Gesundheitsökonomie & Qualitätsmanagement 2011; 16(5): 274-291
DOI: 10.1055/s-0031-1273282
Originalarbeit

© Georg Thieme Verlag KG Stuttgart · New York

Anforderungen an ein effektives Adherence-Persistence-Programm am Beispiel von oralen Antidiabetika bei Diabetes mellitus Typ 2-Patienten

Requirements of an Effective Adherence-Persistence Program Using the Example of Oral Diabetics for Diabetes Mellitus Type 2 PatientsT. Wilke1 , S. Müller1 , A. Groth1 , U. Maywald2 , F. Verheyen3
  • 1Institut für Pharmakoökonomie und Arzneimittellogistik, Hochschule Wismar
  • 2AOK Plus
  • 3WINEG – Wissenschaftliches Institut der TK für Nutzen und Effizienz im Gesundheitswesen
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
09. März 2011 (online)

Zusammenfassung

Zielsetzung: Ziel dieses Beitrags ist es, ein systematisches Review zur medikationsbezogenen Non-Adherence (NA)/Non-Persistence (NP) von Patienten und zur Effektivität von Adherence-/Persistence-Programmen (AP-Programmen) am Beispiel von oralen Antidiabetika (OAD) zur Behandlung von Diabetes Mellitus Typ 2 (DM 2) durchzuführen. Ein besonderer Schwerpunkt liegt dabei auf der Konzeption von AP-Programmen und möglichen konzeptionsbedingten Gründen für deren Effektivitätsunterschiede. Methodik: Es wurde ein systematisches Review (Medline/NML und EMBASE) der verfügbaren Literatur in Bezug auf OAD in der Indikation DM 2 in den zwei Themenbereichen „Ausmaß von NA/NP“ und „Evaluation von AP-Programmen“ durchgeführt. Dabei wurden lediglich AP-Programme in das Review aufgenommen, die explizit auch die medikationsbezogene Adherence/Persistence adressieren. Die identifizierten Studien zu AP-Programmen wurden hinsichtlich ihrer methodischen Konzeption und ihrer Effektivität (2 Outcomes: Adherence-Persistence-Steigerung und/oder Verbesserung klinischer Outcomes) bewertet. Ergebnisse: In das Review wurden 62 Studien bezüglich des NA-/NP-Ausmaßes sowie 15 Studien, die insgesamt 19 unterschiedliche AP-Programme evaluieren, einbezogen. Laut Studienmittel sind je nach verwendetem Messkonzept 29,1 – 39,2 % der untersuchten Patienten von NA und 56,1 % der betrachteten Patienten von NP betroffen; die hohe NP-Rate ist allerdings in zahlreichen Studien auf eine sehr restriktive Definition von Persistence zurückzuführen. Vier Dimensionen der Programmkonzeption, die die Effektivität eines AP-Programms entscheidend beeinflussen, konnten identifiziert werden: 1. Messung von Adherence/Persistence/klinischen Outcomes innerhalb des Programms, 2. Messung von NA-/NP-Ursachen, 3. Qualität der angewandten Interventionen und 4. Programmevaluation. Die Autoren definierten 5 detaillierte methodische Anforderungen für jede dieser 4 Dimensionen und ein darauf basierendes Scoring-Modell (Minimum-Score = 0, Maximum-Score = 20). Die 19 analysierten AP-Programme wurden anhand dieser Scoring-Logik evaluiert (Ø Score = 8,05): Score < 5: drei Interventionen – keines der Programme (0 %) konnte die analysierten Outcomes optimieren; Score 5 – 9: acht Interventionen – 6 (75 %) zeigten eine Verbesserung der analysierten Outcomes; 2 Programme hatten keine Effekte; Score > 9: acht Interventionen – sämtliche Programme (100 %) konnten die Adherence/Persistence und/oder klinische Outcomes verbessern. Schlussfolgerungen: AP-Programme werden in Zukunft in der deutschen Versorgungslandschaft eine deutlich größere Rolle als bislang spielen. Die bislang wenig beeindruckende Evidenz zur Effektivität von AP-Programmen zeigt den Bedarf einer tiefgehenden Analyse von Faktoren, die die Effektivität dieser Programme bestimmen. Das entwickelte Scoring-Modell kann hierfür erste Anhaltspunkte bieten.

Abstract

Aim: The aim of this review is 1. to give an overview about the extent of medication-based nonadherence (NA)/nonpersistence (NP) related to oral antidiabetics (OAD) in Diabetes mellitus type II (DM 2) therapy and 2. to evaluate the effectiveness of adherence interventions (AI) aimed to reduce NA/NP in OAD therapy in relation to their methodological quality. Method: A systematic review of DM 2 studies regarding the extent of NA/NP concerning OAD and of AI effectiveness studies was conducted (Medline/NML and Embase). Only interventions aiming to improve medication adherence/persistence were included. All AI were evaluated regarding their methodological quality and their effectiveness (2 outcomes: adherence/persistence and clinical outcomes). Results: All in all, 62 studies evaluating the NA/NP extent in OAD and 15 publications evaluating 19 different AI were included in this review. According to the study mean, NA affects 29.1 % to 39.2 % and NP affects 56.1 % of the DM 2 patients; naturally, extent of NA/NP depends both on its definition and used NA/NP measures. Four dimensions of the methodological quality of AI were identified: 1. measurement of adherence/persistence/clinical outcomes, 2. measurement of NA/NP causes, 3. use of effective/validated intervention measures, 4. effective program evaluation. The authors defined 5 detailed methodological requirements per dimension and, based on this, developed a corresponding scoring model (MIN Score 0, MAX score 20). All 19 AI programs were evaluated in the scoring model (average score 8.05): Score < 5: 3 AI – no AI (0 %) with adherence/persistence/blood glucose level improvement; Score 5 – 9: 8 AI – 6 AI (75 %) with improvement in adherence/persistence/blood glucose levels; Score > 9: 8 AI – all AI (100 %) improved adherence and/or blood glucose levels. Conclusion: In future, AI will play a much more important part than nowadays in the German health care system. However, the existing evidence concerning their limited effectiveness shows that a lot of research is needed in order to understand factors explain a program’s effectiveness. The scoring model provides first implications for the methodical evaluation of AI.

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1 Strings englisch/deutsch: (oral hypoglycemic agents; oral antidiabetic medications; diabetes; hyperglycemia; Biguanide; Metformin; Sulfonylureas; Glibenclamid; Glimepirid; Dipeptidyl peptidase-4 inhibitors) and (adherence; compliance; persistence) and (measurement; identification; extent; economics; costs; value; resource utilization; expenditures).

2 Strings englisch/deutsch: (oral hypoglycemic agents; oral antidiabetic medications; diabetes; hyperglycemia; Biguanide; Metformin; Sulfonylureas; Glibenclamid; Glimepirid; Dipeptidyl peptidase-4 inhibitors) and (adherence; compliance; persistence) and (improvement; enhancement; pharmacy, pharmacist; doctors; interventions; programs; reminder; prevention; patient education).

3 www.prisma-statement.org

Prof. Dr. Thomas Wilke

Institut für Pharmakoökonomie und Arzneimittellogistik, Hochschule Wismar

PF 1210

23952 Wismar

Telefon:  ++ 49/38 41/75 35 04

Fax:  ++ 49/38 41/75 31 31

eMail: thomas.wilke@hs-wismar.de