Evidence from Literature: Diabetes Systematic Review
The prevalence of diabetes across the globe has risen exponentially. Therefore, numerous interventions have been developed to counter this trend. However, the adherence of the diabetic patients to these counter-measures is a key factor determining the success of these interventions. As such, Sapkota, Brien, Greenfield, and Aslani (2015) carried a carried a study titled “A systematic review of interventions addressing adherence to anti-diabetic medications in patients with type 2 diabetes- impact on adherence” with the aim of evaluating the impact of these interventions on the success of the anti-diabetic medication adherence. The central aim of this paper is to critique and assess the evidence presented by this article by assessing the databases used to search for the articles as well as the appropriateness of these articles. Moreover, the paper will evaluate the level of evidence from the article with academic justification.
Discussion of the Databases
The article presents a strong evidence from the reviewed literature that addressed the anti-diabetic medication of patients with type 2 diabetes (T2D). This is because the articles used in the article were searched from renowned medical databases, which include Embase, Medline, International Pharmaceutical Abstracts (IPA), PsychINFO, CINAHL, and PUBmed. The article increased its efficiency by using many databases to provide it with a variety of articles addressing the area of interest of the article. Searching in these databases was done using various keywords such as type 2 diabetes, medication adherence, and intervention study. The connector ‘and’ was used to increase the search results.
Besides, the study scrutinized the search results by assessing each result to the inclusion and exclusion criteria developed to separate the review articles. Therefore, the article identified 6,662 citations from which 230 were relevant after meeting the inclusion criteria. The article also used study criteria to assess the applicability of these articles where 49 articles were identified as relevant to the study. Through a hand searching, three more studies were found relevant; thus, the total reviewed studies were 52. This is clearly shown in the citation flowchart that shows the included and rejected studies with supportive reasons.
Appropriateness of the Articles Used
The included studies were from 15 different countries where the USA had the greatest percentage of 57.7%, Europe with 17.3%, and Asia having 15.4% as and the remaining from the rest of the world. This shows the appropriateness of the study articles from different nations with each having unique evidence on the research topic. The article incorporated various studies from different countries across the globe. This was an important aspect of the study since diabetes is a global problem whose prevalence is increasing with time. Moreover, the management and intervention of diabetes are influenced by both social, environmental, and cultural practices that differ globally. Therefore, by assessing various studies on a diverse population enriched the study with information on various aspects that influence the adherence of the anti-diabetic treatment practices.
Moreover, most of the reviewed studies in the article are current with thirty-eight studies were published since 2009, eight from 2000 to 2005, and the rest ranging from 2005 to 2009. This is also represented in a flowchart. Moreover, more than the half of the included studies were randomized controlled trials (RCT) where a group of patients were identified and studies for a specified duration. In addition, the design of other studies varied with some having cluster randomized trials (n=2), post- and pre-interventions, time series analysis, and others with controlled trials without randomization design.
Conversely, the included studies were both primary and secondary sources. Most of the studies (n=38) were primary sources. Moreover, with more than a half of the studies taking the RCT design, the assessed first-hand information from the conducted research. This is because most of these studies were conducted in the clinical, community, or hospital settings where the anti-diabetic medication was administered to the patients. The adherence of the patients on these medications was also assessed to reveal the impact of these medications.
A few studies were based on secondary sources of the already done studies. This includes the studies that used pre and post data instead of conducting the study. This design allowed them to use existing studies and carry a statistical analysis that revealed the outcome measures for the control groups. To gain a deeper insight of the topic, the selection criteria for the participants of the reviewed studies included the individuals of all different age groups starting from eighteen years up to 75 years. Besides, the reviewed studies comprised of all sorts of patients diagnosed with T2D by including the newly diagnosed patients to those who have been diagnosed from 3 months to ten years. This was an effective selection made by the authors for them to evaluate the anti-diabetic medication behaviors of different patients.
Level of Evidence in the Article
Polonsky and Henry (2016) claim that poor medication adherence is the major factor contributing to the increased cases of T2D. Poor medication adherence results to insufficiency glycemic control that leads to the increased mortality and morbidity as well as increased outpatient care, and management problem of T2D patients. As such, adherence to the diabetic medication was evaluated as the prime result of most of the studies. In this case, taking or not taking medication was the medication measure for most of the studies while others assessed the patients who reported or did not report missing a dose.
Moreover, the article found that diabetes requires more than one medication where their medication adherence often differs. This is true according to McGovern, Tippu, Hinton, Munro, Whyte, and de Lusignan (2016) who claim that there are new medication classes integrated into the diabetes treatment. Antoine, Pieper, Mathes, and Eikermann (2014) claim that these classes have introduced new multiple medication options that are taken depending on different factors of the medication such as cost, side effects, contraindications, and efficacy of the medication as well as the mode of administration of the medication.
The article also suggested that there exist a variety of tools for measuring medication adherence depending on the reliability and validity of the tool. Self-report was found to be the most used measurement tool since it is cost effective, easy to use, and flexible. Most of the study (n=16) recommended the use of the medication subscale in the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. Other studies proclaimed that Morisky Medication Adherence Scale (MMAS) is an effective measurement tool. Polonsky and Henry (2016) support the use of MMAS as an effective tool used to enhance the medication adherence of the T2D patients. Sapkota et al., (2015) advocate for the use of SDSCA as revealed in the studies as being reliable, brief, and applicable to clinical and research practices. However, Sapkota et al. (2015) claim that the measurement tools should be combined to enhance their effectiveness. Consequentially, this will ease the process of collecting the medication adherence data.
Most of the studies suggested similar strategies that should be used to enhance the medication adherence. These intervention strategies were reported as unsuccessful in improving the medication adherence. Therefore, it becomes difficult to predict the effective intervention to use in improving the medication adherence for the T2D patients. Nevertheless, most of the studies (65.4%) suggested that HbA1c is an effective control mechanism for T2D diabetes. Therefore, most of the management attempts to control diabetes focus on bringing the HbA1c levels to the satisfactory range. Polonsky and Henry (2016) support these claims by arguing that the treatment of diabetes calls for a reduction of HbA1c levels, as it results in the reduced weight as well as reducing side-effects; thus reducing the chances of discontinuation.
However, the article fails to discuss the factors that influence the adherence of the patients to the medication. McGovern et al., (2016) proclaim that adherence of the T2D patients to the medication is influenced by socioeconomic, patient, health system, condition, and therapy related factors. Therefore, the interventions made to improve the medication adherence for these patients should target these domains (McGovern et al., 2016).
Sapkota et al. (2015) found that most studies focused on the interventions that aimed at influencing more than one patient behavior instead of the medication adherence. Focusing on personal behavior does not directly influence their medication adherence. Therefore, Sapkota et al. (2015) claim that the level of impact of an intervention should be quantified and provide the information that can be used to improve the medication adherence as well as influencing the self-care behavior that enhances the medication adherence of the patients. Polonsky and Henry (2016) state that using a single form of intervention to improve the medication adherence of the T2D patients is not effective; rather, multifaceted interventions are more effective and should therefore be used. Sapkota et al. (2015) affirm this by criticizing the studies and suggesting that a single strategy is not sufficient in addressing the HbA1c levels and self-care behaviors of the diabetic patients. Therefore, it becomes apparent that there is a need for the integration of several intervention methods to influence the patient behavior and medication behavior of the T2D patients (Nathan et al., 2009). Besides, the interventions targeting the side effects of the medication is an effective way of enhancing the medication adherence. The most effective interventions to enhance the medication adherence include education and behavioral support. The two are core pillars interventions that address the medication adherence especially the multifaceted interventions with various strategies.
The fact that the reviewed studies did not have consistency in the intervention strategies made the article to propose only one intervention practice, which is regulating the HbA1c levels. Moreover, the article focused on criticizing these studies and proposing what they could have done for them to identify more interventions for the medication adherence. This is one weakness of this article in that, rather than providing the solution; it is presenting approaches that could have been used to get the solution. Unlike this article, Polonsky and Henry (2016) continuously claim that intervention to medication adherence should focus on reducing the burden of treating the T2D. In this case, healthcare institutions and practitioners should focus on the medication behavior instead of the medication attitudes.
In addition, enhancing the physician communication on the risks and benefits of treatment as well as considering the patient’s concerns on the treatment is a better way of improving medication adherence (Antoine et al., 2014). Moreover, engaging the patients in the decision-making process and providing self-management training are effective interventions that should be used to increase the medication adherence. These interventions should be integrated with the suggested interventions in the article that improve the patient-related outcomes; thus having an overall impact on the diabetes care (Sapkota et al., 2015; Polonsky & Henry, 2016). Therefore, effective interventions should be tailored to address all key factors influencing the medication adherence as well as glycemic control.
Conclusion
Indeed, the article has proved its worth in the nursing practice by highlighting and discussing a variety of issues concerning the type 2 diabetes. First, the article has emphasized that the prevalence of the T2D is a global problem that calls for effective intervention strategies. Besides, the article has introduced and discussed a number of a measurement tool that can be used by nurses to assess the medication adherence of the patients. The article has provided the fundamental factors that should be considered when choosing a measurement tool depending on the situation and increase their effectiveness. The effectiveness of these measurement tools is to allow nurses assess the medication adherence of the patients as well as in collecting data on the effect of the interventions made. Conversely, the article has informed and justified that poor medication adherence is a key factor increasing the dominance of this problem and; therefore, possible interventions of this disease should focus on enhancing the medication adherence of the patients. The article has discussed the major interventions that should be made to influence the self-care behavior of the patient and later impact their medication adherence. Along with this revelation, the article has recommended the use of various intervention strategies instead of relying on a single strategy to enhance the medication adherence.
References
Antoine, S., Pieper, D., Mathes, T., & Eikermann, M. (2014). Improving the adherence of type 2 diabetes mellitus patients with pharmacy care: A systematic review of randomized controlled trials. BMC Endocrine Disorders, 14(1). http://dx.doi.org/10.1186/1472-6823-14-53
McGovern, A., Tippu, Z., Hinton, W., Munro, N., Whyte, M., & de Lusignan, S. (2016). Systematic review of adherence rates by medication class in type 2 diabetes: A study protocol. BMJ Open, 6(2), e010469. http://dx.doi.org/10.1136/bmjopen-2015-010469
Nathan, D. M., Buse, J. B., Davidson, M. B., Ferrannini, E., Holman, R. R., Sherwin, R., & Zinman, B. (2009). Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 32(1), 193-203. https://doi.org/10.2337/dc08-9025
Polonsky, W. & Henry, R. (2016). Poor medication adherence in type 2 diabetes: Recognizing the scope of the problem and its key contributors. Patient Preference and Adherence, Volume 10, 1299-1307. http://dx.doi.org/10.2147/ppa.s106821
Sapkota, S., Brien, J., Greenfield, J., & Aslani, P. (2015). A systematic review of interventions addressing adherence to anti-diabetic medications in patients with Type 2 Diabetes—impact on adherence. PLOS ONE, 10(2), 1-17. http://dx.doi.org/10.1371/journal.pone.0118296
