The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review

Figures & data

Figure 1 PRISMA diagram.

Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1 Program and evaluation characteristics

Characteristics	N (%)
Disease states
Type 2 diabetes mellitus/metabolic syndrome	12 (18.8)
HIV	11 (17.2)
Cardiovascular disease/CHF	10 (15.6)
Hypertension	8 (12.5)
Dyslipidemia/coronary risk reduction	5 (7.8)
Asthma/COPD	4 (6.3)
Osteoporosis	3 (4.7)
Renal transplant/failure	3 (4.7)
Rheumatoid arthritis	2 (3.1)
Multiple sclerosis	2 (3.1)
Cancer	1 (1.6)
Cerebral vascular disease	1 (1.6)
Glaucoma	1 (1.6)
Parkinson’s disease	1 (1.6)
Study design
Randomized controlled triala	46 (71.9)
Prospective cohort (with controls)	8 (12.5)
Retrospective cohort (with controls)	7 (10.9)
Quasi-experimentalb	4 (6.3)

Notes:

a Includes cluster RCT and pragmatic trials,

b pre–post design (2), waitlist design with control crossover (1), nonrandomized controlled trial (1).

Abbreviations: HIV, human immunodeficiency virus; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; RCT, randomized controlled trial.

Table 2 Included programs, components and outcomes

Source	Disease state	Practitioner implementing	Service delivery mechanism	Study design/comparator	Outcomes				Funding source(s)
					Adherence	Clinical	Humanistic outcomes (results direction)	Cost/utilization outcomes (results direction)
Abdelhamid et al^Citation19	Asthma/COPD	Pharmacist	C	RCT/standard care		Acute attacks, nocturnal asthma symptoms, peak expiratory flow rate, hospitalizations (mixed)	Self-reported sickness days (Pos)	Hospitalizations (Pos)	Private
Achieng et al^Citation20	HIV	Pharmacist, community health workers, physician	C, H	Prospective cohort/nonprogram participants	90-day filled prescriptions (mixed)	Virologic failure (mixed)			Pharma/PBM
Aguado et al^Citation21	Cardiovascular disease/heart failure	Nurse	H	RCT/standard care		Mortality, hospitalizations, ED visits (mixed)	Functional status/QOL (Neg)	Hospital/ED costs, ED (Pos)
Al Hayek et al^Citation22	T2DM	Diabetes educators, physician	C	Prospective cohort/baseline as control	Morisky Medication Adherence Scale (Pos)	Glycemic control (Pos)	Anxiety/depression, self-care (mixed)
Ali et al^Citation23	T2DM	Pharmacist	C	RCT/standard care plus one pharmacist session		Glycemic control, lipids, BMI, BP control (mixed)	Mixed satisfaction, functional status/QOL (mixed)		Pharma/PBM
Amado Guirado et al^Citation24	Hypertension	Nurse	C	RCT/standard care	Haynes–Sackett and Morisky–Green self-reports and pill counts (mixed)	BP control, BMI (Neg)	Knowledge (Neg)		Govt
Antonicelli et al^Citation25	Cardiovascular disease/heart failure	MD led team	C, P	RCT/standard care	Compliance (unspecified) Pos	Mortality and hospitalization composite, BP control, ejection fraction, heart rate, lipids, electrolytes, urine output (mixed)	QOL (Neg) (Neg)	Hospital costs (unclear)	Govt
Böhme et al^Citation26	Cardiovascular disease/heart failure	Trained counselors	P	Prospective cohort/baseline as control		Symptoms, impairment (Pos)	Perceived health (Pos)		Pharma/PBM, private
Cate et al^Citation27	Glaucoma	Interprofessional	C, P	RCT/standard care	Medication possession ratio via MEMSCAP/Morisky Medication Adherence Scale (Neg)	Intraocular pressure (Neg)	Satisfaction (mixed)	Hospital costs (Neg)	Pharma/PBM, Govt
Chiou et al^Citation28	HIV	Interprofessional	C, H, P	RCT/standard care	Customized adherence self-report questionnaire (Pos)	Viral load, CD4^+ (Pos)	QOL (Pos)		Pharma/PBM
Chung et al^Citation29	HIV	Trained counselors/pharmacist	C, M	RCT/standard care plus one pharmacist session	Monthly pill counts (mixed)	Virologic failure, CD4^+, mortality (mixed)			Govt
Cleland et al^Citation30	Cardiovascular disease/heart failure	Nurse	H, P	RCT/standard care		Days lost to mortality, hospitalization (mixed)		Hospitalization, hospital days (mixed)	Pharma/PBM
Clifford et al^Citation31	T2DM	Pharmacist	C, P	RCT/standard care		Glycemic control, lipids, BP control, CHD/stroke risk (mixed)	QOL data not reported (Neg)		Private
Criswell et al^Citation32	Hypertension	Pharmacist	C, P	Cluster RCT/standard care plus one study nurse visit	Modified Morisky scale (Neg)	Blood pressure, symptoms (Pos)	Self-efficacy, Social support (mixed)		Govt
Crowley et al^Citation33	Coronary risk reduction/dyslipidemia	Nurse	E, P	RCT/standard care	Morisky Medication Adherence Scale (Pos)	Glycemic control, lipids, BP control (Neg)			Govt
de Bruin et al^Citation34	HIV	Nurse	C	RCT/standard care	MEMSCAP (mixed)	Viral load suppression (Pos)	Usefulness (Pos)		Private
Del Sindaco et al^Citation35	Cardiovascular disease/heart failure	MD and nurse	C, H, P	RCT/standard care		Death, exacerbation leading to hospitalizations (mixed)	QOL, health status (unclear)	Hospital costs (Pos)	Private
DiIorio et al^Citation36	HIV	Nurse	C, P	RCT/standard care	MEMSCAP (mixed)	Viral load, CD4^+, (Neg)			Govt
Erhun et al^Citation37	Hypertension	Pharmacist	C	Prospective cohort/retrospective data as control	Missed dose incident (unclear)	BP control (Pos)	Satisfaction (Pos)
Evans et al^Citation38	Coronary risk reduction/dyslipidemia	Pharmacist	C, E, H, M, P	RCT/standard care	Proportion of days covered (Neg)	Framingham risk score, lipids, blood pressure (Neg)			Govt
Gabbay et al^Citation39	T2DM	Nurse	C, E, P	RCT/standard care		Glycemic control, lipids, BP control (mixed)	Satisfaction, self-care, QOL (mixed)		Private
Grosset and Grosset^Citation40	Parkinson’s disease	Physician	C	RCT/standard care	MEMSCAP (Pos)	Disease progression, adverse events (Neg)	QOL (Neg)		Private
Heisler et al^Citation41	T2DM	Pharmacist	C, M, P	Cluster RCT/printed education materials only		Glycemic control, lipids, BP control (Neg)			Govt
Hlubocky et al^Citation42	Renal transplant/failure	Pharmacist	M, P	Retrospective cohort study/retrospective data as control	Continuous measures of medication adherence (unclear)	Need for hospitalization(Neg)	Satisfaction (Pos)	Program revenue after expenses, readmissions, length of stay (mixed)	Private
Hohmann et al^Citation43	Cerebral vascular disease	Pharmacist	C	Non-randomized RCT/standard care		Physical functioning (mixed)	Satisfaction (Pos)		Private
Holzemer et al^Citation44	HIV	Nurse	C, P	RCT/standard care	MEMS, pill count, self-report AIDS clinical trial group, Morisky Medication Adherence Scale (Neg)	Viral load, CD4^+ (unclear)			Govt
Jacobs et al^Citation45	T2DM/hypertension/high cholesterol	Pharmacist and MD	C, P	RCT (pragmatic)/standard care		Glycemic control, lipids, blood pressure (Pos)			Pharma/PBM
Jorstad et al^Citation46	Cardiovascular disease/heart failure	Nurse	C	RCT/outpatient clinic visits, referral to rehab per country guidelines	Self-reported maximum adherence (Neg)	Coronary risk, need for hospitalization(mixed)	Smoking, lifestyle changes (mixed)	Hospital readmissions (Pos)	Pharma/PBM
Kennedy et al^Citation47	Rheumatoid arthritis	Interprofessional	C	Quasi-experimental, controlled/waitlisted control crossover		Self-efficacy, health assessment questionnaire (Neg)	Knowledge, illness intrusiveness, coping (Neg)		Pharma/PBM
Koenig et al^Citation48	HIV	Nurse	C	RCT/standard care	MEMSCAP (Pos)	Viral suppression, CD4^+ (Neg)			Govt
Lai et al^Citation49	Osteoporosis	Pharmacist	C, P	RCT/standard care, plus information package at 12 months	Self-reported adherence (mixed)	Bone turnover markers (Neg)	Knowledge, QOL, satisfaction (Pos)		Govt
Liekweg et al^Citation50	Breast, ovarian cancer	Pharmacist	C	Prospective cohort/standard care in control cohort		Chemotherapy related nausea, emesis (mixed)	QOL, satisfaction, Pos)		Private
Maduka and Tobin-West^Citation51	HIV	Trained counselors	C	RCT/standard care	Self-reported pills missed (Pos)	CD4^+ (Pos)	Knowledge (Pos)		Private
Márquez Contreras et al^Citation52	Hypertension	Physician	M, P	RCT/standard care	Pill counts (Pos)	BP control (Pos)			Pharma/PBM
McDermott et al^Citation53	Coronary risk reduction/dyslipidemia	Trained counselors	P	RCT/standard care	Brief medication questionnaire (Neg)	Lipids (mixed)	Knowledge, patient activation, self-efficacy in physician communication (mixed)
Morgado et al^Citation54	Hypertension	Pharmacist	C	RCT/standard care	Morisky Medication Adherence Scale (Pos)	BP control (Pos)	Knowledge (Pos)		Govt
Mugusi et al^Citation55	HIV	Nurse	C	RCT/standard care with monthly adherence counseling	Self-reported adherence (Neg)	CD4^+ (Neg)			Govt
Nieuwkerk et al^Citation56	Coronary risk reduction/dyslipidemia	Nurse	C	RCT/standard care	Self-reported adherence (Pos)	Lipids, anxiety (mixed)	QOL, risk perception (Neg)		Pharma/PBM
Ogedegbe et al^Citation57	Hypertension	Research assistants	C	RCT/standard care	MEMSCAP (Pos)	BP control Neg			Govt
Phumipamorn et al^Citation58	T2DM	Pharmacist	C	RCT/standard care	Pill counts (Pos)	Glycemic control, lipids (mixed)	Knowledge (Pos)		Govt
Ruan et al^Citation59	HIV	Not clear	P	Prospective cohort/baseline as control		Viral suppression (Pos)			Govt
Sadik et al^Citation60	Cardiovascular disease/heart failure	Pharmacist	C, I	RCT/standard care	Self-reported adherence (Pos)	2-minute walk test, BP control, weight, forced vital capacity (Pos)	QOL, knowledge (mixed)
Sauvageot et al^Citation61	T2DM/hypertension/high cholesterol	Pharmacist and patient advocate	Ph	Retrospective cohort/baseline as control		Glycemic control, lipids, blood pressure (mixed)			Private
Shanmugam et al^Citation62	Asthma/COPD	Pharmacist	C	RCT/standard care		Asthma control, Peak expiratory flow rate (Pos)	QOL (Pos)		Private
Sisk et al^Citation63	Cardiovascular disease/heart failure	Nurse	C, M, P	RCT/standard care		Need for hospitalization, physical functioning (mixed)	Knowledge, QOL (mixed)	Hospitalizations (Pos)	Govt
Skowron et al^Citation64	Hypertension	Pharmacist	C	Quasi-RCT/randomize pharmacists to provide intervention or standard care		BP control (Neg)	Knowledge, QOL (Neg)
Solomon et al^Citation65	Osteoporosis	Health educator	P	RCT/standard care plus mailed information	Medication possession ratio, persistence (Neg)	Fractures, falls, depression (Neg)	Satisfaction (unclear)		Govt
Sriram et al^Citation66	T2DM	Pharmacist	C, P	RCT/standard care		Glycemic control, BMI (Pos)	QOL, satisfaction (Pos)		Private
Stockl et al^Citation16	Multiple sclerosis	Pharmacist	P, M	Retrospective cohort study/standard care in non-participating cohort	Medication possession ratio, persistence (Pos)	Relapses (Pos)	QOL, employment (Neg)		Pharma/PBM
Stockl et al^Citation17	Rheumatoid arthritis	Pharmacist	P, M	Retrospective cohort study/non-participating cohort	Proportion of days covered, persistence, switching (mixed)	Physical functioning, Health assessment questionnaire (mixed)	QOL, employment productivity (mixed)	Pharmacy costs (mixed)	Pharma/PBM
Stone et al^Citation67	T2DM	Nurse	H, P	RCT/monthly care coordinator phone call		Glycemic control, lipids, blood pressure (mixed)			Govt
Stroup et al^Citation68	Osteoporosis	Pharmacist	C, P	Prospective cohort/baseline as control		Bone mineral density, T-score (mixed)			Private
Tan et al^Citation69	Multiple sclerosis	Nurse	P, M	Retrospective cohort study/nonparticipant controls	Medication possession ratio, persistence (Pos)	Hospitalizations, mixed		Hospital/pharmacy costs (mixed)	Pharma/PBM
Thompson et al^Citation70	Cardiovascular disease/heart failure	Nurse	C, H	RCT/standard care	Hill–Bone compliance to high blood pressure therapy scale (Neg)	Event-free survival, mortality, need for hospitalization (mixed)	QOL (Neg)	Hospital readmissions, length of stay (Pos)	Pharma/PBM
Triller and Hamilton^Citation71	Cardiovascular disease/heart failure	Nurse and pharmacist	C, H, P	RCT/standard care		Hospitalization, mortality (Neg)	QOL (Neg)	Hospital, health system, and home care costs (Neg)	Govt
Tschida et al^Citation72	Renal transplant/failure	Pharmacist	P	Retrospective cohort study/nonparticipant controls	Medication possession ratio, medication gaps, persistence (Pos)	Mortality, transplant related complications, need for hospitalization (Neg)		Total health care costs, hospitalization, office visits, transplant costs (mixed)	Pharma/PBM
Van Camp et al^Citation73	Renal transplant/failure	Nurse	C, P	Prospective cohort/baseline as control	MEMSCAP, self-reported adherence (Pos)	Phosphate, calcium, parathyroid hormone (mixed)	Knowledge (Pos)
Villeneuve et al^Citation74	Coronary risk reduction/dyslipidemia	Pharmacist and physician	C	Cluster RCT/standard care	Pills dispensed(Neg)	BP control, BMI, glycemic control, coronary risk factors (Neg)	Lifestyle changes (Pos)		Pharma/PBM
Wang et al^Citation75	Hypertension	Pharmacist	C, P	RCT/standard care	Modified Morisky scale (Pos)	BP control (Pos)
Wang et al^Citation76	Asthma/COPD	Nurse, Pharmacist	C	RCT/standard care	Self-assessment of medication adherence questionnaire (Neg)	Asthma symptoms (unclear)	QOL, knowledge (mixed)
Wei et al^Citation77	Asthma/COPD	Pharmacist	C, P	RCT/standard care	Self-reported missed doses, pill counts (Pos)	Hospitalization due to acute exacerbation (Pos)	QOL (Neg)	Hospitalizations (Pos)
Winter et al^Citation78	HIV	Not clear	C	Retrospective cohort study/non program participants	Appointment adherence/abandonment (mixed)	CD4^+ (Neg)			Private
Wu et al^Citation79	T2DM	Nurse	C, P	Quasi-experimental (randomized pre-posttest)/standard care		Social support, functioning, depression (Neg)	QOL, social support (Neg)
Zolfaghari et al^Citation80	T2DM	Nurse	P	Quasi-experimental (pre-posttest)/phone message vs phone call	Self-reported adherence (Neg)	Glycemic control (Neg)	Lifestyle changes (Neg)

Abbreviations: BP, blood pressure; BMI, body mass index; C, clinic; COPD, chronic obstructive pulmonary disease; CHD, coronary heart disease; E, Email; ED, emergency department cost/utilization of services; Govt, government funded; HIV, human immunodeficiency virus; H, hospital costs/utilization of hospital services; I, inpatient; M, mail; MD, medical doctor; MEMS, medication event monitoring system; MEMSCAP, MEMS cap; Neg, negative outcome; P, phone; PBM, pharmacy benefit manager funded; Ph, pharmacy; Pharma, pharmaceutical industry funded; Pos, positive outcome; QOL, quality of life; RCT, randomized controlled trial; T2DM, type 2 diabetes mellitus.

Figure 2 Overall outcome results in patient support programs assessed.

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