title: Adherence to warfarin assessed by electronic pill caps, clinician assessment, and patient reports: results from the IN-RANGE study.
abstract: BACKGROUND
  Patient adherence to warfarin may influence anticoagulation control; yet, adherence among warfarin users has not been rigorously studied.
  
  
  OBJECTIVE
  Our goal was to quantify warfarin adherence over time and to compare electronic medication event monitoring systems (MEMS) cap measurements with both self-report and clinician assessment of patient adherence.
  
  
  METHODS
  We performed a prospective cohort study of warfarin users at 3 Pennsylvania-based anticoagulation clinics and assessed pill-taking behaviors using MEMS caps, patient reports, and clinician assessments.
  
  
  RESULTS
  Among 145 participants, the mean percent of days of nonadherence by MEMS was 21.8% (standard deviation+/-21.1%). Participants were about 6 times more likely to take too few pills than to take extra pills (18.8 vs. 3.3%). Adherence changed over time, initially worsening over the first 6 months of monitoring, which was followed by improvement beyond 6 months. Although clinicians were statistically better than chance at correctly labeling a participant's adherence (odds ratio = 2.05, p = 0.015), their estimates often did not correlate with MEMS-cap data; clinicians judged participants to be "adherent" at 82.8% of visits that were categorized as moderately nonadherent using MEMS-cap data (>or=20% nonadherence days). Similarly, at visits when participants were moderately nonadherent by MEMS, they self-reported perfect adherence 77.9% of the time.
  
  
  CONCLUSIONS
  These results suggest that patients may benefit from adherence counseling even when they claim to be taking their warfarin or the clinician feels they are doing so, particularly several months into their course of therapy.
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Parker
authors.forename: Zhen
authors.initials: Z
authors.lastname: Chen
authors.forename: Maureen
authors.initials: M
authors.lastname: Price
authors.forename: Robert
authors.initials: R
authors.lastname: Gross
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
authors.forename: Jason D
authors.initials: JD
authors.lastname: Christie
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Brensinger
authors.forename: Craig W
authors.initials: CW
authors.lastname: Newcomb
authors.forename: Frederick F
authors.initials: FF
authors.lastname: Samaha
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Kimmel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016903:Drug Monitoring / Q000295:instrumentation / Q000379:methods*; D004349:Drug Packaging / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D010820:Physicians; D011446:Prospective Studies; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D014859:Warfarin