040-00538
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Published: Ann Intern Med. 2012;157(11):785-795.
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