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Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider
  1. Valentin Ritschl1,
  2. Tanja A Stamm1,
  3. Daniel Aletaha2,
  4. Johannes W J Bijlsma3,
  5. Peter Böhm4,
  6. Razvan Dragoi5,
  7. Emma Dures6,7,
  8. Fernando Estévez-López8,
  9. Laure Gossec9,10,
  10. Annamaria Iagnocco11,
  11. José B Negrón12,
  12. Michal Nudel13,
  13. Andréa Marques14,
  14. Ellen Moholt15,
  15. Conni Skrubbeltrang16,
  16. Bart Van den Bemt17,18,
  17. Kirsten Viktil19,20,
  18. Marieke Voshaar21,
  19. Loreto Carmona22 and
  20. Annette de Thurah23,24
  1. 1 Section for Outcomes Research, Medical University of Vienna, Wien, Austria
  2. 2 Division of Rheumatology, Medical University of Vienna, Wien, Austria
  3. 3 Rheumatology, UMC Utrecht, Utrecht, Netherlands
  4. 4 Deutsche Rheuma-Liga Bundesverband e.V., Bonn, Germany
  5. 5 University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
  6. 6 University of the West of England Bristol, Bristol, UK
  7. 7 Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
  8. 8 Erasmus MC University Medical Centre, Rotterdam, Netherlands
  9. 9 Institut Pierre Louis d’Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
  10. 10 APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
  11. 11 Università Degli Studi di Torino, Torino, Italy
  12. 12 Instituto de Investigación Social y Sanitaria, Puerto Rico
  13. 13 Mifrakim Tz’eirim, Haifa, Israel
  14. 14 Centro Hospitalar e Universitário de Coimbra, Health Sciences Research Unit: Nursing, UICISA-E, Coimbra, Portugal
  15. 15 Diakonhjemmet Hospital, Division of Rheumatology and Research, Oslo, Norway
  16. 16 Aalborg Universitetshospital, Aalborg, Denmark
  17. 17 Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands
  18. 18 Radboud University Medical Centre, Nijmegen, Netherlands
  19. 19 University of Oslo, Oslo, Norway
  20. 20 Diakonhjemmet Hospital Pharmacy, Oslo, Norway
  21. 21 University of Twente, Enschede, Netherlands
  22. 22 Instituto de Salud Musculoesquelética (Inmusc), Madrid, Spain
  23. 23 Rheumatology, Aarhus University Hospital, Århus N, Denmark
  24. 24 Clinical Medicine, Aarhus University, Aarhus, Denmark
  1. Correspondence to Tanja A Stamm; tanja.stamm{at}


Objective To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

Methods An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

Results After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

Conclusions The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

  • Epidemiology
  • Patient Care Team
  • Health services research

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  • Twitter Fernando Estévez-López @FerEstevezLope1 and José B Negrón @negronjb.

  • Contributors VR wrote the manuscript draft, directly supervised by TS, AdT and LC. CS performed the search strategies, JBN, AdT and LC selected the studies, VR assessed risk of bias of all SR, VR, LC and JBN extracted the data, and synthesised the results. LC and AdT reviewed processes and excluded articles, and tailored the synthesis reports. All other authors suggested and agreed upon the research questions, read the report prior to the manuscript, discussed results and made contributions to the text. All authors approved the final version of the manuscript.

  • Funding This Project was funded by EULAR (project number HPR037).

  • Competing interests VR, PB, FEL, JBN, AI, MN, AM, EM, KV and AdT did not have competing interest to declare. TS has received grant/research support from AbbVie and Roche, has been consultant for AbbVie, Sanofi Genzyme, and has been paid speaker for AbbVie, Roche and Sanofi. DA has received grant/research support from AbbVie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi Genzyme and UCB, has been consultant for AbbVie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi Genzyme and UCB, and has been paid speaker for AbbVie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi Genzyme and UCB. JB has received grant/research support from Roche, and has been paid speaker for Roche and Lilly. RD has been paid speaker for MSD, AbbVie, Novartis, Roche, Pfizer, Mylan and Sandoz. ED has received grant/research support from Independent Learning, Pfizer, combined funding for a research fellow from Celgene, Abbvie and Novartis, and has been paid instructor for Novartis to deliver training to nurses. LG has received grant/research support from Fresenius, Lilly, Pfizer and Sandoz, and has been consultant for AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Sandoz, Sanofi-Aventis and UCB Pharma. BvdB has been paid speaker for MSD, Abbvie and Biogen. MV has been paid speaker for Pfizer. LC has received grant/research support through her institute from Novartis, Pfizer, MSD, Roche, Sanofi Aventis, AbbVie and Gebro Pharma.

  • Patient consent for publication Not required.

  • Ethics approval No ethical approval is required for systematic reviews.

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

  • Data availability statement Data including Endnote files are available upon reasonable request.

  • 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.