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Multilevel factors predict medication adherence in rheumatoid arthritis: a 6-month cohort study
  1. Alejandro Balsa1,
  2. Maria Jesus García de Yébenes2,
  3. Loreto Carmona2
  4. ADHIERA Study Group
    1. 1Rheumatology, Hospital Universitario La Paz, Madrid, Spain
    2. 2Instituto de Salud Musculoesquelética, Madrid, Spain
    1. Correspondence to Dr Loreto Carmona, Instituto de Salud Musculoesquelética, Madrid 28040, Spain; loreto.carmona{at}


    Non-adherence challenges efficacy and costs of healthcare. Knowledge of the underlying factors is essential to design effective intervention strategies.

    Objectives To estimate the prevalence of treatment adherence in rheumatoid arthritis (RA) and to evaluate its predictors.

    Methods A 6-month prospective cohort study of patients with RA selected by systematic stratified sampling (33% on first disease-modifying rheumatic drug (DMARD), 33% on second-line DMARD and 33% on biologics). The outcome measure was treatment adherence, defined by a score greater than 80% both in the Compliance Questionnaire in Rheumatology and the Reported Adherence to Medication scale, and was estimated with 95% CIs. Predictive factors included sociodemographic, psychological, clinical, drug-related, patient–doctor relationship related and logistic. Their effect on 6-month adherence was examined by multilevel logistic models adjusted for baseline covariates.

    Results 180 patients were recruited (77% women, mean age 60.8). The prevalence of adherence was 59.1% (95% CI 48.1% to 71.8%). Patients on biologics showed higher adherence and perceived a higher medication need than the others; patients on second-line DMARDs had experienced more adverse events than the others. The variables explaining adherence in the final multivariate model were the type of treatment prescribed (second-line DMARDs OR=5.22, and biologics OR=3.76), agreement on treatment (OR=4.57), having received information on treatment adaptation (OR=1.42) and the physician perception of patient trust (OR=1.58). These effects were independent of disease activity.

    Conclusion Treatment adherence in RA is far from complete. Psychological, communicational and logistic factors influence treatment adherence in RA to a greater extent than sociodemographic or clinical factors.

    • patient care team
    • outcome and process assessment
    • health care
    • health services research

    Data availability statement

    Data are available upon reasonable request.

    Statistics from

    Data availability statement

    Data are available upon reasonable request.

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    • Handling editor Josef S Smolen

    • Twitter @carmona_loreto

    • Collaborators ADHIERA Study Group (in alphabetical order of centre): Laura Garrido Courel, Javier Mendizábal, Juliana Restrepo (Complejo Hospitalario de Navarra); Dolores Fábregas (Hospital de Barbastro); Joana Atxotegi Saenz de Buruaga, Javier Duruelo Etxebarrieta, Nathali Rivas Zavaleta (Hospital de Cruces); Eugenio Chamizo Carmona, Lara Chaves, Sara Rojas (Hospital de Mérida); Francisca Sivera (Hospital General Universitario de Elda); Laura Casas Hernández, Beatriz González Álvarez (Hospital Nuestra Señora de Candelaria); Antonio Gómez Centeno, Eduard Graell (Hospital Universitari Parc Taulí:); Mercedes Alperi (Hospital Universitario Central de Asturias); Susana Holgado, Melania Martinez Morillo (Hospital Universitario Germans Trias i Pujol); Fermín Medina Varo, Alba Pérez Linaza, Isabel Serrano García (Hospital Universitario Puerta del Mar).

    • Contributors LC and AB conceived the study, which was designed by LC, guarantor, and MJGY; the ADHIERA study group reviewed and approved the protocol, recruited the patients and collected the data; MJGY and LC analysed the data. All authors contributed to drafting the manuscript and approved the final version.

    • Funding The ADHIERA study was supported by a grant from Roche España to the Spanish Foundation of Rheumatology.

    • Competing interests AB has received honoraria as speaker from Amgen, Gilead, Galapagos, Pfizer, Novartis, BMS, Nordic, Sanofi, Sandoz, Lilly, UCB and Roche. LC and MJGY have not received fees or personal grants from any laboratory, but their institute works by contract for laboratories among other institutions, such as Abbvie, Gebro Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Grünenthal and UCB.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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