In order for a medication treatment to be considered successful, several roles and functions along the pharmacological treatment chain must function and cooperate effectively. The chain can most easily be described as five transitions; diagnosis, prescription treatment, dispensing, drug use and finally results and follow-up. Unfortunately, there are many problems and inefficiencies in the pharmacological drug chain. Unfortunately, those who study medication errors and their solutions have focused on individual parts of the pharmacological treatment system. However, for this reason, this study aims to develop a general framework for system analysis of inefficiencies along the pharmacological treatment chain. Due to the size of the problem, this project focused on medication adherence. Adherence can be defined as to what extent the patient follows the medication treatment plan. Adherence has many known problems and difficulties, among other things, it has major financial consequences. It can also be difficult to measure compliance, and there is no recognized perfect method. A system dynamic model is a theoretical image of a real system or object, which is a model used to understand the nonlinear behavior of complex systems. These models are useful when considering interventions and their effects when there are complex relationships. The project started with a literature study, and then went into data collection. Here, a search design and refinements were designed to find relevant articles. Once the articles were selected, the data was compiled from the articles and the analysis began. Here, factors and effects on adherence were identified as well as other interesting information from the articles. When the information was compiled and analyzed, the system dynamic model was created. The model was then sent via email to experts in the field to validation and revise the model. During the data collection, 23 relevant articles were found, compiled into 38 factors associated with compliance. In addition to these factors, 8 were excluded because they were too disease-specific or too ambiguous in their effect of adherence. The various articles studied many different chronic diseases, but hypertension was the most common. How adherence was measured in the articles also varied greatly, however, some form of self-report or questionnaire was most common method used. Three out of seven experts responded to the sent-out model and provided valuable comments. Although these are not sufficient to validate the model, their views showed that a validation can be designed in this way. The model would have to be sent to a larger set of experts and stakeholders, but because these experts are recognized in their fields, it gave weight to the results even though they were few reviewers. With the support of the literature and the experts’ statement, it was concluded that this model provides a good foundation and structure to continue to build upon. In addition, the model has proven to have many key relationships and cornerstones with important and relevant factors. It is also concluded that it is possible to translate the model into quantitative patterns, which is based on the fact that the factor itself can be translated quantitatively. Overall, it is also finally concluded that the model created in this project could be of great use in future projects when working towards a framework for system analysis of inefficiencies along the pharmacological treatment chain.

I takt med att andelen äldre ökar i samhället rapporteras om stigande läkemedelsanvändning. Normala åldersförändringar, ökad risk för multisjuklighet och kroniska sjukdomar i kombination med polyfarmaci och bristande följsamhet medför en ökad risk för läkemedelsrelaterad ohälsa hos äldre. Bristande följsamhet till läkemedelsbehandling är en stor och problematik hos äldre vilket kan medföra negativa konsekvenser för både patienten och samhället. Syftet med studien är att beskriva kunskapsläget avseende associerade faktorer till den äldres upplevelse av följsamhet och bristande följsamhet till läkemedelsbehandling. Studien är en integrativ litteraturstudie med sammanställning av totalt 11 vetenskapliga artiklar både kvalitativa och kvantitativa från databaserna CINHAL, PubMed, Web of Science och Nursing and Allied Health database. Efter granskning av artiklarna framträdde tre huvudteman; Kunskap och förståelse, Minne och vardagliga hinder, Stöd och strategier, utifrån dessa formades tio subteman. I resultatet framkom det att äldres upplevelse av bristande följsamhet till läkemedelsbehandling var associerade till flertal faktorer. Bakomliggande orsaker till äldres upplevelse av bristande följsamhet var således relaterade till bristande kunskap om sin läkemedelsbehandling, kognitiv svikt samt otillräckligt stöd och brist på strategier. Faktorer som hade positiv effekt på följsamhet till läkemedelsbehandling var kunskap och information om sina läkemedel, stöd från anhöriga, stöd och god relation med sin vårdgivare samt hitta rätt strategier. Studiens slutsats är att med hjälp av patientens egna strategier samt vårdgivarens stöd, information och undervisning kan äldres följsamhet till läkemedel främjas och osäker läkemedelsbehandling reduceras. / With the growing number of older people in society there is a report of increasing drug use. Normal age changes, increased risk of multiple morbidity and chronic diseases in combination with polypharmacy and lack of medication adherence entail an increased risk of drug-related illness in the elderly. Lack of medication adherence is a major problem in the elderly, which could have negative consequences for both the patient and society. The purpose of the study is therefore to describe the state of knowledge regarding factors associated with the elderly's experience of medication adherence and lack of medication adherence. The study is an integrative literature study with a compilation of a total of 11 peer reviewed articles both qualitative and quantitative from the databases CINHAL, PubMed, Web of Science and Nursing and Allied Health database. Through review of the articles, three main themes emerged; Knowledge and understanding, Memory and everyday obstacles, Support and strategies, based on these, ten sub-themes were formed. The result showed that the elderly's experience of lack of medication adherence was associated with several factors. The underlying causes of the elderly´s experience of lack of medication adherence were related to lack of knowledge about their drug treatment, cognitive impairment and insufficient support and lack of strategies. Factors that had a positive effect on medication adherence were knowledge and information about their drug treatment, support from relatives, support and a good relationship with their healthcare providers and finding the right strategies. The study concludes that with the help of the patient's own strategies and the support from the healthcare provider, information and education, the elderly's medication adherence can be promoted and unsafe medication treatment can be reduced

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Contexte: À date, il existe peu de données sur l’adhésion, la persistance et les coûts associés aux antidépresseurs selon le type d’assurance médicament (privé ou public). Objectif: Comparer selon le régime d’assurance médicament (privé ou public), l'adhésion, la persistance et les coûts des antidépresseurs. Méthodes de recherche: Une étude de cohorte appariée a été réalisée en utilisant des bases de données du Québec. Sujets: Nous avons sélectionné 194 patients assurés par un régime privé et 1923 patients assurés par le régime public de la Régie de l’assurance maladie du Québec (RAMQ) (18-64 ans) qui ont rempli au moins une ordonnance pour un antidépresseur entre décembre 2007 et septembre 2009. Mesures: L’adhésion, mesurée sur une période d’un an, a été estimée en utilisant le proportion of prescribed days covered (PPDC). Un modèle de régression linéaire a été utilisé afin d’estimer la différence moyenne en PPDC entre les patients assurés par un régime privé et ceux assurés par le régime public de la RAMQ. La persistance a été comparé entre ces deux groupes avec un modèle de régression de survie Cox, et le coût mensuel d'antidépresseurs ($ CAN) a été comparé entre ces deux groupes en utilisant un modèle de régression linéaire. Résultats: Le PPDC parmi les patients assurés par un régime privé était de 86,4% (intervalle de confiance (IC) 95%: 83,3%-89,5%) versus 81,3% (IC 95%: 80,1%-82,5%) pour les patients assurés par le régime public de la RAMQ, pour une différence moyenne ajustée de 6,7% (IC 95%: 3,0%-10,4%). La persistance après un an parmi les patients assurés par un régime privé était de 49,5% versus 18,9% pour les patients assurés par le régime public de la RAMQ (p <0,001), et le rapport de risque ajusté était de 0,48 (IC 95%: 0,30-0,76). Comparativement aux patients assurés par le régime public de la RAMQ, les patients ayant une assurance privée ont payé 14,94 $ CAD (95% CI: $12,30-$17,58) de plus par mois en moyenne pour leurs antidépresseurs. Conclusion: Les patients assurés par un régime privé avaient une meilleure adhésion, persistance, mais avaient aussi un plus haut coût pour leurs antidépresseurs que ceux assurés par le régime public de la RAMQ. Cette différence de coûts peut être due aux différentes exigences de paiement en pharmacie entre les deux régimes ainsi qu’aux limites des honoraires des pharmaciens imposés par le régime public. / Background: The influence of the type of drug insurance on adherence, persistence and cost of antidepressants is not well known. Objective: To compare adherence, persistence and cost of antidepressants in patients with private and public drug insurance. Research Design: A matched cohort study was conducted using prescription claims databases from Quebec, Canada. Subjects: 194 privately and 1923 publicly insured patients (18-64 years) who filled at least one prescription for an antidepressant between December 2007 and September 2009. Measures: Adherence over one year was estimated using the proportion of prescribed days covered (PPDC). The difference in mean PPDC between patients with private and public drug insurance was estimated with a linear regression model. Persistence was compared between the groups with a Cox regression model, and the monthly cost of antidepressants (CAD$) was compared between the two groups using linear regression. Results: The PPDC was 86.4% (95% CI: 83.3-89.5) in patients with private and 81.3% (95%CI: 80.1-82.5) in patients with public drug insurance and the adjusted mean difference was 6.7% (95% CI: 3.0-10.4). Persistence was 49.5% in patients with private and 18.9% in patients with public drug insurance at one year (p<0.001), and the adjusted hazard ratio was 0.48 (95%CI: 0.30-0.76). Patients privately insured paid 14.94$ CAD (95% CI: 12.30; 17.58) more per month on average for their antidepressants. Conclusion: Better adherence and persistence and higher costs were observed in privately insured patients. Cost difference might be due to different pharmacy payment requirements and pharmacists’ honorary restrictions under the public plan.

L’assurance médicaments est un des facteurs qui peuvent influencer l’adhésion aux médicaments. Les objectifs de ce mémoire étaient d’évaluer l’impact du type d’assurance médicaments (publique versus privée) sur l’adhésion et le coût des antihypertenseurs et d’évaluer l’impact des procédures de remboursement et de la contribution du patient sur l’adhésion aux médicaments prescrits pour traiter une maladie chronique. Afin de répondre à ces objectifs, deux cohortes rétrospectives ont été construites à partir des bases de données de la RAMQ et reMed : une cohorte appariée d’utilisateurs d’antihypertenseurs couverts par une assurance médicaments privée ou publique et une cohorte de patients couverts par une assurance médicaments privée ayant rempli au moins une ordonnance pour un médicament traitant une maladie chronique. Les résultats montrent que le niveau d’adhésion aux antihypertenseurs était similaire entre les deux types d’assurance médicaments et que le coût des antihypertenseurs était 28,9 % plus élevé au privé. De plus, il a été observé que les procédures de remboursement n’affectaient pas l’adhésion, alors que le niveau de contribution des patients l’affectait. Les patients qui déboursaient un plus grand montant à l’achat de leurs médicaments étaient moins adhérents (différence : -19,0 %, Intervalle de confiance [IC] à 95 % : -24,0 à -13,0), alors que les patients qui n’avaient rien à débourser étaient moins adhérents (différence : -9,0 %, IC à 95 % : -15,0 à -2,0), que ceux qui devaient débourser une petite somme. Les résultats présentés dans ce mémoire montrent que l’assurance médicaments influence l’adhésion par l’entremise des caractéristiques des plans d’assurance. / Drug insurance is one of many factors that can influence medication adherence. The objectives of this thesis were to evaluate the impact of the type of drug insurance (private versus public) on adherence to antihypertensive medications and the cost of medications, and to evaluate the impact of drug reimbursement procedures and out-of pocket expenses on adherence to medications prescribed for chronic diseases. To meet these objectives, two retrospective cohorts were constructed from the RAMQ and reMed databases: a matched cohort of antihypertensive users covered by private or public drug insurance and a cohort of patients covered by private drug insurance who filled at least one prescription for a medication prescribed for a chronic disease. The results have shown that the level of adherence to antihypertensive medications was similar between the two types of drug insurance and that the cost of antihypertensive medications was 28,9% higher for those privately insured. It was also observed that drug reimbursement procedures didn’t affect medication adherence, while the level of out-of-pocket expenses affected it. Patients with the highest out-of-pocket expenses were less adherent (difference: –19.0%; 95% confidence interval [CI]: –24.0 to –13.0), while patients with no out-of-pocket expenses were less adherent (difference: -9.0%; 95% CI: –15.0 to –2.0) than those with low out-of-pocket expenses. The results presented in this thesis have shown that drug insurance affects medication adherence through the characteristics of drug insurance plans.

A adesão do paciente ao tratamento é crucial para a efetividade dos programas de aids. O Programa Brasileiro recomenda monitorar a adesão e incorporar ao cuidado atividades de promoção, tais como atendimentos individuais com foco em adesão. Revisões sistemáticas apontam maior efetividade das intervenções complexas, que incluem sessões de conversas entre profissional-paciente: informativas, educativas e aconselhamentos motivacionais. Criticam: insuficiente explicitação das bases teóricometodológicas das intervenções; enfoque excessivo no nível individual com baixa incorporação do contexto sociocultural; insuficiência de informação acerca da fidelidade aos protocolos. Poucos estudos descrevem a \"intimidade\" das sessões. Planejada para o cuidado individual, uma modalidade de intervenção psicossocial de apoio à adesão teve seu protocolo implementado em ensaio clínico com pacientes adultos, com carga viral detectável, em serviço especializado do SUS, em São Paulo- Brasil. Suas bases teórico-metodológicas: Quadro da Vulnerabilidade e Direitos Humanos na dimensão psicossocial do Cuidado, filiados a uma perspectiva construcionista de psicologia social na saúde. Focada na noção de sucesso prático, a intervenção objetivou contribuir para que as pessoas construíssem formas de conviver melhor com o tratamento que lhes fossem mais convenientes. Baseada na interação profissional-paciente buscou intensificar a dialogia mediante a exploração dos sentidos intersubjetivos que as \"tomadas\" das medicações adquirem em diferentes cenas/cenários. Para avaliar qualitativamente a implementação selecionaram-se 12 casos (4 de cada uma das profissionais que conduziram a intervenção) entre os 44 pacientes do grupo experimental. A análise contemplou dois eixos interdependentes: a) fidelidade da implementação ao protocolo; b) qualidade dialógica das conversações. Apresentamse os resultados em três artigos. A variação nas modalidades e enfoques comunicacionais implementados permitiu a classificação em quatro níveis crescentes de fidelidade ao protocolo: nível 1 (3 casos), nível 2 (6), nível 3 (1), nível 4 (2). A inflexão na direção da dialogia não ocorreu plenamente. Princípios relacionais como solidariedade, não repreensão, foram bem desenvolvidos. As conversas valorizaram experiências singulares de dificuldades com o tratamento e produziram coentendimentos sobre o que acontecia cotidianamente. Entretanto, a decodificação de sentidos na compreensão \"dos problemas\" e criação de \"soluções\" priorizou o nível individual cognitivo-comportamental. Por exemplo, ao invés de dialogar sobre atrasos/perdas de doses em situações sociais relacionadas ao estigma/discriminação, o sentido \"problemas de memória\" prevaleceu na decodificação das falhas no tratamento. Foi incipiente a incorporação de dimensões socioculturais e programáticas ao entendimento das situações e construção/imaginação de estratégias para lidar com \"impasses\" que implicavam prejuízos à adesão. Mesclados à comunicação de enfoque cognitivo-comportamental ocorreram momentos dialógicos que se mostraram mais promissores à construção pelos participantes de enunciados de satisfação, bem-estar, intenções e mudanças práticas benéficas à adesão. Situações psicossociais dos pacientes influíram sobre a comunicação. Quanto mais complexas, desafiam \"o como dialogar\" sobre aspectos graves, sinérgicos e multidimensionais que prejudicam a saúde. São necessárias, mas insuficientes, estratégias que aprimorem a qualidade comunicacional e o enfoque psicossocial das intervenções em adesão nos serviços. Devem complementálas: a coordenação do Cuidado em equipe e ações clínicas e sociais, imediatas e objetivas, para mitigar situações que implicam graves vulnerabilidades, prejudiciais tanto à adesão ao tratamento da aids como à saúde integral / Patient\'s adherence to treatment is essential to the effectiveness of AIDS programs. The Brazilian Program recommends monitoring adherence and incorporating activities to care that promote adherence, such as individual care focusing adherence. Systematic reviews point towards greater effectiveness of complex interventions, which include conversation sessions - educational, informative, motivational counseling - between the health professional and the patient. They criticize: incomplete explanation of the theoretical-methodological bases of interventions; excessive focus on the individual level, with low incorporation of the sociocultural context; insufficient information on the fidelity to protocols. Few studies describe the \"intimacy\" of the conversation sessions. Planned for the individual care, a modality of psychosocial intervention supporting adherence had its protocol implemented in a clinical trial with adult patients with detectable viral load in a specialized care service of the Brazilian Unified Health System (SUS), in São Paulo. The following theoretical-methodological bases were adopted: the Framework of Vulnerability and Human Rights in the psychosocial dimension of Care, affiliated to a social psychology constructionist perspective in health. Focused on the notion of practical success, the intervention aimed at contributing so that people would build ways of coping better with the treatment which was the most convenient for them. Based on the health professional-patient interaction, it sought to intensify dialogic in exploring intersubjective meanings that the medication intake acquires in different scenes/scenarios. In order to qualitatively evaluate implementation, 12 cases (4 cases of each one of the health professionals who conducted the intervention) were selected among 44 cases of the experimental group. The analysis comprised two interdependent axes: a) implementation fidelity to protocol; and b) dialogic quality of conversations. The findings are presented in three papers. Variation in the implemented modalities and communicational approaches allowed the classification in four levels of increasing fidelity to protocol: level 1 (3 cases), level 2 (6 cases), level 3 (1 case), and level 4 (2 cases). Inflection towards dialogic has not completely occurred. Relational principles, such as solidarity and no reprimand, were well developed. The conversations valued singular experiences of difficulties with the treatment. Furthermore, they produced co-understandings on what happened in the daily routine. Nevertheless, the decoding of meanings in understanding \"problems\" and creating \"solutions\" prioritized the cognitive-behavioral individual level. For example, rather than dialoguing on delays/abolishing doses of medication intake in social situations concerning stigma/discrimination, it prevailed the sense of \"memory problems\" in decoding treatment failures. Programmatic and sociocultural dimensions were incipiently incorporated to the understanding of contexts and construction/imagination of strategies to cope with \"impasses\" which implied adherence losses. Mingled with the communication of cognitive-behavioral approach, there were more dialogic moments which showed to be more promising to the construction by the participants of utterances regarding satisfaction, well-being, intentions, and beneficial and practical changes to adherence. The psychosocial situations of patients influenced communication. The more complex, the more they challenge \"how to have a conversation\" about multidimensional, synergistic, serious issues which harm health. It is necessary, but insufficient, to have strategies which enhance the communication quality and psychosocial approach of adherence interventions in care. The coordination of Care as a team and social and clinical actions, both immediate and objective, should complement them in order to mitigate situations which imply serious vulnerabilities that impair AIDS treatment adherence as well as the overall health