|
Background: Diabetes can be managed well by adherence to prescribed oral hypoglycemic agents (OHAs) and/or insulin. Between 33% and 69% of all medication-related hospital admissions in the US are due to poor medication adherence, at a cost ranging from ≥100 to ≥300 annually.
Objective: The objective of this study was to study the prevalence of poor medication adherence among known diabetics and its association between poor medication adherence and glycemic control among adults known type II diabetes.
Materials and Methods: A cross-sectional study was carried out among 225 adults with known type II diabetes. Known diabetics with type II and adults above the age of 30 years taking treatment at Malla Reddy Hospital were included in the study. Morisky Green Levine Medication Adherence Scale (MGLS) was used to assess patients' adherence to diabetic medications. The American College of Physicians guidelines on glycated hemoglobin (HbA1c) was used to classify glycemic control.
Results: The majority (40%) were 60–69 years, males (64%) and (69.3%) were from urban areas. 37.8% were illiterate. 47.6% were doing business or service. The majority (82.7%) had diabetes for >5 years. As per the American College of Physicians guidelines, HbA1c should be kept at 7%–8% for diabetics. Accordingly, only 16.4% had HbA1c levels of <8%. The majority were using OHA only (80.4%). As per MGLS classification, only 29.3% had high adherence. 57.8% were found to have intermediate adherence and 12.9% had low adherence. The mean levels of HbA1c were significantly higher in those with low medication adherence (13.01 ± 1.3) compared to those with intermediate and high adherence (P < 0.05).
Conclusion: The poor medication adherence was high in the present study. It was affecting glycemic control. It was significantly associated with the poor glycemic control.
Keywords: Adherence, diabetes, glycemic control, insulin
How to cite this URL:
Eda S, Motgi S, Singh TR. Medication adherence among known adult type-II diabetics and its association with glycemic control at a tertiary care hospital. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=357065 |
| Introduction | |  |
Diabetes mellitus (DM), the most common disorder of the endocrine system, is a growing worldwide epidemic with the number of people with diabetes rising from 108 million in 1980 to 422 million in 2014.[1] Chronic hyperglycemia and other metabolic disturbances of DM lead to potential long-term complications including cardiovascular diseases, retinopathy, nephropathy, neuropathy, and diabetic foot disorders.[2],[3] Diabetes can be managed well by adherence to prescribed oral hypoglycemic agents (OHAs) and/or insulin. The glycated hemoglobin (HbA1c) test measures the average blood glucose of patients for the previous 2–3 months and has strong predictive value for diabetes complications. To reduce the risk of long-term complications of diabetes, a reasonable A1c goal for nonpregnant adults is <7%.[4]
The WHO defines adherence for long-term treatment as “the extent to which a person's behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health-care provider.”[5],[6] According to the WHO report, the average adherence to long-term therapy for chronic diseases in developed countries is approximately 50%, and in developing countries, the adherence rate is even lower. The report illustrated that the range of adherence for medicines is 31%–71% and much lower for lifestyle instructions, even with the availability of up-to-date and effective methods of treatment.[6] As a result, poor medication adherence leads to worsening of the disease and increased mortality and imposes a significant financial burden on both the individual patient and the health-care system. Globally, diabetes accounts for 11% of total health-care expenditure in 2011. In 2017, the total estimated cost of diabetes in the US was ≥327 billion.[7] In Saudi Arabia, the national health-care burden from DM reached ≥0.9 billion in 2010, and this number is projected to exceed ≥6.5 billion by 2020.[8] Actually, between 33% and 69% of all medication-related hospital admissions in the US are due to poor medication adherence, at a cost ranging from ≥100 to ≥300 annually.[5] Osterberg and Blaschke observed that each 10% increase in adherence among diabetes patients was associated with an 8.6%–28.9% decrease in total annual health-care costs.
The present study was carried out to study the prevalence of poor medication adherence among known diabetics and its association between poor medication adherence and glycemic control among adults known type II diabetes.
| Materials and Methods | | |
A cross-sectional study was carried out among 225 adults with known type II diabetes for 2 months from April 1, 2022, to May 31, 2022. The study was carried out at Malla Reddy Institute of Medical Sciences Hospital, Hyderabad.
The prevalence of poor medication adherence among known diabetics was 64.5% as per one study published.[9] Using this as prevalence with 95% confidence level and relative error as 5% of prevalence, the sample size was 220. The formula used was 4pq/L2.
Known diabetics of either gender aged 30 years and above, having type II diabetes mellitus and willing to participate participants were included in the present study. Patients with the presence of severe comorbidities were excluded from the present study.
The protocol was submitted to the Institutional Ethics Committee for approval. After their approval, the study was initiated. Informed consent was taken from the study participants.
Known diabetics with type II and adults above the age of 30 years taking treatment at Malla Reddy Institute of Medical Sciences Hospital were included in the study. They were contacted, and their informed consent was taken. Information on sociodemographic characteristics such as gender, age, residence, marital status, education level, and occupational status; clinical profile such as disease type, disease duration, current medications, recent HbA1c result, and other comorbidities if the present was collected in the predesigned, pretested, and semistructured study questionnaire.
The Morisky Green Levine Medication Adherence Scale (MGLS) was used to assess patients' adherence to diabetic medications with permission from the scale owner. The composite four items in this adherence scale are: “Q1: Do you ever forget to take your diabetic medication?;” “Q2: Do you ever have problems remembering to take your diabetic medication?;” “Q3: When you feel better, do you sometimes stop taking your diabetic medication?;” and “Q4: Sometimes if you feel worse when you take your diabetic medication, do you stop taking it?”[10]
Assessment of adherence to diabetic medications was based on patients' self-reported recall of using diabetic medications over the previous 2 weeks using MGLS. The degree of adherence was determined according to the MGLS resulting from the counting of all “yes” answers. In this scale, scores gained from the MGLS range from 0 to 4, and each of the four items is in a (yes/no) format. One point was scored for each positive response, one point was given for a “yes” answer, and zero point was given for a “no” answer. Hence, the lower the score, the more adherences, since the four questions are negatively coded items. A score of 0 indicates high adherence; a score of 1 or 2 illustrates intermediate adherence, and a score of 3 or 4 indicated low adherence.[10]
The latest report of HbA1c not older than 1 month was considered. Otherwise, the investigation was carried out as per the standard protocol. The American College of Physicians guidelines on HbA1c was used in the present study to classify glycemic control. In guidance statement II, they stated that HbA1c levels between 7% and 8% should be the aim of the physicians while treating type II diabetes.[11]
The Chi-square test and t-test were used for proportions and mean values, respectively. P <0.05 was taken as statistically significant. For comparison of mean values in >two levels, analysis of variance test was used. F-test was applied.
| Results | | |
The majority (40%) were in the age group of 60–69 years. Males (64%) were more than females (36%). All were married. The majority (69.3%) were from urban areas. 37.8% were illiterate. 47.6% were doing business or service [Table 1]. | Table 1: Sociodemographic characteristics of the study participants (n=225)
Click here to view |
The majority (82.7%) had diabetes for >5 years. As per the American College of Physicians guidelines,[11] the HbA1c should be kept at 7%–8% for diabetics. Accordingly, only 16.4% had HbA1c levels of <8%. The majority were using OHA only (80.4%) [Table 2].
As per MGLS classification,[10] only 29.3% had high adherence to the medications of diabetes. 57.8% were found to have intermediate adherence and 12.9% had low adherence [Table 3].
Among all the factors studied, the mean levels of HbA1c were significantly higher in those with low medication adherence (13.01 ± 1.3) compared to those with intermediate and high adherence (P < 0.05). All other factors were not found to be significantly associated with medication adherence [Table 4].
| Discussion | | |
The majority (40%) were in the age group of 60–69 years. Males (64%) were more than females (36%). All were married. The majority (69.3%) were from urban areas. 37.8% were illiterate. 47.6% were doing business or service. The majority (82.7%) had diabetes for >5 years. As per the American College of Physicians guidelines,[11] the HbA1c should be kept at 7%–8% for diabetics. Accordingly, only 16.4% had HbA1c levels of <8%. The majority were using OHA only (80.4%). As per MGLS classification,[10] only 29.3% had high adherence to the medications of diabetes. 57.8% were found to have intermediate adherence and 12.9% had low adherence. Among all the factors studied, the mean levels of HbA1c were significantly higher in those with low medication adherence (13.01 ± 1.3) compared to those with intermediate and high adherence (P < 0.05). All other factors were not found to be significantly associated with medication adherence.
Aloudah et al.[12] carried out a cross-sectional study among 395 patients. High adherence was found in 40% of the cases and this was more compared to the present study of 29.3%. They reported that the odds of lower adherence were 1.084 times more in younger adults compared to older adults. More use of drugs not related to OHA was found to be protective. Lower medication adherence was found to be associated with higher levels of HbA1c which we also found that the mean levels of HbA1c were more in those with low adherence.
Arulmozhi and Mahalakshmy.[13] observed that the high medication adherence among 150 known diabetics was 49.3% which is also more compared to the present study of 29.3%. They used the MMAS scores while we used the MGLS scores. 67.3% of their study participants were vigilant about the foot care. In their study, low medication adherence was associated with poor family support.
Al-Qazaz et al.[14] included 505 patients in their analysis. They reported that adherence, knowledge, and HbA1C were significantly correlated. The adherence score was higher in those with lower HbA1C levels. We also observed that the mean HbA1C levels were significantly higher among those with low medication adherence.
Ahmed et al.[15] studied 290 diabetic patients using convenience sampling. They found that only 10.7% had high adherence while we found that 29.3% had high medication adherence. They found that medication adherence was significantly associated with age, sex but we found that age and were not significantly associated with medication adherence. They did not find any significant association between the duration of diabetes and the number of hypoglycemic medications and we also did not find any significant association.
The present study was a single-center study using a small sample size. Hence, the results should be interpreted with caution. Nevertheless, the findings are comparable with other studies. We studied few factors, and the study of more factors with reasonable sample size is required to comment specifically. However, low medication adherence is a matter of concern as it is often associated with the early development of complications leading to poor quality of life.
| Conclusion | | |
Poor medication adherence was high in the present study. It was affecting glycemic control. It was significantly associated with poor glycemic control.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Asche C, LaFleur J, Conner C. A review of diabetes treatment adherence and the association with clinical and economic outcomes. Clin Ther 2011;33:74-109.  |
| 3. | Maddigan SL, Feeny DH, Johnson JA. Health-related quality of life deficits associated with diabetes and comorbidities in a Canadian National Population Health Survey. Qual Life Res 2005;14:1311-20. |
| 4. | American Diabetes Association. Standards of medical care in diabetes-2017: Summary of revisions. Diabetes Care 2017;40 Suppl 1:S4-5. |
| 5. | Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-97. |
| 6. | Sabaté E. WHO Adherence to Long Term Therapies Project, Global Adherence Interdisciplinary Network, World Health Organization Department of Management of Non Communicable Diseases. Adherence to Long-Term Therapies: Evidence for Action. Geneva: World Health Organization; 2003. Available from: http://whqlibdoc.who.int/publications/2003/ 9241545992.pdf. [Last accessed on 2022 Mar 05]. |
| 7. | American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018;41:917-28. |
| 8. | Alhowaish AK. Economic costs of diabetes in Saudi Arabia. J Family Community Med 2013;20:1-7. |
| 9. | Alqarni AM, Alrahbeni T, Qarni AA, Qarni HM. Adherence to diabetes medication among diabetic patients in the Bisha governorate of Saudi Arabia – A cross sectional study. Patient Prefer Adherence 2019;13:63-71. |
| 10. | Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74. |
| 11. | Qaseem A, Wilt TJ, Kansagara D. Hemoglobin A1c targets for glycemic control with pharmacologic therapy for non-pregnant adults with type 2 diabetes mellitus: A guidance statement update from the American College of Physicians. Ann Intern Med 2018;168:569-76. |
| 12. | Aloudah NM, Scott NW, Alijadhey HS, Araujo-Soares V, Alrubeaan KA, Watson MC. Medication adherence among patients with Type 2 diabetes: A mixed methods study. PLoS One 2018;13:e0207583. |
| 13. | Arulmozhi S, Mahalakshmy T. Self care and medication adherence among type 2 diabetics in Puducherry, Southern India: A hospital based study. J Clin Diagn Res 2014;8:UC01-3. |
| 14. | Al-Qazaz HK, Sulaiman SA, Hassali MA, Shafie AA, Sundram S, Al-Nuri R, et al. Diabetes knowledge, medication adherence and glycemic control among patients with type 2 diabetes. Int J Clin Pharm 2011;33:1028-35. |
| 15. | Ahmed NO, Abugalambo S, Almethen GH. Adherence to oral hypoglycemic medication among patients with diabetes in Saudi Arabia. Int J Health Sci (Qassim) 2017;11:45-9. |
Correspondence Address:
Shashikala Eda,
Department of Pharmacology, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjhs.mjhs_37_22
[Table 1], [Table 2], [Table 3], [Table 4] |
Search Pubmed for