title: Patterns and Predictors of Adherence to Statin Therapy Among Older Patients: Protocol for a Systematic Review.
abstract: BACKGROUND
  The benefits of statin therapy are significantly compromised by noncompliance. Although elderly patients may have particular challenges with medication adherence and persistence, previous reviews on statin adherence have not focused on this population. Additionally, comparisons of adherence and persistence specific to statin indication (primary or secondary prevention) have not been thoroughly explored.
  
  
  OBJECTIVE
  We aim to assess the extent of, and factors associated with, adherence and persistence to statin therapy among older populations (aged ≥65 years).
  
  
  METHODS
  A systematic review will be undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Searches will be performed using multiple electronic databases (Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and the National Health Service Economic Evaluation Database) to identify relevant randomized trials and observational studies that evaluated statin adherence and/or persistence as an outcome. Eligible studies will include those involving community-living or outpatient elderly individuals. The methodological quality of randomized controlled trials (RCTs) will be assessed via the Joanna Briggs Institute's critical appraisal checklist for RCTs, and the quality assessment of observational studies will be undertaken using a set of questions formulated with resort to the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. When possible, meta-analyses will be conducted using random-effect modeling and generic inverse variance analyses for adjusted-effect estimates. Heterogeneity across studies will be quantified using the I2statistic. The presence of publication bias will be assessed using funnel plots and Egger's regression tests. A leave-one-out sensitivity analysis will also be conducted to assess the impact of individual study results on pooled estimates. To explore possible sources of heterogeneity across studies, subgroup analyses will be performed based on covariates such as study design, statin indication, country of study, and length of patient follow-up.
  
  
  RESULTS
  The electronic database searches were completed in December 2016. Retrieved articles are currently being screened and the entire study is expected to be completed by June 2017.
  
  
  CONCLUSIONS
  This systematic review will provide further understanding of the patterns of, and barriers to, statin adherence and persistence among older patients. The findings will inform clinical practice and the design of appropriate interventions.
  
  
  BACKGROUND
  PROSPERO CRD42016053191.
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Richard
authors.identifier: http://orcid.org/0000-0002-6643-3269
authors.initials: R
authors.lastname: Ofori-Asenso
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Ella
authors.identifier: http://orcid.org/0000-0002-9993-4297
authors.initials: E
authors.lastname: Zomer
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Andrea
authors.identifier: http://orcid.org/0000-0003-2407-770X
authors.initials: A
authors.lastname: Curtis
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Andrew
authors.identifier: http://orcid.org/0000-0001-5291-0610
authors.initials: A
authors.lastname: Tonkin
authors.affiliation: Discipline of General Practice, University of Tasmania, Hobart, Australia.
authors.forename: Mark
authors.identifier: http://orcid.org/0000-0001-9941-7161
authors.initials: M
authors.lastname: Nelson
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Manoj
authors.identifier: http://orcid.org/0000-0002-4831-6261
authors.initials: M
authors.lastname: Gambhir
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Danny
authors.identifier: http://orcid.org/0000-0002-0131-623X
authors.initials: D
authors.lastname: Liew
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Sophia
authors.identifier: http://orcid.org/0000-0003-2672-0949
authors.initials: S
authors.lastname: Zoungas
keywords: adherence; compliance; elderly patients; geriatrics; persistence; statin therapy