Enhancing adherence in clinical research

Desirability and feasibility of wireless electronic monitoring of medications in clinical trials

Medication nonadherence is a vexing problem in health care necessitating patients and health professionals' efforts to prevent, minimize, or reverse it. Research participants' inconsistent medication taking obscures treatment efficacy and adds costs to biomedical research. Electronic monitoring devices (EMDs), like the Medication Event Monitoring System (MEMS), have grown in sophistication, providing precise, timely insights into individuals' medication-taking patterns across clinical populations. This article reports on the desirability and feasibility study of using a wireless EMD in clinical research to promote adherence to clinical regimens and research protocols. Nonadherence in transplant patients has been linked to late acute rejection and graft loss. High levels of adherence (97.7 %) were documented for six renal transplant recipients for a mean of 6 months (M = 196.1 ± 71.2 days) who indicated acceptance of the technology. MEMS data confirmed the feasibility of using wireless EMDs to monitor medication use. Monitoring provides greater assurance that research studies reflect the biological impact of medications and provide a basis for targeting adherence enhancement efforts within research investigations.

Enhancing adherence in trials promoting change in diet and physical activity in individuals with a diagnosis of colorectal adenoma; a systematic review of behavioural intervention approaches

BACKGROUND

Little is known about colorectal adenoma patients' ability to adhere to behavioural interventions promoting a change in diet and physical activity. This review aimed to examine health behaviour intervention programmes promoting change in diet and/or physical activity in adenoma patients and characterise interventions to which this patient group are most likely to adhere.

METHODS

Searches of eight databases were restricted to English language publications 2000-2014. Reference lists of relevant articles were also reviewed. All randomised controlled trials (RCTs) of diet and physical activity interventions in colorectal adenoma patients were included. Eligibility and quality were assessed and data were extracted by two reviewers. Data extraction comprised type, intensity, provider, mode and location of delivery of the intervention and data to enable calculation of four adherence outcomes. Data were subject to narrative analysis.

RESULTS

Five RCTs with a total of 1932 participants met the inclusion criteria. Adherence to the goals of the intervention ranged from 18 to 86 % for diet and 13 to 47 % for physical activity. Diet interventions achieving ≥ 50 % adherence to the goals of the intervention were clinic based, grounded in cognitive theory, delivered one to one and encouraged social support.

CONCLUSIONS

The findings of this review indicate that behavioural interventions can encourage colorectal adenoma patients to improve their diet. This review was not however able to clearly characterise effective interventions promoting increased physical activity in this patient group. Further research is required to establish effective interventions to promote adherence to physical activity in this population.

Treatment adherence and health outcomes in MSM with HIV/AIDS: patients enrolled in "one-stop" and standard care clinics in Wuhan China

BACKGROUND

Conducted in Wuhan China, this study examined follow-up and health markers in HIV patients receiving care in two treatment settings. Participants, all men who have sex with men, were followed for 18-24 months.

METHOD

Patients in a "one-stop" service (ACC; N = 89) vs those in standard care clinics (CDC; N = 243) were compared on HIV treatment and retention in care outcomes.

RESULTS

Among patients with CD4 cell count ≦350 cells/µL, the proportion receiving cART did not differ across clinic groups. The ACC was favored across five other indicators: proportion receiving tests for CD4 cell count at the six-month interval (98.2% vs. 79.4%, 95% CI 13.3-24.3, p = 0.000), proportion with HIV suppression for patients receiving cART for 6 months (86.5% vs. 57.1%, 95% CI 14.1-44.7, p = 0.000), proportion with CD4 cell recovery for patients receiving cART for 12 months (55.8% vs. 22.2%, 95% CI 18.5-48.6, p = 0.000), median time from HIV confirmation to first test for CD4 cell count (7 days, 95% CI 4-8 vs. 10 days, 95% CI 9-12, log-rank p = 0.000) and median time from first CD4 cell count ≦350 cells/µL to cART initiation (26 days, 95% CI 16-37 vs. 41.5 days, 95% CI 35-46, log-rank p = 0.031). Clinic groups did not differ on any biomedical indicator at baseline, and no baseline biomedical or demographic variables remained significant in the multivariate analysis. Nonetheless, post-hoc analyses suggest the possibility of self-selection bias.

CONCLUSIONS

Study findings lend preliminary support to a one-stop patient-centered care model that may be useful across various HIV care settings.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Intervention strategies for improving patient adherence to follow-up in the era of mobile information technology: a systematic review and meta-analysis

BACKGROUND

Patient adherence to follow-up plays a key role in the medical surveillance of chronic diseases and affects the implementation of clinical research by influencing cost and validity. We previously reported a randomized controlled trial (RCT) on short message service (SMS) reminders, which significantly improved follow-up adherence in pediatric cataract treatment.

METHODS

RCTs published in English that reported the impact of SMS or telephone reminders on increasing or decreasing the follow-up rate (FUR) were selected from Medline, EMBASE, PubMed, and the Cochrane Library through February 2014. The impacts of SMS and telephone reminders on the FUR of patients were systematically evaluated by meta-analysis and bias was assessed.

RESULTS

We identified 13 RCTs reporting on 3276 patients with and 3402 patients without SMS reminders and 8 RCTs reporting on 2666 patients with and 3439 patients without telephone reminders. For the SMS reminders, the majority of the studies (>50%) were at low risk of bias, considering adequate sequence generation, allocation concealment, blinding, evaluation of incomplete outcome data, and lack of selective reporting. For the studies on the telephone reminders, only the evaluation of incomplete outcome data accounted for more than 50% of studies being at low risk of bias. The pooled odds ratio (OR) for the improvement of follow-up adherence in the SMS group compared with the control group was 1.76 (95% CI [1.37, 2.26]; P<0.01), and the pooled OR for the improvement of follow-up adherence in the telephone group compared with the control group was 2.09 (95% CI [1.85, 2.36]; P<0.01); both sets showed no evidence of publication bias.

CONCLUSIONS

SMS and telephone reminders could both significantly improve the FUR. Telephone reminders were more effective but had a higher risk of bias than SMS reminders.

Adherence reporting in randomized controlled trials

Background

Treatment adherence may influence the therapeutic effect that is observed in a randomized controlled trial (RCT). Adherence may also be an indicator of research quality and treatment acceptance by participants. Despite the importance of adherence in RCT research, little is known about current practices for its measurement and reporting.

Purpose

The objective of this study was to determine and evaluate adherence measurement and reporting practices in RCTs involving oral pharmacologic interventions published in high impact factor journals.

Methods

We conducted a systematic review of RCTs involving oral pharmacotherapy published during 2010 in 10 high-impact general medicine and subspecialty journals. Two investigators independently abstracted data regarding trial characteristics, adherence monitoring, and adherence reporting. Differences were reconciled in conference. Descriptive statistics were calculated, statistical comparisons were made using chi-square analysis, and associations assessed using Spearman’s rank correlation coefficient.

Results

Of 111 RCT manuscripts included in the sample, 51 (45.9%) reported study-drug adherence among participants. Studies that reported adherence results were more likely to report negative findings (i.e., no significant treatment effect in a superiority trial, non-equivalence in an equivalence trial) (p = 0.032). The most common method for adherence monitoring was pill count-back on returned bottles. Among the studies that reported adherence, the median adherence was 88.4% (range: 48%−100%), and trials with longer follow-up time reported lower adherence (r = −0.45; p = 0.0015). A minority of the 51 studies described a strategy for calculating adherence that accounted for participants who were lost to follow-up (11/51 studies; 21.6%), discontinued the study medication temporarily (6/51 studies; 11.8%), or discontinued the study drug permanently (1/51 study; 2%).

Limitations

This study is limited by the inclusion of a small set of journals with the highest impact factors in specific fields of clinical medicine, including general medicine. Although the analysis pertains to studies published in 2010, no new guidelines in the field since the last Consolidated Standards of Reporting Trials (CONSORT) statement have been issued that would be expected to change practices for adherence monitoring, analysis, and reporting.

Conclusions

Adherence measurement methodology and results are underreported in published RCTs. In the minority of RCTs that provided adherence information, there was substantial heterogeneity in how adherence was defined, analyzed, and reported. Improved reporting of adherence may enhance the interpretation of study quality and results.

Adherence and renal biopsy feasibility in the Renin Angiotensin-System Study (RASS) primary prevention diabetes trial

AIMS

Enhancing adherence in research trials is fundamental to the proper testing of treatment hypotheses.

METHODS

Regimen and follow-up adherence as well as factors associated with adherence in the Renin Angiotensin-System Study (RASS) diabetic nephropathy primary prevention trial were evaluated. Adherence to medication (i.e., pill count), follow-up visits, and follow-up renal biopsies was evaluated.

RESULTS

89.8% of subjects completed the second renal biopsy. 96% of follow-up visits were attended within prescribed time windows. Mean medication adherence was 85.6%. Subgroup analyses revealed greater declines in the least adherent participants over time. Factors associated with greater adherence levels included older age, type 1 diabetes (TIDM) duration, lower HbA1c and blood pressure, GFR, ethnicity, and participants', principal investigators' (PI), and trial coordinators' (TC) baseline predictions of adherence.

CONCLUSIONS

T1DM patients without nephropathy were willing to take experimental medications and undergo repeat renal biopsies. Although overall adherence was excellent, patterns of adherence varied among participants, suggesting the need to better track adherence and to develop customized and targeted approaches for promoting adherence to clinical research regimens. Staff subjective predictions of adherence were imprecise, supporting need for further development of adherence predictors.

The effect of physical exercise strategies on weight loss in postpartum women: a systematic review and meta-analysis

For women of reproductive age, excessive gestational weight gain and/or postpartum weight retention can increase the risk of obesity. This systematic review evaluates the effectiveness of lifestyle modification control trials that utilize exercise interventions, with or without dietary intervention, on weight loss among postpartum women. A search of randomized clinical trials (RCT) was performed using the follow databases and the bibliography of candidate studies: MEDLINE, Web of Science, EMBASE, CENTRAL/Cochrane and Physiotherapy Evidence Database. English language RCT papers published up to 31 October 2012, which present changes on maternal body weight from baseline to the end of exercise intervention were included. The primary meta-analysis examined the effects of exercise interventions, with or without complementary dietary intervention, on weight loss during the postpartum period compared with usual standard of care. Five subgroup analyses were performed to examine differences in study interventions and exercise modalities: duration of intervention, quality of study methodology, supervision of exercise intervention, exercise intervention goals used and the type of dietary intervention. In total 11 studies met eligibility criteria with 769 participants, 409 under intervention and 360 in the control group. The primary meta-analysis included all 11 studies and found a mean difference (MD) on weight loss of -2.57 kg (95% CI -3.66 to -1.47). The subgroup analysis demonstrated that the most effective interventions in reducing weight in postpartum women were exercise programs with objectively defined goals, such as the use of heart rate monitors or pedometer (MD of -4.09 kg-95% CI -4.94 to -3.25, I(2)=0%) and exercise combined with intensive dietary intervention (MD of -4.34 kg-95% CI -5.15 to -3.52, I(2)=0%). Thus, there is benefit from overall lifestyle interventions on weight loss in postpartum women and exercise plus intensive diet and objective targets are the most effective intervention strategies.

The impact of succimer chelation on blood cadmium in children with background exposures: a randomized trial

Succimer lowers blood lead concentrations in children, and the structure of succimer chelates of lead and cadmium are similar. Using blood samples from a randomized trial of succimer for lead poisoning, however, we found that succimer did not lower blood cadmium in children with background exposure.

SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials

High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.

Challenges of loss to follow-up in tuberculosis research

Background

In studies evaluating methods for diagnosing tuberculosis (TB), follow-up to verify the presence or absence of active TB is crucial and high dropout rates may significantly affect the validity of the results. In a study assessing the diagnostic performance of the QuantiFERON®-TB Gold In-Tube test in TB suspect children in Tanzania, factors influencing patient adherence to attend follow-up examinations and reasons for not attending were examined.

Methods

In 160 children who attended and 102 children who did not attend scheduled 2-month follow-up baseline health characteristics, demographic data and risk factors for not attending follow-up were determined. Qualitative interviews were used to understand patient and caretakers reasons for not returning for scheduled follow-up.

Results

Being treated for active TB in the DOTS program (OR: 4.14; 95% CI:1.99–8.62;p-value<0.001) and receiving money for the bus fare (OR:129; 95% CI 16->100;P-value<0.001) were positive predictors for attending follow-up at 2 months, and 21/85(25%) of children not attending scheduled follow-up had died. Interviews revealed that limited financial resources, i.e. lack of money for transportation and poor communication, were related to non-adherence.

Conclusion

Patients lost to follow-up is a potential problem for TB research. Receiving money for transportation to the hospital and communication is crucial for adherence to follow-up conducted at a study facility. Strategies to ensure follow-up should be part of any study protocol.

Development and preliminary results of the Financial Incentive Coercion Assessment questionnaire

Financial incentives are often used in research, yet no measure exists to determine whether they lead to perceptions of coercion in subjects. We present a preliminary evaluation of a recently developed Financial Incentive Coercion Assessment (FICA) questionnaire. FICA measures perceived coercion specifically related to payment for participation in a research study. Two hundred sixty-six subjects were recruited from a large randomized controlled trial; 152 returned for a 6-month follow-up and completed the FICA. Approximately 30% of participants reported the major reason for participating was "for the money," but less than 5% felt that the financial incentives were coercive. FICA results are consistent with levels of perceived coercion using an alternative measure. Initial assessment of responses on the FICA suggests that it may provide a novel approach to measuring perceived coercion from financial incentives in research. Future work will refine the FICA and analyze its psychometric properties.

Protocol-driven costs in trial-based pharmacoeconomic analyses

Many authors and guidelines have proposed to exclude protocol-driven costs from cost-effectiveness analyses alongside clinical trials because they do not occur in clinical practice. This article, however, argues that only costs to improve patient adherence can be excluded, as the underlying protocol-driven activities have a clearly distinguishable cost and utility impact (most of the time). All other protocol-driven costs need to be included because the cost and utility impact of the underlying protocol-driven activities cannot be easily separated.

Longitudinal changes in magnetisation transfer ratio in secondary progressive multiple sclerosis: data from a randomised placebo controlled trial of lamotrigine

Sodium blockade with lamotrigine is neuroprotective in animal models of central nervous system demyelination. This study evaluated the effect of lamotrigine on magnetisation transfer ratio (MTR), a putative magnetic resonance imaging measure of intact brain tissue, in a group of subjects with secondary progressive multiple sclerosis (MS). In addition, the utility of MTR measures for detecting change in clinically relevant pathology was evaluated. One hundred seventeen people attending the National Hospital for Neurology and Neurosurgery or the Royal Free Hospital, London, UK, were recruited into a double-blind, parallel-group trial. Subjects were randomly assigned by minimisation to receive lamotrigine (target dose 400 mg/day) or placebo for 2 years. Treating and assessing physicians and patients were masked to treatment allocation. Results of the primary endpoint, central cerebral volume, have been published elsewhere. Significant differences between the verum and placebo arms were seen in only two measures [normal appearing grey matter (NAGM) p = 0.036 and lesion peak height (PH) p = 0.004], and in both cases there was a greater reduction in MTR in the verum arm. Significant correlations were found of change in MS functional composite with all MTR measures except lesion and normal appearing white matter (NAWM) PH. However, the change in MTR measures over 2 years were small, with only NAGM mean (p = 0.001), lesion peak location (p = 0.11) and mean (p < 0.0001) changing significantly from baseline. These data did not show that lamotrigine was neuroprotective. The clinical correlation of MTR measures was consistent, but the responsiveness to change was limited.

Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM)

Background

Achieving adequate follow-up in clinical trials is essential to establish the validity of the findings. Achieving adequate response rates reduces bias and increases probability that the findings can be generalized to the population of interest. Therefore, the purpose of this study was to determine the influence of attention, demographic, psychological, and health status factors on web-based response rates in the ongoing Prevention of Low Back Pain in the Military (POLM) trial.

Methods

Twenty companies of Soldiers (n = 4,325) were cluster randomized to complete a traditional exercise program including sit-ups (TEP) with or without a psychosocial educational program (PSEP) or a core stabilization exercise program (CSEP) with or without PSEP. A subgroup of Soldiers (n = 371) was randomized to receive an additional physical and ultrasound imaging (USI) examination of key trunk musculature. As part of the surveillance program, all Soldiers were encouraged to complete monthly surveys via email during the first year. Descriptive statistics of the predictor variables were obtained and compared between responders and non-responders using two sample t-tests or chi-square test, as appropriate. Generalized linear mixed models were subsequently fitted for the dichotomous outcomes to estimate the effects of the predictor variables. The significance level was set at .05 a priori.

Results

The overall response rate was 18.9% (811 subjects) for the first year. Responders were more likely to be older, Caucasian, have higher levels of education and income, reservist military status, non smoker, lower BMI, and have received individualized attention via the physical/USI examination (p < .05). Age, race/ethnicity, education, military status, smoking history, BMI, and whether a Soldier received the physical/USI examination remained statistically significant (p < .05) when considered in a full multivariate model.

Conclusion

The overall web based response rate during the first year of the POLM trial was consistent with studies that used similar methodology, but lower when compared to rates expected for standard clinical trials. One year response rate was significantly associated with demographic characteristics, health status, and individualized attention via additional testing. These data may assist for planning of future trials that use web based response systems.

Trial Registration

This study has been registered at reports at http://clinicaltrials.gov (NCT00373009).

Newsletters and adherence to a weekly home spirometry program after lung transplant

CONTEXT

Newsletters are a common intervention for patients in clinical trials. However, it is not clear whether newsletters are associated with increased adherence to the health regimen, and if so, which aspects of the newsletter are reported as most helpful to patients.

OBJECTIVE

To examine the association between patients' ratings of worthwhileness of a quarterly newsletter and adherence with a home spirometry regimen.

DESIGN

Patients (n=48) were in a research-based spirometry program after lung transplant and had received at least 1 newsletter; 24 (50%) returned completed surveys via postal mail.

MAIN OUTCOME MEASURES

Adherence for forced vital pulmonary function tests for respondents versus nonrespondents, number of weeks they were adherent, ratings they gave the newsletter, and which components of the newsletters were helpful to the respondents.

RESULTS

Respondents had more forced vital capacity pulmonary function tests ("blows") overall, blew more times weekly, and blew more consistently from week to week than did nonrespondents. Although it was not statistically significant, a mild correlation was found between the number of weeks that the respondents were adherent and their ratings of the newsletter (r = 0.36, P = .08). Most respondents reported that newsletter length was "about right", and 86% reported that newsletters helped encourage regular spirometer use, maintain interest in the study, educate about general health, and alert readers to seasonal health risks.

IMPLICATIONS FOR PRACTICE

High ratings for newsletters used to encourage participation among adults in our home spirometry study were associated with higher adherence.

A model to transfer trial-based pharmacoeconomic analyses to clinical practice

This article deals with the question of how to handle costs to enhance medication adherence in trial-based pharmacoeconomic analyses. It argues that resources to improve patient adherence have a clearly distinguishable impact on costs and utility and thus are relatively easy to exclude when transferring trial-based pharmacoeconomic analyses to clinical practice. It proposes a model that adjusts trial-based incremental costs and effectiveness for lower medication adherence in clinical practice. It shows that, contrary to conventional wisdom, drug cost effectiveness in clinical practice can be better than in clinical trials. This may have implications for policy recommendations, depending on how close trial-based cost effectiveness is to the maximum willingness to pay. In many situations, the adjustment may not result in a change in policy recommendations.

Newsletters and adherence to a weekly home spirometry program after lung transplant

CONTEXT

Newsletters are a common intervention for patients in clinical trials. However, it is not clear whether newsletters are associated with increased adherence to the health regimen, and if so, which aspects of the newsletter are reported as most helpful to patients.

OBJECTIVE

To examine the association between patients' ratings of worthwhileness of a quarterly newsletter and adherence with a home spirometry regimen.

DESIGN

Patients (n=48) were in a research-based spirometry program after lung transplant and had received at least 1 newsletter; 24 (50%) returned completed surveys via postal mail.

MAIN OUTCOME MEASURES

Adherence for forced vital pulmonary function tests for respondents versus nonrespondents, number of weeks they were adherent, ratings they gave the newsletter, and which components of the newsletters were helpful to the respondents.

RESULTS

Respondents had more forced vital capacity pulmonary function tests ("blows") overall, blew more times weekly, and blew more consistently from week to week than did nonrespondents. Although it was not statistically significant, a mild correlation was found between the number of weeks that the respondents were adherent and their ratings of the newsletter (r = 0.36, P = .08). Most respondents reported that newsletter length was "about right", and 86% reported that newsletters helped encourage regular spirometer use, maintain interest in the study, educate about general health, and alert readers to seasonal health risks.

IMPLICATIONS FOR PRACTICE

High ratings for newsletters used to encourage participation among adults in our home spirometry study were associated with higher adherence.

Adherence and its measurement in phase 2/3 microbicide trials

Adherence optimization and measurement have emerged as critically challenging issues for clinical trials of topical microbicides. Although microbicide trials have routinely collected adherence data, their utilization in trial design, implementation, and interpretation has been inconsistent. Drawing on data-driven presentations from several focused meetings, this paper synthesizes lessons from past microbicide trials and provides recommendations for future trials of microbicide and other HIV prevention technologies. First, it describes four purposes for adherence data collection, with particular attention to intention-to-treat versus adherence-adjusted analyses for determining effectiveness. Second, the microbicide field’s experiences with adherence measures and data collection modes are discussed, including the strengths and weaknesses of various options and approaches for improving measurement. Then, several approaches to optimizing trial participants’ adherence are presented. The paper concludes with a set of recommendations for immediate use or further research.

Treatment non-adherence in teenage and young adult patients with cancer

Adhering to treatment can be a significant issue for many patients diagnosed with chronic health conditions and this has been reported to be greater during the adolescent years. However, little is known about treatment adherence in teenage and young adult (TYA) patients with cancer. To increase awareness of the adherence challenges faced by these patients, we have reviewed the published work. The available evidence suggests that a substantial proportion of TYA patients with cancer do have difficulties, with reports that up to 63% of patients do not adhere to their treatment regimens. However, with inconsistent findings across studies, the true extent of non-adherence for these young patients is still unclear. Furthermore, it is apparent that there are many components of the cancer treatment regimen that have yet to be assessed in relation to patient adherence. Factors that have been shown to affect treatment adherence in TYA patients include patient emotional functioning (depression and self-esteem), patient health beliefs (perceived illness severity and vulnerability), and family environment (parental support and parent-child concordance). Strategies that foster greater patient adherence are also identified. These strategies are multifactorial, targeting not only the patient, but the health professional, family, and treatment regimen. This review highlights the lack of interventional studies addressing treatment adherence in TYA patients with cancer, with only one such intervention being identified: a video game intervention focusing on behavioural issues related to cancer treatment and care. Methodological issues in measuring adherence are addressed and suggestions for improving the design of future adherence studies highlighted, of which there is a great need.

Medication adherence in people of culturally and linguistically diverse backgrounds: a meta-analysis

BACKGROUND

Medication adherence is of particular importance for people of culturally and linguistically diverse (CALD) backgrounds due to language difficulties, lack of social and organizational supports, lack of access to healthcare resources, and disengagement with the health-care system.

OBJECTIVE

To evaluate the impact of interventions to improve medication adherence in people of CALD backgrounds through a systematic review and meta-analysis.

METHODS

A search was performed using the following databases: Cochrane Database of Systematic Reviews, Cumulative Index to Nursing & Allied Health Literature, EMBASE, Journals@Ovid, PsychInfo, PubMed, Science Direct, Scopus, and Web of Science. Databases were searched from January 1978 to October 2009.

RESULTS

Forty-six articles reviewed were assessed as being relevant, which included 36 randomized controlled trials, 2 observational cohort studies, and 8 quasi-experimental studies. The most common method for assessing medication adherence was self-reporting measures, such as the Morisky Scale and its modifications. Few studies used combinations of adherence measures, and adherence involving a medication event monitoring system (MEMS) was used in only 6 studies. Individuals of CALD backgrounds were recruited with people of non-CALD backgrounds and subsequent analyses tended to be undertaken of the whole sample. Twenty studies showed statistically significant improvements in medication adherence, 15 of which were randomized controlled trials. Six of the successful interventions involved delivery by a bilingual person or the use of translated materials and 4 involved the use of a conceptual model. Meta-analyses demonstrated modest improvements in medication adherence.

CONCLUSIONS

Relatively little high-quality work has been conducted on adherence-enhancing interventions for people of CALD backgrounds. Greater attention needs to be given to examining the needs of specific CALD population groups. Future researchers should consider rigorously testing interventions that take into account the enormous diversity and differences that exist within any particular CALD group.

Barriers to clinical research participation in a diabetes randomized clinical trial

Little is known about how barriers to research participation are perceived, affected by or interact with patient characteristics, or how they vary over the course of a clinical trial. Participants (285) in the Renin-Angiotensin System Study (RASS), a randomized clinical primary prevention study of diabetic nephropathy and retinopathy at 2 Canadian and 1 US university, rated potential barriers to research participation yearly for 5 years. Baseline barriers rated as most adversely affecting participation were: missing work; frequency of appointments and procedures; study length; number of appointments and procedures; access to study location; and physical discomfort associated with procedures. Inadequate social support, unstable job, and the use of alcohol and drugs were cited relatively infrequently, suggesting that although they may be important, candidates for whom these might be issues likely self-selected out of the study. Gender and gender by age interactions were found for specific perceived barriers, such as work and child care, and baseline barriers correlated with adherence. Elucidating the natural history of barriers to research participation is a step toward identifying strategies for helping participants overcome them, and ultimately may enhance the conduct of research.

Different frequencies of acupuncture treatment for chronic low back pain: an assessor-blinded pilot randomised controlled trial

OBJECTIVES

To examine the feasibility of a main RCT to compare the effectiveness of two frequencies (2 versus 5 times/week) of acupuncture treatment for chronic low back pain (LBP).

METHODS

Participants (n=30) with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: Low Frequency Group, 2 times/week for five weeks (n=15); High Frequency Group, 5 times/week for two weeks (n=15). The following outcomes were measured blindly at baseline, 2 weeks, 5 weeks, 3 months and 1 year: pain on a VAS, functional disability using the RMDQ, quality of life using the Measure Yourself Medical Outcome Profile (MYMOP-2), psychological impact with the Coping Strategies Questionnaire (CSQ) and Pain Locus of Control (PLC) questionnaire. Two objective outcomes, the Shuttle Walk Test (SWT) and Lateral Trunk Flexibility (LTF), were also measured.

RESULTS

The compliance rate was 100% for each group. Some of the measurements were shown to be sensitive (VAS, RMDQ, MYMOP-2 Wellbeing). 66-330 participants would be required for a fully powered non-inferiority trial. The groups were balanced at baseline for LBP and demographic characteristics. There were no significant differences between the groups in terms of any of the outcomes, at each follow-up time point. It was notable however that the clinically important improvement in terms of pain, functional disability, quality of life, and SWT in both groups was achieved within the first two weeks, which was maintained at one year follow-up.

CONCLUSIONS

It is feasible to conduct a main RCT, to compare different frequencies of acupuncture for LBP, using sensitive measurements. Also the trend for early clinically important improvement within a minimum of four measurements is worthy of further study.

Adherence to yoga and exercise interventions in a 6-month clinical trial

Background

To determine factors that predict adherence to a mind-body intervention in a randomized trial.

Design

We analyzed adherence data from a 3-arm trial involving 135 generally healthy seniors 65–85 years of age randomized to a 6-month intervention consisting of: an Iyengar yoga class with home practice, an exercise class with home practice, or a wait-list control group. Outcome measures included cognitive function, mood, fatigue, anxiety, health-related quality of life, and physical measures. Adherence to the intervention was obtained by class attendance and biweekly home practice logs.

Results

The drop-out rate was 13%. Among the completers of the two active interventions, average yoga class attendance was 77% and home practice occurred 64% of all days. Average exercise class attendance was 69% and home exercise occurred 54% of all days. There were no clear effects of adherence on the significant study outcomes (quality of life and physical measures). Class attendance was significantly correlated with baseline measures of depression, fatigue, and physical components of health-related quality of life. Significant differences in baseline measures were also found between study completers and drop-outs in the active interventions. Adherence was not related to age, gender, or education level.

Conclusion

Healthy seniors have good attendance at classes with a physically active intervention. Home practice takes place over half of the time. Decreased adherence to a potentially beneficial intervention has the potential to decrease the effect of the intervention in a clinical trial because subjects who might sustain the greatest benefit will receive a lower dose of the intervention and subjects with higher adherence rates may be functioning closer to maximum ability before the intervention. Strategies to maximize adherence among subjects at greater risk for low adherence will be important for future trials, especially complementary treatments requiring greater effort than simple pill-taking.

Understanding the quality chasm for hypertension control in diabetes: a structured review of "co-maneuvers" used in clinical trials

BACKGROUND

Observational studies routinely describe a significant gap between rates of blood pressure control in routine diabetes care compared with those achieved in randomized controlled trials (RCTs).

METHODS

We performed a systematic review of the literature to identify co-maneuvers used in RCTs, defined as ancillary activities or agents administered before, during, or immediately after the main agent under investigation (ie, principal maneuver), but not effectively translated to routine diabetes care. We searched multiple databases for RCTs evaluating the efficacy of treatments for hypertension control in adults with type 2 diabetes mellitus. We considered only phase III human studies of interventions that achieved blood pressure control and scrutinized all elements related to the implementation of the principal maneuver in each candidate study. These elements were then sorted into a taxonomy of co-maneuvers.

RESULTS

Nearly all eligible RCTs used highly consistent groups of co-maneuvers. These typically began with (1) the use of consensual and clearly stated blood pressure goals; (2) frequent visits in which blood pressure levels were measured and compared with predefined goals; and, if the goal was not attained, (3) modifications to the treatment based on a detailed action plan that included communication of adverse events. Patient education, feedback to clinicians, and interventions for medication adherence were not commonly used among eligible trials.

CONCLUSIONS

Clinicians should translate key behavioral co-maneuvers along with clinically proven treatments for hypertension control in diabetes. These co-maneuvers are conceptually similar to collaborative goal setting and action planning interventions used in innovative chronic care programs.

Preferences of patients receiving bisphosphonates--how to influence the therapeutic adherence

BACKGROUND

Therapeutic adherence determines the efficacy of treatments in the clinical practice. Especially in chronic asymptomatic diseases large differences exist between therapeutic success in clinical studies and clinical practice. The treatment of osteoporosis using bisphosphonates is considerably influenced by the low adherence of patients due to the complicated drug application.

SUBJECTS AND METHODS

The VIVA study analyzed the preferences of 1635 patients with osteoporosis in Slovakia using a simple questionnaire.

RESULTS

The majority of patients--76% preferred the monthly regime of bisphosphonate therapy, 22% of patients preferred the weekly regimen and only a minority--2% preferred daily application.

CONCLUSION

The results are in agreement with results of the BALTO study in the USA and the SWIFT study in Switzerland showing a clear preference to the monthly regime. The preferences of patients were motivated by various different aspects of improved quality of life, which is offered by the new bisphosphonate regimen once monthly.

Adherence to pharmacological treatment for juvenile bipolar disorder

OBJECTIVE

The objective of this study was to describe the prevalence and correlates of adherence to divalproex sodium (DVPX) and lithium carbonate (Li) combination treatment during the initial stabilization treatment phase.

METHOD

Adherence to Li/DVPX combination therapy was measured by the presence or absence of minimum serum concentrations of DVPX (50 microg/mL) or Li (0.6 mmol/L). Secondary measures included pill count, patient/parent report, and clinical judgment. Correlates of adherence, including patient characteristics, medication side effects, and family variables, were evaluated.

RESULTS

One hundred seven patients (70 males and 37 females) were studied. The proportion of serum concentrations in the therapeutic range across the study period was 0.84 for DVPX and 0.66 for Li. Maternal (r = -0.31; p<.01) and paternal (r = -0.44; p < .01) hospitalization for a psychiatric disorder and less adaptive family functioning (r=-0.26; p < .05) related to treatment nonadherence for DVPX. Better treatment adherence to DVPX (r = 0.21; p < .05) and Li (r = 0.23; p < .05) was associated with a greater number of side effects, whereas male sex was associated with worse adherence to both DVPX (r= -0.24; p < .05) and Li (r = -0.22; p < .05) pharmacotherapy. Clinical response to treatment correlated with adherence to DVPX treatment (r = 0.33; p < .01).

CONCLUSIONS

Nonadherence may limit the statistical power of treatment efficacy studies and the effectiveness of pharmacotherapy treatment for juvenile BPD and necessitate strategies to evaluate and enhance levels of treatment adherence.

Maximizing the value of validation findings to better understand treatment satisfaction issues for diabetes

BACKGROUND

Variables associated with treatment satisfaction (TS) can be broadly categorized as precursors, ongoing treatment issues, and treatment outcomes. This study continues the validation process for the Insulin Treatment Satisfaction Questionnaire (ITSQ) while examining relationships between TS and these broader influences.

METHODS

Data (N = 299) were collected in a RCT comparing safety and efficacy of inhaled vs. injectable insulin. Validation examined item and factor characteristics, reliability and validity. Regression analyses examined relationships between overall and domain specific TS and the broader influences.

RESULTS

Patients with less previous or current treatment burden had greater TS (p < 0.001). Gender, injection fear, functioning, age, compliance and glycemic control were differentially related to TS at the beginning and end of study. Baseline satisfaction was predictive of future TS (p < 0.001). When all significant factors were examined together, lower burden with the current treatment and higher satisfaction with previous treatment continued to be key (p < 0.001) while other factors were no longer significant. Validation findings confirmed the ITSQ was psychometrically sound.

CONCLUSION

Over the course of treatment, some factors are associated with TS at treatment start while others are key drivers at treatment end. This suggests that TS is not a static concept.

Therapeutic adherence to bisphosphonates

Therapeutic adherence of patients is a key factor of treatment success in clinical praxis, although it is often neglected. Several studies have shown that insufficient persistence and compliance cause differences in the efficiency of treatments in clinical studies and clinical praxis. A recent meta-analysis even showed a clear inverse relationship between therapeutic adherence and mortality. Factors influencing the adherence to treatment include explanations by the physician, characteristics of the disease, patient's attitudes, but also the therapeutic regime. Osteoporosis as a chronic disorder with relatively long asymptomatic initial course represents a major problem. In addition, the currently available therapeutic regimes are discomfortable and, thus, contribute to the low therapeutic adherence of the patient. One of the factors causing discomfort in bisphosphonates therapy is the frequency of application--once daily or once weekly. Several questionnaire-based studies have shown that patients clearly prefer the new alternative once monthly regime available for ibandronate. Although the efficiency of the drug is proven in large clinical trials, the effects of the once monthly regime itself on hard clinical end-points like mortality can only be analyzed in long-term follow-up studies.