The 14th European Symposium on Patient Adherence… 2010 abstract book.pdf · The 14th European...

The 14th European Symposium on Patient Adherence, COMpliance and Persistence, Lodz, Poland, 17-18.09.2010

1

The 14th European Symposium on Patient Adherence,

COMpliance and Persistence

LODZ, POLAND

17-18.09.2010

Poznanski’s Palace - Museum of the City of Lodz.

Scientific Comittee:

Sabina de Geest

Eric Van Ganse

Rob Heerdink

Kurt Hersberger

Dyfrig Hughes

Przemyslaw Kardas

Marie P. Schneider

John Urquhart

Robert VanderStichele

Bernard Vrijens


2

About ESPACOMP

ESPACOMP is a non-profit association established to promote the science concerned with the quantitative assessment of what patients do with medicines they have been prescribed. Both the reasons for, and the clinical and economic consequences of, differences between caregivers‟ prescriptions and patients‟ execution of those prescriptions are principal topics of research with which the Society is concerned, along with facilitation of the translation of this research into information that is useful to patients, healthcare providers, healthcare policy makers, and pharmaceutical researchers.

Since 1996, a group of scientists from Belgium and the Netherlands organized the “Lowlands” symposium to share their research on patient compliance and persistence with prescribed therapy. This symposium has grown over the years reflecting the increased interest for adherence related issues across Europe. In order to reflect the international expansion of the symposium, in 2006, the organizing committee decided to rename the symposium as “European Symposium on Patient Adherence Compliance and Persistence” and to extend it to other European countries. In 2009, The European Society for Patient Adherence, Compliance, and Persistence was founded.

Today, the principal activity of ESPACOMP is to organize a yearly symposium. It has become the meeting place for an increasing number of international adherence researchers, pharmacoepidemiologists, statisticians and industry people interested in compliance and persistence.

Board of trustees 2010

President, Dr. Kardas Przemyslaw

Vice-predidents, Dr. Heerdink Rob & Dr. Hughes Dyfrig

Secretary, Dr. Schneider Marie-Paule

Treasurer, Dr. Vander Stichele Robert

Managing Director, Dr. Vrijens Bernard

Trustees 2010

Dr. Bouvy, Marcel, The Netherlands

Dr. De Geest, Sabina, Switzerland

Dr. Heerdink, Rob, The Netherlands

Dr. Hersberger, Kurt, Switzerland

Dr. Hughes, Dyfrig, UK

Dr. Kardas, Przemyslaw, Poland

Dr. Schneider, Marie-Paule, Switzerland

Dr. Urquhart, John, USA

Dr. Vander Stichele, Robert, Belgium

Dr. Van Ganse, Eric, France

Dr. Vrijens, Bernard, Belgium


3

WELCOME MESSAGE

Dear Colleagues and Friends,

It is a great pleasure for us to invite you to Lodz to attend 14th ESPACOMP meeting!

The ambitious aim of this conference is to encourage researchers from all over Europe to

conduct scientific research in the field of adherence, and share it with their peers. We hope

that this conference will be an excellent platform for such activities. Scientific programme is

loaded with a number of keynote lectures and multiple oral and poster presentations. The

thematic spectrum of these communications is wide ranging and interesting, thanks to a

large number of submissions received. We also invited excellent speakers, who will provide

the attendees with up-to-date information, which they may find useful in both their scientific

work, and clinical practice. Therefore, we are sure that this conference will be a really

unforgettably event. Last but not least, you will meet a lot of friends and colleagues from

around the world, and have a chance to relax during informal conference dinner. We hope

that you will enjoy this exceptional Conference.

While the programme is full of important presentations, you should not miss the opportunity

to discover Lodz, the second biggest town in Poland and one of the most beautiful and

dynamic cities in this country. Besides the vivid life of the large city, you will find a lot of

architectural and cultural highlights within.

We wish you a fruitful conference and an enjoyable stay in Lodz!

Przemyslaw Kardas,

President of ESPACOMP 2010

ESPACOMP 2010 Organising Comittee:

Justyna Gawrys

Przemyslaw Kardas

Pawel Lewek

Anna Piaszczynska

Michal Matyjaszczyk

Joanna Sawicka

LIST OF CONTENTS

PROGRAM _______________________________________________________________ 4

KEYNOTE SPEAKERS _____________________________________________________ 9

ORAL PRESENTATIONS _________________________________________________ 20

POSTER PRESENTATIONS _______________________________________________ 40

PRACTICAL INFORMATION ______________________________________________ 59

MAP OF LODZ ___________________________________________________________ 61

NOTES __________________________________________________________________ 62


4

PROGRAM

DAY1 - September 17th

09:00-09:15 Welcome and Introduction

09:15-10:00 Jean-Michel Métry Memorial Lecture

Improvement of drug adherence using single pill combinations: what is the evidence?

Michel Burnier

Service of Nephrology and Hypertension, CHUV, Lausanne, Switzerland

10:00-11:30 Session 1

What’s new in direct measurement of adherence

Measuring, Managing and Improving Adherence

Aunia Grogan

Global Head of Adherence, Novartis, Switzerland

Contributed papers

Adaptive analysis of electronic medication adherence data for african-american

patients with hypertension

Antoinette Schoenthaler, George Knafl, Gbenga Ogedegbe

Center for Healthful Behavior Change Department of Medicine NYU School of Medicine New

York, USA

Intervention and control care determines adherence intervention effects among

patients treated for HIV: A meta-analysis of randomized controlled trials

Marijn de Bruin, Herman Schaalma, Gerjo Kok, Charles Abraham, Harm J Hospers

(Assistant profession Intervention Design&Behavior Change) Department of Communication

Science, Wageningen University, the Netherlands

The growing market of adherence technologies. The challenges and implications of

implementing electronic medication reminders.

Pernille Dam, Hanne Herborg, Marianne Agergaard, Claus Møldrup, Charlotte Rossing

Pharmakon, Danish College of Pharmacy Practice

11:30-12:00 Break & Posters

12:00-13:30 Session 2

Use of electronic monitoring of drug intake to promote adherence

Improving adherence and treatment decision-making: the power of electronically compiled

drug-dosing histories

Marijn de Bruin

(Assistant profession Intervention Design&Behavior Change) Department of Communication Science,

Wageningen University, the Netherlands

Contributed papers

Persistence and execution to oral anticancer medications

Marie Paule Schneider, Leila Achtari Jeanneret , Silvia Domingues, Anne-Catherine Lange,

Bernard Vrijens, François Lüthi, Olivier Bugnon

Community pharmacy, Department of ambulatory care&community medicine, University of

Lausanne, Switzerland


5

Large scale monitoring program for hypertensive patients in a romanian community

pharmacy chain

Ana Maria Petculescu, Diana Simona Negru

S.C. S.I.E.P.C.O.F.A.R. S.A, Bucharest, Romania

Compliance to phosphate binders: a nurse' lead intervention made difference

Monique M. Elseviers, Yoleen Van Camp, Sofie Huybrechts

Department of Nursing Sciences, University of Antwerpen, Antwerp, Belgium

13:30-14:30 Lunch & Posters

14:30-15:40 Session 3

Use of e-health and telemedicine to improve adherence

eHealth in Europe: need, vision and practice

Pepijn van de Ven

Wireless Access Research Centre, Department of Electronic and Computer Engineering, University of

Limerick, Ireland

Contributed papers

Real-time Adherence data as input to an ICT based system for the treatment of

depression

Eric Tousset, Pim Cuijpers, Mark Hoogendoorn, Michel Klein

Aardex Group, Vise, Belgium

Real time medication monitoring with sms reminders improves adherence to oral

antidiabetic medication in patients with suboptimal adherence

Marcia Vervloet, Liset van Dijk, Arno Wormgoor, Jacqueline Santen-Reestman, Dinny de

Bakker, Marcel Bouvy

NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands

15:40-16:00 Break&Posters

16:00-17:00 Session 4

Evolution of terminology and taxonomy of adherence in English and the other languages, and

medical practices

Contributed papers

A simple, robust taxonomy to describe deviations from prescribed drug therapy

Bernard Vrijens, For the ABC Project Team

AARDEX Group, Sion, Switzerland and Department of Biostatistics and Medical Informatics,

University of Liège, Belgium

Evolution of meaning and use of 'observance' / 'education thérapeutique' ('therapeutic

education patient') versus 'compliance' / 'adherence' in French and English languages

Marguerite Cognet, Emilie Adam, Rosane Braud

Researcher, teacher, UFR Social Sciences Université Paris 7 Diderot, Migrations and Society

Research Unit (URMIS) Paris, France

Differences and changes in attitude towards chronic medication between adherent and

non-adherent patients

Harm Geers, Eibert (Rob) Heerdink, Marcel Bouvy

Utrecht University, Faculty of Science Utrecht Institute for Pharmaceutical Sciences Division of

Pharmacoepidemiology&Pharmacotherapy Utrecht, the Netherlands

17:00-18:30 Meeting of the General Assembly


6

DAY 2 - September 18th

09:00-09:10 Introduction

09:10-10:20 Session 5

Miscellanea 1

Telemonitoring of Long Term Oxygen Therapy: Air Liquide Experience&Research

Marc Lemaire

Air Liquide Santé

Contributed papers

Application of health psychology and behavioural economics to explain adherence to

medicines in adult patients: a systematic review of empirical studies

Emily Fargher, Val Morrison, Todd Ruppar, Dyfrig Hughes

Bangor University, UK

Mobile phone SMS for optimizing asthma treatment outcome - a controlled trial

Claus Møldrup, Birthe Søndergaard, Jonathan Stein

University of Copenhagen Faculty of Pharmaceutical Sciences Department of Pharmacology

and Pharmacotherapy

10:20-11:30 Session 6

Miscellanea 2

Patient adherence in pre- and post-registration studies: different objectives, different

approaches

Ivo Abraham

University of Arizona, College of Nursing

Contributed papers

Factors associated with medication adherence among psychiatric outpatients with

substance abuse risk

Stephen Magura, Andrew Rosenblum, Chunki Fong

Western Michigan University

The heart foundation's "Improving cardiovascular adherence project": develoment of

an evidence-based training package for health care professionals

Parisa Aslani, Ines Krass, Beata Bajorek, Jill Thistlethwaite, Jeremy Bunker, Geoffrey Tofler

Faculty of Pharmacy, University of Sydney, Australia

11:30-12:00 Break & Posters

12:30-13:50 Session 7

Miscellanea 3

To Encourage or Coerce? The law's role in achieving patient compliance

Stewart Duffy

Contributed papers

Comparison of real life objective reliable compliance data assessed by an innovative

electronic system in patients recruited either by a pharmacist or a general practitioner

study: Differences and potential bias


7

Eric Leutenegger, Eric Vicaut, Bernard Bousquet

ABR Pharma, Paris; School of Medicine, University of Paris Lariboisière

The effect of a clinical trial on adherence and persistence to treatment

Hein A.W. van Onzenoort, Frederique E Menger, Cees Neef, Willem J Verberk, Peter W de

Leeuw, Paul-Hugo M van der Kuy

Department of Clinical Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen,

The Netherlands

Determinants of patient adherence to medical treatment: a systematic review of reviews

Przemyslaw Kardas, Pawel Lewek, ABC Project Team

Medical University of Lodz, First Department of Family Medicine, Lodz, Poland; ABC Project

www.abcproject.eu

13:50-14:00 Concluding remarks and the future of ESPACOMP

14:00-15:00 Lunch

Poster presentation

Impact of prolonged antihypertenive duration of action on predicted clinical outcomes in

imperfectly adherent patients: comparison of aliskiren, irbesartan and ramipril

Adam Lowy, Yvonne Brede, Deborah Keefe

Assessment of adherence of cinacalcet HCl in dialysed patients

Valentina Forni, Menno Pruijm, Carole Zweiacker, Michel Burnier

Evaluation of the medication compliance of liver transplant patients switched from a twice-

daily to a once-daily tacrlimus-based regimen

Marion Eberlin, Irene Kraemer

Improving patients' compliance - the role of pharmacists

Tatjana Crnjanski, Svetlana Stojkov-Rudinski, Ivana Tadic

Twelve-month persistence of COPD therapy after initiation in patients aged 50 and over: results

from the L777 study

Laurent Laforest, Mélanie Broquet, Gaëlle Désaméricq, Eric Van Ganse

Role of data-acquisition rate in defining salient patterns of drug exposure in ambulatory

pharmacotherapy

Bernard Vrijens, John Urquhart

Objective adherence measurement with an electronic blister: a feasibility study in primary care

Hein A.W. van Onzenoort, Cees Neef, Willem J Verberk, H Peter van Iperen, Peter W de Leeuw,

Paul-Hugo M van der Kuy

Studying the impact of medication counseling for patients starting a treatment with

antidepressant drugs: study design

Sophie Liekens, Tim Smits, Gert Laekeman, Veerle Foulon

Occurrence of prescriptions for noncurrent - changed or terminated - treatment and

prescription duplicates in electronic medical records and the Swedish national prescription


8

repository

Anders Ekedahl

Beliefs about medicines predict non-adherence with medication intended for chronic use

Harm Geers, Eibert (Rob) Heerdink, Marcel Bouvy

Impact of Drug Reminder Packaging on Compliance ? Where Are the Research Gaps?

Fabienne Boeni, Katja Suter, Isabelle Arnet, Kurt. E. Hersberger

Medication adherence in patients treated for COPD

Tamás Ágh, Ágnes Mészáros

Exploring ethnic differences in patient perspectives on medicines and medicine-taking: a

cross-cultural study in New Zealand

Beata Bajorek, Debbie Bassett-Clarke, Ines Krass

Achieving INR Target and Patient Satisfaction of Warfarinised Patients in HKL

Subramaniam Thanimalai, Agnes HSY, Chan BS, Chan CK, Nadrah N

A nationwide survey on medication adherence among polish patients and healthcare workers

Wojciech Kuzmierkiewicz

Involving patients in the development of a group-based educational intervention for a

randomised controlled trial to improve adherence to glaucome eye drops

Heather Waterman, Lisa Brunton, Cliff Richardson, Cecilia Fenerty, Fiona Spencer, David Henson

Medication Persistence in the Treatment of HIV Infection: A Review of the Literature and

Implications for Future Clinical Care and Research

Jason W. Bae, William Guyer, Kristy Grimm, Frederick L. Altice


9

KEYNOTE SPEAKERS


10

Prof. Michel Burnier Pr. Michel Burnier, MD, FASN, is Professor of Medicine and Head of the Division of Nephrology and Hypertension Consultation at the University Hospital of Lausanne, Switzerland. He has been trained in Internal Medicine and Nephrology in Lausanne, Switzerland and at the University of Colorado Health Science Centre, Denver, Colorado. He is a member of several Swiss and international societies in the field of nephrology and hypertension. He is a member of the Scientific Council of the European Society of Hypertension and member of the Committee of the Swiss Society of Hypertension. He is the president elect of the Swiss Society of Nephrology. Pr M. Burnier is also the president of the ethical review board of the Canton de Vaud and member of the board of Swissmedic, the Swiss Agency for Therapeutic Products. Pr Burnier participates in the Editorial Board of several journals including Hypertension and Blood Pressure. His research interests are the renal mechanisms of hypertension and the pathogenesis of disease progression in chronic kidney diseases with a special emphasis on the role of sodium. He has also worked on the clinical pharmacology of new antihypertensive drugs in humans with a special emphasis on drugs affecting the renin-angiotensin system and on drug adherence.

Improvement of drug adherence using single pill combinations: what is the evidence? M. Burnier, Service of Nephrology and Hypertension, CHUV, Lausanne, Switzerland In all therapeutic areas, patients are asked to adhere to their therapeutic regimen as closely as possible in order to achieve the defined therapeutic goals. In some situations such as hypertension or the management of cardiovascular risks, patients need to take several therapeutic agents. It has been well recognized that increasing the pill burden and frequency leads to a reduction in persistence and a decline in drug adherence over time. To avoid a low persistence, it is increasingly recommended to prescribe single combinations rather than multiple single drug therapies. Among the arguments in favor of the use of single pill combinations, authors usually mention the improved drug adherence, a better tolerability and a better acceptation by the patients. The purpose of the presentation will be to review the actual evidence favoring the use of single pill combinations in clinical. If there are undoubtedly some advantages for the use of single pill combinations, the scientific evidence for a clear benefit remains relatively weak and carefully conducted prospective studies are still missing to support the general hypothesis.


11

Aunia Grogan Aunia joined Novartis in 2009 from McKinsey & Company where she served a broad range of Fortune 500 companies on sales and marketing issues, with a special focus on Pharma clients and understanding consumer behaviour and decision making. Prior to joining McKinsey in 2003, Aunia was a market researcher for 15 years working across a diverse range of sectors including financial services, consumer packaged goods, travel/ leisure and publishing.

MEASURING, MANAGING AND IMPROVING ADHERENCE Global Head of Adherence, Novartis Pharma AG, Switzerland Email: [email protected] Aunia heads a new team within Novartis Pharma, tasked with building adherence capabilities across therapies. To that end the team are defining best practice for the organisation when designing adherence programmes: defining the barriers to adherence; exploring ways in which those barriers can be overcome; and finally defining how the measure adherence and the impact of programmes. In this session Aunia with give some background on why Novartis believes it is important to support patient adherence, and the specific challenges that presents. She will also review some of the areas Novartis is exploring to improve adherence and support patients.


12

Marijn de Bruin Marijn de Bruin is assistant professor Intervention Design & Behavior Change, working at the Communication science department of Wageningen University. He graduated in Health Education and Health Promotion (Faculty of Health Sciences, Maastricht University, the Netherlands) and completed his PhD-thesis at the Faculty of Psychology of the same university. His primary expertise is the design, evaluation and comparison of behavior change interventions, and his focus is mainly on improving medication adherence in chronic diseases (and HIV specifically). For his research, Marijn combines qualitative and quantitative research methods to study the causes of behavior, conducts (randomized controlled) trials to assess the impact of interventions, and uses meta-regression analysis to synthesize the adherence intervention literature. For that purpose he also developed a Taxonomy of adherence intervention techniques suitable for designing, reporting and comparing the active content of adherence interventions. A recent additional focus in his research is on the adoption and implementation of evidence-based adherence care practices into routine clinical care, and cost-effectiveness evaluations of adherence interventions. His work is embedded in social psychological, communication, and innovation research and theories.

Improving adherence and treatment decision-making: The power of electronically compiled drug-dosing histories Although electronic monitoring (EM) has been used extensively as an adherence measurement instrument in research, electronically compiled drug dosing histories can also be a powerful tool to promote patients‟ medication intake. If used skillfully, the data can be used to apply a range of potent behavior change techniques directed at behavioral awareness, motivation, self-confidence, action planning, and behavioral maintenance. Such interventions are ideally suited for enhancing patients‟ self-management capacities. For health care providers, the availability of continuous and objective adherence data can guide medical decisions, raise awareness about the importance of dealing with non-adherence, and demonstrate the positive impact of efforts to support patients. Hence, drug dosing histories (the „hardware‟) combined with efficient adherence support programs (the „software‟) could have a notable impact on patient health and the cost-effectiveness of care. Future technologies, including the monitoring of adherence real-time, may provide additional possibilities for adherence self-management, alter the mode and costs of intervention delivery, and permit intervention delivery at the time adherence support can make the most difference. In this presentation these ideas will be illustrated with data from intervention trials to promote adherence among patients treated for HIV.


13

Dr. Pepijn van de Ven Dr. Pepijn van de Ven is a Senior Research Fellow in the Wireless Access Research Centre at the University of Limerick (UL) and part time lecturer in the department of Electronic and Computer Engineering at UL. Pepijn received an MSc in Electrical and Electronic Engineering from the Eindhoven University of Technology in the Netherlands in 2000. He subsequently worked for Philips in the Eindhoven based Philips Research Laboratories as a research scientist investigating new RF front ends for 3rd generation telecommunication hand sets on experimental BiCMOS processes. In 2002 Pepijn obtained an IRCSET award to pursue a PhD at the University of Limerick on the „Identification and Control of Marine Vehicles Using Artificial Intelligence Techniques‟. After finalizing his PhD in 2005, Pepijn has had several postdoctoral positions in the area of wireless technologies and technologies for ambient assisted living. These include a role as Senior Research Fellow in the FP6 CAALYX project, co-Principal Investigator in MoSAiC, an Enterprise Ireland funded proof of concept project and co-Principal Investigator and lead researcher for the University of Limerick on the FP7 project ICT4Depression. Pepijn‟s research interests are wireless sensors for biomedical and ambient assisted living applications with a particular focus on falls and activity monitoring and smart user interfaces for wireless body area sensor networks.

eHealth in Europe: need, vision and practice Dr. Pepijn van de Ven, Dr. John Nelson Since its inception, the European Union (EU) has had welfare of its member states‟ citizens as one of its primary targets. In conjunction with medical and technological advances worldwide this has lead to a significant improvement in our wellbeing and lifestyle. The economic models supporting the various national health provision systems have led to widely accessible services that aim to look after the health and wellbeing of each and every individual within the state. Moreover, in a reaction to globalisation and the huge increase in human movement across the EU, these national health systems are indeed freely available to citizens of other member states. In the last decades the strain on the health care systems across the nations of the EU has increased significantly. For several nations, the initial reaction to the higher demand for healthcare staff was to employ health care professionals from outside the EU. However, this was never to be more than a short-term reaction to a problem requiring a far wider approach. As sustainability of the traditional health care systems is seriously threatened, eHealth has been embraced by the EU as an effective means of lowering the strain on the health systems to such an extent that these can be sustained into the future. As alluded to in the previous, the need for eHealth is largely driven by the fact that the resources are simply not available to sustain traditional health care systems given current demand and demographics. Of prime importance in this respect are the care for elderly people, the care for the chronically ill and the treatment of lifestyle induced diseases. To effectively target these, and other areas, the EU has developed a vision for eHealth endeavours within the EU. As stated in the Declaration on European Co-operation on eHealth which resulted from the eight High Level eHealth Conference in Barcelona (2010), the vision of the European Community is:

http://www.epractice.eu/en/library/312491

http://www.epractice.eu/en/library/312491


14

„That ICT for Health (eHealth) is a tool to improve quality and patient safety, to modernise national healthcare systems, to increase their efficiency and make them better adapted to the individual needs of citizens, patients, health professionals, and the challenges of an ageing society. The importance of ensuring that the deployment of ICT in healthcare, to be successful has to be accompanied by the necessary organisational reforms, driven by leadership and supported by adequate skills.‟ These words have not come without actions. Examples of use of eHealth in the EU are abundant. In the last two decades over 450 projects investigating ICT for health were funded by the European Commission with a total investment of over €1 billion. These projects focus on such diverse areas as remote monitoring, medication adherence, patient control / empowerment and integration of clinical information systems. In the presentation, the need, vision and practice of eHealth within the EU will be further discussed.


15

Marc LEMAIRE Marc LEMAIRE is 54 years old, married, 2 children and he is currently AIR LIQUIDE R&D Healthcare Program Director Medical Doctor (1984) by training, he is awarded in Immunology (Pasteur Institute 1985) and in Hepatology-Gastro-Enterology (1986). Before joining Air Liquide, he was in charge of departments related to R&D (Hoechst) and Marketing (Parke-Davis-Pfizer) Marc LEMAIRE joined Air Liquide 12 years ago as Medical and Regulatory Affairs Director and since 2005 he is R&D Healthcare Program Director. Marc LEMAIRE is memberships of several scientific and strategic committees and the author of more 50 publications and 20 patents

Telemonitoring of Long Term Oxygen Therapy: Air Liquide Experience & Research Marc Lemaire, MD, R&D Air Liquide Healthcare Director VitalAire (Air Liquide group) is the European leader of homecare services particularly involved in main markets “Long Term Oxygen Therapy” (LTOT) for treating Chronic Obstructive Pulmonary Disease (COPD) and “Sleep Apnoea Disorder” as well. Due to the evolution of the population (in 2050, 2 billion will be over 60), the new technology in surgery (coelioscopy) and anaesthesia allowing to back home in one day, the improvement of devices interconnectivity, more and more patients will be treated at home. This Hospital cost reduction is counterbalanced by increasing cost of cares at home which have to be better managed in terms of patient (improvement of quality of life…) and also in terms of costs for the society. To answer these challenges, telemedicine is a very useful tool…if we are able to provide and manage the right information in the right timing. In COPD, the risk for the patient is to diagnose and treat too late an exacerbation leading often to the hospitalization in an emergency or Intensive Care Unit department. The consequences are to decrease the survival curve for the patient by reducing the lung functionality, and also to increase dramatically the cost of the treatment. In a unique European research program, Air Liquide (VitalAire) is proposing a global management based on telemonitoring (training, clinical monitoring, new monitoring LTOT device…) to improve the quality of life for the patient, to reduce the cost of the disease and to get information for the payer for reimbursing the cost of LTOT. This global approach will need to harmonize the payers‟ practices and could have also a significant regulatory impact for the development of new drugs or services.


16

Ivo Abraham, PhD Ivo Abraham is Professor (part-time) in the Department of Pharmacy Practice and Science and Investigator in the Center for Health Outcomes and PharmacoEconomic Research at The University of Arizona College of Pharmacy. He has also served on the faculty of Case Western Reserve University (Cleveland, OH), University of Virginia (Charlottesville, VA), and (part-time) Katholieke Universiteit Leuven (Leuven, Belgium); and as Visiting Professor at Universiteit Maastricht (Maastricht, The Netherlands), University of Florida (Gainesville, FL), Rijksuniversiteit Groningen (Groningen, The Netherlands), University of Pennsylvania (Philadelphia, PA), and Chang Gung University (Kwei-Shan Tao-Yuan, Taiwan). He has lectured, consulted, and conducted research throughout the Americas, Europe, and the Asia-Pacific region. He divides his time between The University of Arizona and Matrix45, a biopharmaceutical research and consulting company, where he serves as Chief Scientist. Matrix45 offers two major service lines: (1) strategic, scientific, and clinical consulting for phase 4 and phase 5 studies; and (2) the development and promotion of evidence-based health care, from research synthesis, guidelines development and evaluation, and clinical support at the point of care. For the past decade or so, Ivo Abraham‟s research has focused mainly on how variability in (drug-centric) treatment regimens is associated with variability in patient outcomes. However, instead of merely evaluating effectiveness (“does the treatment work?”), his work addresses the equally important questions of “when does the treatment work, and when not?”, “what influences whether the treatment works?”, “why does the treatment work in some patients but not in others?”, “why does the treatment work with some clinicians but not with others?”, “why is the treatment tolerated by some patients but not by others?”, and “how much of patient outcomes is related to patient vs. clinician or treatment center.” With his colleagues, he has developed a comprehensive framework of treatment patterns and outcomes assessment, vulnerability profiling, hierarchical modeling, (non-)responder analysis, and pharmacovigilance; and drawing methodologies and statistical models from other disciplines into biomedical research. More recently, concerned about the abundance of evidence but clinicians‟ persistent low adoption of evidence-based guidelines, he started examining how practicing in accordance with evidence-based guidelines is directly associated with patient outcomes. He has (co-)authored 290+ articles and 60+ chapters, and has (co-)edited 29 books, monographs, and journal issues. His research has been funded continuously since 1984 by governmental funding agencies, foundations, and corporations. Ivo Abraham received the BS in nursing (equiv.) from Leuven University College, Associatie Katholieke Universiteit Leuven (Leuven, Belgium; 1979); and the MS in psychiatric-mental health nursing (1982) and the PhD in clinical research (1984) from the University of Michigan (Ann Arbor, MI, USA).


17

Patient adherence in pre- and post-registration studies: different objectives, different approaches Ivo Abraham, PhD [1,2,3]; Christopher Lee, PhD [2,4]; Karen MacDonald, PhD [3]; Sabina De Geest, PhD [5,6]; Marie-Chisholm Burns, PharmD, MPH [1]; Stefaan Vancayzeele, MD, MSc [7]; Marie-Anne van Lierde, MD [7]; Christine Hermans, PharmD [7]; Kris Denhaerynck, PhD [3,8]; [1] Department of Pharmacy Practice and Science, The University of Arizona (Tucson, AZ, USA), [2] Center for Health Outcomes and Pharmacoeconomic Research, The University of Arizona (Tucson, AZ, USA), [3] Matrix45 (Earlysville, VA, USA), [4] School of Nursing, Oregon Health and Science University (Portland, OR, USA), [5] Institute of Nursing Science, University of Basel (Basel, Switzerland), [6] Center for Health Services and Nursing Research, Katholieke Universiteit Leuven (Leuven, Belgium), [7] Novartis (Vilvoorde, Belgium), [8] Department of Internal Medicine, University Hospital Basel (Basel, Switzerland) The premise of this lecture is that patient (non-)adherence, defined per the World Health Organization as the extent to which a person‟s behavior (e.g., taking medications) corresponds with the agreed recommendations of a health care provider, has different implications for pre-registration versus post-registration studies because of the different focus of both types of studies on, respectively, efficacy and effectiveness. In pre-registration trials, poor adherence is a behavioral confounder to be managed to assure the purest possible efficacy signal about a drug candidate. In post-registration trials, poor adherence is part of the clinical reality of drug-centric treatment in the “real world”. Here the emphasis is on detecting and managing adherence in ways that are clinically realistic within the context of routine patient care. Under this premise, we identify methodological principles for consideration in the design of controlled and non-controlled investigations for pre- and post-registration studies. Further, relying on a series of (mainly) multilevel modeling studies conducted within a novel comprehensive framework for effectiveness studies, we show conceptually how clinically feasible, rapid evaluations of adherence perceptions and behaviors are consistent determinants of clinical outcomes. We also release new findings from meta-analyses on the association between adherence perceptions and behaviors and blood pressure values, blood pressure control, and total cardiovascular risk following antihypertensive therapy.


18

Stewart Duffy Stewart Duffy is an Irish born medical doctor and lawyer now living and working in London. Stewart graduated from Trinity College Dublin medical school in 1998. After three years in hospital practice Stewart took up a position as a post-doctoral research fellow at the University of Toronto‟s Department of Laboratory Medicine and Pathobiology. Based at Toronto General Hospital he spent two years researching the role of chemokines in the regulation of leukcocyte adhesion. He was awarded an M.D for his work by Trinity College Dublin in 2005. Stewart returned to hospital based surgical practice in Ireland in 2003. In 2004 he began an undergraduate law degree at University College Dublin graduating with an honours degree in law in 2007. Stewart was admitted to the New York State Bar in 2008. In September 2008 Stewart began work at the healthcare law department of Radcliffes Le Brasseur, a Westminster based law firm. Stewart‟s interest in healthcare law developed whilst living in Toronto during the SARS outbreak. He has been involved in research into Irish public health law including the history of its development and use. He has been the Irish rapporteur for the EU PH Law Flu project since 2008. He is a member of the EU PH Law Flu Network and has been an independent peer reviewer for a number of international journals.

To Encourage or Coerce? The Law’s role in achieving patient compliance Stewart Duffy M.D. Attorney-at-Law (New York) The idea of a Medical Police (“Medicinal Polizie”) became popular in Europe in the mid-nineteenth century arising out of concerns about the adverse health effects of poor sanitation, food adulteration, the unregulated sale of medicines and an unregulated medical profession. This was also the era in which many jurisdictions embarked on large scale legislative regulation for public health much of which survived essentially unchanged into the twenty-first century. Medical „Police‟ powers still exist in most jurisdictions. These include powers to compel vaccination or treatment, to require compliance or to detain patients in the context of infectious diseases or mental illness. Indeed the European Convention on Human Rights (ECHR) expressly permits the detention of individuals of unsound mind or for the control of the spread of infectious disease. Non-compliance with anti-infective therapy poses a direct threat to others through the spread of infection or the development of drug resistant organisms. Modern public health statutes have developed powers to facilitate compliance whilst retaining the older coercive powers. The traditional paternalistic attitudes of the State and medical professionals has radically diminshed since the second half of the twentieth century. That period was marked by the rise in the concept of patient autonomy and the development of the legal doctrine of informed consent. Whilst the right to personal autonomy, protected by Article 8 of the ECHR and by many national constitutions, clearly entitles a patient with capacity to decline treatment, even where it is irrational to do so, social and legal norms have also shifted to make health


19

professionals accountable for patient outcomes through the doctrine of medical negligence or its civil law equivalent. The tension between these norms can create real difficulties for healthcare professionals. The use of prescription medications has become more pervasive. Long term therapy for the control of blood pressure, cholesterol and coagulation are widespread. Compliance is a significant concern with many such interventions for asymptomatic conditions. The cost of non-compliance are borne by both the individual patient and the wider community. If individual and population benefit is to be maximised, and significant waste of resources avoided, strategies to improve compliance are essential. The law should facilitate, or at least not obstruct the development and implementation of such strategies yet at a time when the delivery of health care is becoming increasingly systematised controls on the exchange of personal information have become more exacting. The law, though a neglected tool, continues to have a symbolic and instrumental potential to contribute to improvements in individual and population health by regulating healthcare professionals and influencing their conduct as well as the conduct of their patients and by facilitating evidenced-based interventions to improve health.


20

ORAL PRESENTATIONS


21

ADAPTIVE ANALYSIS OF ELECTRONIC MEDICATION ADHERENCE

DATA FOR AFRICAN-AMERICAN ATIENTS WITH HYPERTENSION

Antoinette Schoenthaler1, George Knafl3, Gbenga Ogedegbe2

(1) Center for Healthful Behavior Change Department of Medicine NYU School of Medicine New York,

NY USA [email protected], (2) Center for Healthful Behavior Change Department

of Medicine NYU School of Medicine New York, NY USA [email protected], (3) The

University of North Carolina at Chapel Hill School of Nursing Chapel Hill, NC USA [email protected]

BACKGROUND: Electronic monitoring devices (EMD) are regarded as the 'gold standard' for

assessing rates of medication adherence in clinical research, allowing researchers to evaluate the

longitudinal nature of patient medication adherence. However, most analyses focus on simple

summary adherence measures based on an implicit assumption of constant adherence over time,

which often does not hold, and thus, does not account for the complex patterns that often characterize

medication-taking behaviors.

AIM: To employ Adaptive Statistical Modeling (ASM) methods on EMD data from Medication Event

Monitoring System (MEMS) devices to assess: (1) individual-subject adherence patterns, (2) clustering

of individual-subject adherence patterns, (3) the relationship between membership in adherence

clusters and subject characteristics, and (4) the effect of membership in adherence clusters and in

treatment groups on psychosocial outcomes over time in a sample of 141 hypertensive African-

American patients participating in a 12-month RCT.

METHODS: ASM methods were used to analyze grouped EMD data and to evaluate consistency

between subjects' actual and prescribed adherence. Generated adherence patterns were adaptively

clustered and related to patient demographic characteristics (e.g., age, insurance status, gender) and

treatment group membership (intervention vs. usual care). Adherence cluster and treatment group

membership were also used to predict psychosocial outcomes (e.g., self-efficacy, depression,

knowledge) over time.

RESULTS: EMD data were available for 141 patients consisting of from 0.0 to 1.0 (median 0.52)

openings per day for subjects and combining to over 18,000 openings for over 40,000 days of MEMS

usage. There were 7 adherence clusters: (1) consistently high mean adherence, (2) consistently near-

zero adherence, (3) improving adherence, (4) gradually deteriorating adherence, and (5-7) early

consistent adherence (at 3 different levels) with late deterioration. The chance of having consistently

high adherence (cluster 1) changed with type of insurance in a way (89% for HMO, 35% for Medicare,

27% for Medicaid, 9% for self-insured) that was significantly different than for the chance of being in

adherence clusters 2-7 (Fisher's exact test, p<0.001). No other characteristics were significantly

associated with adherence cluster membership. Mean self-efficacy changed differently post-baseline

for patients in the intervention/control groups. Mean self-efficacy increased for both groups from a

common baseline value, but to higher levels for intervention group subjects. Mean self-efficacy

changed in a similar manner for subjects with consistently high adherence as compared to the other

clusters. It was highest for subjects in the intervention group with high adherence, lowest for control

group subjects in the other clusters, and in between for control group subjects with high adherence

and intervention group subjects in the other clusters.

CONCLUSIONS: Type of insurance was significantly related to having consistently high adherence in

a sample of hypertensive African-American primary care patients participating in a 12-month

behavioral intervention study. Self-efficacy was higher for subjects in the intervention group and/or

with having consistently high adherence. Alternate methods for modeling EMD data can provide novel

insights into patients' medication-taking behaviors and their relationships with subject characteristics

and clinical outcomes.


22

Intervention and control care determines adherence intervention

effects among patients treated for HIV: A meta-analysis of

randomized controlled trias

Marijn de Bruin1, Herman Schaalma1, Gerjo Kok1, Charles Abraham1, Harm J Hospers1

(1) PhD

Background: Poor adherence limits the effectiveness of HIV-treatments. Systematic reviews have the

potential to identify practical and effective interventions. Meta-analyses that control for variability in

standard care provided to comparison groups may produce more accurate estimates of intervention

effects and a better understanding of effective intervention ingredients.

Objectives: To examine whether viral load and adherence success rates could be accurately

explained by the active content of adherence interventions when controlling for variability in care

delivered to controls.

Methods: Databases were searched for randomized controlled trials of Highly Active Antiretroviral

Therapy adherence interventions published from 1996 to January 2009. A total of 1342 records were

retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions

targeting specific patient groups (ie, psychiatric or addicted patients) were excluded, yielding a final

sample of 31 trials. A comprehensive Taxonomy of behavior change techniques to promote treatment

adherence was developed and reliably used by two coders to determine the active

content of care provided to intervention and control groups. Authors were contacted to complete

missing data.

Results: The capacity (the number of active ingredients to support adherence, weighted for tailoring

and repetition) of standard care provided to control groups varied considerably between studies. The

active content of adherence care provided to both the control and intervention groups predicted viral

load and adherence success rates in the respective conditions (P<.001 for all comparisons), with an

estimated total impact of optimal adherence care of 55 percentage points. After controlling for

variability in care delivered to controls, the capacity of the interventions accurately predicted the viral

load and adherence effect sizes (R2 = 0.78, P = .02; R2 = 0.28, P<.01). Although interventions were

generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care.

Conclusions: Intervention and control patients were exposed to effective adherence care. Future

meta-analyses of adherence interventions should assess and control for variability in care delivered to

active controls. At present, clinical practice may be best served by implementing current best practice.


23

The growing market of adherence technologies. The challenges and

implications of implementing electronic medication reminders.

Pernille Dam 4, 5, Hanne Herborg2, 5, Marianne Agergaard3, 5, Claus Møldrup6, 7, Charlotte

Rossing1, 5

(1) e-mail: [email protected], (2) e-mail: [email protected], (3) e-mail: [email protected], (4) e-

mail: [email protected], (5) Pharmakon, Danish College of Pharmacy Practice, Milnersvej 42, DK-

3400 Hillerod, Denmark, (6) Universitetsparken 2, DK-2100 Copenhagen, [email protected], (7)

University of Copenhagen, Faculty of Pharmaceutical Sciences, Department of Pharmacology and

Pharmacotherapy

Background Adherence technologies constitute a rapidly growing market where several actors are

interested in acting as distribution channels. Community pharmacies have an opportunity to become

the chosen channel for delivery of adherence technology services in primary health care. Pharmacies

may be an independent distributor of adherence technologies in relation to the companies that

promote the technologies.

• To identify and categorize relevant adherence technologies suited for a pharmacy product selection

• To test selected adherence technologies with medicine users in order to gain qualitative experience

about the devices, outline which type of medicine users they may be suited for and identify counselling

needs

• To develop indicators for technical quality, safety&usability

Methods A search was made in Medline (Pubmed) and Google for adherence

technologies/medication reminders/AIDS and similar terms. Adherence technologies were identified

and categorized according to their technology level and characteristics. The selection of adherence

technologies were field-tested on 20 voluntary medicine users for 2 weeks as part

of a pilot study. A semi-structured questionnaire and qualitative interviews were used to collect data.

Results 83 different medication reminder devices were identified from the literature and internet

search. Devices could be categorized from a user perspective (non-electronic reminders, electronic

reminders, one room electronic reminders, 'dosette-like' electronic reminders, automated dose

dispensing devices and 'other') as well as from a technology level point of view (low tech, intermediate,

high tech). The field test showed that technologies matching the user?s needs were accepted and

implemented when introduced with relevant counselling. Five medicine users failed to implement the

adherence technology. Reasons for not implementing the adherence technologies were no need for

technology, technical difficulties or other practical problems. Seventeen medicine users returned the

sent questionnaire. Eight medicine sers reported an improvement, seven reported no change, and

none reported a decrease in adherence after implementing the adherence technology. Four themes

were identified as the most important (either positively og negatively) for the medicine users:

'Flexibility&applicability in daily use', 'adherence support', 'visual reminding', 'audio reminding'.

Indicators for technical quality, safety & usability were developed under the following main categories:

'materials & medicine', 'patient safety', 'service operation', 'user friendliness' and 'documentation'.

Conclusion The market of adherence technologies is large. The products available vary in terms of

quality and level of technology. When field-tested, the adherence technologies benefitted some, but

not all users. Half of the medicine sers stated that their adherence was improved while it was

unchanged for the rest. To implement adherence technologies in the community pharmacy supply, it is

recommended that quality criteria are outlined, and that counselling including a matching procedure

between product and user is carried out in each individual case.


24

PERSISTENCE AND EXECUTION TO ORAL ANTICANCER

MEDICATIONS

Marie Paule Schneider1, Leila Achtari Jeanneret 3, Silvia Domingues1, 2, Anne-Catherine Lange4,

Bernard Vrijens4, François Lüthi3, Olivier Bugnon1, 2

(1) Community pharmacy, Department of ambulatory care & community medicine, University of

Lausanne, Switzerland, (2) Community pharmacy, School of pharmaceutical sciences, University of

Geneva, University of Lausanne, Switzerland, (3) Multidisciplinary oncology center, University

Hospital, Lausanne, Switzerland, (4) Pharmionic research center, Aardex group, Visé, Belgium

Background

Oral anti-cancer treatments have expanded rapidly over the last years. While managing oral tablets at

Home ensures better quality of life, it also exposes patients to the risk of sub-optimal adherence.

Aim

To assess persistence and execution to oral anticancer medications.

Methods

A 12-month nonrandomized, longitudinal, on-going study. Consecutive patients starting an oral

treatment (tyrosine kinase inhibitors (TKI) (imatinib/sunitinib); aromatase inhibitors (AI)

(letrozole/exemestane); capecitabine; temozolomide) are proposed to enter the study by the

oncologist. Then, patients are referred to the pharmacy, where oral anticancer treatment is dispensed

in the Medication Event Monitoring System (MEMS). Electronically compiled dosing history data from

the MEMS bottles are summarized and used as feedback during semi-structured interviews with the

pharmacist, which are dedicated to prevention of nonadherence and management of side effects.

Interviews are scheduled before each medical visit. Report of the interview is available to the

oncologist via an on-line secured portal. Adherence was described as: persistence (length of time

between the first-taken and the last-taken doses) and execution (proportion of days with correct

dosing).

Results

Study started in March 2008 and 36 patients (19 men, median age 63 yrs (range 29-80)) have been

included. Fifteen patients were prescribed a TKI, 10 an IA, 10 capecitabine, 1 temozolomide.

Administration was continuous in 30 patients and cyclic in 6 patients. Regimens were QD or BID.

Length of follow-up was 221 days (range 90-457). Persistence at 365 days was 58.2% and execution

90.6%. Reasons for nonpersistence were: adverse effects (4), death (2), progression of cancer (2),

psychosocial issues (2), and patient own

decision to stop treatment (1).

Conclusion

The 12-month execution of the prescribed dosing regimens was high. However, persistence was lower

and reasons for nonpersistance were diverse. Modelization of persistence should discriminate

between Real patients nonpersistence and nonpersistence due to clinical circumstances. Further

research in this area is needed as more oral cancer drugs will be available in the future. Published

data on long term persistence and execution are scarce. These parameters need to be explored.


25

LARGE SCALE MONITORING PROGRAM FOR HYPERTENSIVE

PATIENTS IN A ROMANIAN COMMUNITY PHARMACY CHAIN

Ana Maria Petculescu1, Diana Simona Negru2

(1) S.C. S.I.E.P.C.O.F.A.R. S.A, Bucharest, Romania, [email protected], (2) S.C.

S.I.E.P.C.O.F.A.R. S.A, Bucharest, Romania, [email protected]

Background: Involving the hypertensive patients in their therapeutic plan, gaining blood pressure

(BP) control and adopting a healthier lifestyle will increase the adherence and will delay cardiovascular

complication onset. Due to prescription refill visits, community pharmacists are in contact with most of

the chronic patients. Thus, they are able to implement and use complex monitoring programs that can

help hypertensive patients to better achieve their therapy goals.

Aim: The researchers' aims were: (1) to assess hypertensive patients for personal and medical data

and to record in an especially designed "Personal Cardio Logbook" (PCL) repetitive BP

measurements, during the study period, (2) to investigate patient's awareness on lifestyle

modifications, and (3) to evaluate program's benefits and effectiveness on patient's adherence to

therapy.

Methods: This program was developed for Dona Chain community pharmacies and it runs since

November 2007. The data analysis provided below refers to recordings made over 24 months of

research (till November 2009). During the initial visit in community pharmacies, designated

pharmacists and physicians, co-workers for this study, assessed the hypertensive patients (record all

relevant data in an electronic Patient Data Sheet (e-PDS)), and request their acceptance for

participation in program. After the e-PDS was filled in and the initial BP measurement was taken, the

patient received her/his PCL, meant to serve both the patient and her/his family or specialist physician

to closely monitor patient's evolution. The patients were invited to come back for regular BP values

measurements (taken in the pharmacy and recorded in PCL).

Results: At the beginning of the study, the total number of registered participants was 4,539

(distributed as 3,245 women - 71.5%, and 1,294 men - 28.5%) and most of them agreed to participate

in the program and to receive PCL. A single exception was accepted for 293 hypertensive patients

(6.5%) that did not agree to share medial data or to receive PCL, but insisted to be part of the

monitoring program, as they considered being more motivated in following their therapy and

recommended lifestyle regimen. Unfortunately, less than half (2,028 patients) choose to come back in

pharmacies for regular BP measurements. From all subjects (n = 4,539) included in the study, 56.0%

had (initially) hypertension under control.

As per their statement, only some of them have adopted at least one lifestyle changing measure:

2,660 patients (58.6%) follow a low-sodium diet, 1,808 patients (39.8%) have a diet enriched in fruits

and vegetables and even lesser participate in regular physical activities (1,462 patients, 32.2%). After

the initial visit, the 2,028 patients generated a number of 10,929 come-back (monitoring) visits, for

regular BP measurements. In 24 months of study duration, 148 patients actively participating in the

monitoring program gained control of BP values, showing an increase rate of 7.3% for controlled

hypertension patients.

Conclusion: Hypertension monitoring programs in community pharmacies, along with designated

instruments to regularly collect and record BP measurements, such as the PCL, have shown to

contribute to patients' beneficial by increasing their adherence to hypertensive therapy and lifestyle

regimen.


26

COMPLIANCE TO PHOSPHATE BINDERS: A NURSE' LEAD

INTERVENTION MADE THE DIFFERENCE

Monique M Elseviers2, Yoleen Van Camp2, Sofie Huybrechts1, 2

(1) Department of Clinical Pharmacology, University of Ghent, (2) Department of Nursing Sciences,

University of Antwerpen, Antwerp, Belgium

Background Phosphate binders (PBs) are commonly prescribed in hemodialysis (HD) patients to

control serum levels of phosphorus. Compliance to PBs is complicated by the high pill burden and the

irregular pattern of intake.

Aim

This study aims to compare the compliance to phosphate binders blindly controlled by the Medication

Event Monitoring System (MEMS) to the results obtained by a nurse lead intervention focusing on

medication knowledge and personalized support.

Methods

Baseline compliance to PBs was evaluated in 3 Belgian and 1 Dutch dialysis centre. All adult patients

treated with PBs, in chronic HD for more than 3 months and without mental disorders, were asked for

participation. Compliance was measured during a period of 14 weeks using MEMS-V Track-Cap

devices (Aardex Ltd, CH). Non-compliance was defined as a registered intake <80% of prescribed

doses. Patients' characteristics and lab results (phosphorus, calcium, PTH) were collected using a

structured questionnaire. An interventional study was set up in an additional Belgian centre using

identical inclusion and observation methods. In the latter centre, 4 weeks after the start of the

observation period, a nurse visited all participating patients, offering an information chart and an

individualized explanation about PBs. Thereafter, she contacted all participants bi-weekly for a

personalized talk about compliance.

Results

In the total cohort of 257 patients (including 216 baseline and 41 intervention patients), mean age was

67.5 years (range 21-90), 59% were males, mean HD treatment was 47 months (range 3-267).

Patients had a mean pill burden of 14 pills per day (range 2-35) with 33% of patients taking more than

one PB. PBs studied were calcium carbonate, sevelamer and lanthanum in 46, 42 and 12% of

patients, respectively with a mean intake of 3.9 (range 1-9) PB pills per day. Patients of the

intervention study did not differ from the Basic cohort except for a higher number of lanthanum users.

During the first week of observation, non-compliance was observed in 23.3% of patients in the

baseline cohort compared to 24.4% in the intervention study (p=0.875). In the baseline cohort,

compliance decreased from a mean of 85.5% (SD 24.4) in week 1 to 75.9% (SD 30.5) in week 14. In

contrast, in the intervention group compliance increased from a mean of 82.5% (SD 22.9) to 94.4%

(SD 13.5). Interrupted time series analysis revealed that the decreasing trend of compliance per week

in the baseline cohort with a slope of -0.782 (95% CI -1.07 - -0.489) significantly differed from the

slope of 0.672 (95% CI -0.13 - 1.40) in the intervention group. During the intervention study, serum

phosphorus levels decreased accordingly (from 4.8 to 4.6 mg/dL - p=0.110) and knowledge about PBs

increased from a mean score of 53 to 75%.

Conclusion

Although non-compliance to PBs was frequently observed in HD patients, a nurse lead program of

education and close follow-up of PB intake is worth considering to improve compliance.


27

Real-time Adherence data as input to an ICT based system for the

treatment of depression

Eric Tousset3, Pim Cuijpers2, Mark Hoogendoorn1, Michel Klein 1

(1) Computer Science department, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, (2)

Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, The netherlands, (3)

Pharmionic Systems, Vise, Belgium

Major depression is currently the fourth disorder worldwide in terms of disease burden, and is

expected to be the disorder with the highest disease burden in high-income countries by 2030.

Estimated costs of depression are annually 177 and 147 million euro per 1 million inhabitants for major

and minor depression respectively.

The increasing needs for individualised therapies and the scarcity of human resources put a

tremendous pressure on the healthcare system. The emerging concept of Ambient Assisted Living

(AAL) provides a natural approach to this important issue. By combining methods, electronic systems,

devices as well as services in an integrated framework, AAL set the stage for a individualised support

based on the situation of the person in need. AAL are also able to broadly deliver health care services

at the point of need.

In this R&D project, funded by the 7th framework of the European Union, 5 research organisations and

2 SME companies at the forefront of Artificial and Ambient Intelligence and Clinical Psychology have

joined their efforts to tackle the challenge of building an AAL system for the self-management of

depression in a highly collaborative framework. The convergence between new ultra-light devices

such as smart-phone and non invasive and wearable systems for the monitoring of bio-signals

provides the technological basis of the

system.

Several therapeutic modules will be used to support and improve the state of the patient via a smart-

phone and/or web-based communication. Those modules will be driven by an artificial reasoning

system: in this context, monitored data will be used as input to judge the current state of the patient

and push the adequate therapy module. Adherence to the prescribed medication is one of the

essential components of an effective therapy. This project will explore, beyond the current state-of-the-

art, technologies in monitoring medication adherence, exploiting patient's drug dosing history in

combination with other bio-signals, and communicating effectively the individualized information and

messages about medication intakes to the patient. Several scenarios In this advanced technological

setting will be developed to identify the appropriate information to be provided to each stakeholder in

managing patient adherence to the prescribed medication.

The AAL system under construction requires the use of modular and interoperable concepts

supporting the sharing of relevant information between sub-systems and services. An overview of the

system and the principles of its architecture will be presented. The use of adherence to the prescribed

anti-depressive medication in the system will be highlighted.


28

REAL TIME MEDICATION MONITORING WITH SMS REMINDERS

IMPROVES ADHERENCE TO ORAL ANTIDIABETIC MEDICATION IN

PATIENTS WITH SUBOPTIMAL ADHERENCE

Marcia Vervloet2, Liset van Dijk2, Arno Wormgoor1, Jacqueline Santen-Reestman1, Dinny de

Bakker2, 3, Marcel Bouvy4

(1) Mediq Apotheken, Utrecht, The Netherlands, (2) NIVEL, Netherlands Institute for Health Services

Research, Utrecht, The Netherlands, (3) Tranzo, Scientific Centre for Transformation in Care and

Welfare, Tilburg University, The Netherlands, (4) Utrecht Institute for Pharmaceutical Sciences (UIPS),

Division of Pharmacoepidemiology and Pharmacotherapy, University Utrecht, The Netherlands

Background Poor adherence to antidiabetics has a negative influence on glycemic control in type 2

diabetes patients. Real Time Medication Monitoring (RTMM) aims to improve adherence. RTMM offers

the combination of monitoring patients' medication use in real time with an electronic medication

dispenser and reminding patients of their medication intake through SMS. These reminders are

tailored to the patients' needs: the SMS is only sent if the medication has not been taken.

Aim Evaluate the effect of RTMM with tailored SMS reminders on patients' adherence to oral

antidiabetics.

Methods Randomised Controlled Trial with two intervention and one control arm, in which a total of

161 diabetes type 2 patients with suboptimal levels of adherence to oral antidiabetics (less than 80%

based on pharmacy refill data) participated. Patients were randomly assigned to one of the three arms.

Patients in the first intervention arm (n=56) used RTMM including tailored SMS reminders and a

personal webpage where they could monitor their medication use (SMS group). Patients in the second

intervention arm (n=48) used RTMM without SMS reminders or internet access (non-SMS group).

Patients in the control arm (n=57) were not exposed to any intervention. The intervention lasted for six

months. Pharmacy refill data of all patients were available from 11 months before, and until 11 months

after the start of the intervention. Detailed data on medication use registered by RTMM were available

for patients in the intervention groups (comparison between these groups is discussed elsewhere). To

compare the adherence in the intervention groups with the control group, pharmacy refill data is used.

Primary outcome measure is refill adherence to oral antidiabetics calculated from pharmacy data by

taking the number of days for which oral antidiabetics are dispensed during the study period divided

by the total number of days of the study period. Differences In adherence between the intervention

and control group were tested with Students' T-tests.

Preliminary results Average refill adherence at baseline of included patients in the SMS group, non-

SMS group and control group was respectively 61.5% (SD=14.1), 62.2% (SD=12.8), and 61.7%

(SD=13.5) and did not differ significantly between the three groups. At present, pharmacy refill data

were available for 40 patients in the SMS group, 40 patients in the non-SMS group and 34 patients in

the control group. Patients receiving SMS reminders had an average refill adherence of 86.7%

(SD=22.3). Average refill adherence of patients not receiving reminders was lower: 78.5% (SD=20.2).

With an average of 73.5% (SD=20.7), patients in the control group had the lowest refill adherence.

The differences in refill adherence were significant between the SMS and control group (p<0.01), and

between the SMS and the non-SMS group (p<0.05). The adherence did not differ significantly

between the non-SMS group and the control group.

Conclusion These preliminary results suggest that RTMM with SMS reminders are effective in

improving adherence to oral antidiabetics. Since not only patients with diabetes experience difficulties

in following prescribed therapy, RTMM can also provide opportunities for increasing adherence to

medication for Rother chronic diseases.


29

A simple, robust taxonomy to describe deviations from prescribed

drug therapy

Bernard Vrijens1, For the ABC Project Team

(1) AARDEX Group, Sion, Switzerland and Department of Biostatistics and Medical Informatics,

University of Liège, Belgium

Background

The ABC project, sponsored by the 7th Framework program of the European Union, started in January

2009, as an international collaboration of European research groups in the field of patient adherence.

One of the main objectives of this project is to conduct a systematic review to assess the terminology

used in the literature and, based on that review, to propose a sound taxonomy for medication-taking

behavior that will support adequate measurements. The purpose of this paper is to retrace the steps

by which the ABC Project Team proceeded.

Methods

A systematic review was conducted, searching MEDLINE, EMBASE, CINAHL, the Cochrane Library,

and PsycINFO for all English-language papers addressing the taxonomy/terminology of describing

deviations from prescribed drug treatment in ambulatory patients. Internal and external meetings were

organized to reach a consensus.

Results

142 papers were identified for this review. Over ten different terms were used to describe medication-

taking behaviour, often with differing conceptual definitions, resulting in methodological weakness. The

term most currently used and widely accepted is 'medication adherence'. It is the process by which

patients Take prescribed medications. It is composed of three parts: 'initiation', 'execution' and

'discontinuation'. 'Medication Management' is an over-arching construct for naming the practice and

processes of monitoring and supporting medication adherence by patients.

Conclusions

The outcome of this collaborative project is a new conceptual foundation and transparent taxonomy. It

provides researchers and caregivers with a sound logical structure and coherent language to

measure, interpret, study, and improve medication-taking behavior.


30

Evolution of meaning and use of 'observance' / 'education

thérapeutique' ('therapeutic education patient') versus 'compliance'

/ 'adherence' in French and English languages

Marguerite Cognet3, Emilie Adam1, Rosane Braud2

(1) Ph.D candidate, Anthropology Université Paris 7 Diderot, Migrations and Society Research Unit

(URMIS) Paris, France, (2) Ph.D candidate, Sociology Université Paris 7 Diderot, Migrations and

Society Research Unit (URMIS) Paris, France, (3) Researcher, teacher, UFR Social Sciences

Université Paris 7 Diderot, Migrations and Society Research Unit (URMIS) Paris, France

The notion of 'observance', which first emerged in the French healh system in the 1980's, spread

widely over the following decade. Although heavily influenced by anglo-saxon scientific circles, the

notion would go on to evolve differently in francophone academic literature, as well as in medical

practice.

While the notion of 'compliance' in anglophone countries competes with that of 'adherence' in the

francophone world the notion of 'therapeutic education patient' ('éducation thérapeutique') is becoming

the most commonly used term.

Basing ourselves on critical reviews of medical and social sciences literature in both languages over a

period spanning the late sixties to the first decade of the 21st century, we will show how the notions of

'compliance' versus 'observance' have evolved in quantitative and qualitative terms and how their

applications in medical practice have changed.


31

Differences and changes in attitude towards chronic medication

between adherent and non-adherent patients

Harm Geers2, Eibert (Rob) Heerdink1, 2, Marcel Bouvy2

(1) University Medical Center Utrecht Department of Clinical Pharmacy, division of Laboratory and

Pharmacy PO Box 85 500, 3508 GA Utrecht, the Netherlands, (2) Utrecht University, Faculty of

Science Utrecht Institute for Pharmaceutical Sciences Division of Pharmacoepidemiology &

Pharmacotherapy PO Box 80 082, 3508 TB Utrecht, the Netherlands

Background

It is unclear whether necessity and concerns about chronic medication change over time and how

possibile changes are related to adherence. We studied the difference and changes in attitude

towards chronic medication and the association with adherence.

Methods

Patients with a first prescription for a drug intended for chronic use were identified in 9 pharmacies. All

patients received the Believes about Medicines Questionnaire specific (BMQs) at the start (t0) and

after one (t1) month. Dispensing records were extracted from the pharmacies after at least 10 months

and ta king compliance defined as a continuous measure of medication acquisition (CMA) <80% and

persistence were assessed. A patient was non-persistent if a gap in which no medication was

available to the patient of 90 days or longer emerged. Patients' believes were classified as either

ambivalent (high necessity, high

concerns), skeptical (low necessity, high concerns), indifferent (low necessity, low concerns) and

accepting (high necessity, low concerns), based on their BMQs scores.

Results

Included were 376 patients. Response rates were 50% and 39% at t0 and t1. Of the responders at t0

39 (22%) had poor taking compliance, and 51 (29%) were non-persistent. No significant difference in

believes between patients with good and poor taking compliance was observed. A trend however was

observed towards less indifference at t1 in the group with good taking compliance (23%), compared to

the group with poor taking compliance (32%). In the non-persistent group were less accepters (15%

vs. 23%) and more skeptical (28% vs. 9%) users compared to the persistent group. In persistent

users, acceptance increased significantly from 15% to 23% and indifference decreased significantly

from 14% to 9% at t1.

Conclusion

Accepting users are more likely to continue their medication, while skeptical users are more likely to

discontinue treatment. Changes in attitude towards chronic medication take place early in the

treatment course. Pharmacists should address concerns and necessity with patients during the early

course of treatment to prevent non-persistence and possibly poor taking compliance.


32

ECONOMICS TO EXPLAIN ADHERENCE TO MEDICINES IN ADULT

PATIENTS: A SYSTEMATIC REVIEW OF EMPIRICAL STUDIES

Emily Fargher1, Val Morrison1, Todd Ruppar2, Dyfrig Hughes1

(1) Bangor University, UK., (2) K.U.Leuven, Belguim.

Background: Health psychology and economic models of patient behaviour may be used to explain

adherence to medicines. Aims: As part of the ABC project, we aim to examine the contribution of

Heath psychology and behavioural economic models to the understanding of adherence to medicines

in adults; then to consolidate this evidence in a conceptual framework of determinants of adherence.

Methods: A systematic review was conducted using MEDLINE, EMBASE, the Cochrane Library,

CINAHL, PsychINFO, and EconLit (1990-2010, no language restrictions), with additional studies

identified by experts and bibliographic scrutiny. Search terms relating to adherence, medicines, theory,

and behavioural models were combined in two separate searches of the health psychology and

economic literature. All study types containing empirical data on adherence determinants were

included. Independent extraction of articles by two reviewers using predefined data fields.

Results: 2308 publications were identified, 1605 were excluded following title and abstract screening.

703 full papers were assessed and 203 included in the review.

Conclusions: Health psychology models derived from social cognitive theory, self-regulation theory or

social learning theory; and, economic theories of consumer demand and time preference have been

used to explain adherence to medicine. Self-report was the most common measure of adherence. The

extent to which individual components of the relevant model were tested varied. Conclusions:

Identifying the determinants of non-adherence may help guide the development of interventions to

improve adherence by targeting the factors that influence intentional non-adherence to long-term

treatment. Consolidation of behavioural models may provide a theoretical basis for the development

and assessment of effective adherence-enhancing interventions.


33

Mobile phone SMS for optimizing asthma treatment outcome – a

controlled trial.

Claus Møldrup2, Birthe Søndergaard2, Jonathan Stein1

(1) Privat consultant, (2) University of Copenhagen Faculty of Pharmaceutical Sciences

Department of Pharmacology and Pharmacotherapy

Background: A pilot study by Anhoj and Moldrup on the feasibility of collecting asthma diary data

from asthma patients via mobile phones and text messaging, or Short Messaging Service (SMS),

concluded that it isfeasible, and that SMS may be a useful tool for supporting the self-management of

asthma.

Objective: The objective of this study is to assess the health-related effects of a SMS compliance and

monitoring system for optimized asthma treatment.

Methods: In total 244 asthmatics participated in a prospective controlled randomized trial (114

intervention,130 control). The intervention consisted of sequences of SMS messages sent to the

intervention group, each containing 2 or 3 monitoring questions and one reminder to take the

preventive medication. Both the intervention and control group received questionnaires on days 0, 45,

and 90.Primary outcome measures were self assessed outcome questionnaire included the 5 question

asthma control test, EQ-5D, use of health services and use of preventive medicine questions.

Results: The use of SMS monitoring yields no health-related effects, no decrease in the use of

healthcare services, and no change in the use of medicine between the control and intervention

groups. The lack of outcomes for the intervention is not due to recruitment or the randomizing of

participants, not due to dropout. This study furthermore supports other findings concerning the lack of

asthma control in the asthma population.

Discussion: SMS is a reliable, convenient, affordable, secure, widespread and a feasible technology

for communication between the patient and healthcare system. However, even given the poor level of

asthma control determined at baseline, this study clearly documents that a SMS compliance and

monitoring intervention design like the one presented in this paper does not improve asthma control,

nor does it generate fewer contacts with the healthcare system or improve the use of medicines.


34

FACTORS ASSOCIATED WITH MEDICATION ADHERENCE AMONG

PSYCHIATRIC OUTPATIENTS WITH SUBSTANCE ABUSE RISK

Stephen Magura2, Andrew Rosenblum1, Chunki Fong1

(1) National Development and Research Institutes, U.S.A. (2) Western Michigan University, U.S.A.

Background: Recognizing predictors of medication adherence among patients with psychiatric and

substancje abuse problems is important because poor medication adherence is associated with

relapse and hospitalization. Aims: (1) To determine the extent of psychiatric medication non-

adherence among a sample of psychiatric outpatients with a high rate of substance abuse, and (2) the

factors associated with non-adherence which could suggest means for improving adherence in this

population.

Methods: Consecutive new admissions to an urban continuing psychiatric day treatment program

were recruited Turing 2003-2005. The analysis involves patients who were prescribed psychiatric

medication from different providers during the prior six months (N=131). Confidential research

interviews were conducted at admission that included a modified Medication Adherence Rating Scale

(MARS). All results reported are statistically

significant at p<.05.

Results: Age (mean) 39 y; male 61%; Hispanic 60%; Black 36%; White 18%; public

assistance/disability 73%; DSM-IV diagnoses: major depression 26%, schizoaffective 21%, bipolar,

16%, schizophrenia 13%, other mood 9%, psychotic NOS 7%, other 8%; substance abuse history

(93%); drug/alcohol abuse within past 90 days (74%). At least one non-adherence item on an 8-item

MARS was endorsed by 78%, with a mean of 3.3 items endorsed, e.g., forgot to take (31%); careless

at times (44%); stopped when felt better (44%); stopped when felt worse (32%). Lower medication

adherence was associated

more psychiatric symptoms, which supports the construct validity of the MARS in this sample. Factors

related to lower MARS adherence scores during the past six months in bivariate analysis were: lower

satisfaction with medication, lower friends? support for drug/alcohol abstinence, higher engagement in

processes of change, more medication side effects, lower self-efficacy for drug avoidance and lower

social support for recovery. In multivariate regression analysis with backward elimination, only the last

three factors remained as significant predictors of adherence. One-third of the patients said their

psychiatrists did not spend enough time with them to explain side effects or were rushed, although this

was not directly associated with non-adherence.

Conclusion: Low medication adherence was associated with side effects, a cognitive factor

and a social factor. This suggests that technical aids such as pill dispensers with alarms, while

potentially useful, may be insufficient since low adherence is not attributable solely to forgetting to take

medication. Our previous work with dually-diagnosed patients has documented that self-help groups

providing social suport for recovery can increase medication adherence. Strengthening adherence

should also include better education about side effects and the importance of adherence to sustain the

benefits of medication. This education, which might also involve assertiveness training, should

encourage patients to discuss their symptoms and side effects with their psychiatrists, rather than

simply to stop taking medication. Psychiatrists should also be encouraged to address patients?

adherence strategies, since the time devoted to ad dressing that during treatment may prevent serious

adverse events such as relapse, treatment drop-out and hospitalization.


35

THE HEART FOUNDATION'S 'IMPROVING CARDIOVASCULAR

ADHERENCE PROJECT': DEVELOPMENT OF AN EVIDENCE-

BASED TRAINING PACKAGE FOR HEALTH CARE

PROFESSIONALS

Parisa Aslani2, Ines Krass2, Beata Bajorek2, Jill Thistlethwaite3, Jeremy Bunker4, Geoffrey Tofler1

(1) Department of Cardiology, Royal North Shore Hospital, NSW Australia, (2) Faculty of Pharmacy,

University of Sydney, Australia, (3) Institute of Clinical Education, University of Warwick, United

Kingdom, (4) Sydney Institute of General Practice Education & Training, NSW Australia

Introduction

The expanding burden of cardiovascular disease has emphasised the importance of ongoing

adherence and persistence to prescribed therapy for effective disease prevention and management,

including the treatment of symptomless risk factors (e.g., hypertension, dyslipidaemia). Research has

shown that during long-term therapy for chronic illnesses, adherence to medication averages only

50%, highlighting the need for targeted practice interventions. However, most interventions usually

target barriers to adherence that are under the patients' control, whereas barriers related to the health

care system and health care professionals (HCPs) have received less attention.

Yet, these HCP-related barriers are particularly important in vulnerable patients and/or acute situations

(e.g.,after periods of hospitalisation resulting in treatment changes, such as after an acute

cardiovascular event), especially where inadequate discharge planning and follow-up with primary

health care practitioners (e.g. GP, community pharmacist, community nurse) can compromise

adherence to therapy. These problems are further compounded by the fact that HCPs are often poor

judges of patient medication-taking behaviours and, rather than using systematic approaches to

identify non-adherence, they tend to rely on personal intuition. Thus, there is a clear need to educate

and upskill HCPs in the issues surrounding medication adherence as well as the implementation of

systems to identify, address and monitor non-adherence and non-persistence to therapy. For optimal

impact, this also requires systems support, multiprofessional collaboration, and an in-depth

understanding how to support patient self-management behaviour.

Aim

The aim of this project was to develop an evidence-based training package for HCPs, high lighting

interprofessional and collaborative strategies, to promote medication-taking in patients on

cardiovascular therapy. The project is supported by the Heart Foundation's (Australia) 'Improving

cardiovascular adherence project'.

Method

Using an iterative feedback process and consultation from an expert panel, a versatile training

package, which can be delivered as a face-to-face workshop, self-directed learning program, or an

interactive on-line course, was designed. The package was structured to demonstrate how HCPs

based in primary care (i.e., general practitioners, pharmacists, nurses) can facilitate appropriate

intervention. Its specific objectives were to help HCPs achieve a comprehensive understanding of the

issues related to: the importance of adherence to medicines; adherence in cardiovascular drug

therapy; and appropriate management strategies.

Outcome

The final training package comprises a series of six educational modules focusing on:

Module 1: Adherence to Cardiovascular Medicines, the Principles

Module 2: Identifying Patients' Non-Adherence

Module 3: Creating Concordance and Making Shared Treatment Decisions

Module 4: Aiding Patient Self-Management in Cardiovascular Treatment

Module 5: Interventions to Improve Your Patients' Adherence

Module 6: Specific Roles of Health Care Professionals


36

Each module provides an overview of the topic (referring to the evidence-based literature), a selection

of resources to support learning, presentation of practice tools, and facilitated discussion and

interaction with other participants. Importantly, self-directed learning is integral to each module,

providing examples of worked patient cases (6 in total) with accompanying scripted dialogue,

demonstrating the identification of non-adherence and the practical application of evidence-based

strategies and selected tools to promowe adherence, highlighting areas where interprofessional

collaboration is warranted.

Summary

This training package not only provides a unique and comprehensive resource for practitioners, but

specifically targets issues in adherence by addressing barriers presented by the health system and/or

health care professionals. Through a better understanding of the issues in adherence, and

development of skills In identifying and addressing adherence, health care professionals will be able to

work more collaboratively to optimise medication use and provide appropriate patient support.


37

Comparison of real life objective reliable compliance data assessed

by an innovative electronic system in patients recruited either by a

pharmacist or a general practitioner study : Differences and

potential bias.

Eric Leutenegger1, 2, Eric Vicaut2, Bernard Bousquet1

(1) ABR Pharma, Paris, (2) School of Medicine, University of Paris Lariboisière

Objective

An innovative electronic compliance measurement system has been developed. This system allow to

obtain quantitative data however it may induce bias in patients, pharmacists (PHs) or general

practitioner (GPs). The data from 2 studies conducted either with PHs or GPs give us the opportunity

to explore the potential differences and bias.

Method

29 GPs and 40 PHs in France selected consecutively, over a 4-week period, all patients receiving

rosuvastatin 5 or 10 mg, clopidrogel 75 mg or sitagliptine 100 mg. 132 HPs' patients and 69 GPs' one

returned at least one blister. We compare for each drug the main compliance criteria in each

population.

Results

For rosuvastatin, GPs' patients show a similar range of taking/prescribed dose ratio than PH's ones

(95 vs 86%, NS). GP's patients show higher level of days in accordance with the prescription (76 vs

67%, p<0,05) and lower level of skipped days defined as days without intakes (14 vs 24 %, p=0,01).

Conclusion

First comparison of data compliance between GPs' patients and PHs' one show a better compliance in

the GP's group. These results could reflect slight bias from the GPs' patients' selection in a Real life

compliance study due to their willingness to obtain positive feed back on compliance.


38

THE EFFECT OF A CLINICAL TRIAL ON ADHERENCE AND

PERSISTENCE TO TREATMENT

Hein A.W. van Onzenoort4, Frederique E Menger6, Cees Neef2, Willem J Verberk5, Peter W de

Leeuw1, Paul-Hugo M van der Kuy3

(1) Cardiovascular Research Institute Maastricht (CARIM), Maastricht University and, Department of

Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands, (2) Department of

Clinical Pharmacy and Toxicology, University Hospital Maastricht, Maastricht, The Netherlands, (3)

Department of Clinical Pharmacy, Orbis Medical Centre, Sittard, The Netherlands, (4) Department of

Clinical Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, (5)

Microlife Corporation, Taipei, Taiwan, (6) Utrecht Institute for Pharmaceutical Sciences, Division of

Pharmacoepidemiology and Pharmacotherapy, Utrecht, The Netherlands

Background Although it is generally acknowledged that poor adherence to treatment is one of the

major determinants of an uncontrolled blood pressure, results of clinical trials show much better

figures for adherence, suggesting that the degree of adherence found in clinical trials does not

represent a 'real-life' situation.

Aim To investigate adherence and persistence profiles in patients with hypertension who had

participated in a clinical trial by collecting refill data before, during, and after participation in a clinical

trial. Methods Two-hundred-and-twenty-eight patients who participated in the HOMERUS trial between

2001-2005 and whose adherence to treatment had been monitored electronically and by pill count

were invited to participate in this study. After signing informed consent, patients' filled prescriptions

from computerized pharmacy systems were obtained from 1999 until 2010. Refill adherence was

calculated for each ATC code as the theoretical duration divided by the period between the start date

and the date of the last prescription

filled. The theoretical duration was calculated by dividing the number of units dispensed by the

prescribed daily dose.

Results In total, 182 patients agreed to participate in this study. Refill data were available of 22,600

prescriptions. The monitored periods covered 993 (standard deviation (SD) 517 days), 250 (SD 71)

days, and 1695 (SD 475) days for the corresponding period before, during, and after the trial,

respectively. Participation into the trial significantly increased refill adherence: 90.6% versus 95.6%

(p<0.001). After the trial period refill adherence decreased significantly to 91.8% (p<0.001), which was

non-significantly different from the adherence before the start of the trial (p=0.45). After termination of

the trial, median duration of continuation of the trial medication was 1424 days.

Conclusions Participation in a clinical trial significantly increases adherence to treatment. The long

persistence of trial medication and the high refill adherence rates might suggest that patients are more

involved with their condition and treatment, and therefore more willing to participate in a trial in which

adherence is monitored.


39

Determinants of patient adherence to medical treatment: a

systematic review of reviews.

Przemyslaw Kardas

1,2, Pawel Lewek

1,2, ABC Project Team

2

1Medical University of Lodz, First Department of Family Medicine, Lodz, Poland, e-mail:

[email protected]; 2 ABC Project www.abcproject.eu, e-mail: [email protected]

Background: Patients' non-adherence to medical treatment is a rising problem worldwide. Many

interventions to improve patient adherence were found to have their effectiveness far from the

expectations. This may be partly explained by the lack of a theoretical foundations for these

interventions. Innovations in theory and practice are badly needed. To lay a solid foundation for future

interventions, a systematic review of publication on determinants of patient adherence was conducted.

Aim: The aim of this study was to perform a systematic review of recent publication on determinants

on patient adherence.

Methods: Electronic literature searches were performed in January, 2010 in Medline (through

PubMed), Psychinfo, Embase, Cinahl, International Pharmaceutical Abstracts (IPA) and the Cochrane

Library. Major inclusion criteria were 1) adherence to medication as a major topic of publication 2) type

of publication - systematic review 3) determinants of compliance provided 4) publication date

01/01/2000 or later. Studies primarily focusing on adherence-enhancing interventions were excluded.

All the identified abstracts were assessed against the inclusion and exclusion criteria by at least one of

the authors. With inconsistent result of the assessment, publications were accepted for full text

assessment.

Results: Out of 833 abstract screened, 100 were selected for full text evaluation, and finally, 53 were

found to fulfil all study criteria. The scope of the identified publications covered wide range of chronic

treatment, with HIV being the most frequent topic. Noticeably, no publication with the major focus on

the short-term treatment was identified. A large number of factors affecting adherence was listed,

including patient-, condition-, therapy-, healthcare system-related factors, as well as social and

economic factors. Only several studies differentiated factors related to execution, and persistence.

Conclusion: An extensive literature search provided updated review on the determinants of patient

adherence. Further studies in this field could benefit from implementing rigorous scientific terminology,

and particularly, making clear distinction between factors affecting execution, and persistence.


40

POSTER PRESENTATIONS


41

POSTER No 1

IMPACT OF PROLONGED ANTIHYPERTENSIVE DURATION OF

ACTION ON PREDICTED CLINICAL OUTCOMES IN IMPERFECTLY

ADHERENT PATIENTS: COMPARISON OF ALISKIREN,

IRBESARTAN AND RAMIPRIL

Adam Lowy1, Yvonne Brede1, Deborah Keefe2

(1) Novartis Pharma AG, Basel, Switzerland, (2) Novartis Pharmaceuticals Corporation, East Hanover,

NJ, USA

Background. Most patients miss occasional doses of antihypertensive treatment. The consequent

loss of BP control may be mitigated by prescribing forgiving drugs (i.e. prolonged BP-lowering action

beyond 24h), but the clinical consequences of gaps in dosing and the impact of drug duration of action

have not been evaluated quantitatively.

Aim. To estimate the effects of adherence and drug duration of action on mean systolic BP (SBP)

reduction and predicted cardiovascular disease (CVD) risk.

Methods. We simulated 256-day dosing histories for 1250 subjects, incorporating realistically

distributed gaps in dosing based on a published study of electronically monitored dosing records from

4783 patients with hypertension in clinical trials. Adherence was set to 90%, 75% and 60% by altering

the proportion of doses missed. SBP reductions were averaged over time and subject to estimate

population mean reductions In SBP. Ten-year CVD risk was predicted using the Framingham Risk

Equation with baseline characteristics from NHANES 2005-2006 (average data: age 65.2 years;

52.9% women; SBP 155.95 mmHg; Total cholesterol 5.41 mmol/L); baseline absolute 10-year CVD

risk was 27.0%. Mean office SBP-lowering effect (mmHg; aliskiren 300 mg -14.1, irbesartan 300 mg -

13.3, ramipril 10 mg -10.1) and the rate of SBP increase after stopping treatment (mmHg/day; aliskiren

1.0, irbesartan 3.6, ramipril 4.0) were taken from a randomized, double-blind trial in patients with

hypertension. The rate of decrease in SBP upon resuming treatment after a gap in dosing was fixed at

5 mmHg/day.

Results. With adherence set at 90% (typical of randomized trials of antihypertensives), predicted

population average SBP reductions were larger for aliskiren (13.7 mmHg) than irbesartan (12.3

mmHg) or ramipril (9.3 mmHg), as were predicted absolute reductions in 10-year CVD risk (aliskiren

4.1%, irbesartan 3.7%, ramipril 2.8%). Adherence in real-world use is typically much lower; with

adherence reduced to 60%, the predicted SBP-lowering effect of aliskiren (12.7 mmHg) was

diminished less than that of irbesartan (9.8 mmHg) or ramipril (7.1 mmHg). For aliskiren, the decrease

in adherence predicted a rise in SBP of 1.0 mmHg and 3 additional CVD events per 1000 patients;

larger differences were predicted for irbesartan (2.5 mmHg; 7.5 events/1000) and ramipril (2.2 mmHg;

6.7 events/1000). The number needed to treat to avoid 1 CVD event was 26 for aliskiren, 34 for

irbesartan and 47 for ramipril.

Conclusion. Occasional non-adherence to antihypertensive medication - the rule rather than the

exception In real-world practice - has a clinically relevant impact on BP reduction and CVD risk. This

may be mitigated In part by prescribing regimens based on forgiving drugs (i.e. prolonged BP-lowering

action beyond 24h).


42

POSTER No 2

ASSESSMENT OF ADHERENCE OF CINACALCET HCL IN

DIALYSED PATIENTS WITH SECONDARY

HYPERPARATHYROIDISM: A EUROPEAN SURVEY

Valentina Forni1, Menno Pruijm¹, Carole Zweiacker¹, Michel Burnier¹

¹Service of Nephrology and Hypertension, CHUV Lausanne, Switzerland

Background: In the treatment of secondary hyperparathyroidism (sHPT) in dialysis patients, a lack of

responsiveness to drug therapy may be due to pharmacological and biological

factors as well as to non-adherence to the complex prescribed regimens. Low adherence to drugs

used in the treatment of sHPT is particularly worrisome, since high PTH values have been associated

with elevated morbidity and mortality rates. The calcimimetic cinacalcet-HCl (Mimpara®) is an

effective treatment of sHPT approved for dialysis patients. When Ipoh values do not improve despite

an initial dose of 30mg/day, an increase up to a maximum of 180mg/day is recommended. Suboptimal

adherence to cinacalcet is difficult to identify In clinical practice, but it may be crucial to recognize it in

order to prevent costs and dosedependent side-effects. Therefore, a European multinational survey of

drug adherence to Cinacalcet-HCL using an electronic monitor was performed in dialysis patients.

Aim: We monitored and described drug history of Cinacalcet-HCL in a large longitudinal international

survey, involving five European countries (Switzerland, France, Germany, Austria, Italy).

Methods: Medication adherence was compiled using the MEMS® system. Several aspects of drug

history were considered:

- the adherence, used as blanket term to subsume persistence and execution

- the persistence, defined as the time elapsed (in days) between entry in the monitoring period and the

time of discontinuation;

- the execution, which refers to the comparison between the prescribed drug dosing

regimen and the patient‟s drug history while on treatment. The latter definition includes: the

percentage of skipped days (= 1 or 2 days without intake), the percentage of „drug holidays‟ (3 or more

consecutive days without drug intake), the “day of the week effect” (the compliance of one day of the

week is significantly lower, p < 15 %, than the average compliance).

Results: The drug history of 157 patients was analyzed (Switzerland: 58 pts., France 21 pts, Germany

and Austria 55 pts., Italy 23 pts.). The adherence and persistence were found to decline substantially

over 200 days, with 22% classified as “non-adherent” at 200 days and 18% interrupting their

treatment. There were some differences between countries (persistence 76% in Italy vs. 90% in

France at 200 days), however statistically not significant (p=0.078). Concerning execution, the drug

history of 121 patients with single daily tablet regimen was available for analysis: more than 21%

(n=26) missed more than 10% of their doses, corresponding to more than 36 days without medication

during a year; more than 71% (n = 86) experienced at least one “drug holiday” during their monitoring

period. Finally almost 50% of the patients (n=57) had a “day of the week effect”, for all countries

mostly on week end.

Conclusions: Assessment of drug adherence to Cinacalcet-HCL allowed to detect problems both in

the persistence and execution indices, with some countries specific differences, but also with

international analogies.


43

POSTER No 3

EVALUATION OF THE MEDICATION COMPLIANCE OF LIVER

TRANSPLANT PATIENTS SWITCHED FROM A TWICE-DAILY TO A

ONCE-DAILY TACROLIMUS-BASED REGIMEN

Pharm. D. Marion Eberlin1, Ph. D. Irene Kraemer2

(1) Department of Pharmacy, University Medical Center, Langenbeckstrasse 1, 55131 Mainz,

Germany, [email protected], (2) Department of Pharmacy, University Medical Center,

Langenbeckstrasse 1, 55131 Mainz, Germany, [email protected]

Background: Compliance with the immunosuppressive therapy plays a major role in the long-term

success and outcome of liver transplantation. Thus, the development of strategies to promote

compliance of liver transplant patients and the evaluation of compliance over time are of particular

interest.

Aim: The main objective of this study is to compare medication compliance rates in liver transplant

patients with increasing time intervals after transplantation, switched from a twice-daily to a once-daily

Tacrolimus-based regimen (Prograf® vs. Advagraf®).

Methods: 65 liver-transplant patients with Tacrolimus-based therapy were included in a non-

interventional, prospective trial. Patients were assigned to 3 groups with regard to months or years

post transplantation (p.t.): Group 1: > 6 months < 2 years p.t., Group 2: > 2 years < 5 years p.t., Group

3: > 5 years p.t. in order to study the relationship of compliance rates and time interval after

transplantation. Medication compliance with the immunosuppressive therapy was measured over a 12

months period (each patient taking 6 months Prograf®, consecutive 6 months Advagraf®) with

medication event monitoring systems (MEMS®), AARDEX Ltd., Switzerland). Dosing (DC)-, Taking

(TC)-, Timing (TIC). Compliance and Drug Holidays were calculated for each patient by using the data

collected with MEMS®. Medians of compliance were compared between the 3 subgroups.

Results: According to a per protocol-analysis, the data of 63 patients were eligible both after the first

and the second period of 6 months (Prograf®: Group 1: 15 patients (pat.), Group 2: 23 pat., Group 3: >

5 years: 22 pat., drop-outs: 3 pat., Advagraf®: Group 1: 16 pat., Group 2: 23 pat., Group 3: 23 pat.,

drop-outs: 1 pat.). While taking Prograf® twice-daily the median of DC was 97% for group 1, 97% for

group 2 and 98% for group 3 (p=0.931). While taking Advagraf® once-daily the median of DC was

99% for group 1, 98% for group 2 and 97% for group 3 (p=0.158). Compliance rates of patients with

the once-daily regimen were higher than with the twice-daily regimen in nearly all measured

parameters. Differences in the compliance rates with the immunosuppressive drug therapy were

respectively not significant between the 3 groups assigned. Compliance with the immunosuppressive

medication was better the shorter transplantation was dated back. In all patient groups the resulting

DC- and TC-rates were higher than the TIC-rate. Patients seemed to Lack awareness for TIC, i.e.

patients did not take the drugs in the correct time interval. The correct timing of the evening dose

turned out to be more difficult than the correct timing of the morning dose.

Conclusion: Patients are aware of the importance of taking their immunosuppressive medication.

Measured compliance rates are high and do not vary significantly between the subgroups. Better

compliance with the once-daily regimen was observed.


44

POSTER No 4

IMPROVING PATIENTS' COMPLIANCE - THE ROLE OF

PHARMACISTS

Tatjana Crnjanski3, Svetlana Stojkov-Rudinski2, Ivana Tadic1

(1) Department of Social Pharmacy and Pharmaceutical Legislation, Faculty of Pharmacy, University

of Belgrade, Serbia, [email protected], (2) The Public Pharmacy Subotica, Subotica,

Republic of Serbia, [email protected], (3) The Public Pharmacy Subotica, Subotica,

Republic of Serbia, [email protected]

Background: Low compliance may reduce the benefits of pharmacotherapy. There are many factors

which may affect the compliance. Recognizing these factors by the pharmacist at the primary health

care level provides the proper approach to patients. On the other hand, pharmacists' knowledge and

attitude also do not necessarily contribute to better compliance.

Aim: To assess the pharmacists' knowledge and attitude toward compliance.

Methods: Prospective, cross-sectional study was conducted in 25 different community pharmacies

from different regions of Serbia. In total, 356 pharmacists participated in the study. The study lasted

four months (January - April 2010). Knowledge and opinions about compliance were collected through

a self-reported questionnaire which had been designed to meet the purpose of this study. Descriptive

statistics and correlation analyses were used to summarize the results. The results of the pilot study

will be presented AT the 70th FIP World Congress of Pharmacy/Pharmaceutical Sciences. In this

abstract we will present the results of the complete study.

Results: One quarter of pharmacists (25%) know what compliance means. There is no significant

relationship (chi-square test; p>0.05) and no positive correlation (r=-0.44; p>0.05) between years in

service and knowledge about compliance. The largest number of pharmacists thinks that their

pharmacotherapy education, rather than: education of patients on health topics, cooperation with

physicians, installing electronic patients' records, pharmacists' education in psychology and

communication (respectively), May affect the proper and regular use of medication by patients.

Pharmacists believe that the lack of time, due to the large number of patients, is the major problem for

adequate counseling of patients. Other problems that pharmacists are stated as the cause of

inadequate counseling of patients were: patients' impatience, the Lack of conditions for confidential

conversation with patients, poor communication with patients and lack of pharmacists' self-confidence.

The attitude of the largest number of pharmacists is that the main reason for poor patients' compliance

is dosing frequency and polypharmacy. Other reasons were: medication's cost, patients' forgetfulness

to take medicines, expression of drug's side effects and patients' lack of confidence In the therapy

outcome.

Conclusion: Pharmacists can play a vital role in counseling and educating patients in an effort to

improve compliance. Conducted study has shown that the education of pharmacists may affect the

improvement of compliance. The years of service have no impact of pharmacists' knowledge. Lack of

time during working hours is one of the major problems for adequate counseling of patients.

Pharmacists believe that polypharmacy is one of the causes for bad patients' compliance. Further

research needs more specific questionnaire to determine precisely what the attitudes of patients are

which impact the compliance.


45

POSTER No 5

TWELVE-MONTH PERSISTENCE OF COPD THERAPY AFTER

INITIATION IN PATIENTS AGED 50 AND OVER: RESULTS FROM

THE L777 STUDY

Laurent Laforest1, Mélanie Broquet1, Gaëlle Désaméricq1, Eric Van Ganse1

(1) Unité de Pharmacoépidémiologie, CHU Lyon, Hopital Pierre Wertheimer, Bron, France

Background: Tiotropium, a specific therapy for COPD, was launched in France in May 2006. Early

persistence under tiotropium is poorly documented.

Aims: To determine the 12-month persistence under tiotropium and to identify its predicting factors.

Methods: Health insurance's claims databases from the French Rhône-Alpes region were used.

Patients aged 50 and over, with at least 3 prescriptions of a respiratory drug (ATC R03) in 2006 were

pre-selected. Those to whom tiotropium was dispensed at least once between May 2006 and April

2007 and with at least a 12-month follow-up in the database after the drug initiation were studied.

Persistence was defined as the definitive interruption of therapy within 12 months following the drug

initiation.

Results: 1,341 patients (mean age 68 yrs, 34% women) were studied. 75% remained under

tiotropium therapy over 5 months and 61% remained at least 12 months after the initiation. A better

persistence to tiotropium was observed in males (p=0.01), patients with long-term disease status

(p=0.0001) and those with associated respiratory drugs (p=0.002). Conversely no difference was

observed according to age or past hospital admissions. Persistence was significantly better for

tiotropium compared to salmeterol-fluticasone fixed combination (p<0.0001), also in patients taking

both drugs simultaneously.

Conclusions: In real-life settings, persistence was inadequate for COPD patients under therapy, even

though better results were observed for tiotropium. Our data suggest a better persistence in case of

more severe disease.


46

POSTER No 6

Role of data-acquisition rate in defining salient patterns of drug

exposure in ambulatory pharmacotherapy

Bernard Vrijens3, 4, John Urquhart1, 2

(1) AARDEX group, Zug, CH, (2) Department of Bioengineering and Therapeutic Sciences, Center for

Drug Development Science, UCSF, San Francisco CA USA, (3) Pharmionic Systems, Visé, Belgium,

(4) University of Liège, Belgium

Studies of patients' drug exposure patterns during ambulatory pharmacotherapy divide into two

methodologic categories: pre-electronic and electronic methods for compiling ambulatory patients'

drug dosing histories. Pre-electronic methods include diaries, histories, questionnaires, counts of

returned untaken doses, and audits of prescription refill data. Diaries were discredited by the finding,

via electronic time-stamping of diary entries, of a high incidence of long intervals between events and

times of their recording (1). The Rother pre-electronic methods are subject to a variety of uncertainties,

but all have rates of data acquisition that are inked to frequencies of clinic visits or prescription refills,

i.e., 1-24 data points/year. In contrast, electronic medication-event monitoring, in which package

opening times are automatically time-stamped by electronic means, has a data-acquisition rate of 4

data points/hr. The link between package opening times and drug ingestion is robust, shown by

measured concentrations of drug in plasma compared to those projected on the assumption that

package opening times signify the time of ingestion of the prescribed dose (2). The 4/hr rate of

sampling, ~3 orders of magnitude richer than pre-electronic methods can achieve, has defined the

following temporal patterns of drug exposure: (a) time-of-day effects, with dose-omission rates 1.5-2x

more frequent with PM than with AM dosing; (b) day-of- week effects, with patient-specific clustering of

dose-omissions on particular days of the week; (c through i) precise definition of (c) when dosing

starts, (d) when missed doses occur, (e) when multi-day lapses in dosing start and stop, (f) when

dosing halts permanently; (g) when white-coat effects occur; (h) the temporal sequence of dosing halts

and putative rebound effects - does dosing-cessation trigger harm, or does harm trigger dosing-

cessation? (i) coincidence of drug non-response with dosing history data - does non-response arise

from PK/PD or non-adherence? (j) comparative effectiveness of different methods of medication

management. Clinical correlates of the foregoing confirm the early prediction (3) that variable

adherence vies with PK as the leading source of variance in drug response. Richly sampled dosing

history data lay the foundation for pharmacometrically sound interpretation of variations in drug

response in ambulatory care, including exposure-informed safety assessment.

References:

1. Stone AA, Shiffman S, Schwartz JF, Broderick JF, Hufford MR. Patient noncompliance with paper

diaries. BMJ 2002; 324:1193-4.

2, Vrijens B, Tousset E, Rode R, Bertz R, Mayer S, Urquhart J. Successful projection of the time-

course of drug concentration in plasma during a one-year period from electronically compiled dosing-

time data used as input to individually parameterized pharmacokinetic models. J Clin Pharmacol 2005;

45:461-7.

3. Harter JG, Peck CC. Chronobiology: suggestions for integrating it into drug development. Ann NY

Acad Sci 1991;618:563-71.


47

POSTER No 7

OBJECTIVE ADHERENCE MEASUREMENT WITH AN ELECTRONIC

BLISTER: A FEASIBILITY STUDY IN PRIMARY CARE

Hein A.W. van Onzenoort4, Cees Neef2, Willem J Verberk6, H Peter van Iperen5, Peter W de

Leeuw1, Paul-Hugo M van der Kuy3

(1) Cardiovascular Research Institute Maastricht (CARIM), Maastricht University and, Department of

Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands, (2) Department of

Clinical Pharmacy and Toxicology, University Hospital Maastricht, Maastricht, The Netherlands, (3)

Department of Clinical Pharmacy, Orbis Medical Centre, Sittard, The Netherlands, (4) Department of

Clinical Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, (5)

DSM-THC, Veldhoven, The Netherlands, (6) Microlife Corporation, Taipei, Taiwan

Background Although several methods are available for measuring adherence to treatment, no

method fulfils all requirements for valid adherence measurement. The electronic blister (e-blister)

could be a valuable tool for adherence measurement.

Aim The investigate the feasibility of the e-blister

Methods The feasibility, the functionality, robustness, and adherence to treatment determined by the

e-blister were investigated in 115 patients. Functionality was determined by variables that could

influence the interpretation of registered events, and as a result the interpretation of adherence rates.

The robustness of the e-blister was determined by calculating the percentage of blisters that registered

multiple events at the same time as a consequence of breaking multiple conductive tracks. Adherence

was expressed as ta king and timing adherence, and days of correct dosing.

Results In total, 245 e-blisters were used during a mean period of 60 days (standard deviation [SD] 29

days). The registration of handing-out date and time of the e-blister took place in 72% of all e-blisters.

Registration of patient number or name, identification number of the e-blister, identification of the event

(i.e. date and time of pushing the pill through the e-blister), and handing-in date and time of the e-

blister was 100%. Forty-two e-blisters (17%) registered multiple events at the same time as a

consequence of breaking multiple conductive tracks. Mean taking and timing adherence, and days of

correct dosing were 97.6% (SD 11%), 86.9% (SD 29%), and 94.3% (SD 14%).

Conclusions The e-blister may be a valuable tool for measuring adherence to treatment. However,

functionality and robustness of the e-blister need further development.


48

POSTER No 8

STUDYING THE IMPACT OF MEDICATION COUNSELING FOR

PATIENTS STARTING A TREATMENT WITH ANTIDEPRESSANT

DRUGS: STUDY DESIGN

Sophie Liekens2, Tim Smits1, 3, Gert Laekeman2, Veerle Foulon2

(1) Faculty of Business and Economics, K.U. Leuven, (2) Research centre for pharmaceutical care

and pharmaco-economis, K.U.Leuven, Leuven, (3) Research group Marketingmanagement, Lessius

University College

Background

Depressive disorders have a global impact on health-related quality of life as well as on socio-

economic parameters. Treatment with antidepressant drugs has shown to be effective if executed

correctly for an appropriate period of time. However, recent data suggest that only a minority of

patients ta king antidepressant drugs adhere to treatment recommendations.

Aim

I. The overall aim of this project is to study the impact of adherence- supporting counseling by

community pharmacists. The counseling will focus on new users of antidepressant drugs and the

impact will be measured on adherence as well as clinical, economic and humanistic parameters.

The project will also investigate

II. Attitude and stigma of community pharmacists towards patients with mental disorders

III. Impact of an education program involving consumer educators on stigma and attitudes

IV. Usage patterns of antidepressant drugs, including adherence (pharmaco- epidemiological study)

Methods

To answer the main research question (I), a randomized controlled trial will be set up. Pharmacists in

the intervention arm will be trained to counsel patients with a new prescription for an antidepressant

drug. Pharmacists in the control arm will deliver standard care. Four telephone-based surveys (0 to 6

months post-intervention) will be used to gather information on different parameters. In the pharmaco-

epidemiological study (IV), the database of a pharmacy-network containing patient-level data will be

analysed. To investigate stigma and attitudes of pharmacists (II) and to study the impact of an

education program (III) on these parameters, a mental health survey will be used that was previously

tested on pharmacy students.

Results

A survey of attitude and stigma by community pharmacists towards patients with depression was the

first step in the realization of this project and shows that in spite of pharmacists' positive attitude

towards depression and their willingness to play a role in depression care, current practice is far from

ideal. In the near future, interventions will be planned in order to improve pharmacists' competencies

in the care for depressive patients. The first results of the analysis of the dataset of the pharmacy-

network (still on-going), suggest that almost 40% of patients who use antidepressant drugs buy only 1

package (within the pharmacy network), which may point to non-adherence.

Conclusion

This project focuses on the impact of an underused group of healthcare professionals on an important

aspekt in the treatment of depressive disorders, i.e. non-adherence to treatment recommendations.


49

POSTER No 9

Occurrence of prescriptions for noncurrent - changed or terminated

- treatment and prescription duplicates in electronic medical

records and the Swedish national prescription repository.

Anders Ekedahl,

Associate professor, Department of Drug Use (Social Pharmacy), Medical Product Agency, Sweden

Patient adherence to prescribed treatment for chronic conditions has been estimated to be on average

about 50% [1] and drug related problems may cause as much as 30% of acute admittances to hospital

care [2]. Discrepancies between medical records and patients‟ actual current medication are common

[3-5]. The objective of the present study was to compare current prescribed treatment stated by

patients with the printouts from the electronic medical record (EMR) and the Swedish national

prescription repository (NPR) with regard to (1) prescriptions for noncurrent (previously changed or

terminated) treatment, (2) prescription duplicates and (3) missing prescriptions.

Design: Cross-sectional study. Patients over 18 years of age with 5 or more prescriptions stored in

the NPR or the EMR, with follow-up visit at a health care centre or visiting a pharmacy, were invited to

the study. Patients giving written informed consent to participate were interviewed. The stated

prescribed current, ongoing treatment was compared with printouts of prescribed medication from the

EMR and of the stored prescriptions in the NPR.

Main Outcome Measures: Proportions of prescriptions for (a) noncurrent treatment (changed or

terminated), (b) prescription duplicates and (c) missing prescriptions in the EMR and the NPR.

Results: 216 patients with altogether 2515 prescriptions were included. In total, 71% were unique

prescriptions for current ongoing treatment, 17% were prescriptions for noncurrent treatment (changed

or terminated therapy) and 11% were prescription duplicates. Of 2195 prescriptions in the EMR, 75%

were unique prescriptions for current treatment, 13% were noncurrent, 11% were prescription

duplicates and 8% of the current prescriptions were missing. Of 1904 prescriptions in the NPR, 75%

were unique prescriptions for current ongoing medication, 13% were noncurrent prescriptions, 11%

were prescription duplicates and 20% of the current prescriptions were missing. The EMR and the

NPR contained _1 noncurrent prescription or duplicate for 76% and 69% of patients.

Conclusion: Prescriptions for noncurrent treatment and prescription duplicates as well as missing

prescriptions are common in both EMR and the Swedish NPR. Consequently, claims data based on

data of prescribed medicines in the EMR or the stored prescriptions in NPR contain many errors.

Adherence estimates measured as “claims data” for prescriptions in the EMR and NPR may deviate

significantly from true figures.


50

POSTER No 10

Beliefs about medicines predict non-adherence with medication

intended for chronic use.

Harm Geers2, Eibert (Rob) Heerdink1, 2, Marcel Bouvy2

(1) University Medical Center Utrecht Department of Clinical Pharmacy, division of Laboratory and

Pharmacy PO Box 85 500, 3508 GA Utrecht, the Netherlands, (2) Utrecht University, Faculty of

Science Utrecht Institute for Pharmaceutical Sciences Division of Pharmacoepidemiology &

Pharmacotherapy PO Box 80 082, 3508 TB Utrecht, the Netherlands

Introduction

Many patients discontinue chronic medication early. It is unclear if non-adherence can be predicted at

the start of therapy.

Objective

To investigate whether poor taking compliance or non-persistence of chronic medication can be

predicted from patients' beliefs about medicines.

Methods

A prospective follow study. Patients were included in nine pharmacies in The Netherlands and were

eligible for inclusion if they filled a first prescription for a drug intended for chronic use. All patients

received a questionnaire at the time of the first prescription (t0), one month (t1) and six months (t6)

after the first prescription. The questionnaire consisted of both the Believes about Medicines

Questionnaire general and specific (BMQ) and the Satisfaction about Information on Medicines Scale

(SIMS). Electronic dispensing records were extracted from the pharmacies 10 months after inclusion.

Poor taking compliance was defined as a medication possession rate (CMA) less than 80% and non-

persistence was defined after a 90 day medication gap had emerged. Multivariable logistic regression

models were constructed with either taking compliance or non-persistence as a dependent variable,

using the questions at t0, t1 and t6 as covariates. The best predictive model was selected and a risk

score was calculated from the remaining significant covariates. Sensitivity and specificity were

calculated for each risk score to determine the optimal cutoff value for each model.

Results

Response rates at t0, t1 and t6 were 50%, 39% and 34% respectively. Medication histories of 355

patients were extracted, 21 patients were lost to follow-up or excluded. At t0 no predictive model could

be constructed. The areas under the Receiver Operator Characteristic (ROC) curve for the best

predicting model (t1) were 0.840 [95% CI 0.760-0.920] for taking compliance and 0.799 [95% CI

0.709-0.889] for non-persistence. At the optimal cutoff values of the risk scores sensitivity and

specificity were 0.80 and 0.71 for non-persistence and 0.79 and 0.69 for poor taking compliance.

Conclusions

Predicting non-adherence from patients' beliefs and knowledge about medicines is possible using the

multivariate risk model from this study.


51

POSTER No 11

Impact of Drug Reminder Packaging on Compliance? Where Are the

Research Gaps?

Fabienne Boeni2, Katja Suter1, Isabelle Arnet2, Kurt. E. Hersberger2

(1) Clinical Pharmacy & Epidemiology, University Hospital, Spitalstrasse 26 & Hebelstrasse 2, CH-

4031 Basel, (2) Pharmaceutical Care Research Group, University of Basel, Klingelbergstr. 50, CH-

4056 Basel

Background: Non compliance is a common problem occurring in all age classes, long- and short-term

treatment, and all medical conditions with rates around 50%. Reasons for non compliance are

manifold. Various authors have assumed drug reminder packaging to be a solution for forgetful and

elderly patients with complex therapeutic regimens. Such drug reminder packaging is widely used in

practice, but the effect on compliance and patient relevant endpoints has not been established yet.

Previous reviews applied rather rigid selection criteria for literature inclusion.

Aims: To analyse the impact of drug reminder packaging through comprehensive literature search, to

compile an evidence map, to uncover research gaps, and to support the rationale for future study

approaches.

Methods: In a systematic review PubMed, Embase, Cinhal, and PsychInfo were searched until May

2010, using 16 different terms for "drug reminder packaging". Studies were included if they used a

prospective controlled setting, if the intervention involved a specific unit-of-use drug packaging

intended to serve as a reminder system, if patients took one or more medications without the

assistance of a healthcare professional and if at least one of the following four parameters was

measured: taking compliance, economic, clinical, or humanistic outcomes. To map evidence, articles

were analysed with respect to methodological quality and outcomes. Methodological analysis was

based on a quality assessment tool for quantitative studies (Effective Public Health Practice Project)

and on additional criteria to evaluate specific points of interest.

Results: A total of 1559 references were identified, of which 29 studies fulfilled the inclusion criteria

(24 randomized controlled trials and 5 prospective cohort studies). Taking compliance was measured

in 28 studies. All studies demonstrated improved compliance, but only 15 showed a significant

difference between intervention and control group, and few studies included economic (2 studies),

clinical (16 studies), and humanistic outcomes (6 studies). Although most of the studies chose a

design of high quality, they lacked of methodological exactness. Major methodological weak points

were low patient number, inadequate description of intervention, insufficient information about

potential confounders, short study duration, high dropout rates, and poorly presented results. Mapping

the evidence revealed that main efforts has been put into study design and compliance measurement.

Eminent gaps were poorly tailored interventions, applicability in daily life, sufficient reporting as well as

humanistic and economic outcomes.


52

POSTER No 12

MEDICATION ADHERENCE IN PATIENTS TREATED FOR COPD

Tamás Ágh1, Ágnes Mészáros1

(1) University Pharmacy Department of Pharmacy Administration, Semmelweis University. Hungary.

[email protected]

Background: Many factors that influence adherence to therapy with respiratory drugs are directly

related to patient characteristics and treatment regimen. It is necessary to identify these factors for the

development of more effective strategies to improve medicine taking behaviour.

Aim: The objectives of the study were: (1) to estimate adherence to complex pulmonary therapy and

(2) to identify factors that influence adherence in COPD.

Methods: In the cross-sectional study the following information were obtained: adherence (4-item self-

reported Morisky Medication Adherence Scale), age, gender, disease severity (post-bronchodilator

spirometry: FEV1), smoking, number of drugs and number of daily doses. We did not demarcate the

drugs as inhaled or oral medications. Differences in patient characteristics between adherence stages

were tested using Pearson Chi-square test for categorical variables, and Kruskal-Wallis test for

continuous variables.

Results: Data were obtained from 170 patients (mean age: 63,83 (SD=11,24) years). Seven out of ten

participants did not adhere completely to the medication treatment (32% (n=55) high, 26% (n=44)

medium and 42% (n=71) low adherent). There were significant differences between the median score

of age in the different groups of adherence (Chi-square=53,854, p=0,000). Adherence was correlated

with smoking (Chi-square=14,66, p=0,001), number of drugs (Chi-square=81,061, p=0,000) and

number of daily doses (Chi-square=169,694, p=0,000). Adherence to medication was not related to

gender or disease severity.

Conclusion: Non-adherence represents a significant problem of realizing the optimal disease

management in COPD. Middle age, smoking patients should be heeded with special attention by the

clinicians, because the non-adherent rate is very high in this population. The present study indicates

that number of drugs and doses per day are inversely related to drug taking behaviour. Treatment for

COPD is based on general medical condition and disease severity. Patients with moderate to severe

COPD are treated with complex therapy, so in many cases the number of drug substances can not be

reduced. Using fix combination and/or low dosing-frequency drugs can be expected to be as effective

way to enhance adherence in routine clinical practice. Patient cooperation with medication was low

over six daily doses, therefore it would be necessary to apply less frequent dosing regimens.


53

POSTER No 13

EXPLORING ETHNIC DIFFERENCES IN PATIENT PERSPECTIVES

ON MEDICINES AND MEDICINE-TAKING: A CROSS-CULTURAL

STUDY IN NEW ZEALAND

Beata Bajorek2, Debbie Bassett-Clarke1, Ines Krass2

(1) Faculty of Health and Environmental Science, Auckland University of Technology, New Zealand,

(2) Faculty of Pharmacy, University of Sydney, Australia

Introduction

The literature identifies many barriers to medicines use, including bio-psycho-social issues, but less is

known regarding the ethno-cultural barriers, which are important in culturally diverse nations such as

Australia and New Zealand (NZ). The aim of this study is to explore ethnic differences in medicine-

taking, focussing on the NZ population, comprising NZ Maori, NZ European, Pacific Island (Pasifika)

and Asian immigrants. The results will help inform the development of resources and communication

tools to assist pharmacists in providing pharmaceutical care to diverse patient populations.

Method

A qualitative study involving a series of focus groups (4 per population stratum for each of Maori,

Pacific Islanders, European, and Asian populations) was conducted. Focus groups were chosen

mainly because they are appropriate to the social context of the various ethnic groups involved, as

storytelling is important in oral and/or indigenous cultures. Participants over the age of 55 years and

taking medicines were recruited from various community-based groups (eg local health services,

community groups). The group discussions were transcribed verbatim and then analysed for key

themes via manual inductive coding. The validity of the findings was confirmed through respondent

(participant)-checking and independent researcher review.

Results

Twenty focus groups involving 100 participants (aged >=55 years) were conducted. Overall, three key

common themes emerged across the various groups:

1. Conception of a medicine

2. Issues about medicines information

3. The degree of engagement in self-management of medicines

In general, the NZ European participants had a very narrow view of what a medicine is, were

motivated to source medicines information independently, and were very proactive in medicines

management. At the other end of the spectrum, Pasifika peoples expressed a broad view of what

constitutes a medicine, were not motivated to source medicines information independently, and were

not proactive in medicines management, tending to instead rely on the health care professional to

supply the answers. The findings from the various Ethnic groups highlight differences in attitudes to

medicines per se and medicines-taking, and these influences on medication-taking behaviour need to

be considered in the provision of pharmaceutical care.

Conclusion

Ethnic differences in attitudes to medicines and medicine-taking are apparent, although there are

some commonalities in terms of needs regarding support and advice around medicines use.


54

POSTER No 14

Achieving INR Target And Patient Satisfaction of Warfarinised

Patients in HKL

Subramaniam Thanimalai, Agnes HSY1, Chan BS1, Chan CK1, Nadrah N1

(1) none

All patients receiving warfarin therapy should achieve the recommended INR targets to reduce the risk

of thromboembolic events or bleeding. In 2008, only 50% of the time Hospital Kuala Lumpur (HKL)

atrial fibrillation patients met the INR targets. This quality assurance project aims to improve the

percentage of time patients were within their INR targets and patients satisfaction towards the services

provided by identifying the contributing factors and implementing remedial actions.

To provide a shorter clinic waiting time and to improve patient knowledge, which will contribute to the

increase in percentage of time patients are within their INR targets.

An initial study was done to identify the percentage of time patients were within their INR targets and

this was conducted from January to April 2008. A brainstorming session was held to identify the

contributing factors. Remedial actions were implemented continuously from April 2008. Evaluation of

the effectiveness of remedial action in terms of percentage of time patients were within their INR

targets, clinic waiting time and patient warfarin knowledge took place from April to July 2009.

Atrial fibrillation patients constituted the majority (85%) of patients on warfarin therapy in HKL. The

long waiting time, poor knowledge, non-adherence and reduced opportunity to discuss drug related

issues were the major contributors to the non-achievement of INR targets.

The remedial actions involved were based on 3 aspects, which are Process, Knowledge and Attitude.

Process based remedial actions included introduction of Point of Care Testing (POCT) Coagulometer,

on the spot warfarin dispensing and INR monitoring by pharmacist. Implementation of problem solving

approach during Warfarin Medication Therapy Adherence Clinic(WMTAC), continuous education

sessions, provision of standard counseling checklist and introduction of a new Patient Information

Handbook were part of Knowledge based remedial actions. As for the attitude based remedial actions,

patients were given Warfarin Calendar to record their warfarin consumption.

After remedial action, it was found that the percentage of time patients within their INR targets improve

from 50% to 66%. There was a reduction of clinic waiting time by 51.5%. 90% of the patients were

also satisfied with the remedial actions implemented.


55

POSTER No 15

A NATIONWIDE SURVEY ON MEDICATION ADHERENCE AMONG

POLISH PATIENTS AND HEALTHCARE WORKERS

Wojciech Kuzmierkiewicz1

(1) The Foundation for the Development of Polish Pharmacy and Medicine, Starogard Gdanski,

Poland, e-mail: [email protected]

Background: In Poland, research in the field of patient adherence started only recently. Therefore,

little is known about the attitudes of both patients, and healthcare workers toward adherence.

Aim: The aim of this study was to assess patients' and healthcare workers' attitudes toward

adherence in chronic conditions. The survey consisted of two phases. The qualitative phase aimed at

identifying the barriers to adherence, as well as the factors motivating them to adhere to the therapy.

The goal of the quantitative phase was to determine the scale and reasons for not following the

doctor's instructions in the Polish society.

Methods: A qualitative phase was designed in the form of focus group discussions with both

healthcare workers (cardiologists, diabetologists, psychiatrists, GPs, community nurses, and

pharmacists), as well as patients (those suffering from cardiovascular diseases, schizophrenia,

mothers of children diagnosed with asthma, or allergy, and elderly). A quantitative phase was carried

out in the form of a multi-theme opinion poll on a sample of 1006 respondents aged 15 and over, of

which 228 declared to be diagnosed with one or more of chronic conditions.

Results: Survey results indicate that the healthcare workers are aware of the importance of patient

adherence, but they do not perceive this problem as an important social and medical issue, and they

feel helpless against the real behaviour of patients. Results confirm that many Polish patients

discontinue or modify the prescribed treatment. Only 65% of chronically ill patients declare that they

always take the prescribed doses. Every fourth chronically ill patient failed to follow the doctor's

instructions, either using only a part of the prescribed package, or some or only one of the prescribed

medicines. The survey revealed three key barriers to good adherence:

• The patients' knowledge is limited mainly to the most serious risks - which are the easiest not to treat

seriously since they seem too distant and occur only in extreme cases,

• The knowledge of less serious consequences is lacking, this leads to disregarding one's state of

health or the need for regular treatment;

• Lack of awareness of the positive results of compliance.

It was also observed, that the smaller the trust in the doctors, the more often the patients modify the

therapy on their own.

Conclusion: The results of the survey indicate that Polish patents' compliance with the therapeutic

instructions in the treatment of chronic diseases is far from perfect. At the same time, healthcare

workers are not fully aware of the problem, and often find themselves helpless when facing it. In such

a situation it is worth considering the introduction of changes into the curriculum of medical students

and graduates concerning communication, motivation and negotiations in the context of the chronically

ill patients. It also seems essential to build a strong coalition toward improved compliance, with the

participation of all the relevant stakeholders.


56

POSTER No 16

INVOLVING PATIENTS IN THE DEVELOPMENT OF A GROUP-

BASED EDUCATIONAL INTERVENTION FOR A RANDOMISED

CONTROLLED TRIAL TO IMPROVE ADHERENCE TO

GLAUCOMA EYE DROPS

Heather Waterman3, Lisa Brunton3, Cliff Richardson3, Cecilia Fenerty1, Fiona Spencer1, David

Henson2

(1) Manchester Royal Eye Hospital, (2) School of Medicine, University of Manchester, (3) School of

Nursing, Midwifery and Social Work, University of Manchester

Background

Glaucoma is the leading permanent cause of blindness worldwide. Glaucoma eye drops have been

shown to slow down or prevent loss of sight yet, as in other long term conditions, patients do not instil

them as prescribed. Health policy in the UK identifies that education is important to improve adherence

to glaucoma medicines. A recent Cochrane review could not recommend any particular interventions

for patients with glaucoma due to poor quality research. Evidence from other long term conditions

suggests that group-based education might be a successful and cost-effective alternative method and

the involvement of patients could lead to more relevant programmes.

Aim

The aim of this study, therefore, is to work with people with glaucoma and health professionals to

determine the delivery, content, frequency and duration of a group-based glaucoma education

programme. This study is an important forerunner to future research to conduct a randomized

controlled trial comparing individual education with group-based education.

Methods

The selected research design was action research. An action research group was formed with five

patients with glaucoma, seven health professionals and the research team. The purpose of the ARG

was to critically review literature on group-based education models, identify local organisational

facilities and constraints, and discuss their own prejudices and experiences of education. Meanwhile,

30 people with established and newly diagnosed glaucoma were interviewed. Open-ended questions

focussed on understanding adherence patterns, and needs and preferences for an educational

programme. Data from the interviews and the ARG meetings were analysed qualitatively to identify

barriers or facilitators of adherence. These were taken as potential indicators of what should be

included in an educational programme and thus were reconfigured into learning outcomes. Data was

also searched and categorised according to patients expressed preferences for the length, frequency

and delivery of the programme. A literature review of group-based education models was also

conducted by a research assistant and the components of the models were compared with the

learning outcomes.

Results

Theory: The constituent parts of the Information, Motivation and Behavioural Theory most closely

matched the learning outcomes of the group based education programme thus developed.

Content: Ten learning outcomes were identified for inclusion in the group-based educational

intervention, for example, understanding the diagnosis of glaucoma and the implications of eye drops,

feeling confident to instil their drops, and being able to ask questions of health professionals.

Frequency/Duration: Two sessions lasting no longer than two hours each time, were considered

optimal to be able to deliver the proposed content and to ensure patient acceptability of duration (to

increase attendance).

Delivery: There was strong patient preference for the intervention to be provided by health

professionals and opposition to a layperson led intervention. This is in contrast to recent NHS


57

initiatives such as the Expert Patient Programme. A facilitative method of delivery was favoured over

didactic teaching methods.

Conclusion

The participatory methodology used for this study has proved particularly suited to developing a group-

based education programme.


58

POSTER No 17

Medication Persistence in the Treatment of HIV Infection: A Review

of the Literature and Implications for Future Clinical Care and

Research

Jason W. Bae, William Guyer, Kristy Grimm, Frederick L. Altice

Yale University School of Medicine, email: [email protected]


59

PRACTICAL INFORMATION

TRANSFER FROM FOCUS HOTEL TO CONFERENCE VENUE AND BACK

There will be shuttle buses to the conference venue departing from Focus Hotel at 8.15 on

17th and 18th September.

After the conference on the 17th , there will be a shuttle bus from the conference venue to

Focus Hotel at 17:00.

Or... you may like to take a walk around the Manufaktura Shopping and Leisure Centre

neighbouring the Poznanski‟s Palace (located in former industrial buildings belonging to

Israel Poznanski‟s cotton empire. http://www.wirtualnafabryka.com/ )

CONFERENCE VENUE AND REGISTRATION DESK

The conference pack and registration will be available from 08:00 in the mornings of 17th

and 18th September. There will be a place to leave your luggage if required – please enquire

at the desk.

The conference will take place at Israel Poznanski’s Palace - Museum of the City of Lodz

located at 15, Ogrodowa Str. In 70s and 80s, of the 19th century, Izrael Poznanski became

the “King of cotton” in Lodz. He was the owner of the biggest palace and the textile factory in

Lodz in the 19th century. The Poznanski Palace has been listed as one of the largest and

greatest residence of its type.

The palace was functionally connected with a huge cotton production plant, a housing estate

for workers and other accompanying buildings. Former industrial buildings have been

revitalized and adapted into the 4-star deluxe hotel, as well as shopping, entertainment and

cultural centre Manufaktura – one of the most interesting in Europe.

CONFERENCE LUNCH

Tea & coffee breaks and lunch will be provided at the conference venue on 17th and 18th

September.

PRESENTERS

http://www.wirtualnafabryka.com/


60

The conference venue will be open from 08:00 on 17th and 18th September. Poster

presenters are asked to set up their posters as early as possible on 17th September.

Adhesives accessories will be made available.

Paper presenters are asked to send their slides by email at the latest on 15th September to

[email protected]. If you are bringing your slides with you, a technician will assist

you with uploading them between 08:00 and 9:00 in the mornings of 17th and 18th September

or during coffee breaks.

CONFERENCE GALA DINNER

The conference dinner will be organized at “U Fabrykanta” Restaurant. The address is 2,

Plac Zwycięstwa. There will be shuttle buses departing from Focus Hotel at 19.45; and

returning from 23:00 onwards.

TRANSFER FROM LODZ TO WARSAW AIRPORT ON 18th SEPTEMBER

Conference participants who marked an option “require transfer to Warsaw airport on 18th

September” during registration are free to take a bus shuttle provided by the organizers at

15.00 o’clock. The bus will leave from the conference venue.

Alternative ways of getting to Warsaw airport:

- A taxi to the airport. The fare would be 400-450 zloty (100-120 Euro). Corporate taxis

(the ones having a company name and phone number on them) are less expensive.

We can book a taxi for you on request.

- Train from Lodz Fabryczna Station to Warsaw Central Station and a taxi to the

airport. Trains leave app. every 80 minutes. The journey lasts about 90 minutes. The

timetable in English is available at http://rozklad-pkp.pl/. Tickets are available at cash

desks in the main hall of the train station and credit cards are accepted.

Please note that due to construction work, the Warsaw airport will be partially closed

in the evening of 17th, on the 18th (morning to evening) and on the morning of 19th

September. Some departures will be on schedule, some will be redirected to other

airports, mostly to Lodz (which is good news). Please, check with your airlines if your

arrival/departure will be from Warsaw or will be redirected to a different airport.

ADDITIONAL INFORMATION FOR ESPACOMP BOARD

The dinner for Board Members and Invited Speakers on 16th September will be organized at

FOCUS hotel at 20:00. FOCUS hotel is located in Lodz, at 23/25 Lakowa Str.

The ESPACOMP Board Meeting will take place on 17th September from 17.00:18.30 at the

conference site.

ADDITIONAL INFORMATION FOR INVITED SPEAKERS

The hotel rooms for you have been booked at FOCUS hotel, located in Lodz at 23/25

Lakowa Str.

The dinner for Invited Speakers and Board Members on 16th September will be organized at

FOCUS hotel at 20:00.

CONTACTS

Contact telephone numbers: Anna +48 509 686 431, Pawel + 48 501 183 148

http://rozklad-pkp.pl/


61

MAP OF LODZ

Legend:

1. Poznanski‟s Palace -

Museum of the City of

Lodz (Conference venue),

15, Ogrodowa Str.

2. Focus Hotel, 25, Łąkowa

Str.

3. “U Fabrykanta”

Restaurant, 2, Plac

Zwycięstwa Sq.


62

NOTES


63

NOTES


64

NOTES


65

The 14th European Symposium on Patient Adherence… 2010 abstract book.pdf · The 14th European...

Documents

Transcript of The 14th European Symposium on Patient Adherence… 2010 abstract book.pdf · The 14th European...