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Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review |
Gleeson T, Iversen MD, Avorn J, Brookhart AM, Katz JN, Losina E, May F, Patrick AR, Shrank WH, Solomon DH |
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CRD summary The authors concluded that few interventions designed to improve adherence and persistence with osteoporosis medications were efficacious and that no clear trends in successful intervention techniques were identified in this small sample of studies. These conclusions reflect the evidence presented, but the poor quality of included studies and the potential for publication and language bias should be borne in mind. Authors' objectives To evaluate the effectiveness of interventions designed to improve adherence and persistence with osteoporosis medications. Searching MEDLINE, EMBASE, CINAHL and the Cochrane Systematic Reviews databases were searched for studies published in English from January 1990 to July 2008. Search terms were reported. Bibliographies of relevant publications were scanned for additional articles, as were abstracts from the previous nine years of the American Society for Bone Mineral Research (ASBMR) annual meetings. Study selection Controlled studies of interventions aimed to improve adherence or persistence with osteoporosis medications were eligible for inclusion.
Interventions varied between the included studies. Most of the studies included a structured patient education component which was delivered face-to-face or via brochures, letters and telephone calls. Other intervention components included response to therapy feedback, telephone patient counselling, or combined patient and physician education. Control groups included usual care, meeting with physician, or information brochure. In one study, control data were derived from national baseline data on medication adherence. Settings of the included studies included general practitioners offices and specialty clinics. Definitions of medical adherence, persistence, and compliance varied between studies. Studies were conducted in the USA and Europe; one study was multi-national.
The authors did not state how many reviewers selected studies for inclusion. Assessment of study quality Study quality was assessed using the Jadad scale and included assessment of randomisation, blinding and withdrawals and drop-outs. The maximum possible score was 5 points.
Three reviewers independently assessed validity. Data extraction Data on adherence and persistence were independently extracted by two reviewers; disagreements were resolved through discussion. Data were used to calculate effect sizes (ES) for each outcome. Clinical importance was deemed to be crucial (ES=0.80 or more), moderate (ES=0.50 or more), and negligible (ES=0.20 or more), as per Cohen 1987. Methods of synthesis Data were combined in a narrative synthesis. Results of the review Seven studies (approximately 4,361 participants, range 68 to 2,302) were included in the review; six were randomised controlled trials (RCTs) and one was a non-randomised historical controlled trial. Six RCTs scored 3 points and one non-randomised RCT scored 1 point. Six studies reported random assignment. None of the studies were described as double-blinded. All the studies included adequate descriptions of withdrawals and dropouts.
Adherence (five studies): Three studies (two RCTs and one non-RCT) reported a statistically significant improvement in adherence for the intervention group compared to control group (ES ranged from 0.17 to 0.58). Two RCTs reported no significant differences between groups.
Persistence (five studies): Only one RCT reported a statistically significant improvement in persistence for the intervention group compared with control (57% versus 39%, ES 0.36). One RCT reported better persistence in the intervention group than control (88% versus 67%, ES 0.52) but this difference was not statistically significant (p=0.06). The remaining three RCTs reported better persistence in the control group. Authors' conclusions Few interventions were efficacious and no clear trends regarding successful intervention techniques were identified in this small sample of studies. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial. CRD commentary The review question was clearly defined with appropriate inclusion criteria. Several relevant sources were searched, but the limitation to studies published in English meant there was the potential for language and publication bias. Appropriate methods to reduce reviewer error and bias were undertaken for assessment of validity and extraction of data, but it is unclear whether similar methods were used for selection of studies.
Quality assessment was conducted and the results were reported for included studies. A narrative synthesis was appropriate given the differences between studies for interventions and definitions of adherence and persistence. Most of the included studies had small sample sizes.
The authors' conclusions reflect the evidence presented, but the small number of included studies of poor quality and the potential for publication and language bias should be borne in mind. Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that, as well as measuring adherence and persistence to osteoporosis medications, future randomised controlled trials should have longer, more detailed follow-up to measure fracture outcomes; in addition, reasons for non-adherence should be explored. To enable comparison between future studies, the authors recommended that standard definitions (such as those proposed by ISPOR) are adopted and that studies utilise a medication possession ratio for adherence as well as measuring continuous or dichotomous variables for persistence based on length of time from initiation to discontinuation of therapy. Funding National Institutes of Health, USA, grant number AR-47782; National Heart, Lung and Blood Institute, USA, career development award HL-090505; National Institutes of Health, USA, career development award AG-027400. Bibliographic details Gleeson T, Iversen MD, Avorn J, Brookhart AM, Katz JN, Losina E, May F, Patrick AR, Shrank WH, Solomon DH. Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review. Osteoporosis International 2009; 20(12): 2127-2134 Indexing Status Subject indexing assigned by NLM MeSH Bone Density Conservation Agents /therapeutic use; Evidence-Based Medicine; Humans; Medication Adherence /statistics & Osteoporosis /drug therapy /psychology; Randomized Controlled Trials as Topic /methods /standards; Research Design /standards; Treatment Outcome; numerical data AccessionNumber 12011000723 Date bibliographic record published 11/05/2011 Date abstract record published 20/10/2011 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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