Medication adherence and persistence in type 2 diabetes mellitus: perspectives of patients, physicians and pharmacists on the Spanish health care system

Figures & data

Table 1 Ad hoc self-administered survey used in the study

Importance given to:
Factors associated with adherence and persistence	Patient characteristics
	Patients motivation
	Patients knowledge about medication adherence
	Patients–clinicians shared decision making
	Patients confidence in the effectiveness of medication
	Patients knowledge about medication
	Patients knowledge about disease
	Environmental characteristics of patients
	Patients’ place of residence
	A family member or patient’s friend has the condition
	Medication administration supervision
	Medication characteristics
	Cost and co-payment
	Complexity of medication container
	Organoleptic characteristics
	Long-term medication
	Complexity of administration
	Adverse events
	Multiple medications
	Disease characteristics
	Coexistence of different diseases (comorbidities)
	Asymptomatic disease
	Absence of disease complications
	Chronic disease
	Health care professional characteristics
	Doctor
	Coordination among physicians and pharmacist
	Easy-to-follow medical instructions
	Physician’s motivation
	Physician’s attitude
	Doctor–patient relationship
	Nurse
	Accessibility to the health care center
	Coordination among physicians and nurses
	Easy-to-follow nurse instructions
	Nurse’s motivation
	Nurse’s attitude
	Nurse–patient relationship
	Pharmacist
	Coordination among nurse and pharmacist
	Easy-to-follow pharmacist instructions
	Pharmacist’s motivation
	Pharmacist’s attitude
	Pharmacist–patient relationship
Strategies to improve T2DM medication adherence and persistence	Health care professional who provided the information
	Pharmacist
	Nurse
	Physician
	Ways by which information was provided by health care professionals
	Group education
	Home visit (individualized education)
	Audiovisual content
	By email/web
	By phone
	In writing
	Oral
	Complexity of therapeutic regimen
	To reduce complexity of medication regimen
	Ways to reduce the complexity of therapeutic regimen
	Adjust medication regimen to activities of daily living
	Modify route of administration
	Reduce the number of tablets
	Reduce the frequency of administration
	Techniques to improve adherence to medication
	Mobile applications
	Medication schedule
	Reminders over telephone, mail or email
	Pill dispensers (weekly)
	Pill dispensers (daily)
	Tablet counting
	Social support
	Involvement of family and friends

Note: All questions were scored using a 5-point Likert scale.

Abbreviation: T2DM, type 2 diabetes mellitus.

Table 2 Sociodemographic and clinical characteristics of T2DM patients, physicians and pharmacists

Characteristics	T2DM patients (n=963)	Physicians (n=998)	Pharmacists (n=419)
Age, years, mean (SD)	60.4 (15.5)	52.8 (7.9)	43.9 (9.9)
Male, n (%)	481 (49.9)	687 (68.8)	119 (28.4)
Place of residence, n (%)
Rural (<5,000 inhabitants)	67 (7)	125 (12.5)	19 (4.5)
Semi-urban (5,000–19,999 inhabitants)	187 (19.4)	191 (19.1)	71 (16.9)
Urban (≥20,000 inhabitants)	709 (73.6)	682 (68.3)	329 (78.5)
Educational level, n (%)
No education	69 (7.2)	–
Primary school	275 (28.6)
High school	176 (18.3)
Job training	151 (15.7)
College studies (undergraduate)	212 (22)
College studies (graduate)	80 (8.3)
Employment status, n (%)
Worker	282 (29.3)	–
Freelance	82 (8.5)
Incapacity	18 (1.9)
Student	1 (0.1)
Unemployed	54 (5.6)
Retired	417 (43.3)
Housework	94 (9.8)
Other	15 (1.6)
Time from diagnosis, years, mean (SD)	11.3 (8.9)	–
Time duration of T2DM medication, years, mean (SD)	10.5 (8.2)	–
Oral medication type, n (%)
Oral	852 (88.5)	–
Injectable	398 (41.3)
Combined (oral and injectable)	265 (27.5)
Comorbidities, n (%)
Hypertension
Diagnosis	656 (68.1)
Pharmacological treatment	585 (89.2)
Hypercholesterolemia		–	–
Diagnosis	575 (59.7)
Pharmacological treatment	451 (78.4)
Hypertriglyceridemia
Diagnosis	359 (37.3)
Pharmacological treatment	236 (65.7)
Obesity
Diagnosis	354 (36.8)
Pharmacological treatment	57 (16.1)
Medical specialty, n (%)
Primary care	–	805 (80.9)	–
Others*	–	190 (19.1)	–

Notes:

* Endocrinology and nutrition: n=59 (6%); internal medicine: n=59 (6%); cardiology: n=47 (4.7%); others: n=25 (2.5%).

Abbreviations: T2DM, type 2 diabetes mellitus; SD, standard deviation.

Table 3 Importance given to patients’ characteristics

Frequency of importance given to factors associated with adherence (%)
Group	Patient characteristics	Not important	Neither important nor unimportant	Important
Patients		2.8	9.7	87.5
Physicians	Patient motivation	0.6	4.3	95.1
Pharmacists		8.2	15.6	76.3
Patients		3.0	8.9	88.1
Physicians	Patients knowledge about medication adherence	1.6	6.0	92.4
Pharmacists		11.9	13.6	74.5
Patients		2.6	11.9	85.5
Physicians	Patients–clinicians shared decision making	3.3	12.2	84.5
Pharmacists		27.1	25.6	47.3
Patients		1.1	7.3	91.6
Physicians	Patients confidence in the effectiveness of medication	1.1	9.1	89.8
Pharmacists		4.8	16.2	79.0
Patients		1.5	7.2	91.4
Physicians	Patients knowledge about medication	1.9	9.1	89.0
Pharmacists		8.6	18.7	72.7
Patients		1.8	6.0	92.2
Physicians	Patients knowledge about disease	1.1	3.3	95.6
Pharmacists		6.4	15.8	77.8
	Environmental characteristics of patients
Patients		7.6	20.6	71.8
Physicians	Patients’ place of residence	3.3	18.0	78.7
Pharmacists		12.6	30.1	57.3
Patients		11.2	33.4	55.4
Physicians	A family member or patient’s friend has the condition	4.4	23.2	72.3
Pharmacists		14.4	32.5	53.1
Patients		8.2	18.4	73.4
Physicians	Administration supervision	3.6	15.2	81.2
Pharmacists		5.5	21.7	72.8

Notes: Patients: n=963; physicians: n=998; pharmacists: n=419. P<0.001 in all comparisons.

Table 4 Importance given to medication and disease characteristics

Frequency of importance given to factors associated with adherence (%)
Group	Medication characteristics	Not important	Neither important nor unimportant	Important
Patients		8.0	11.2	80.8
Physicians	Cost and co-payment	4.5	14.7	80.8
Pharmacists		26.4	25.0	48.6
Patients		18.5	24.3	57.2
Physicians	Complexity of medication container	6.6	20.6	72.7
Pharmacists		18.1	26.5	55.4
Patients		14.9	23.4	61.7
Physicians	Organoleptic characteristics	8.5	34.7	56.8
Pharmacists		22.1	34.6	43.3
Patients		4.9	15.0	80.1
Physicians	Long-term medication	2.3	12.5	85.2
Pharmacists		9.1	23.0	67.9
Patients		5.4	13.0	81.6
Physicians	Complexity of administration	0.2	2.8	97.0
Pharmacists		7.2	16.3	76.6
Patients		3.5	10.4	86.1
Physicians	Adverse events	0.2	2.3	97.5
Pharmacists		9.6	18.2	72.2
Patients		5.5	18.2	76.3
Physicians	Multiple medications	0.5	3.0	96.5
Pharmacists		7.2	18	74.8
	Disease characteristics
Patients		2.4	15.2	82.5
Physicians	Coexistence of different diseases (comorbidities)	0.9	8.3	90.8
Pharmacists		6.6	17.8	75.7
Patients		3.0	16.4	80.6
Physicians	Absence of disease complications	2.8	17.2	80.0
Pharmacists		13.4	26.5	60.1
Patients		2.8	16.5	80.7
Physicians	Asymptomatic disease	3.1	9.9	87.0
Pharmacists		15.3	21.1	63.6
Patients		2.2	11.0	86.8
Physicians	Chronic disease	0.8	4.7	94.5
Pharmacists		5.8	15.9	78.3

Notes: Patients: n=963; physicians: n=998; pharmacists: n=419. P<0.001 in all comparisons.

Table 5 Importance given to health care professionals characteristics

Frequency of importance given to factors associated with adherence (%)
Group	Physician characteristics	Not important	Neither important nor unimportant	Important	Nurse characteristics	Not important	Neither important nor unimportant	Important	Pharmacist characteristics	Not important	Neither important nor unimportant	Important
Patients	Coordination among physicians and pharmacists	–	–	–	Coordination among physicians and nurses	2.5	9.8	87.7	Coordination among nurses and pharmacists	8.1	21.1	70.8
Physicians		9.2	35.5	55.3		1.2	4.5	94.3		14.8	38.2	47.0
Pharmacists		11.2	13.7	75.1		–	–	–		–	–	–
Patients	Easy-to-follow medical instructions	2.5	8.9	88.6	Easy-to-follow nurse instructions	3.7	11.0	85.2	Easy-to-follow pharmacist instructions	5.7	13.3	81.0
Physicians		0.8	8.1	91.1		1.4	10.5	88.1		7.9	22.5	69.5
Pharmacists		–	–	–		–	–	–		3.6	9.0	87.4
Patients	Physician’s motivation	0.5	7.2	92.3	Nurse’s motivation	3.9	13.2	82.9	Pharmacist’s motivation	7.7	21.9	70.4
Physicians		0.4	3.2	96.4		1.0	6.9	92.1		10.0	32.7	57.3
Pharmacists		–	–	–		–	–	–		1.9	6.5	91.5
Patients	Physician’s attitude	1.0	6.8	92.2	Nurse’s attitude	3.0	14.5	82.5	Pharmacist’s attitude	6.7	19.1	74.1
Physicians		0.0	1.6	98.4		0.9	5.2	93.9		8.3	29.4	62.3
Pharmacists		–	–	–		–	–	–		0.7	5.1	94.2
Patients	Doctor–patient relationship	1.5	6.3	92.2	Nurse–patient relationship	3.7	15.6	80.6	Pharmacist–patient relationship	7.8	19.0	73.2
Physicians		0.3	1.6	98.1		1.1	5.9	93.0		10.5	36.6	52.9
Pharmacists		–	–	–		–	–	–		2.7	12.1	85.3
Patients	Accessibility to the health care center	2.7	9.3	88.0
Physicians		2.9	19.0	78.1
Pharmacists		–	–	–

Notes: Patients: n=963; physicians: n=998; pharmacists: n=419. P<0.001 in all comparisons, with the exception of “Easy-to-follow medical instructions” (P=0.009) and “Easy-to-follow nurse instructions” (P=0.004).

Table 6 Importance given to the information provided by health care professionals

Frequency of importance given to strategies to improve T2DM medication adherence and persistence (%)
Group	Information provided by health care professionals	Not important	Neither important nor unimportant	Important
Patients		5.7	20.4	73.9
Physicians	Pharmacists	8.9	31.5	59.6
Pharmacists		1.0	4.4	94.7
Patients		3.1	14.5	82.3
Physicians	Nurses	0.5	4.0	95.5
Pharmacists		–	–	–
Patients		0.9	5.1	94.0
Physicians	Physicians	0.1	0.7	99.2
Pharmacists		–	–	–

Notes: Patients: n=963; physicians: n=998; pharmacists: n=419. P<0.001 in all comparisons.

Abbreviation: T2DM, type 2 diabetes mellitus.

Figure 1 Importance given to strategies to reduce the complexity of therapeutic regimen.

Table 7 Importance given to techniques to improve adherence to medication and social support

Frequency of importance given to strategies to improve T2DM medication adherence and persistence (%)
Group	Techniques to improve adherence to medication	Not important	Neither important nor unimportant	Important
Patients		27.9	26.8	45.3
Physicians	Mobile applications	13.9	32.7	53.4
Pharmacists		30.7	35.2	34.2
Patients		10.9	22.2	66.9
Physicians	Medication schedule	6.9	25.2	67.9
Pharmacists		14.6	32.0	53.3
Patients		24.0	28.9	47.1
Physicians	Reminders over telephone, mail or email	18.2	39.7	42.1
Pharmacists		28.5	28.8	42.7
Patients		10.0	24.3	65.7
Physicians	Pill dispensers (weekly)	4.2	18.2	77.6
Pharmacists		4.9	13.3	81.7
Patients		9.0	22.8	68.1
Physicians	Pill dispensers (daily)	2.5	14.2	83.3
Pharmacists		4.0	15.6	80.4
Patients		15.2	28.8	56.1
Physicians	Tablet counting	14.9	32.9	52.2
Pharmacists		13.8	28.6	57.6
	Social support
Patients		7.8	21.6	70.6
Physicians	Involvement of family and friends	0.4	3.5	96.1
Pharmacists		1.5	8.2	90.3

Notes: Patients: n=963; physicians: n=998; pharmacists: n=419. P<0.001 in all comparisons with the exception of “Tablet counting” (P=0.218).

Abbreviation: T2DM, type 2 diabetes mellitus.