Adherence to Medication in Older Adults as a Way to Improve Health Outcomes and Reduce Healthcare System Spending

Medications are used as the primary approach to prevent and effectively manage the chronic conditions. Non-adherence to medication is recognized as a worldwide public health problem with important implications for the management of chronic diseases, which affects every level of the population, particularly older adults due to the high number of coexisting diseases and consequent polypharmacy. Estimated rates of adherence to long-term medication regimen are of about 50%, and there is no evidence for significant changes in the past 50 years. The consequences of non-adherence include poor clinical outcomes, increased morbidity and mortality and unnecessary healthcare costs. Factors contributing to non-adherence are multifaceted and embrace those that are related to patients, to physicians and to healthcare systems. Cognitive, sensorial and functional decline, poor social support, anxiety, depression symptomatology and reduced health literacy have been linked to medication non-adherence in the elderly patients. Many interventions to improve medication adherence have been described in the study for different clinical conditions; however, most interventions seem to fail in their aims. In this chapter, a revision of the implications of poor adherence as well as its predictors and available tools to improve adherence is performed

Self-Assessment of Adherence to Medication: A Case Study in Campania Region Community-Dwelling Population.

Objectives. The aim of the study was to assess self-reported medication adherence measure in patients selected during a health education and health promotion focused event held in the Campania region. The study also assessed sociodemographic determinants of adherence. Methods. An interviewer assisted survey was conducted to assess adherence using the Italian version of the 8-item Morisky Medication Adherence Scale (MMAS-8). Participants older than 18 years were interviewed by pharmacists while waiting for free-medical checkup. Results. A total of 312 participants were interviewed during the Health Campus event. A total of 187 (59.9%) had low adherence to medications. Pearson's bivariate correlation showed positive association between the MMAS-8 score and gender, educational level and smoking (P < 0.05). A multivariable analysis showed that the level of education and smoking were independent predictors of adherence. Individuals with an average level of education (odds ratio (OR), 2.21, 95% confidence interval (CI), 1.08-4.52) and nonsmoker (odds ratio (OR) 1.87, 95% confidence interval (CI), 1.04-3.35) were found to be more adherent to medication than those with a lower level of education and smoking. Conclusion. The analysis showed very low prescription adherence levels in the interviewed population. The level of education was a relevant predictor associated with that result

Valutazione economica dello studio CARDS: un aggiornamento

Introduction: in the last decades, prevalence and incidence of type II diabetes mellitus have been rapidly growing worldwide. Most recent projections estimate that the number of people affected by diabetes is destined to double in 2030, producing a significant increase of the healthcare expenditure for the management of complications. Prevention of cardiovascular events in diabetes population represents a priority for decision makers, who have to evaluate the cost-effectiveness of therapeutic interventions. Objective: to provide an updated cost-effectiveness evaluation of treating type II diabetes patients with atorvastatin versus placebo, in the light of the imminent price reduction of atorvastatin due to loss of exclusivity and of other therapeutic and hospital costs. Material and Methods: we derived clinical information from the CARDS study, a randomized, multicenter clinical trial evaluating efficacy of atorvastatin versus placebo in preventing the occurrence of cardiovascular events in a cohort of type II diabetes patients without previous history of coronary events. A cost-effectiveness analysis in the perspective of the National Healthcare System (SSN) has been performed, under the hypothesis of the imminent price reduction of atorvastatin, due to the loss of exclusivity. Results: after a median follow up of 3.9 years, the number of patients with at least a major cardiovascular event requiring hospitalization was lower in the atorvastatin arm (5.8%) compared to the placebo arm (9.0%; p=0.001). Based on a cohort of 1,000 patients, treatment with atorvastatin permitted to gain 29.28 life years. The incremental cost of adding atorvastatin to the standard therapy amounted to €305,682, and was partially balanced by a cost reduction due to fewer hospitalizations, compared to the placebo arm (€ 168,313). Total direct costs were of €602.186 in the atorvastatin group and of € 464,818 in the placebo group, resulting into an incremental cost-effectiveness ratio of € 4,692 for Life Year Gained (LYG). Conclusion: the present study is an update of a previous economic analysis of the CARDS trial. Under the assumed new cost scenario, the cost-effectiveness profile of treating diabetic patients with atorvastatin becomes highly favourable, and leads to a significant reduction of the cost for Life Year Gained compared to the previous findings

Fixed Versus Free Combinations of Antihypertensive Drugs: Analyses Of Real-World Data Of Persistence With Therapy In Italy

Purpose: To analyse the pattern of use and cost of antihypertensive drugs in new users in an Italian population, and explore the patient/treatment factors associated with the risk of therapy discontinuation. Patients and methods: In this retrospective study, information was collected from a population-based electronic primary-care database. Persistence with medication use 1 year from therapy initiation was evaluated for each user using the gap method. Each new user was classified according to his/her pattern of use as: \u201ccontinuer\u201d, \u201cdiscontinuer\u201d \u201cswitching\u201d or \u201cadd-on\u201d. A Cox regression model was used to analyse the factors influencing therapy discontinuation. Primary-care costs comprised specialists\u2019 visits, diagnostic procedures and pharmacologic therapies. Results: Among 14,999 subjects included in persistence analyses, 55.1% of cases initially started on monotherapy were classified as discontinuers vs 36.5% of cases taking combination therapy (42.3% vs 32.7%, respectively, for free and fixed combinations, P < 0.01). Old age, high cardiovascular risk and being in receipt of fixed-combination therapy were associated with greater persistence. Overall, the primary-care cost/person/year of hypertension management was 3c\u20ac95.3 (IQR, 144.9). The monotherapy cost was \u20ac88 per patient (IQR, 132.9), and that for combination therapy was \u20ac151\ub1148.3. The median cost/patient with a fixed combination was lower than that for a free combination (\u20ac98.4 (IQR, 155.3) and \u20ac154.9 (IQR, 182.6), respectively). Conclusion: The initial type of therapy prescribed influences persistence. Prescribing fixed combinations might be a good choice as initial therapy

Valutazione economica dello studio CARDS

Introduction: cardiovascular diseases (CVD) are the major component of premature mortality, generate disability and are a relevant source of cost. The growing incidence of CVD is associated with lifestyle and other modifiable risk factors. Prevention and preclinical detection of CVD reduce morbidity and mortality. Type 2 diabetes is associated with a substantially increased risk of cardiovascular disease. Objective: the aim of the study was to evaluate the health economic consequence of medical therapy with atorvastatin for primary prevention of major cardiovascular events in patients with type 2 diabetes in Italy. Materials and method: in order to reach our objective we drew clinical information from the CARDS study. This economic evaluation was carried out conducting a cost/effectiveness analysis from the perspective of National Health Service (NHS). The analysis was applied to a time horizon in conformity with the observational period adopted in the CARDS study (3.9 years). An incremental cost/effectiveness ratio (ICER) was calculated and is expressed as cost per life years gained (LYG). In order to test the robustness of the results, a one-way sensitivity analysis was performed. Results: the total cost of atorvastatin therapy over 3.9 years amounts to around 1.5 million of euros per 1,000 patients. The total cost of adding atorvastatin to standard care in people treated for primary prevention of major cardiovascular events in type 2 diabetes as those involved in the CARDS study would entail an additional cost of about 1,2 million of euros per 1,000 patients treated per 3.9 years, with an incremental cost/effectiveness ratio (ICER) equivalent to 36,566 euros per patient per LYG. Discussion: the current study is the first economic evaluation of CARDS study to the Italian situation. The results of the current study show that hypolipemic therapy with atorvastatin 10 mg in diabetic individuals is to be considered cost effective

Prescription Appropriateness of Drugs for Peptic Ulcer and Gastro-Esophageal Reflux Disease: Baseline Assessment in the LAPTOP-PPI Cluster Randomized Trial

Background: Drugs for peptic ulcer and gastro-esophageal reflux disease (GERD) are among the most widely prescribed, frequently without appropriate indications. This represents an important issue, as it leads to risk of adverse events for patients and unnecessary costs for National Health Service. Aim: To assess the prescription appropriateness of drugs for GERD, in the frame of the "Evaluation of the effectiveness of a Low-cost informative intervention to improve the Appropriate PrescripTiOn of Proton PumP Inhibitors in older people in primary care: a cluster-randomized controlled study" (LAPTOP-PPI) (Clinicaltrial.gov: NCT04637750). Methods: The appropriateness of drug prescription was assessed on data collected in administrative databases, by integrating information on concomitant medications, outpatient medical and laboratory procedures and hospital discharge diagnoses, according to the reimbursement criteria provided by the Italian Medicine Agency. We analyzed data of community-dwelling people aged 65 years and over, living in the areas of Bergamo (Northern Italy) and Caserta (Southern Italy), from July 1 to 31 December 2019. Results: Among 380,218 patients, 175,342 (46.1%) received at least one prescription of drugs for GERD. All in all, we found that only 41.2% of patients received appropriate prescriptions. Conclusion: Given the potential risk of adverse drug reactions, especially in older people, educational interventions should be prompted for physicians, in order to improve the quality of prescription of drugs for GERD and, in turn, avoid unfavorable health outcomes and unnecessary costs

Farmaci oppioidi e Cannabis nella terapia del dolore

[English]:“Opioid and Cannabis in Pain Control” is the result of studies performed by the Pharmacy Department and the “Centro Interdipartimentale di Ricerca in Farmacoeconomia e Farmacoutilizzazione” (CIRFF) of the University of Naples, “Federico II”. This book is aimed to those who work in a pharmacy and who, scholars, teachers or students, are interested in delve into the issue. The text analyzes different topics with an interdisciplinary approach. A large part is devoted to the chemical and pharmacological aspects related to this topic. Subsequently, the text focuses the theme, still very debated, of using opioids and Cannabis in therapy through an exhaustive analysis of the entire existing legislation: from the first laws promulgated by the Kingdom of Italy until the last ministerial circulars by Italian republic. Finally yet importantly, an important part of the book focuses on medical and therapeutic interpretation with regard to the effects on pain control, where opioids and Cannabis are not only a fruitful frontier of research, but also a consolidated and effective tool to counteract some types of pain / [Italiano]: “Farmaci oppioidi e Cannabis nella terapia del dolore” rappresenta il frutto di alcuni studi, condotti per almeno tre lustri nel Dipartimento di Farmacia e nel Centro Interdipartimentale di Ricerca in Farmacoeconomia e Farmacoutilizzazione (CIRFF) della Federico II, e si rivolge sia a chi presta servizio ogni giorno in una farmacia, sia a chi, studioso, docente o studente, è interessato ad approfondire l’argomento. Il testo, utilizzando un approccio interdisciplinare, si muove su piani euristici differenti. Naturalmente, ampio spazio è stato dedicato alla parte farmaceutica, analizzando tutti gli aspetti chimici e farmacologici connessi a questo tema. Un secondo punto di rilievo riguarda la problematica normativa legata alla dibattuta questione dell’utilizzo in terapia degli oppioidi e della Cannabis. In tal senso, si è cercato di offrire una prospettiva chiara ed esauriente del complesso quadro legislativo vigente: a partire dalle prime leggi promulgate dal Regno d’Italia, fino ad arrivare alle ultime circolari ministeriali in materia, è stata rivista ed esaminata l’intera normativa sulle sostanze stupefacenti, spiegandone anche i passaggi più delicati e controversi. Infine, soprattutto per ciò che concerne le ricadute sulla terapia del dolore, una parte significativa del libro si è concentrata sull’interpretazione medica e terapeutica, dove i farmaci oppioidi e la Cannabis costituiscono non solo una feconda frontiera di ricerca, ma anche un consolidato ed efficace strumento per contrastare alcune tipologie di dolore

Proceedings of the eip on aha: a3 action group on frailty

The present issue of TranslationalMedicine@ UNISA provides a sample of the activities of the partners of the EIP on AHA that are contributing to transform ageing from a burden into an opportunity for the EU, and beyond. It is the expression of a multifaceted approach to a societal challenge that can be only tackled by using inclusive strategy that exploit and valorizes the good practices of multiple stakeholders

Valutazione economica dello studio AVERT

Introduction: the AVERT study (“Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease”) compared aggressive cholesterol-lowering (with the statin atorvastatin) to angioplasty in patients with mild to moderate coronary artery disease. Aim: our aim was to investigate the economic consequence of high dose of atorvastatin vs percutaneous coronary revascularization followed by standard therapy in Italian patients with stable coronary artery disease Methods: clinical information were taken from the AVERT study. We conducted a cost-effectiveness analysis, comparing high dose of atorvastatin (80 mg/die) versus angioplasty in the perspective of the Italian National Health Service. We identified and quantified medical costs: drug costs according to the Italian National Therapeutic Formulary and hospitalizations were quantified based on the Italian National Health Service tariffs (2006). Effects were measured in terms of mortality and morbidity reduction (number of deaths, life years gained and frequency of hospitalizations). We considered an observation period of 18 months. The costs borne after the first 12 months were discounted using an annual rate of 3%. We conducted one and multi-way sensitivity analyses on unit cost and effectiveness. We also conducted a threshold analysis. Results: the cost of atorvastatin therapy or angioplasty over the 18 months period amounted to approximately 779 euro and 5.5 millions euro per 1,000 patients respectively. Atorvastatin was more efficacious compared to angioplasty and the overall cost of care per 1,000 patients over 18 months of follow-up was estimated at 1.8 millions euro in the atorvastatin group and 7.2 millions euro in the angioplasty group, resulting into a cost saving of 5.4 millions euro that is 74,9% of total costs occurred in the angioplasty group. Discussion: this study demonstrates that high does atorvastatin treatment leads to a reduction of direct costs for the National Health System if compared to angioplastic treatment. Atorvastatin therapy is dominant since it is both less costly and more effective than angioplasty. Results of sensitivity analysis showed that atorvastatin therapy remains dominant even in the most unfavourable hypotheses

Italian translation and cultural adaptation of the communication assessment tool in an outpatient surgical clinic

The aim of the study is to translate and cross-culturally adapt, for use in the Italian context, the Communication Assessment Tool (CAT) developed by Makoul and colleagues