Nonadherence

Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of Nonadherence

  • treatment nonadherence


  • Selected Abstracts


    Increasing Self-Management Skills in Heart Failure Patients: A Pilot Study

    CONGESTIVE HEART FAILURE, Issue 6 2005
    Kristin J. Flynn PhD
    Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment-only pilot study examined whether a year-long group-based self-management intervention is feasible and improves self-management skills in patients with mild-to-moderate heart failure (ejection fraction ,40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty-six (84%) completed the year-long self-management program. Compared with baseline, the intervention was associated with an increase in overall self-efficacy in practicing self-management skills (p<0.001) and in four of five specific self-management skills. Patients and their group leaders also reported an increase in actual use of self-management skills (p<0.001) and in several psychosocial outcomes. The success of this pilot study suggests the need for a randomized clinical trial to test the efficacy of group-based self-management training on medical outcomes. [source]


    Behavioral Facilitation of Medical Treatment of Headache: Implications of Noncompliance and Strategies for Improving Adherence

    HEADACHE, Issue 2006
    Jeanetta C. Rains PhD
    Clinical recommendations were gleaned from a review of treatment adherence published in the regular issue of Headache (released in tandem with this supplement). The recommendations include: (1) Nonadherence is prevalent among headache patients, undermines treatment efficacy, and should be considered as a treatment variable; (2) Calling patients to remind them of appointments and recalling those who miss a scheduled appointment are fundamentally the most cost-effective adherence-enhancing strategies, insofar as failed appointment-keeping acts as a ceiling on all future treatment and adherence efforts; (3) Simplified and tailored medication regimens improve adherence (eg, minimized number of medications and dosings, fixed-dose combinations, cue-dose training, stimulus control); (4) Screening and management of psychiatric comorbidities, especially depression and anxiety, is encouraged; (5) The concept of self-efficacy as a modifiable psychological process often can be employed to predict and improve adherence. [source]


    Patients' attitudes to medicines and adherence to maintenance treatment in inflammatory bowel disease

    INFLAMMATORY BOWEL DISEASES, Issue 6 2009
    Rob Horne PhD
    Abstract Background: Nonadherence has been reported in over 40% of patients taking maintenance therapies (MT) for inflammatory bowel disease (IBD). Studies in other illness groups have shown that nonadherence is related to negative attitudes to treatment. The aim of this study was to assess patients' attitudes to MT for IBD (beliefs about personal need for MT and potential adverse effects) and to identify whether such beliefs are associated with adherence to MT. Methods: A cross-sectional survey was conducted in which 1871 members of the National Association for Colitis and Crohn's Disease (NACC) completed validated questionnaires assessing beliefs about MT and adherence to MT. Results: Low adherence to MT was reported by 29% of participants and was associated with doubts about personal need for MT (odds ratio [OR] = 0.56; 95% confidence interval [CI]: 0.48,0.64; P < 0.001) and concerns about potential adverse effects (OR = 1.66; 95% CI: 1.42,1.94; P < 0.001). Attitudinal analysis showed that while almost half (48%) of the participants were "accepting" of MT (high necessity, low concerns), a large proportion of the sample (42%) were "ambivalent" about MT (high necessity, high concerns), 6% were "sceptical" (low necessity, high concerns) and 4% were "indifferent" (low necessity, low concerns). Compared to those who were "accepting" of MT, participants in all 3 other attitudinal groups were significantly more likely to be nonadherent. Conclusions: The way in which patients judge their personal need for MT relative to their concerns about MT can be a significant barrier to adherence. Interventions to facilitate optimal adherence to MT for IBD should address such perceptual barriers. (Inflamm Bowel Dis 2008) [source]


    Asthma Pharmacotherapy Prescribing in the Ambulatory Population of the United States: Evidence of Nonadherence to National Guidelines and Implications for Elderly People

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2008
    Prakash Navaratnam MPH
    OBJECTIVES: To examine the level of physician adherence to the Expert Panel Report 2 (EPR-2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States. DESIGN: Retrospective cross-sectional study using a national survey. SETTING: National Ambulatory Medical Care Survey data of U.S. elderly patients from 1998 through 2004. PARTICIPANTS: The weighted population sample size was 82,020,318 patients. There were 1,540 observations in this study (preweighted sample size) and 96 strata, with 446 population sampling units (PSUs). There were 11,868,340 patients that were elderly, and they accounted for 14.5% of the overall population sampled. MEASUREMENTS: Specific patient demographic variables, physician demographic variables, and information about asthma medications prescribed were extracted from the data set and analyzed. Descriptive statistics for the patient demographic, physician demographic, and asthma pharmacotherapy variables were generated. A series of logistic regression models were created, with the choice of asthma pharmacotherapy agent used as the dependent variable and patient and physician demographic variables as the independent variables. RESULTS: A major finding was that physicians were not adherent to the National Asthma Education and Prevention Program EPR-2 asthma pharmacotherapy guidelines. Another finding was that, although elderly patients (aged ,65) were exposed to more-stable patterns of care, they were less likely to be prescribed controller medications, long-acting bronchodilators (LABAs), combinations of inhaled corticosteroids and LABAs, and short-acting beta agonists than patients aged 35 to 64. CONCLUSION: A more-concerted effort needs to be undertaken to improve physician adherence to the EPR-2 guidelines, especially in prescribing asthma pharmacotherapy to elderly patients. [source]


    ASH Position Paper: Adherence and Persistence With Taking Medication to Control High Blood Pressure

    JOURNAL OF CLINICAL HYPERTENSION, Issue 10 2010
    Martha N. Hill RN
    J Clin Hypertens (Greenwich). 2010;12:757-764. © 2010 Wiley Periodicals, Inc. Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now. [source]


    Nonadherence as a predictor of antidiabetic drug therapy intensification (augmentation),

    PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 9 2004
    Dr Stephen J. Kogut MBA
    Abstract Purpose To determine if nonadherence with antidiabetic drug therapy is predictive of subsequent antidiabetic drug therapy intensification. Methods We conducted a retrospective cohort study examining retail pharmacy dispensings of sulfonylureas or metformin to 1067 patients having diabetes. Patients that did not receive a sufficient quantity of medication to cover at least 80% of days during the evaluation period were classified as nonadherent. Outcomes identified were increase in the dose of antidiabetic medication utilized, the addition of a second antidiabetic agent to the regimen or either. Results Among users of sulfonylurea monotherapy, those classified as nonadherent were 45% more likely to intensify therapy in subsequent months as compared with those classified as adherent (age-adjusted odds ratio (OR) 1.45; 95% confidence interval (CI) 1.06,2.00). This finding was largely driven by observed increases in dosage, which were more likely among patients classified as nonadherent (age-adjusted OR 1.48, 95%CI 1.07,2.05). Nonadherence was not found to be predictive of the subsequent addition of a second antidiabetic agent (OR 1.02; 95%CI 0.64,1.63). Overall findings were similar for the smaller sample of patients receiving metformin monotherapy, though observed differences did not achieve statistical significance. Conclusions Patients who were poorly adherent to oral antidiabetic drug therapy more frequently experienced an increase in the dose of medication prescribed, as compared to patients that were classified as adherent. This finding underscores the need for prescribers to consider nonadherence as a root cause when patients fail to achieve therapeutic goals. Copyright © 2004 John Wiley & Sons, Ltd. [source]


    Adolescent attitudes toward psychiatric medication: the utility of the Drug Attitude Inventory

    THE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES, Issue 12 2009
    Lisa Townsend
    Background:, Despite the effectiveness of psychotropic treatment for alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adolescent adherence rates range from 10,80% (Swanson, 2003; Cromer & Tarnowski, 1989; Lloyd et al., 1998; Brown, Borden, and Clingerman, 1985; Sleator, 1985) depending on the population and medication studied. Youth with serious mental illness face increased potential for substance abuse, legal problems, suicide attempts, and completed suicide (Birmaher & Axelson, 2006). Nonadherence may increase the potential for negative outcomes. The Drug Attitude Inventory (DAI) was created to measure attitudes toward neuroleptics and to predict adherence in adults (Hogan, Awad, & Eastwood, 1983). No studies have been identified that have used this instrument in adolescent psychiatric populations. The present study was undertaken to evaluate the utility of the DAI for measuring medication attitudes and predicting adherence in adolescents diagnosed with mental health disorders. Method:, Structural equation modeling was used to compare the factor structure of the DAI in adults with its factor structure in adolescents. The relationship between adolescent DAI scores and adherence was examined also. Results:, The adult factor structure demonstrated only "fair" fit to the adolescent data (RMSEA = .061). Results indicated a low, but significant positive correlation (r = .205, p < .05) between DAI scores and adherence. Conclusions:, Lack of optimal model fit suggests that DAI items may require alteration to reflect adolescent experiences with psychiatric medication more accurately. Differences between adolescents and adults in developmental stage, symptom chronicity, diagnosis, and medication class may explain why the adult model demonstrated only "fair fit" to the adolescent data and why the correlation between DAI scores and adherence was low. The DAI may be improved for use with adolescents by creating items reflecting autonomy concerns, diagnostic characteristics, treatment length, and side effect profiles relevant to adolescent experiences. [source]


    Selective Retransplant After Graft Loss to Nonadherence: Success with a Second Chance

    AMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2009
    T. B. Dunn
    Nonadherence (NA) is a difficult posttransplant problem that can lead to graft loss. A retransplant is controversial because of a fear of recurrent NA. We reviewed our center's data base and identified 114 kidney recipients who lost their graft to overt NA; of this group, 35 (31%) underwent a retransplant after a thorough reevaluation. We compared this NA retransplant group to a control group of second transplant recipients who did not lose their first graft to overt NA (non-NA) (n = 552). After 8 years of follow-up, we found no significant differences between the groups in actuarial graft or patient survival rates, renal function, or the incidence of biopsy-proven chronic rejection. However, 5 of 35 (14%) NA recipients versus 10 of 552 (2%) non-NA recipients lost their retransplant to NA (p = 0.0001). Twenty of 35 (57%) of the NA group exhibited repeat NA behavior after retransplant. We conclude that prior graft loss to NA is associated with increased graft loss to NA after retransplant. However, the majority of NA retransplant recipients did well,with overall long-term outcomes similar to those of the non-NA group. With careful patient selection and aggressive intervention, prior overt NA should not be an absolute contraindication to retransplantation. [source]


    Psychological Functioning, Nonadherence and Health Outcomes After Pediatric Liver Transplantation

    AMERICAN JOURNAL OF TRANSPLANTATION, Issue 8 2007
    E. M. Fredericks
    The present study empirically assessed the relationships between adherence behaviors and HRQOL, parent and child psychological functioning and family functioning, and investigated the relationship between adherence behaviors and health outcomes in children who were within 5 years of their liver transplantation. Participants included 38 children (mean = 8.5 years, range 28 months to 16 years) and their parent/guardian(s). HRQOL and psychological functioning were examined using well-validated assessment measures. Measures of adherence included the rate of clinic attendance and standard deviations (SDs) of consecutive tacrolimus blood levels, which were collected and evaluated retrospectively. Measures of child health status included the frequency of hospital admissions, liver biopsies, episodes of rejection and graft function for the year prior to study participation. Results indicated that nonadherence was related to lower physical HRQOL, more limitations in social and school activities related to emotional and behavioral problems, parental emotional distress and decreased family cohesion. Nonadherence was also related to frequency and duration of hospitalizations, liver biopsies and rejection episodes. These results suggest that empirically based assessment of HRQOL, parenting stress and family functioning may help identify patients at risk for nonadherence, and may allow for the need-based delivery of appropriate clinical interventions. [source]


    Calculating Sample Size for Studies with Expected All-or-None Nonadherence and Selection Bias

    BIOMETRICS, Issue 2 2009
    Michelle D. Shardell
    Summary We develop sample size formulas for studies aiming to test mean differences between a treatment and control group when all-or-none nonadherence (noncompliance) and selection bias are expected. Recent work by Fay, Halloran, and Follmann (2007, Biometrics63, 465,474) addressed the increased variances within groups defined by treatment assignment when nonadherence occurs, compared to the scenario of full adherence, under the assumption of no selection bias. In this article, we extend the authors' approach to allow selection bias in the form of systematic differences in means and variances among latent adherence subgroups. We illustrate the approach by performing sample size calculations to plan clinical trials with and without pilot adherence data. Sample size formulas and tests for normally distributed outcomes are also developed in a Web Appendix that account for uncertainty of estimates from external or internal pilot data. [source]


    Prevalence and cost of nonadherence with antiepileptic drugs in an adult managed care population

    EPILEPSIA, Issue 3 2008
    Keith L. Davis
    Summary Purpose: This study assessed the extent of refill nonadherence with antiepileptic drugs (AEDs) and the potential association between AED nonadherence and health care costs in an adult-managed care population. Methods: Retrospective claims from the PharMetrics database were analyzed. Inclusion criteria were: age ,21, epilepsy diagnosis between January 01, 2000 and March 12, 2005, ,2 AED prescriptions, and continuous health plan enrollment for ,6 months prior to and ,12 months following AED initiation. Adherence was evaluated using the medication possession ratio (MPR). Patients with an MPR <0.8 were classified as nonadherent. Multivariate regression was used to assess the effect of AED nonadherence on annualized cost outcomes. Regression covariates included patient demographics, Charlson Comorbidity Index (CCI), and follow-up duration. Results: Among patients meeting all inclusion criteria (N = 10,892), 58% were female, mean age was 44 years, mean CCI was 0.94, and mean follow-up was 27 months. Mean MPR was 0.78 and 39% of patients were nonadherent. AED nonadherence was associated with an increased likelihood of hospitalization (odds ratio [OR]= 1.110, p = 0.013) and emergency room (ER) admission (OR = 1.479, p < 0.0001), as well as increased inpatient and ER costs of $1,799 and $260 (both p = 0.001), respectively, per patient per year. Outpatient and other ancillary costs were not significantly affected by nonadherence. A large net positive effect of nonadherence on total annual health care costs remained (+$1,466, p = 0.034) despite an offset from reduced prescription drug intake. Discussion: Adherence with AEDs among adult epilepsy patients is suboptimal and nonadherence appears to be associated with increased health care costs. Efforts to promote AED adherence may lead to cost savings for managed care systems. [source]


    Collective AIDS activism and individuals' perceived self-advocacy in physician-patient communication

    HUMAN COMMUNICATION RESEARCH, Issue 3 2000
    E Brashers
    In a study of AIDS activism and communication patterns between people with HIV or AIDS and health care personnel, parallel persuasive processes are described between social or political activism and personal self-advocacy. The analysis of public and private discourse leads to 3 interrelated conclusions about AIDS activist behaviours at the collective and individual levels: (a) greater patient education about the illness and treatment options is encouraged, (b) a more assertive stance toward health care is promoted, and mindful nonadherence is considered. Activists perceived that their self-advocacy behaviors, in turn, impact the physician-patient interaction. In communicative interactions, education allows patients to challenge the expertise of the physician, assertiveness allows them to confront paternalistic or authoritarian interactional styles, and mindful nonadherence allows them to reject treatment recommendations and offer reasons for doing so. Participants reported that physicians had mixed reactions to their self-advocacy attempts. [source]


    Factors associated with treatment nonadherence among US bipolar disorder patients,

    HUMAN PSYCHOPHARMACOLOGY: CLINICAL AND EXPERIMENTAL, Issue 2 2008
    Ross J. Baldessarini
    Abstract Objective Since sustained treatment-adherence is often problematic and may limit clinical outcomes among bipolar disorder (BPD) patients, we sought risk factors to guide clinical prediction of nonadherence. Methods Data were from a 2005 US national sample providing questionnaire responses by 131 randomly selected prescribing psychiatrists and their adult BPD patients. We contrasted demographic and clinical factors in treatment-adherent versus nonadherent patients (strictly defined as missing ,1 dose within 10 days) in univariate analyses followed by multivariate logistic-regression modeling. Results Of 429 DSM-IV BPD patients (79% type-I; 62% women; 17% minorities), 34% reported missing,,,1 dose of psychotropic medication within 10 days, 20% missed entire daily doses at least once, and only 2.5% missed all doses for 10 days. However, their prescribing psychiatrists considered only 6% as treatment-nonadherent. Factors significantly associated with nonadherence in multivariate modeling ranked: alcohol-dependence,>,youth,>,greater affective morbidity,>,various side effects,,,comorbid obsessive-compulsive disorder,,,recovering from mania-hypomania. Unrelated were sex, diagnostic subtype, and other comorbidities. Since most patients received,,,2 psychotropics, potential relationships between treatment-complexity and adherence were obscured. Conclusions Prevalent treatment-nonadherence among American BPD patients, and striking underestimation of the problem by prescribing clinicians may encourage increasingly complex treatment-regimens of untested value, but added expense, risk of adverse effects, and uncertain impact on treatment-adherence itself. Copyright © 2007 John Wiley & Sons, Ltd. [source]


    Barriers to adherence among adolescents with inflammatory bowel disease

    INFLAMMATORY BOWEL DISEASES, Issue 1 2010
    Rachel Neff Greenley PhD
    Abstract Background: The purpose of this study was to describe barriers to adherence among adolescents with inflammatory bowel disease (IBD) and to examine demographic, disease-related, and treatment regimen-related correlates of adherence barriers using a multimethod reporting strategy. A final goal was to examine relationships between the frequencies of barriers and levels of nonadherence. Methods: In all, 64 adolescents (ages 11,18) participated, along with 61 mothers and 25 fathers. Barriers to adherence and ratings of medication adherence were assessed via patient and parent reports. Disease activity ratings were provided by pediatric gastroenterologists. Results: Lack of time and medication side effects were commonly reported barriers across adolescent, mother, and father reports. Other adolescent-reported barriers included missing medication due to feeling well or discontinuing medication based on the belief that the medication was not working. The prevalence of adherence barriers was not consistently associated with adolescent age, sex, time since diagnosis, or disease activity. Adolescents whose regimen involved more than 1 daily medication administration had more adherence barriers based on adolescent and maternal report than did those whose regimen involved 1 or less than 1 daily medication administration. Finally, adherence barriers were significantly higher among families reporting imperfect adherence as compared to those reporting perfect adherence. Conclusions: Barriers to medication adherence do exist among adolescents with IBD and may have negative implications for medication adherence. Systematic assessment of barriers during routine medical appointments may help to identify and modify these barriers and ultimately improve adherence. Inflamm Bowel Dis 2010 [source]


    Patients' attitudes to medicines and adherence to maintenance treatment in inflammatory bowel disease

    INFLAMMATORY BOWEL DISEASES, Issue 6 2009
    Rob Horne PhD
    Abstract Background: Nonadherence has been reported in over 40% of patients taking maintenance therapies (MT) for inflammatory bowel disease (IBD). Studies in other illness groups have shown that nonadherence is related to negative attitudes to treatment. The aim of this study was to assess patients' attitudes to MT for IBD (beliefs about personal need for MT and potential adverse effects) and to identify whether such beliefs are associated with adherence to MT. Methods: A cross-sectional survey was conducted in which 1871 members of the National Association for Colitis and Crohn's Disease (NACC) completed validated questionnaires assessing beliefs about MT and adherence to MT. Results: Low adherence to MT was reported by 29% of participants and was associated with doubts about personal need for MT (odds ratio [OR] = 0.56; 95% confidence interval [CI]: 0.48,0.64; P < 0.001) and concerns about potential adverse effects (OR = 1.66; 95% CI: 1.42,1.94; P < 0.001). Attitudinal analysis showed that while almost half (48%) of the participants were "accepting" of MT (high necessity, low concerns), a large proportion of the sample (42%) were "ambivalent" about MT (high necessity, high concerns), 6% were "sceptical" (low necessity, high concerns) and 4% were "indifferent" (low necessity, low concerns). Compared to those who were "accepting" of MT, participants in all 3 other attitudinal groups were significantly more likely to be nonadherent. Conclusions: The way in which patients judge their personal need for MT relative to their concerns about MT can be a significant barrier to adherence. Interventions to facilitate optimal adherence to MT for IBD should address such perceptual barriers. (Inflamm Bowel Dis 2008) [source]


    How adherent to treatment with azathioprine are patients with Crohn's disease in long-term remission?

    INFLAMMATORY BOWEL DISEASES, Issue 4 2007
    Gerassimos J. Mantzaris MD
    Abstract Background: Patients with longstanding quiescent Crohn's disease on azathioprine usually maintain an excellent quality of life but are also concerned about long-term safety. This may affect adherence to treatment. The aim of the present study was to assess the adherence to azathioprine in a cohort of patients with Crohn's disease in long-term remission. Methods: Thirty patients with Crohn's disease in remission on azathioprine for ,48 months were enrolled in the study. All were asked to record the number of azathioprine tablets they consumed daily. Notes were kept every other month for 6 months. Adherence was defined as consumption of ,80% of medication. Results: Most patients (18/28, 74.3%) were not adherent to treatment. The mean (±SD) daily dose of azathioprine in adherent and nonadherent patients was 145 ± 45 mg and 102 ± 20 mg, respectively. However, there were no significant differences between the 2 groups in the mean IBDQ score and mean Crohn's Disease Activity Index (CDAI) score, both throughout the entire study and at each time point of the study. Male gender, single status, and consumption of >5 concomitant medications were associated with nonadherence. Conclusions: Most patients with Crohn's disease in longstanding remission had low self-reported adherence to azathioprine. Both male gender and single status were associated with nonadherence to azathioprine, whereas disease factors were not related to self-reported adherence. Patients considered nonadherent to treatment maintained disease remission and a quality of life similar to patients who were adherent to treatment. (Inflamm Bowel Dis 2006) [source]


    The effects of antidepressant medication adherence as well as psychosocial and clinical factors on depression outcome among older adults

    INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 2 2008
    Hayden B. Bosworth
    Abstract Objective To examine the contribution of medication adherence to 12-month depression scores in the context of other psychosocial and clinical predictors of depression in a sample of older adults treated for depression. Methods Secondary analysis of a prospective cohort study involving 241 older patients undergoing depression treatment using a standardized algorithm. Depression was measured at baseline and 12-months post-baseline. Baseline predictor variables included antidepressant adherence, barriers to antidepressant adherence, four domains of social support, basic and instrumental activities of daily living (BADLs and IADLs), and clinical factors including past history of depression and medical comorbidities. Results Nearly 28% of patients reported being nonadherent with their antidepressant medication. In bivariate analyses, greater antidepressant medication nonadherence, more medication barriers, poorer subjective social support, less non-family interaction, greater BADL and IADL limitations, poor self-rated health, higher baseline depression scores, and not having diabetes were related to higher 12-month depression scores. In multivariable analyses, greater medication nonadherence, not having diabetes, poorer subjective social support, greater BADL limitations, and higher baseline depression scores were related to higher 12-month depression scores. Conclusion Interventions should be directed toward improving antidepressant adherence and modifiable psychosocial variables. Copyright © 2007 John Wiley & Sons, Ltd. [source]


    ASH Position Paper: Adherence and Persistence With Taking Medication to Control High Blood Pressure

    JOURNAL OF CLINICAL HYPERTENSION, Issue 10 2010
    Martha N. Hill RN
    J Clin Hypertens (Greenwich). 2010;12:757-764. © 2010 Wiley Periodicals, Inc. Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now. [source]


    Infant feeding practices of Pakistani mothers in England and Pakistan

    JOURNAL OF HUMAN NUTRITION & DIETETICS, Issue 6 2002
    T. Sarwar
    Abstract Objectives To investigate infant feeding practices followed by Pakistani mothers in Pakistan and in England. To establish if practices conform to current guidelines and to investigate reasons for adherence and nonadherence. Methods Ninety mothers of weaning age children were interviewed; 45 were in England and 45 in Pakistan. A questionnaire available in English and Urdu sought to find out about the methods of milk feeding and weaning used and the advice received, together with general beliefs about weaning. Results Characteristics of the infants in terms of current age, gender distribution, birth order of baby and age of weaning showed no significant differences between the two groups. Thus, differences between the two groups could be attributed to cultural differences rather than any of these factors. Chi-square analysis showed that the initial method of feeding chosen was significantly different (P < 0.001, d.f. = 2) with 73% of mothers in Pakistan breast-feeding compared with 24% in England. Similar proportions of mothers in both groups commenced weaning between 3 and 4 months. Common weaning foods included rice, cereals and eggs with progression to fruit and vegetables and family food in Pakistan, and fruit, vegetables, meat and convenience foods (especially sweet options) in England. Both groups of mothers wanted more information about infant feeding practices. Conclusion Mothers in Pakistan demonstrated more confidence in weaning practices than in England because of experiences with other siblings and advice from relatives. More advice from health professionals was requested and is needed by all mothers in order to improve weaning practices of the infants. [source]


    Improving Adherence to Abnormal Pap Smear Follow-Up

    JOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 1 2001
    Priscilla DeRemer Abercrombie RN
    Objective: To gain a better understanding of factors that affect follow-up and the strategies that have been found to improve follow-up after an abnormal Papanicolaou (Pap) smear test. Data Sources: A computer-based search of the literature was conducted using MEDLINE with the keywords adherence, nonadherence, compliance, Follow-up, and abnormal Pap smears. Study Selection: Research studies published between 1985 and 1999 in the English language were included. If relevant studies were cited in the articles reviewed, these studies also were reviewed. A total of 25 studies were reviewed. Data Extraction: A critical review of these studies was conducted, with special attention to implications for clinical practice as well as future research. The studies fell into two groups: factors associated with nonadherence and strategies developed to improve adherence. Data Synthesis: A number of factors were identified that affect adherence to follow-up among women with abnormal Pap smears. Some of these factors involve characteristics of the woman, such as demographics, social support, lack of understanding, and fear. Factors that pertain to the health care system, such as inconvenient clinic hours, male providers, and insensitive staff, also were identified. A number of strategies have been successful in improving follow-up, including telephone counseling, educational programs, and economic incentives. Conclusions: Nurses play a crucial role in Facilitating adherence to recommendations for follow-up. They can identify women at risk for poor follow-up, increase awareness of the factors that affect follow-up, and implement strategies shown to be successful in improving adherence. Future research should take into account the rnultifactoral nature of adherence as well as the patient's perspective. In addition, studies should be designed with special attention to generalizability and should include women from populations most at risk for cervical cancer. [source]


    A Randomized, Double-Blind, Placebo-Controlled Pilot Study of Naltrexone in Outpatients With Bipolar Disorder and Alcohol Dependence

    ALCOHOLISM, Issue 11 2009
    E. Sherwood Brown
    Background:, Alcohol dependence is extremely common in patients with bipolar disorder and is associated with unfavorable outcomes including treatment nonadherence, violence, increased hospitalization, and decreased quality of life. While naltrexone is a standard treatment for alcohol dependence, no controlled trials have examined its use in patients with co-morbid bipolar disorder and alcohol dependence. In this pilot study, the efficacy of naltrexone in reducing alcohol use and on mood symptoms was assessed in bipolar disorder and alcohol dependence. Methods:, Fifty adult outpatients with bipolar I or II disorders and current alcohol dependence with active alcohol use were randomized to 12 weeks of naltrexone (50 mg/d) add-on therapy or placebo. Both groups received manual-driven cognitive behavioral therapy designed for patients with bipolar disorder and substance-use disorders. Drinking days and heavy drinking days, alcohol craving, liver enzymes, and manic and depressed mood symptoms were assessed. Results:, The 2 groups were similar in baseline and demographic characteristics. Naltrexone showed trends (p < 0.10) toward a greater decrease in drinking days (binary outcome), alcohol craving, and some liver enzyme levels than placebo. Side effects were similar in the 2 groups. Response to naltrexone was significantly related to medication adherence. Conclusions:, Results suggest the potential value and acceptable tolerability of naltrexone for alcohol dependence in bipolar disorder patients. A larger trial is needed to establish efficacy. [source]


    Medication Adherence Among Adolescents in a School-Based Health Center

    JOURNAL OF SCHOOL HEALTH, Issue 2 2006
    Cynthia J. Mears
    Medication adherence for these patients may be challenging because the student is often responsible for bringing home the prescription and receiving the instructions. This study assesses medication fill, initiation, and adherence rates among adolescents in a school-based health center to identify major barriers to medication compliance. Students enrolled in a school-based health center, ,10 years old, able to read and write English, and whose parent had provided consent for participation, were eligible for the study. Eligible students who received a prescription from the health center were invited to return to the clinic a week later to complete a questionnaire (with verbal assent). Primary outcome measures included medication fill rates, medication initiation rates, medication adherence rates, and reasons for nonadherence. Eighty-one students completed the questionnaire: 45 students (55.6%) filled their prescription. Of the students who filled their prescriptions, 75.6% reported always taking their medication at the appropriate time, 22.2% reported sometimes forgetting to take their medication, and 2.2% reported never taking the medication. However, many discrepancies were found between reported medication-taking behavior and the instructions provided to the student. Medication fill, initiation, and adherence rates among students receiving prescriptions for medications in school-based health centers are suboptimal. Interventions that address key identified barriers need to be developed and evaluated in order to achieve optimal fill and adherence rates. (J Sch Health. 2006;76(2):52-56) [source]


    Improving Compliance in Your Dyslipidemic Patient: An Evidence-based Approach

    JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 5 2001
    Diane M. Becker RN
    Purpose To synthesize the evidence from landmark clinical studies of lipid-lowering pharma-cotherapy and nurse management of hyperlipidemia, discuss issues related to nonadherence, and proposes strategies for achieving long-term cholesterol control. Data Sources All publications of lipid-lowering clinical trials related to pharmacotherapy for dyslipidemias were accessed from a thorough Medline Search and reviewed by two nurse experts. Conclusions Randomized controlled studies provide com-pelling evidence that reduction of blood cho-lesterol with pharmacotherapy reduces both first and subsequent coronary events. Nonetheless, inadequate provider and patient adherence to guidelines for lipid lowering remains prevalent. Studies show that nurses provide safe and effective care for patients with abnormal lipids. Implications This article assists nurse practitioners in playing an active role in the implementation of the National Cholesterol Education Program Adult Treatment Panel III Report to be released in Spring 2001, where a strong emphasis will be placed on multidisciplinary approaches and adherence. [source]


    Introduction of the flash-lamp pulsed-dye laser treatment of facial port-wine stains in childhood: A case of health care technology assessment

    LASERS IN SURGERY AND MEDICINE, Issue 2 2001
    C.A.J.M. De Borgie MSc
    Abstract Background and Objective Lasers have been used in the treatment of port-wine stains (PWS) for more than 30 years. With the introduction of the flash-lamp pulsed-dye laser (FPDL) it was assumed that infants could be treated safely, effectively, and probably more efficiently. Nowadays, FPDL treatment is an established form of treatment of PWS in childhood. Study Design/Materials and Methods On the basis of the iterative Health Care Technology Assessment (HCTA) loop, we examined whether sufficient evidence from evaluations has been present to support the introduction of FPDL treatment for facial PWS at an early age. Such an assessment requires an interdisciplinary approach focusing on aspects of safety, efficacy, effectiveness, quality of life, costs, and the ethical issues of treatment. Results Assessment of the FPDL in PWS treatment of children did not follow the model of medical innovation and evaluation. Most assessments have been focused on laser applications that were already in clinical use. Efficacy and effectiveness of laser treatment have been the major concern in most assessments. Only a few studies have looked at costs and ethical aspects of treating children. Conclusions The introduction and diffusion of the use of the FPDL in the treatment of PWS in childhood were uncontrolled, and the field was not prepared to use this technique properly. We believe that this nonadherence to the iterative HCTA model reflects the gradual way by which innovations find their way into clinical practice. Lasers Surg. Med. 28:182,189, 2001. © 2001 Wiley-Liss, Inc. [source]


    Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs,

    LIVER TRANSPLANTATION, Issue 2 2008
    Mary Amanda Dew
    For patients receiving liver or other organ transplants for diseases associated with substance use, risk for relapse posttransplantation is a prominent clinical concern. However, there is little consensus regarding either the prevalence or risk factors for relapse to alcohol or illicit drug use in these patients. Moreover, the evidence is inconsistent as to whether patients with pretransplantation substance use histories show poorer posttransplantation medical adherence. We conducted a meta-analysis of studies published between 1983 and 2005 to estimate relapse rates, rates of nonadherence to the medical regimen, and the association of potential risk factors with these rates. The analysis included 54 studies (50 liver, 3 kidney, and 1 heart). Average alcohol relapse rates (examined only in liver studies) were 5.6 cases per 100 patients per year (PPY) for relapse to any alcohol use and 2.5 cases per 100 PPY for relapse with heavy alcohol use. Illicit drug relapse averaged 3.7 cases per 100 PPY, with a significantly lower rate in liver vs. other recipients (1.9 vs. 6.1 cases). Average rates in other areas (tobacco use, immunosuppressant and clinic appointment nonadherence) were 2 to 10 cases per 100 PPY. Risk factors could be examined only for relapse to any alcohol use. Demographics and most pretransplantation characteristics showed little correlation with relapse. Poorer social support, family alcohol history, and pretransplantation abstinence of ,6 months showed small but significant associations with relapse (r = 0.17-0.21). Future research should focus on improving the prediction of risk for substance use relapse, and on testing interventions to promote continued abstinence posttransplantation. Liver Transpl 14:159,172. 2008. © 2008 AASLD. [source]


    Prevalence and cost of medication nonadherence in Parkinson's disease: Evidence from administrative claims data,

    MOVEMENT DISORDERS, Issue 4 2010
    Keith L. Davis MA
    Abstract We estimated the prevalence of medication nonadherence in Parkinson's disease (PD) and the association between treatment nonadherence and healthcare costs. Insurance claims from over 30 US health plans were analyzed. Inclusion criteria were as follows: PD diagnosis, ,1 PD-related prescription between 1/1/1997 and 12/31/2004, continuous health plan enrollment for ,6 months before and ,12 months after first PD prescription. Adherence, all-cause healthcare utilization, and all-cause costs were evaluated over 12 months post-treatment initiation. Adherence was measured using the medication possession ratio (MPR), with MPR < 0.8 defining nonadherence. Among patients identified for inclusion (N = 3,119), 58% were male and mean age was 69 years. Mean MPR was 0.58 and 61% of patients were nonadherent. Unadjusted mean medical costs were significantly higher (P < 0.01) among nonadherers ($15,826) compared with adherers ($9,228), although nonadherers had lower prescription drug costs ($2,684 vs. $3,854; P < 0.05). After controlling for confounders in multivariable analyses, a large positive relationship between nonadherence and both medical and total healthcare costs remained (+$3,451, P < 0.0001 and +$2,383, P = 0.0053, respectively). Medication adherence in PD is suboptimal and nonadherence may be associated with increased healthcare costs despite offsets from reduced drug intake. Efforts to promote medication adherence in PD may lead to cost savings for managed care systems. © 2010 Movement Disorder Society [source]


    Adherence According to Mary Poppins: Strategies to Make the Medicine Go Down

    PERSPECTIVES IN PSYCHIATRIC CARE, Issue 1 2010
    PMHNP-BC, Suzanne M. Hardeman MRC
    PURPOSE., This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence. CONCLUSION., A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden. PRACTICE IMPLICATIONS., Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers. [source]


    Nonadherence as a predictor of antidiabetic drug therapy intensification (augmentation),

    PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 9 2004
    Dr Stephen J. Kogut MBA
    Abstract Purpose To determine if nonadherence with antidiabetic drug therapy is predictive of subsequent antidiabetic drug therapy intensification. Methods We conducted a retrospective cohort study examining retail pharmacy dispensings of sulfonylureas or metformin to 1067 patients having diabetes. Patients that did not receive a sufficient quantity of medication to cover at least 80% of days during the evaluation period were classified as nonadherent. Outcomes identified were increase in the dose of antidiabetic medication utilized, the addition of a second antidiabetic agent to the regimen or either. Results Among users of sulfonylurea monotherapy, those classified as nonadherent were 45% more likely to intensify therapy in subsequent months as compared with those classified as adherent (age-adjusted odds ratio (OR) 1.45; 95% confidence interval (CI) 1.06,2.00). This finding was largely driven by observed increases in dosage, which were more likely among patients classified as nonadherent (age-adjusted OR 1.48, 95%CI 1.07,2.05). Nonadherence was not found to be predictive of the subsequent addition of a second antidiabetic agent (OR 1.02; 95%CI 0.64,1.63). Overall findings were similar for the smaller sample of patients receiving metformin monotherapy, though observed differences did not achieve statistical significance. Conclusions Patients who were poorly adherent to oral antidiabetic drug therapy more frequently experienced an increase in the dose of medication prescribed, as compared to patients that were classified as adherent. This finding underscores the need for prescribers to consider nonadherence as a root cause when patients fail to achieve therapeutic goals. Copyright © 2004 John Wiley & Sons, Ltd. [source]


    Latest news and product developments

    PRESCRIBER, Issue 12 2008
    Article first published online: 14 JUL 200
    Patients want to stop ,Z' drugs more than benzos A study from Lincolnshire has revealed that patients prescribed a ,Z' drug - zaleplon (Sonata), zolpidem or zopiclone - for insomnia are more likely to want to stop treatment than those prescribed a benzodiazepine (Br J Gen Pract 2008;58:417-22). The cross-sectional survey of 705 patients prescribed a hypnotic for insomnia found that more patients taking a Z drug wanted to stop (23 vs 12 per cent prescribed a benzodiazepine) and tried to stop treatment (52 vs 41 per cent). New NICE guidance NICE has published an updated clinical guideline for the management of type 2 diabetes, covering: the control of blood glucose with lifestyle modification, oral hypoglycaemic drugs and insulin; reducing blood pressure and lipids, antithrombotic therapy and estimating cardiovascular risk; and screening and treatment for long-term complications. There is also a new clinical guideline on cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. New technology appraisals include the use of erythropoietin analogues for cancer-associated anaemia, and adalimumab (Humira) and etanercept (Enbrel) for ankylosing spondylitis; infliximab (Remicade) is not recommended. See New from NICE (pages 13-14) for further details. Prescriber consultant editor wins award Professor Tony Avery, professor of primary care at Nottingham University and consultant editor for Prescriber, has won the John Fry Award for his work in promoting the discipline of general practice through research and publishing as a practising GP. The citation acknowledges Professor Avery as ,quite simply one of the best researchers we have had in general practice,' describing his output of original work and research as impressive. The award commemorates the work of the late Dr John Fry, perhaps the most prominent GP of his generation involved in research. Antihypertensive dose ignores adherence Clinicians take no account of poor adherence when they increase the dose of antihypertensive therapy due to apparent lack of effect, US researchers say (Circulation 2008; published online May 27; doi 10.1161/CIRCULATIONAHA.107.724104). Their retrospective analysis included reimbursement records for 38 327 patients with hypertension who presented with elevated BP (140-200/>90mmHg) in one year (mean 1.8 events per patient). After adjusting for potential confounders, they found that antihypertensive medications were added or the dose of medication increased in about one-third of patients regardless of the degree of nonadherence in the previous year. LABAs improve COPD Inhaled long-acting beta2-agonists (LABAs) improve COPD and do not increase the risk of death, a new safety review has concluded (Chest 2008;133:1079-87). The meta-analysis of 27 RCTs in patients with moderate to severe stable COPD found that LABAs reduced exacerbations by 22 per cent, improved lung function, reduced use of rescue medication and improved quality of life. There was no effect on respiratory deaths, though a combination of a LABA with an inhaled steroid reduced the risk by two-thirds compared with LABA monotherapy. Tiotropium (Spiriva) was associated with a 50 per cent lower risk of exacerbations than LABAs. These findings follow the MHRA's review of LABAs in the treatment of asthma, which found no increase in mortality provided they are used with an inhaled steroid (Drug Safety Update 2008;1:9). Naproxen as effective in acute gouty arthritis Naproxen is as effective as prednisolone in the treatment of acute gouty arthritis, say researchers from The Netherlands (Lancet 2008;371:1854-60). Their study in 118 primary care patients showed that five days' treatment with naproxen 500mg twice daily or prednisolone 35mg daily reduced pain scores to a similar extent with a comparable incidence of adverse effects. Copyright © 2008 Wiley Interface Ltd [source]


    Latest news and product developments

    PRESCRIBER, Issue 22 2007
    Article first published online: 28 DEC 200
    Glitazones: benefits outweigh the risks Following a review of the safety of rosiglitazone and pioglitazone, the European Medicines Agency (EMEA) has concluded that their benefits outweigh their risks in the approved indications. The review was prompted by reports of an increased risk of fractures in women and, in patients taking rosiglitazone, ischaemic heart disease. The EMEA concluded that prescribing information for rosiglitazone should now include a warning that, in patients with ischaemic heart disease, it should only be used after careful evaluation of each patient's individual risk, and the combination of rosiglitazone and insulin should only be used in exceptional cases and under close supervision. No change was considered necessary to the prescribing information for pioglitazone. Modern dressings no better? A systematic review has found only weak evidence that modern dressings are better than saline gauze or paraffin gauze for healing acute and chronic wounds (Arch Dermatol 2007;143: 1297-304). The analysis, which included 99 studies, found that only hydrocolloids were demonstrably better than older dressings for healing chronic wounds, and alginates were superior to other modern dressings for debriding necrotic wounds. There was no evidence that modern dressings offered superior overall performance to the older alternatives. Hospital inflation twice primary care level The cost of drugs prescribed in secondary care but dispensed in the community increased by 6.4 per cent in 2006 - twice the rate of inflation in primary care - according to the latest statistics on hospital prescribing in England. The increase follows a reduction in costs in 2005 after the introduction of the new PPRS scheme. Data from The Information Centre (www.ic.nhs.uk) show that hospital medicines make up about 24 per cent of the NHS drugs budget. Secondary care has a consistently better record than primary care in prescribing lower-cost alternatives within therapeutic categories, eg simvastatin and pravastatin among the statins, omeprazole and lansoprazole among PPIs, and ACE inhibitors among drugs acting on the renin angiotensin system. The most expensive drug prescribed by hospital specialists and dispensed in the community is interferon beta. MHRA limits the use of fibrates The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that fibrates should now be reserved for the treatment of isolated severe hypertriglyceridaemia. They should be considered for hypercholesterolaemia only when a statin or other treatment is contraindicated or not tolerated. In the latest Drug Safety Update, the MHRA says there is insufficient evidence of long-term benefits from fibrates, and first-line use is no longer justified because the evidence for the benefits of statins is robust. The MHRA also warns that some breastfeeding infants have increased susceptibility to the adverse effects of codeine taken by their mother, and that St John's wort may affect the hepatic metabolism of any anticonvulsant. Annual zoledronic acid infusion cuts mortality after hip fracture Once-yearly infusion of zoledronic acid (Aclasta) after hip fracture reduces deaths over a two-year period by 28 per cent compared with placebo, US investigators say (N Engl J Med 2007;357:1799-809). The HORIZON Recurrent Fracture Trial randomised 2127 men and women (mean age 75) within 90 days of surgery for hip fracture to zoledronic acid 5mg yearly or placebo. Mortality over 1.9 years of follow-up was 9.6 per cent with zoledronic acid and 13.3 per cent with placebo. Zoledronic acid also significantly reduced the rate of any new clinical fractures (by 35 per cent) and new clinical vertebral fractures(by 45 per cent),but the lower rate of hip fracture (2.0 vs 3.5 per cent with placebo) was not statistically significant. Rivastigmine patch for mild to moderate AD Rivastigmine (Exelon) is now available as a transdermal patch for the treatment of mild to moderate Alzheimer's disease. Applied once daily, the patch delivers 9.5mg per 24 hours and, says manufacturer Novartis, is associated with a lower incidence of nausea and vomiting than a comparable oral dose. The patch is available in two strengths: 4.6mg per 24hr is equivalent to oral doses of 3 or 6mg per day, and the 9.5mg per 24hr patch is equivalent to 9 or 12mg per day orally. The recommended dose of the patch is 9.5mg per day; both strengths cost £83.84 for 30 patches. Women more aspirin resistant than men? The cardioprotective effect of low-dose aspirin may be lower in women than men, say Canadian investigators (BMC Medicine 2007;5:29 doi: 10.1186/1741-70155-29). Their meta-analysis of 23 randomised trials involving a total of 113 494 participants found that aspirin significantly reduced the risk of nonfatal but not fatal myocardial infarction (MI). About one-quarter of the variation in its effects on nonfatal MI was accounted for by the sex mix of the trial population. Separating the results by sex showed the reduction in risk with aspirin use was statistically significant in men (relative risk, RR, 0.62) but not in women (RR 0.87). Look after physical health of mentally ill GPs and other primary care workers should take more responsibility for the physical health of their mentally ill patients, say advocacy groups. Mind and Body: Preventing and Improving Physical Health Problems in Patients With Schizophrenia points out that the mental health needs of patients with schizophrenia are met in secondary care, but their physical health needs should be met in primary care. In particular, the metabolic effects of antipsychotics may lead to obesity, diabetes and cardiovascular disease, and weight gain in particular is a frequent reason for nonadherence to treatment. The Mind and Body Manifesto was developed by SANE, The Mental Health Nurses Association, The National Obesity Forum and The Disability Rights Commission and sponsored by Bristol-Myers Squibb Pharmaceuticals Limited and Otsuka Pharmaceuticals (UK) Ltd. Copies are available from elizabeth.green@ ogilvyhealthworld.com. Health eCard costs Some costs quoted in our article on the Health eCard (The Health eCard: the way ahead for medical records?,5 October issue, pages 28-9) have been revised: the card and initial download will cost patients £39.50, and GPs will be entitled to charge patients £10 per annum for subsequent downloads. NICE appraisals of cytokine inhibitors in RA NICE has endorsed the use of the anti-TNF agents adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), normally in conjunction with methotrexate, for the treatment of active RA when methotrexate and another DMARD have failed (also see New from NICE below). NICE has provisionally concluded, subject to consultation, that abatacept (Orencia) should not be recommended for the treatment of RA. Boots and BMJ launch health advice site www.askbootshealth.com is a new website providing information about health and medicines for the public produced by Boots using information provided by the BMJ Publishing Group. The website covers many of the topics already available from NHSDirect, with perhaps more information about available treatments. Diabetes care shows small improvement The third National Diabetes Audit in England and Wales has found that more people with diabetes were achieving the targets set by NICE for cholesterol levels, glycaemic control and blood pressure in 2005/06 - but younger patients were doing less well. Overall, the HbA1C target of ,7.5 per cent was achieved in 60 per cent of people with diabetes compared with 58 per cent in 2004/05. However, HbA1C was >9.5 per cent in 30 per cent of children and young people, of whom 9 per cent experienced at least one episode of ketoacidosis. More topics for NICE New topics referred to NICE include clinical guidelines on ovarian cancer, coeliac disease and stable angina, public health guidance on preventing cardiovascular disease, and technology appraisals on insulin detemir (Levemir) for type 1 diabetes, several treatments for cancer and hepatic and haematological disorders, and biological therapies for juvenile arthritis. New from NICE NICE appraisal on anti-TNFs for RA Since NICE published its first appraisal of agents acting against tumour necrosis factor-alpha (anti-TNFs) for the treatment of RA in 2002, the product licences for etanercept (Enbrel) and infliximab (Remicade) have changed and a new agent, adalimumab (Humira), has been introduced. The anti-TNFs act in different ways. Infliximab is a chimeric monoclonal antibody that binds to TNF-alpha, neutralising its activity. Etanercept, a recombinant human TNF-alpha receptor fusion protein, and adalimumab, a human-sequence antibody, both bind to TNF-alpha and block its interaction with cell surface receptors. Adalimumab also modulates some biological responses induced or regulated by TNF-alpha. These agents are recommended for adults with severe active RA (defined as a disease activity score - DAS28 - greater than 5.1) who have already tried two disease-modifying drugs, including methotrexate (if not contraindicated). Prior treatment should have been of at least six months' duration, including two months at the standard dose (unless limited by toxicity). Anti-TNFs should normally be prescribed with methotrexate; when this is not appropriate, etanercept and adalimumab may be prescribed as monotherapy. Treatment with an anti-TNF should be continued beyond six months only if there is an adequate response (defined as an improvement in DAS28 of at least 1.2). Data from the British Rheumatology Society Biologics register show that, after six months, 67 per cent of patients met NICE criteria for an adequate response; this declined to 55 per cent at 18 months. The basic annual cost of treatment is £9295 for adalimumab 40mg on alternate weeks or etanercept 25mg twice weekly; infliximab costs £3777 for a loading dose, then £7553-£8812 depending on dose. Assuming no progression of disability, the incremental costs per QALY (compared with sequential DMARDs) were £30 200 for adalimumab, £24 600 for etanercept and £39 400 for infliximab. There are no direct comparative trials of the anti-TNFs, and their clinical trial findings are not directly comparable. Unless other factors determine treatment choice, NICE therefore recommends the least expensive. If the first anti-TNF is withdrawn within six months due to an adverse event, a second may be tried. [source]