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Introduction: The impact of impaired kidney function on healthcare use among medical hospitalisations with multimorbidity and frailty is incompletely understood. In this study, we assessed the prevalence of acute kidney injury (AKI) and chronic kidney disease (CKD) among multimorbid medical hospitalisations in Switzerland and explored the associations of kidney disease with in-hospital outcomes across different frailty strata., Methods: This observational study analysed nationwide hospitalisation records from 1 January 2012 to 31 December 2020. We included adults (age ≥18 years) with underlying multimorbidity hospitalised in a medical ward. The study population consisted of hospitalisations with AKI, CKD or no kidney disease (reference group), and was stratified by three frailty levels (non-frail, pre-frail, frail). Main outcomes were in-hospital mortality, intensive care unit (ICU) treatment, length of stay (LOS) and all-cause 30-day readmission. We estimated multivariable adjusted odds ratios (OR) and changes in percentage of log-transformed continuous outcomes with 95% confidence intervals (CI)., Results: Among 2,651,501 medical hospitalisations with multimorbidity, 198,870 had a diagnosis of AKI (7.5%), 452,990 a diagnosis of CKD (17.1%) and 1,999,641 (75.4%) no kidney disease. For the reference group, the risk of in-hospital mortality was 4.4%, for the AKI group 14.4% (adjusted odds ratio [aOR] 2.56 [95% CI 2.52-2.61]) and for the CKD group 5.9% (aOR 0.98 [95% CI 0.96-0.99]), while prevalence of ICU treatment was, respectively, 10.5%, 21.8% (aOR 2.39 [95% CI 2.36-2.43]) and 9.3% (aOR 1.01 [95% CI 1.00-1.02]). Median LOS was 5 days (interquartile range [IQR] 2.0-9.0) in hospitalisations without kidney disease, 9 days (IQR 5.0-15.0) (adjusted change [%] 67.13% [95% CI 66.18-68.08%]) in those with AKI and 7 days (IQR 4.0-12.0) (adjusted change [%] 18.94% [95% CI 18.52-19.36%]) in those with CKD. The prevalence of 30-day readmission was, respectively, 13.3%, 13.7% (aOR 1.21 [95% CI 1.19-1.23]) and 14.8% (aOR 1.26 [95% CI 1.25-1.28]). In general, the frequency of adverse outcomes increased with the severity of frailty., Conclusion: In medical hospitalisations with multimorbidity, the presence of AKI or CKD was associated with substantial additional hospitalisations and healthcare utilisation across all frailty strata. This information is of major importance for cost estimates and should stimulate discussion on reimbursement.

Aim of the Study: The first and second waves of the COVID-19 pandemic led to a tremendous burden of disease and influenced several policy directives, prevention and treatment strategies as well as lifestyle and social behaviours. We aimed to describe trends of hospitalisations with COVID-19 and hospital-associated outcomes in these patients during the first two pandemic waves in Switzerland., Methods: In this nationwide retrospective cohort study, we used in-hospital claims data of patients hospitalised with COVID-19 in Switzerland between January 1st and December 31st, 2020. First, stratified by wave (first wave: January to May, second wave: June to December), we estimated incidence rates (IR) and rate differences (RD) per 10,000 person-years of COVID-19-related hospitalisations across different age groups (0-9, 10-19, 20-49, 50-69, and ≥70 years). IR was calculated by counting the number of COVID-19 hospitalisations for each patient age stratum paired with the number of persons living in Switzerland during the specific wave period. Second, adjusted odds ratios (aOR) of outcomes among COVID-19 hospitalisations were calculated to assess the association between COVID-19 wave and outcomes, adjusted for potential confounders., Results: Of 36,517 hospitalisations with COVID-19, 8,862 (24.3%) were identified during the first and 27,655 (75.7%) during the second wave. IR for hospitalisations with COVID-19 was highest during the second wave and among patients above 50 years (50-69 years: first wave: 31.49 per 10,000 person-years; second wave: 62.81 per 10,000 person-years; RD 31.32 [95% confidence interval [CI]: 29.56 to 33.08] per 10,000 person-years; IRR 1.99 [95% CI: 1.91 to 2.08]; ≥70 years: first wave: 88.59 per 10,000 person-years; second wave: 228.41 per 10,000 person-years; RD 139.83 [95% CI: 135.42 to 144.23] per 10,000 person-years; IRR 2.58 [95% CI: 2.49 to 2.67]). While there was no difference in hospital readmission, when compared with the first wave, patients hospitalised during the second wave had a lower probability of death (aOR 0.88 [95% CI: 0.81 to 0.95], ARDS (aOR 0.56 [95% CI: 0.51 to 0.61]), ICU admission (aOR 0.66 [95% CI: 0.61 to 0.70]), and need for ECMO (aOR 0.60 [95% CI: 0.38 to 0.92]). LOS was -16.1 % (95% CI: -17.8 to -14.2) shorter during the second wave., Conclusion: In this nationwide cohort study, rates of hospitalisations with COVID-19 were highest among adults older than 50 years and during the second wave. Except for hospital readmission, the likelihood of adverse outcomes was lower during the second pandemic wave, which may be explained by advances in the understanding of the disease and improved treatment options.

Background: Hospitals are using nursing-sensitive outcomes (NSOs) based on administrative data to measure and benchmark quality of nursing care in acute care wards. In order to facilitate comparisons between different hospitals and wards with heterogeneous patient populations, proper adjustment procedures are required. In this article, we first identify predictors for common NSOs in acute medical care of adult patients based on administrative data. We then develop and cross-validate an NSO-oriented prediction model., Methods: We used administrative data from seven hospitals in Switzerland to derive prediction models for each of the following NSO: hospital-acquired pressure ulcer (≥ stage II), hospital-acquired urinary tract infection, non-ventilator hospital-acquired pneumonia and in-hospital mortality. We used a split dataset approach by performing a random 80:20 split of the data into a training set and a test set. We assessed discrimination of the models by area under the receiver operating characteristic curves. Finally, we used the validated models to establish a benchmark between the participating hospitals., Results: We considered 36,149 hospitalisations, of which 51.9% were male patients with a median age of 73 years (with an interquartile range of 59-82). Age and length of hospital stay were independently associated with all four NSOs. The derivation and validation models showed a good discrimination in the training (AUC range: 0.75-0.84) and in the test dataset (AUC range: 0.77-0.81), respectively. Variation among different hospitals was relevant considering the risk for hospital-acquired pressure ulcer (≥ stage II) (adjusted Odds ratio [aOR] range: 0.51 [95% CI: 0.38-0.69] - 1.65 [95% CI: 1.33-2.04]), the risk for hospital-acquired urinary tract infection (aOR range: 0.46 [95% CI: 0.36-0.58] - 1.45 [95% CI: 1.31-1.62]), the risk for non-ventilator hospital-acquired pneumonia (aOR range: 0.28 [95% CI: 0.09-0.89] - 2.87 [95% CI: 2.27-3.64]), and the risk for in-hospital mortality (aOR range: 0.45 [95% CI: 0.36-0.56] - 1.39 [95% CI: 1.23-1.60])., Conclusion: The application of risk adjustment when comparing nursing care quality is crucial and enables a more objective assessment across hospitals or wards with heterogeneous patient populations. This approach has potential to establish a set of benchmarks that could allow comparison of outcomes and quality of nursing care between different hospitals and wards.

Background: We recently compared the effects of bedside and outside the room ward rounds on patients' knowledge about their medical care. Here, we report preferences of medical and nursing staff members regarding outside versus bedside ward rounds., Methods: Within this ancillary project of a large multicentre randomised controlled trial, we prospectively conducted a survey of medical and nursing staff members participating in the weekly consultant ward rounds in the internal medicine division of three Swiss teaching hospitals between July 2017 and October 2019. Participants were asked about their preferences on outside versus bedside ward rounds. The primary endpoint was satisfaction of healthcare workers with the ward round measured with a visual analogue scale from 0 to 100., Results: Between July 2017 and October 2019, 919 patients were included in the trial, and we received 891 survey responses (nurses 15.6%, residents 26.8%, attending physicians 29.6%, consultants 7.8% and chief physicians 20.2%. In the overall analysis, mean (± standard deviation) satisfaction of healthcare workers was higher with outside the room than bedside ward rounds (78.03 ± 16.96 versus 68.25 ± 21.10 respectively; age-, gender- and centre-adjusted difference of -10.46, 95% confidence interval [CI] -12.73 to -8.19; p <0.001). Healthcare workers reported better time management, more discussion of sensitive topics and less discomfort when case presentations were conducted outside the room. A stratified subgroup analysis considering the profession, however, showed strong differences, with nurses being more satisfied with bedside rounds (69.20 ± 20.32 versus 65.32 ± 20.92, respectively; adjusted difference 4.35, 95% CI -1.79 to 10.51; p <0.001), whereas attending physicians showed higher satisfaction with outside the room rounds (82.63 ± 13.87 versus 66.59 ± 21.82; adjusted difference -16.51, 95% CI -20.29 to -12.72; p = 0.002)., Conclusions: While bedside ward rounds are considered more patient centred and are preferred by the nursing staff, physicians prefer outside the room presentation of patients during ward rounds because of the perceived better discussion of sensitive topics, better time management and less staff discomfort. Continuous training including medical communication techniques may help to increase satisfaction of physicians with bedside ward rounds. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03210987.

AIMS OF THE STUDY: There is increasing interest in better understanding of long COVID, a condition characterised by long-term sequelae — appearing or persisting after the typical convalescence period — of coronavirus disease 2019 (COVID-19). Herein, we describe long-term outcomes regarding residual symptoms and psychological distress in hospitalised patients 1 year after COVID-19. METHODS: This prospective cohort study included consecutive adult patients hospitalised for confirmed COVID-19 in two Swiss tertiary-care hospitals between March and June 2020. The primary endpoint was evidence of long COVID 1 year after discharge, defined as ≥1 persisting or new symptom related to COVID-19, from a predefined list of symptoms. Secondary endpoints included psychological distress and symptoms of post-traumatic stress disorder (PTSD). RESULTS: Among 90 patients included in the study, 63 (70%) had symptoms of long COVID 1 year after hospitalisation, particularly fatigue (46%), concentration difficulties (31%), shortness of breath (21%) and post-exertion malaise (20%). Three predictors, namely duration of hospitalisation (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.00–1.22; p = 0.041), severity of illness (OR 1.19, 95% CI 1.04–1.37; p = 0.013), and self-perceived overall health status 30 days after hospitalisation (OR 0.97, 95% CI 0.94–1.00; p = 0.027) were associated with long COVID. Regarding secondary endpoints, 16 (18%) experienced psychological distress and 3 (3.3%) patients had symptoms of PTSD. CONCLUSION: A high proportion of COVID-19 patients report symptoms of long COVID 1 year after hospitalisation, which negatively affects their quality of life. The most important risk factors were severe initial presentation of COVID-19 with long hospital stays.

Aim of the Study: To compare admission characteristics, predictors and outcomes of patients with confirmed coronavirus disease 2019 (COVID-19) hospitalised in a tertiary care hospital in Switzerland during the first and second waves of the pandemic., Methods: This retrospective observational analysis included adult patients with&nbsp; severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection confirmed by a real-time reverse transcriptase polymerase chain reaction (RT-PCR) or rapid antigen test and hospitalised at the Cantonal Hospital Aarau from 26 February to 30 April 2020 (first wave) and from 1 October to 31 December 2020 (second wave). The primary endpoint was all-cause in-hospital mortality. The secondary endpoints were transfer to the intensive care unit (ICU) and length of hospital stay (LOS)., Results: Overall, 486 patients (mean age 65.9 years &plusmn; 14.7 SD, 65% male) were included. Ninety-two patients (19%) died during the hospital stay and 92 patients (19%) were transferred to the ICU. Admission characteristics, including comorbidities and frailty, were similar for patients of the first (n = 100) and second wave (n = 386). However, during the second wave the median time from symptom onset to presentation to the emergency department (ED) was shorter (7 days, interquartile range [IQR] 4&ndash;9 vs 8 days, IQR 4&ndash;11; p = 0.02). In the second wave, most patients received high-dose glucocorticoid treatment (0% vs 76%, p &lt;0.01). In-hospital mortality was similar among COVID-19 patients in the first (19/100, 19%) and second wave (73/386, 19%); this finding persisted after full adjustment in multiple regression models (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI] 0.49&ndash;2.80; p = 0.71). Risk for ICU admission was also similar (24% vs 18%; aOR 0.98, 95% CI 0.46&ndash;2.06; p = 0.95). More patients were transferred to rehabilitation facilities in the second wave (18% vs 31%; aOR 2.06, 95% CI 1.04&ndash;4.07; p = 0.04) and LOS was 2.5 days shorter (9.0 vs 6.5 days; adjusted difference &minus;2.53 days, 95%-CI &minus;4.51 to &minus;0.54; p = 0.01). Main predictors for in-hospital death were patient age (aOR 1.07, 95% CI 1.02&ndash;1.11; p &lt;0.01), male sex (aOR 2.41, 95% CI 1.05&ndash;5.55; p = 0.04) and the age-adjusted Charlson comorbidity index (aOR 1.27, 95% CI 1.09&ndash;1.48 p &lt;0.01)., Conclusion: Despite differing treatment regimens, mortality and ICU admission remained largely unchanged for COVID-19 patients admitted during the second wave of the pandemic in our tertiary care hospital. However, discharge processes were optimised with patients leaving the hospital earlier and going to rehabilitation facilities more often. &nbsp.

Importance: Multimorbidity poses a worldwide health- and socio-economic challenge, exacerbated by changing demographics. The association of multimorbidity with healthcare outcomes in hospitalised medical inpatients remains incompletely understood., Objective: To examine the prevalence and burden of in-hospital multimorbidity over a 6-year time period and its association with in-hospital mortality, intensive care unit admission, length of hospital stay and readmission rates., Design: This cross-sectional study analysed Swiss hospital discharge records from 1 January 2012 to 31 December 2017., Setting: The study used population-based, administrative data from the Swiss Federal Statistical Office to investigate all adult medical cases in Switzerland., Participants: 2,220,000 population-based medical discharge records from 1,463,781 anonymised patients were included in the analysis. Multimorbidity was defined according to the World Health Organization as the presence of at least two chronic conditions. We applied the &ldquo;Chronic Condition Indicator for the International Classification of Diseases (ICD-10-CM)&rdquo;, which divides all ICD-10 codes into chronic and acute conditions, to define the number of chronic conditions., Main Measures: Time- and age-stratified prevalence of multimorbidity and its association with in-hospital mortality, ICU admission rate, length of stay, 30-day and 1-year all-cause readmission rates., Results: Of the 2,220,000 cases, 51.3% were male with a mean age of 68.0 years (standard deviation 17.4). A total of 1,769,530 (79.7%) were multimorbid with a median of 4 (interquartile range 2&ndash;6) chronic conditions. The prevalence of multimorbidity increased by about 1.0% per year over the 6-year study period from 76.1% (2012) to 82.2% (2017). Multimorbidity was associated with higher odds of in-hospital mortality (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.28 to 1.34), ICU admission rate (OR 3.29, 95% CI 3.23 to 3.34), length of stay (+2.7 days, 95% CI 2.6 to 2.7), 30-day- (OR 1.92, 95% CI 1.89 to 1.94) and 1-year all-cause readmission rates (OR 1.70, 95% CI 1.68 to 1.71). The associations with in-hospital mortality and readmission were strongest in younger patients., Conclusions: Multimorbidity is highly prevalent in medical inpatients and has a relevant association with poor healthcare outcomes. Further investigation is needed to specify risk factors as well as to optimise the management of multimorbid patients to improve outcomes.

Aims of the Study: To describe admission characteristics, risk factors and outcomes of patients with coronavirus disease 2019 (COVID-19) hospitalised in a tertiary care hospital in Switzerland during the early phase of the pandemic., Methods: This retrospective cohort study included adult patients with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction (PCR) testing and hospitalised at the cantonal hospital Aarau (Switzerland) between 26 February 2020 and 30 April 2020. Our primary endpoint was severe COVID-19 progression defined as a composite of transfer to the intensive care unit (ICU) and in-hospital mortality., Results: A total of 99 patients (median age 67 years [interquartile range 56&ndash;76], 37% females) were included and 35% developed severe COVID-19 progression (24% needed ICU treatment, 19% died). Patients had a high burden of comorbidities with a median Charlson comorbidity index of 3 points and a high prevalence of hypertension (57%), chronic kidney disease (28%) and obesity (27%). Baseline characteristics with the highest prognostic value for the primary endpoint by means of area under the receiver operating characteristic curve were male gender (0.63) and initial laboratory values including shock markers (lactate on ambient air 0.67; lactate with O2 supply 0.70), markers of inflammation (C-reactive protein 0.72, procalcitonin 0.80) and markers of compromised oxygenation (pO2 0.75 on ambient air), whereas age and comorbidities provided little prognostic information., Conclusion: This analysis provides insights into the first consecutively hospitalised patients with confirmed COVID-19 at a Swiss tertiary care hospital during the initial period of the pandemic. Markers of disease progression such as inflammatory markers, markers for shock and impaired respiratory function provided the most prognostic information regarding severe COVID-19 progression in our sample.

Introduction: The physical appearance of a physician may influence patients&rsquo; perceptions of that physician&rsquo;s quality of care. There is a lack of studies investigating whether physician appearance is indeed associated with patient satisfaction and mortality., Methods: This observational study included adult medical inpatients treated at a Swiss tertiary care hospital between 2013 and 2016. We investigated associations of gender and physician appearance (hair colour, wearing of glasses) with in-hospital mortality and perceived quality of care, assessed by a telephone interview 30 days after admission. Regression models were adjusted for patient age, patient gender, and the Charlson Comorbidity Index., Results: We included 18,259 inpatients treated by 494 different physicians during their hospital stay. We had full information regarding patient-perceived quality of care for 9917 patients. Overall, 860 patients (4.7%) died in the hospital and 1479 (14.9%) reported low satisfaction with their care. After multivariable adjustment, there was no difference in mortality or patient-perceived quality of care whether physicians did or did not wear glasses and whether they were male or female. The hair colour of residents was also not associated with outcomes. However, patients treated by grey-haired attending physicians, compared to those with dark or blond hair, had significantly lower in-hospital mortality (adjusted odds ratio 0.70, 95% confidence interval 0.53&ndash;0.92, p = 0.011)., Conclusions: This analysis suggests that physician gender or appearance has little influence on the quality of care provided to hospitalised medical patients. Whether the small but significant mortality benefit observed for grey-haired attending physicians is possibly confounded by age and physician experience clearly needs further investigation. Nevertheless, our analysis provides empirical evidence that having at least some grey-haired attending physicians in the medical physician team seems to be beneficial for patients, even if patients do not recognise the clear superiority of their care.

Aims of the Study: Acromegaly due to a growth hormone-secreting pituitary adenoma is a rare disease with high morbidity if not treated adequately. Using data of the Swiss Pituitary Registry (SwissPit), we studied initial presentation and predictors for adverse clinical outcomes in acromegalic patients treated during the last 10 years in our institution., Methods: We evaluated 21 patients from the SwissPit registry with a final diagnosis of acromegaly confirmed by laboratory results (insulin-like growth factor-1 [IGF-1] and growth hormone suppression tests) and magnetic resonance imaging. Our main endpoint was clinical cure defined as complete remission, remission with need for medical treatment and uncontrolled disease defined by non-normalisation of IGF-1 and growth hormone levels., Results: The most prevalent clinical symptoms at presentation were acral enlargement (81%), headache (29%), macroglossia (29%) and visual field defects (19%). Arterial hypertension was present in 67%, carpal tunnel syndrome in 38% and diabetes in 24%. A total of 19 of the 21 patients underwent initial surgical treatment. Eight patients had complete remission and 13 patients had active disease, with 7 having remission with need for medical treatment and 6 uncontrolled disease. Larger initial adenoma size (odds ratio [OR] 12.0, 95% confidence interval [CI] 1.02-141.3; p = 0.048) and high post-operative IGF-1 levels (OR 4.5, 95% CI 1.1-19.2; p = 0.040) were predictors for non-full remission and uncontrolled disease, respectively., Conclusion: This small, observational registry study showed a relevant success rate of initial pituitary surgery in patients with confirmed acromegaly. Initial tumour size and postoperative IGF-1 levels help to risk stratify patients regarding expected outcomes. In the case of disease persistence, a multimodal approach using drug and radiotherapy is mandatory.

Understanding how best to manage the complex healthcare needs of hospitalised, mostly multimorbid medical patients is an international priority. Healthcare should be effective, safe and provide high quality at a reasonable cost. However, basic logistic and organisational issues of medical ward-based care have received less attention than the medical treatment of specific pathologies. Consequently, we still use old-fashioned care and transition procedures for medical inpatients. This contrasts with dynamic developments in other, non-healthcare industries, where process optimisation is a major part of innovation. Promising new approaches to better align healthcare needs of hospitalised medical patients from clinical trials will help to advance the field significantly. Healthcare costs attributable to the aging, multimorbid population are rising worldwide. One cost driver is the high resource use of in-hospital treatment. In view of the expected demographic evolution of an aging population, better resource allocation is important. As in other countries, the Swiss healthcare system is in the midst of transformation aiming to improve health outcomes of patients at an affordable cost. One important area of redesign is identifying the best setting for diagnosis, treatment and management of acute medical conditions with a shift of in-hospital to outpatient care. Also, safely reducing in-hospital length of stay of inpatient treatment is important, because inpatient care accounts for the largest share of total Swiss healthcare costs. Integration of new technology into these processes holds promises for optimisation. Use of electronic health record-based tools has resulted in improved patient care and patient transitions. But evidence from clinical studies regarding the effect of inter-professional team care interventions on patient relevant outcomes, including activity of daily living, mortality and length of hospital stay, are inconsistent. Thus, there is room for improvement and a need for high quality trials providing evidence on how best to combine technology with innovative transition models for an ameliorated care of medical inpatients. We review in narrative form different transition interventions that have been evaluated for improved medical inpatient care and highlight important patient-centred outcome measures that were investigated. Further, we discuss a novel patient-management tool (In-HospiTOOL), which is currently being evaluated in an ongoing large Swiss multicentre study.

Principles: A decrease in plasma lipids occurs during severe sepsis and has prognostic implications in critical illness. Whether lipids have prognostic implications or could help to differentiate community-acquired pneumonia from other lower respiratory tract infections remains unknown., Methods: We analysed data from patients with lower respiratory tract infections enrolled in four prospective trials. We studied the time courses of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) and compared them with the underlying diagnosis and medical outcomes., Results: Of 572 patients included, 372 had community-acquired pneumonia and 200 acute and exacerbations of chronic obstructive bronchitis. We found significantly lower concentrations of TC, LDL-C and HDL-C in all patients on admission as compared to hospital discharge, particularly in community-acquired pneumonia. A multivariate logistic regression analysis including HDL-C, CRP, age and diabetes showed that HDL-C (OR: 0.18 [95%CI 0.11-0.3]) and CRP (OR: 1.01 [95%CI 1.01-1.02]) were independent predictors of community-acquired pneumonia. TC levels were significantly lower in non-survivors than in survivors (3.26 mmol/L [95%CI 2.58-3.96] vs 3.78 mmol/L [95%CI 3.01-4.65]). The prognostic accuracy, defined as the area under the receiver operator characteristic curve of TC to predict mortality, was 0.63 (95%CI 0.53-0.72) in all patients and increased to 0.94 (95%CI 0.86-1.00) in patients with bacteraemic community-acquired pneumonia., Conclusions: In conclusion, low lipid levels, particularly low HDL-C, pointed to bacterial infection and low TC was predictive of adverse outcomes in patients with lower respiratory tract infections. Reflecting the severity of disease, plasma lipid levels may be a complementary tool in the diagnostic and prognostic workup of patients with lower respiratory tract infections.

Background: Data on adherence to prescribed medication amongst diabetics are scarce. The purpose of this study was to collect information about the dynamics and patterns of compliance of elderly patients with type 2 diabetes mellitus on oral treatment by using different assessment techniques., Methods: Adherence to prescribed sulfonylurea medication was prospectively assessed by Self-report (Sr), Pill count (Pc) and using a Medication Event Monitoring System (MEMS) over a period of 2 months in 19 elderly patients with type 2 diabetes mellitus. A pressure-activated microprocessor allowing the registration of each opening is located in the cap of the MEMS drug container. MEMS dosage adherence (MEMSd) was defined as the number of bottle openings divided by the number of doses prescribed), and MEMS regimen adherence (MEMSr) was defined as the percentage of days in which the dose regimen was taken as prescribed., Results: Adherence rates were 96.8 +/- 19.6% for Pc, 92.6 +/- 19.9% for MEMSd and 78.6 +/- 28.3% for MEMSr. Adherence rates for Pc were 103.8 +/- 10.9% in once daily regimens and 87.3 +/- 25.2% in bid/tid regimens (p = 0.0686). MEMSd was 101.0 +/- 4.8% in once daily regimens versus 81.0% +/- 26.8% in bid/tid regimens (p = 0.0255). MEMSr was 93.6 +/- 5.7% in once daily regimens versus only 57.8 +/- 34.1% in bid/tid regimens (p = 0.0031). Assessed by MEMSd as many as 42.1% of the participants had adherence rates greater than 100%. Over-compliance was found primarily in once daily regimens., Conclusion: Adherence rates varied with different assessment techniques. Adherence rates were far from optimal. Once daily dosage led to significantly better adherence rates than two or three times daily regimens. However, over-compliance was surprisingly high and occurred more frequently on a once daily regimen.