title: Importance of including early nonadherence in estimations of medication adherence.
abstract: BACKGROUND
  Many medication adherence metrics are based on refill rates determined from pharmacy claims databases. However, these methods do not incorporate assessment of nonadherence to new prescriptions when those prescriptions are never dispensed (primary nonadherence), or dispensed only once (early nonpersistence). As a result, published studies may overestimate adherence, but the extent of overestimation posed by not considering patients with primary nonadherence and early nonpersistence has not been assessed.
  
  
  OBJECTIVE
  To estimate the magnitude of misestimation in adherence estimates that results from not including patients with primary nonadherence and early nonpersistence.
  
  
  METHODS
  We conducted a retrospective cohort study of 15,417 patients enrolled in an integrated health care delivery system who were newly prescribed an antihypertensive, antidiabetic, or antihyperlipidemic medication. We linked prescription orders to medication dispensings. Based on dispensing and refill rates, we stratified patients into primary nonadherent, early nonpersistent, and ongoing dispensings groups. Adherence was estimated using the proportion of days covered (PDC). Standardized observation periods were applied across all groups.
  
  
  RESULTS
  A total of 1142 (7.4%) patients were primarily nonadherent, 3356 (21.8%) demonstrated early nonpersistence, and 10,919 (70.8%) patients received ongoing dispensings, with a mean PDC of 84%. Not including primarily nonadherent and early nonpersistent patients in calculations resulted in adherence estimates overestimated by 9-18%.
  
  
  CONCLUSIONS
  When medication adherence is estimated from pharmacy claims databases, adherence estimates are substantially inflated because primarily nonadherent and early nonpersistent patients are not included in the estimations. An implication of this incorrect estimation is potential distortion of the true relationship between medication adherence and clinical outcomes.
authors.affiliation: Institute for Health Research, Kaiser Permanente Colorado, Denver, USA. Marsha.A.Raebel@kp.org
authors.forename: Marsha A
authors.initials: MA
authors.lastname: Raebel
authors.forename: Nikki M
authors.initials: NM
authors.lastname: Carroll
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Ellis
authors.forename: Emily B
authors.initials: EB
authors.lastname: Schroeder
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bayliss
mesh_terms: D000959:Antihypertensive Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D015331:Cohort Studies; D016208:Databases, Factual; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D000960:Hypolipidemic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D055118:Medication Adherence; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000959:Antihypertensive Agents; D007004:Hypoglycemic Agents; D000960:Hypolipidemic Agents