Correlation between patient recall of bone densitometry results and subsequent treatment adherence

DXA Reporting Updates: 2023 Official Positions of the International Society for Clinical Densitometry

INTRODUCTION

Professional guidance and standards assist radiologic interpreters in generating high quality reports. Initially DXA reporting Official Positions were provided by the ISCD in 2003; however, as the field has progressed, some of the current recommendations require revision and updating. This manuscript details the research approach and provides updated DXA reporting guidance.

METHODS

Key Questions were proposed by ISCD established protocols and approved by the Position Development Conference Steering Committee. Literature related to each question was accumulated by searching PubMed, and existing guidelines from other organizations were extracted from websites. Modifications and additions to the ISCD Official Positions were determined by an expert panel after reviewing the Task Force proposals and position papers.

RESULTS

Since most DXA is now performed in radiology departments, an approach was endorsed that better aligns with standard radiologic reports. To achieve this, reporting elements were divided into required minimum or optional. Collectively, required components comprise a standard diagnostic report and are considered the minimum necessary to generate an acceptable report. Additional elements were retained and categorized as optional. These optional components were considered relevant but tailored to a consultative, clinically oriented report. Although this information is beneficial, not all interpreters have access to sufficient clinical information, or may not have the clinical expertise to expand beyond a diagnostic report. Consequently, these are not required for an acceptable report.

CONCLUSION

These updated ISCD positions conform with the DXA field's evolution over the past 20 years. Specifically, a basic diagnostic report better aligns with radiology standards, and additional elements (which are valued by treating clinicians) remain acceptable but are optional and not required. Additionally, reporting guidance for newer elements such as fracture risk assessment are incorporated. It is our expectation that these updated Official Positions will improve compliance with required standards and generate high quality DXA reports that are valuable to the recipient clinician and contribute to best patient care.

Age-dependent assessment thresholds to optimize patient care in a resource-limited setting: an analysis based on the Sri Lankan FRAX model

Age-dependent upper and lower assessment thresholds help categorizing women aged 40 years or more according to their fracture risk, independent of BMD information.

INTRODUCTION

Age-dependent assessment thresholds of the FRAX algorithm help stratifying men and women aged 40 years or more according to their fracture risk. This allows clinicians to decide on those who require interventions without BMD assessment and those who require BMD input for further assessment.

METHODS

Intervention thresholds were defined by 10-year probabilities of a major osteoporotic fracture (MOF) and hip fracture (HF) considering a woman with a BMI of 25.0 kg/m² having a prior fragility fracture but no other clinical risk factors. The lower assessment thresholds (LAT) were set at 0.8 times the 10-year probabilities of a MOF and HF in a woman with a BMI of 25.0 kg/m², without previous fracture or other clinical risk factors. The upper assessment thresholds (UAT) were set at 1.2 times the intervention thresholds of MOF and HF. Fracture probabilities were estimated for the age range of 40-80 years, without BMD input. These values were applied to a group of women who underwent DXA for clinical reasons in a single center.

RESULTS

The LATs of MOF and HF varied from 0.7 to 8.8% and 0.1 to 3.7%, from 40 to 80 years, respectively. The corresponding values for UATs were 2.5 to 21.6% and 0.3 to 8.4%. ITs of MOF and HF varied from 2.1 to 18% and 0.2 to 7%, respectively. When applied to a group of 315 postmenopausal women who underwent DXA for clinical indications, 22.9% of women were above the UATs (high-risk category) while 8.6% were below the LATs (low-risk category). The proportion of women in the intermediate category who require BMD for further assessment was 68.6% (95% CI 59.7 to 77.5%).

CONCLUSIONS

In nearly one-third of women aged 40 years or more, the decision to treat or not to treat can be achieved without BMD estimation. The remaining two-thirds will require a BMD assessment for further evaluation.

The role of psychosocial factors in patients' recollections of breast reconstruction options discussed with their surgeons

A patient's comprehension and memory of conversations with their providers plays an important role in their healthcare. Adult breast cancer patients whose legal sex was female and who underwent treatment at the Center for Reconstructive Surgery at The University of Texas MD Anderson Cancer Center were asked to indicate which breast reconstruction procedures they discussed with their surgeon. We focused on the three most frequent responses: (a) participants who remembered discussing implant-based, tissue-based, and combination procedures; (b) participants who remembered only an implant-based option being discussed; and (c) participants who remember only a tissue-based option being discussed. We used multinomial logistic regression models to explore the psychosocial factors associated with patients' recollections of their breast reconstruction options after discussions with their reconstructive surgeons, controlling for medical factors that impact surgical decision-making. Our analyses identified body mass index, body image investment, and body image as statistically significantly associated with the reconstructive options that a participant recalls discussing with their surgeon. Our findings highlight body image investment and body image as important psychological factors that may influence what patients remember from consultations about breast reconstruction options.

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial

OBJECTIVE

To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS).

DESIGN

Single-centre, single-blind, randomised controlled trial.

SETTING

One university hospital in Norway.

PARTICIPANTS

Thirty-four patients with early-stage MS.

INTERVENTION

A 3-hour training for neurologists on how to provide complex information about MS escalation therapy.

MAIN OUTCOME MEASURES

Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs.

SECONDARY OUTCOME MEASURES

Number of information units provided by the physicians. Effects on patient involvement through questionnaires.

METHODS

Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim.

RESULTS

Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire.

CONCLUSION

A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate.

TRIAL REGISTRATION NUMBER

ISRCTN42739508.

Patient Outcomes in the Years After a DXA-BMD Treatment Monitoring Test: Improved Medication Adherence in Some, But Too Little Too Late

The role of mid-treatment monitoring dual-energy X-ray absorptiometry-bone mineral density (DXA-BMD) for bisphosphonate-treated patients with osteoporosis remains unsettled. A common reason for such monitoring is to encourage ongoing medication adherence. We sought to determine if a DXA-BMD treatment monitoring test was associated with improved medication adherence and whether improved adherence after a DXA-BMD treatment monitoring test was associated with subsequent reduction in fracture rates. Using linked administrative databases within Manitoba, Canada, we performed a retrospective cohort study of women starting and continuing antiresorptive therapy in whom a mid-treatment DXA-BMD monitoring test was performed. From the provincial pharmacy database, we estimated medication adherence by calculating annual medication possession ratio (MPR) and determining the change in MPR with respect to change (stable/decrease) in the DXA-BMD monitoring test, in addition to fracture rates before and after the test. The cohort comprised 3418 women, 90.7% treated with oral bisphosphonate, with pharmacy data for the 3 years before and after the mid-treatment DXA-BMD. Median (interquartile range) MPR was 0.84 (0.49-0.99) in the year before DXA-BMD and 0.84 (0.48-0.99) in the year after DXA-BMD (p = 0.37). Among those whose DXA-BMD declined, MPR in the prior year was 0.54 (0.04-0.92) but improved to 0.70 (0.31-0.92) in the year after DXA-BMD (p < 0.001). Among those whose DXA-BMD monitoring test was stable/improved, the fracture rate before the monitoring DXA-BMD was 10.1 per 1000 person-years and in those whose DXA-BMD monitoring test showed a decrease, the rate was 23.7 per 1000 person-years (p < 0.001). Despite improved adherence in those with DXA-BMD decline, the post DXA-BMD fracture rate was 22.4 per 1000 person-years versus 12.9 per 1000 person-years in those who had stable DXA-BMD (p < 0.001). A mid-treatment DXA-BMD reassessment strategy may be useful to focus attention upon adherence, but for optimal fracture outcomes, treatment adherence should be specifically addressed at the commencement of therapy. © 2021 American Society for Bone and Mineral Research (ASBMR).

Use of a Personalized Multimedia Education Platform Improves Preoperative Teaching for Lung Cancer Patients

We sought to develop and evaluate a personalized multimedia education (ME) tool for preoperative patient education to improve patient health knowledge, quality of life and satisfaction with care in thoracic surgery. The ME tool was developed and deployed in outpatient clinic during preoperative teaching for patients undergoing surgical resection for lung cancer for quality improvement. Patients were given an electronic survey prior to preoperative teaching and at initial postoperative visit to assess teaching effectiveness and care satisfaction. Sequential patients received either standard preoperative teaching or teaching using the ME tool. Pre- and postoperative survey responses were compared using independent sample paired t test and multivariable linear regression modeling for adjustment. The final ME tool was an iPad application that incorporated real-time annotations of 3-dimensional, interactive anatomic diagrams. The tool featured video tours of operations, and radiology image import for annotation by the surgeon. Forty-eight patients were included in this pilot study (standard education n = 26; ME, n = 22). ME patients had significantly higher satisfaction scores compared to SE patients with respect to length of education materials, clarity of content, supportiveness of content and willingness to recommend materials to others. There was no difference in length of clinic visit between groups. Both patient and provider input can be used to create an innovative electronic preoperative educational tool that prepares and empowers patients in shared decision-making before surgery. Improvements in health literacy and self-efficacy may be more difficult to achieve but remain important as multimedia teaching tools are further developed.

Investigation of users' experiences for online access to their electronic health records in Japan

The solution of sharing electronic health records (EHR) with patients has the potential to improve patients' understanding and remembering of their health information. We call this solution the patient open-EHR. In Japan, this solution is not yet widespread, and experiences of actual users are not known. Our aim is to explore the needs and satisfaction of patients who are actually using one patient open-EHR system in Japan that allows registered patients online access to part of their EHR. A cross-sectional study was done using an online questionnaire. Patients registered with our patient open-EHR system were invited to participate by posting an invitation message on the system login page and sending them invitation emails. We investigated their needs regarding the system and their views regarding the system's ability to improve their understanding, remembering, and other perspectives. Answers from 95 patients, collected between August 10 and October 20, 2019 were analyzed. The need to further understand and remember the information received from the doctor was among the top four reasons behind using the system. However, only 48% of patients agreed that the system improved their remembering and 68% agreed that it improved their understanding. Thirty-seven percent of respondents expressed dissatisfaction with access to only blood test results and prescriptions. Despite this dissatisfaction, respondents were positive about the future of the system. Hospitals need to recognize the needs of patients and to consider them when providing patient open-EHR service. The EHR has potential not only for hospitals but also for patients.

Preference for and understanding of graphs presenting health risk information. The role of age, health literacy, numeracy and graph literacy

OBJECTIVE

To investigate 1) younger (< 65) and older (> 65) adults' preference for and understanding of graph formats presenting risk information, and 2) the contribution of age, health literacy, numeracy and graph literacy in understanding information.

MATERIALS AND METHODS

To assess preferences, participants (n = 219 < 65 and n = 227>65) were exposed to a storyboard presenting six types of graphs. Understanding (verbatim and gist knowledge) was assessed in an experiment using a 6 (graphs: clock, bar, sparkplug, table, pie vs pictograph) by 2 (age: younger [<65] vs older [>65]) between-subjects design.

RESULTS

Most participants preferred clock, pie or bar chart. Pie was not well understood by both younger and older people, and clock not by older people. Bar was fairly well understood in both groups. Table yielded high knowledge scores, particularly in the older group. Lower age, higher numeracy and higher graph literacy contributed to higher verbatim knowledge scores. Higher health literacy and graph literacy were associated with higher gist knowledge.

DISCUSSION AND CONCLUSION

Although not the preferred format, tables are best understood by older adults.

PRACTICE IMPLICATIONS

Graph literacy skills are essential for both verbatim and gist understanding, and are important to take into account when developing risk information.

Establishing the dose of memory support to improve patient memory for treatment and treatment outcome

BACKGROUND AND OBJECTIVES

Patient memory for the contents of treatment sessions is poor and this is associated with worse treatment outcome. Preliminary findings indicate that treatment provider use of memory support can be helpful in enhancing patient memory for treatment and improving outcome. The development of a novel Memory Support Intervention is currently underway. A key step in this process is to establish the dose of memory support that treatment providers deliver in treatment-as-usual, as well as the optimal dose of memory support needed to maximize patient memory for treatment points and outcomes.

METHODS

Forty-two adults with major depressive disorder (MDD) were randomized to receive either cognitive therapy plus memory support (CS + Memory Support; n = 22) or cognitive therapy as-usual (CT-as-usual; n = 20). Patients completed a free recall of treatment points task at post-treatment. Outcome measures were administered at baseline and post-treatment.

RESULTS

Treatment providers delivering CT-as-usual used, on average, 8.39 instances of memory support and 3.40 different types of memory support per session. Receiver Operating Characteristics (ROC) analyses using the combined sample indicate that 12.45 instances of memory support and 3.88 to 4.13 different types of memory support are needed to maximize patient recall and functional outcome.

LIMITATIONS

Dosing recommendations were established using a limited sample of participants receiving cognitive therapy for MDD.

CONCLUSIONS

Treatment providers appear to deliver a suboptimal amount of memory support. Delivering the optimal dose of memory support could improve treatment outcome.

Personal decision support for survivor engagement: formulation and feasibility evaluation of a conceptual framework for implementing online cancer survivorship care plans

BACKGROUND

Although cancer survivorship care plans have been in use for several years, they have been shown to not be effective in meeting the long-term needs of cancer survivors, in addition being generic and passive in nature. Interactive survivorship care plans in the form of a personal decision support aid could provide an opportunity to not only engage survivors in their health care, but also capture meaningful treatment-related outcomes to use as a rich data source as the basis for making informed decisions. The objective of this research is to formulate an evidence-based model framework for implementing breast cancer survivorship guidelines via an online breast cancer survivorship care plan (SCP).

METHODS

The study was completed in three steps. In the first step, or the requirements gathering phase, we conducted personal interviews of breast cancer survivors to determine their use of the survivorship care plan (SCP) and related needs to determine core SCP functions and formulate an implementation framework for an online SCP. In the second step, we used the framework as a guide to design and develop the online SCP tool. Finally, in the third step, we conducted preliminary testing to determine the feasibility of the developed tool among online users.

RESULTS

Fifteen breast cancer survivors were consulted, who reported several issues from their use of the traditional paper-based SCP. Four themes were identified that represent the SCP's core desired functions. Eight features were matched to implement these core functions. Using a personal decision approach, an online SCP tool called ACESO that incorporates these features and functions was developed. Preliminary feasibility testing yielded overall positive responses from breast cancer survivors (n = 51).

CONCLUSION

Our study demonstrated that survivors face challenges from their use of a traditional paper-based SCP. The online SCP we developed is technically feasible and has the potential to effectively engage breast cancer survivors in self-management and shared decision-making with their clinicians and caregivers. Further testing is required to assess its usability and long-term impact.

Health literacy and uptake of anti-fracture medications in a population-based sample of Australian women

This study investigated associations between health literacy and use of anti-fracture medications in women with osteoporosis. Data were collected for women participating in the population-based Geelong Osteoporosis Study in Australia. Health literacy was ascertained using the Health Literacy Questionnaire (HLQ) and bone mineral density by dual x-ray absorptiometry. Self-reported current medications were classified using MIMS codes, with the category 'Agent affecting calcium and bone metabolism' indicating osteoporosis treatment. Analysis of Variance (p-value <0.1 indicating a trend) and Cohen's d effect sizes (ES [95%CI]) (categorised; Small >0.2-<0.5, Moderate >0.5-0.8, Large >0.8) were calculated for differences in HLQ scale scores between participants who did vs. did not self-report medication use. Among 620 women, 134 (21.6%) had osteoporosis, 14 (10.5%) of whom self-reported current anti-fracture medication use. Small/moderate ES indicated women taking medication had lower HLQ scores in scales 'Navigating the healthcare system', 'Ability to find health information' and 'Understand health information' (ES 0.36 [0.25-0.79], 0.41 [0.29-0.87] and 0.64 [0.54-1.03], respectively). A trend was observed (p = 0.09) for 'Understand health information' scale scores and utilisation of medication. These data suggest women with less confidence in their ability to find and understand health information may follow healthcare provider recommendations and utilise anti-fracture medications more readily.

Patient learning of treatment contents in cognitive therapy

BACKGROUND AND OBJECTIVES

Research has demonstrated that both memory and learning for treatment contents are poor, and that both are associated with worse treatment outcome. The Memory Support Intervention has been shown to improve memory for treatment, but it has not yet been established if this intervention can also improve learning of treatment contents. This study was designed to document the number of times participants exhibited each of the indices of learning, to examine the indices of learning and their relationship to recall of treatment points, and to investigate the association between the indices of learning and depression outcome.

METHODS

Adults diagnosed with major depressive disorder (N = 48) were randomly assigned to 14 sessions of cognitive therapy-as-usual (CT-as-usual) or cognitive therapy plus the Memory Support Intervention (CT + Memory Support). Measures of learning, memory, and depressive symptomatology were taken at mid-treatment, post-treatment, and at 6-month follow-up.

RESULTS

Relative to the CT-as-usual group, participants in the CT + Memory Support group reported more accurate thoughts and applications of treatment points at mid-treatment, post-treatment, and 6-month follow-up. Patient recall was significantly correlated with application and cognitive generalization. Thoughts and application at mid-treatment were associated with increased odds of treatment response at post-treatment.

LIMITATIONS

The learning measure for this study has not yet been psychometrically validated. The results are based on a small sample.

CONCLUSIONS

Learning during treatment is poor, but modifiable via the Memory Support Intervention. These results provide encouraging data that improving learning of treatment contents can reduce symptoms during and following treatment.

Measuring recall of medical information in non-English-speaking people with cancer: A methodology

BACKGROUND

Many patients who require an interpreter have difficulty remembering information from their medical consultations. Memory aids such as consultation audio-recordings may be of benefit to these patients. However, there is no established means of measuring patients' memory of medical information.

OBJECTIVES

This study aimed to develop a method for eliciting and coding recall of medical information in non-English-speaking patients.

DESIGN

This method, called Patient-Interpreter-Clinician coding (PICcode), was developed in the context of a phase II trial conducted in two outpatient oncology clinics in Melbourne, Australia, and was refined iteratively through consultation with an expert panel and piloting. Between-coder differences in early versions of the coding system were resolved through discussion and consensus resulting in refinements to PICcode.

RESULTS

The final version of PICcode involved transcribing, translating and coding of audio-recorded consultations and semi-structured interviews (SSI). The SSIs were designed to elicit patients' free-recall of medical information. Every unit of medical information in the consultation was identified and categorized in a coding tree. SSIs were coded to identify the extent to which information was recalled from the consultation.

DISCUSSION

The iterative changes involved in developing PICcode assisted in clarifying precise details of the process and produced a widely applicable coding system. PICcode is the most comprehensively described method of determining the amount of information that patients who use an interpreter recall from their medical consultations. PICcode can be adapted for English-speaking patients and other healthcare populations.

Can integrating the Memory Support Intervention into cognitive therapy improve depression outcome? Study protocol for a randomized controlled trial

Background

The Memory Support Intervention was developed in response to evidence showing that: (1) patient memory for treatment is poor, (2) poor memory for treatment is associated with poorer adherence and poorer outcome, (3) the impact of memory impairment can be minimized by the use of memory support strategies and (4) improved memory for treatment improves outcome. The aim of this study protocol is to conduct a confirmatory efficacy trial to test whether the Memory Support Intervention improves illness course and functional outcomes. As a “platform” for the next step in investigating this approach, we focus on major depressive disorder (MDD) and cognitive therapy (CT).

Method/design

Adults with MDD (n = 178, including 20% for potential attrition) will be randomly allocated to CT + Memory Support or CT-as-usual and will be assessed at baseline, post treatment and at 6 and 12 months’ follow-up (6FU and 12FU). We will compare the effects of CT + Memory Support vs. CT-as-usual to determine if the new intervention improves the course of illness and reduces functional impairment (aim 1). We will determine if patient memory for treatment mediates the relationship between treatment condition and outcome (aim 2). We will evaluate if previously reported poor treatment response subgroups moderate target engagement (aim 3).

Discussion

The Memory Support Intervention has been developed to be “transdiagnostic” (relevant to a broad range of mental disorders) and “pantreatment” (relevant to a broad range of types of treatment). This study protocol describes a “next step” in the treatment development process by testing the Memory Support Intervention for major depressive disorder (MDD) and cognitive therapy (CT). If the results are promising, future directions will test the applicability to other kinds of interventions and disorders and in other settings.

Trial registration

ClinicalTrials.gov, ID: NCT01790919. Registered on 6 October 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2276-x) contains supplementary material, which is available to authorized users.

Memory support strategies and bundles: A pathway to improving cognitive therapy for depression?

OBJECTIVE

Therapist use of memory support (MS) alongside treatment-as-usual, with the goal of enhancing patient recall of treatment contents, has been of recent interest as a novel pathway to improve treatment outcome. The memory support intervention (MSI) involves treatment providers' using 8 specific MS strategies to promote patient memory for treatment. The present study examines to what extent therapist use of MS strategies and bundles improves patient recall of treatment contents and treatment outcome.

METHOD

The data were drawn from a pilot RCT reported elsewhere. Participants were 48 adults (mean age = 44.27 years, 29 females) with major depressive disorder (MDD), randomized to receive 14 sessions of either CT + Memory Support (n = 25) or CT-as-usual (n = 23). Therapist use of MS was coded using the Memory Support Rating Scale. Patient memory and treatment outcomes were assessed at baseline, midtreatment (patient recall only), posttreatment, and 6-month follow-up.

RESULTS

Participants in CT + Memory Support received significantly higher amount of MS relative to CT-as-usual. Although not reaching statistical significance, small-to-medium effects were observed between MS strategies and patient recall in the expected direction. Although MS variables were not significantly associated with changes in continuous depressive symptoms, MS was associated with better global functioning. MS also exhibited small to medium effects on treatment response and recurrence in the expected direction but not on remission, though these effects did not reach statistical significance.

CONCLUSIONS

These results provide initial empirical evidence supporting an active method for therapists to implement MS strategies. (PsycINFO Database Record

Patient recall of specific cognitive therapy contents predicts adherence and outcome in adults with major depressive disorder

The current study examined whether and which specific contents of patients' memory for cognitive therapy (CT) were associated with treatment adherence and outcome. Data were drawn from a pilot RCT of forty-eight depressed adults, who received either CT plus Memory Support Intervention (CT + Memory Support) or CT-as-usual. Patients' memory for treatment was measured using the Patient Recall Task and responses were coded into cognitive behavioral therapy (CBT) codes, such as CBT Model and Cognitive Restructuring, and non-CBT codes, such as individual coping strategies and no code. Treatment adherence was measured using therapist and patient ratings during treatment. Depression outcomes included treatment response, remission, and recurrence. Total number of CBT codes recalled was not significantly different comparing CT + Memory Support to CT-as-usual. Total CBT codes recalled were positively associated with adherence, while non-CBT codes recalled were negatively associated with adherence. Treatment responders (vs. non-responders) exhibited a significant increase in their recall of Cognitive Restructuring from session 7 to posttreatment. Greater recall of Cognitive Restructuring was marginally significantly associated with remission. Greater total number of CBT codes recalled (particularly CBT Model) was associated with non-recurrence of depression. Results highlight the important relationships between patients' memory for treatment and treatment adherence and outcome.

Communication and patient participation influencing patient recall of treatment discussions

CONTEXT

Patient recall of treatment information is a key variable towards chronic disease (CD) management. It is unclear what communication and patient participation characteristics predict recall.

OBJECTIVES

To assess what aspects of doctor-patient communication predict patient recall of medication information. To describe lifestyle treatment recall, in CD primary care patients.

DESIGN

Observational study within a RCT.

SETTING & PARTICIPANTS

Community-based primary care (PC) practices. Family physicians (n=18): practicing >5 years, with a CD patient caseload. Patients (n=159): >40 years old, English speaking, computer literate, off-target hypertension, type II diabetes and/or dyslipidaemia.

MAIN VARIABLES

Patient characteristics: age, education, number of CDs. Information characteristics: length of encounter, medication status, medication class. Communication variables: socio-emotional utterances, physician dominance and communication control scores and PACE (ask, check and express) utterances, measured by RIAS. Number of medication themes, dialogue and initiative measured by MEDICODE.

MAIN OUTCOME MEASURES

Recall of CD, lifestyle treatment and medication information.

RESULTS

Frequency of lifestyle discussions varied by topic. Patients recalled 43% (alcohol), 52% (diet) to 70% (exercise) of discussions. Two and a half of six possible medication themes were broached per medication discussion. Less than one was recalled. Discussing more themes, greater dialogue and patient initiative were significant predictors of improved medication information recall.

DISCUSSION

Critical treatment information is infrequently exchanged. Active patient engagement and explicit conversations about medications are associated with improved treatment information recall in off-target CD patients followed in PC.

CONCLUSION

Providers cannot take for granted that long-term off-target CD patients recall information. They need to encourage patient participation to improve recall of treatment information.

Do improved patient recall and the provision of memory support enhance treatment adherence?

BACKGROUND AND OBJECTIVES

Patient adherence to psychosocial treatment is an important but understudied topic. The aim of this study was to examine whether better patient recall of treatment contents and therapist use of memory support (MS) were associated with better treatment adherence.

METHODS

Data were drawn from a pilot randomized controlled trial. Participants were 48 individuals (mean age = 44.27 years, 29 females) with Major Depressive Disorder randomized to receive either Cognitive Therapy (CT) with an adjunctive Memory Support Intervention (CT + Memory Support) or CT-as-usual. Therapist and patient ratings of treatment adherence were collected during each treatment session. Patient recall was assessed at mid-treatment. Therapist use of MS was manually coded for a random selection of sessions.

RESULTS

Patient recall was significantly associated with better therapist and patient ratings of adherence. Therapist use of Application, a specific MS strategy, predicted higher therapist ratings of adherence. Attention Recruitment, another specific MS strategy, appeared to attenuate the positive impact of session number on patient ratings of adherence. Treatment groups, MS summary scores and other specific MS strategies were not significantly associated with adherence.

LIMITATIONS

The measure for treatment adherence is in the process of being formally validated. Results were based on small sample.

CONCLUSIONS

These results support the importance of patient recall in treatment adherence. Although collectively the effects of MS on treatment adherence were not significant, the results support the use of certain specific MS strategy (i.e., application) as a potential pathway to improve treatment adherence. Larger-scale studies are needed to further examine these constructs.

How Can Osteoporosis Patients Benefit More from Their Therapy? Adherence Issues with Bisphosphonate Therapy

Objective:

To review the evidence on adherence with bisphosphonates and evolving dosing strategies for osteoporosis treatment.

Data Sources:

Articles were identified by searching MEDLINE (1975–December 2005) using the following terms: osteoporosis, postmenopausal, fracture, adherence, compliance, persistence, drug therapy, bisphosphonates, alendronate, risedronate, ibandronate, and zoledronate. Additional data included bibliographies from identified articles.

Study Selection and Data Extraction:

All pertinent English-language articles that discussed adherence issues in patients with osteoporosis were included. Both those that reviewed overall issues of medication adherence in osteoporosis and those that focused specifically on adherence to bisphosphonates were included, as were articles that addressed strategies for overcoming nonadherence.

Data Synthesis:

Inadequate diagnosis and treatment of osteoporosis result in a higher risk of fractures than is necessary. Even patients who are diagnosed and beginning treatment often do not persist with their osteoporosis medication because they perceive their fracture risk to be low and, given the asymptomatic nature of osteoporosis, do not experience the benefit of symptom reduction after taking the drugs. Factors that affect adherence to osteoporosis therapy include drug costs, adverse effects, dosing frequency, disease education, patient follow-up, and patient involvement in treatment decisions.

Conclusions:

By considering and implementing strategies that can improve adherence and persistence, primary care providers and pharmacists (via counseling) may enhance long-term outcomes for patients with osteoporosis.

Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial

Patients often do not know or understand their bone density test results, and pharmacological treatment rates are low. In a clinical trial of 7749 patients, we used a tailored patient-activation result letter accompanied by a bone health brochure to improve appropriate pharmacological treatment. Treatment rates, however, did not improve.

INTRODUCTION

Patients often do not know or understand their dual-energy x-ray absorptiometry (DXA) test results, which may lead to suboptimal care. We tested whether usual care augmented by a tailored patient-activation DXA result letter accompanied by an educational brochure would improve guideline-concordant pharmacological treatment compared to usual care only.

METHODS

We conducted a randomized, controlled, double-blinded, pragmatic clinical trial at three health care centers in the USA. We randomized 7749 patients ≥50 years old and presenting for DXA between February 2012 and August 2014. The primary clinical endpoint at 12 and 52 weeks post-DXA was receiving guideline-concordant pharmacological treatment. We also examined four of the steps along the pathway from DXA testing to that clinical endpoint, including (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options.

RESULTS

Mean age was 66.6 years, 83.8 % were women, and 75.3 % were non-Hispanic whites. Intention-to-treat analyses revealed that guideline-concordant pharmacological treatment was not improved at either 12 weeks (65.1 vs. 64.3 %, p = 0.506) or 52 weeks (65.2 vs. 63.8 %, p = 0.250) post-DXA, even though patients in the intervention group were more likely (all p < 0.001) to recall receiving their DXA results letter at 12 weeks, correctly identify their results at 12 and 52 weeks, have contact with their provider at 52 weeks, and have discussed their results with their provider at 12 and 52 weeks.

CONCLUSION

A tailored DXA result letter and educational brochure failed to improve guideline-concordant care in patients who received DXA.

Role of Side Effects, Physician Involvement, and Patient Perception in Non-Adherence with Oral Bisphosphonates

INTRODUCTION

The benefits of osteoporosis therapy are compromised by low adherence, thus requiring a better understanding of its barriers and unmet needs. The objective of this study was to assess reasons for non-adherence with oral bisphosphonates among osteoporotic women.

METHODS

A cross-sectional patient survey of women who initiated therapy with risedronate or alendronate between the years 2010 and 2012 were non-adherent [Medication Possession Ratio (MPR) <70%] or switched therapy within the first year. Survey participants were identified using Maccabi Health Services computerized database. Patients who gave informed consent completed a 20-min telephonic survey, assessing reasons for discontinuation or switching, including physician involvement, side effects, administration regimen, perceptions of bone health, and medications' efficacy.

RESULTS

The study population included 493 females (mean age = 66 ± 7) of whom 40% discontinued all anti-osteoporotic therapy (mean MPR = 19%), 9% remained on initial therapy (mean MPR = 47%), and 51% switched therapy (mean MPR = 62%). Family history, fracture history, socioeconomic status, and index drug class and frequency were similar in all groups. The most common reasons for switching or discontinuation of the first-line therapy were gastrointestinal side effects, such as heartburn, acid reflux or other (40.0%), and physician recommendation (26.7%). The major reasons for complete discontinuation of therapy were side effects (26.9%) and physician recommendation (20.0%). Perceived low importance was more commonly mentioned than high cost of medication (14% vs. 3%).

CONCLUSION

Our findings highlight the importance of low tolerability to non-adherence with osteoporosis therapy and underlines poor patients' awareness and sub-optimal physicians' involvement in conveying the importance of this therapy.

FUNDING

Merck & Co Inc.

The development and validation of the Memory Support Rating Scale

Patient memory for treatment information is poor, and worse memory for treatment information is associated with poorer clinical outcomes. Memory support techniques have been harnessed to improve patient memory for treatment. However, a measure of memory support used by treatment providers during sessions has yet to be established. The present study reports on the development and psychometric properties of the Memory Support Rating Scale (MSRS)-an observer-rated scale designed to measure memory support. Adults with major depressive disorder (MDD; N = 42) were randomized to either cognitive therapy plus memory support (CT + MS; n = 22) or cognitive therapy as-usual (CT-as-usual; n = 20). At posttreatment, patients freely recalled treatment points via the patient recall task. Sessions (n = 171) were coded for memory support using the MSRS, 65% of which were also assessed for the quality of cognitive therapy via the Cognitive Therapy Rating Scale (CTRS). A unidimensional scale composed of 8 items was developed using exploratory factor analysis, though a larger sample is needed to further assess the factor structure of MSRS scores. High interrater and test-retest reliabilities of MSRS scores were observed across 7 MSRS coders. MSRS scores were higher in the CT + MS condition compared with CT-as-usual, demonstrating group differentiation ability. MSRS scores were positively associated with patient recall task scores but not associated with CTRS scores, demonstrating convergent and discriminant validity, respectively. Results indicate that the MSRS yields reliable and valid scores for measuring treatment providers' use of memory support while delivering cognitive therapy. (PsycINFO Database Record

Learning cognitive behavior therapy

BACKGROUND AND OBJECTIVES

Progress toward establishing treatments for mental disorders has been good, particularly for cognitive behavior therapy (CBT). However, there is considerable room for improvement. The goal of this study was to begin the process of investigating the potential for improving treatment outcome via improving our understanding of learning processes.

METHODS

Individuals diagnosed with major depressive disorder (N = 20) participated in three computer-delivered CBT lessons for depression. Indices of learning were taken after each lesson, during three phone calls over the week following the lesson, and one week later. These were: (a) whether the participant thought about the lesson, (b) whether the participant applied the lesson, and (c) whether the participant generalized the lesson. Based on a predetermined list of therapy points (i.e., distinct ideas and principles), all participant responses were coded for the number of therapy points they thought about, applied, or generalized following each lesson.

RESULTS

Less than half of the thoughts and applications were accurate. Generalization, but not thoughts nor application, was associated with improved depression scores one week later.

LIMITATIONS

The follow up period was only one week later and there was no comparison group so we cannot speak to the long term outcome of these measures or generalize to other mental disorders.

CONCLUSIONS

These results point to the importance of improving transfer of learning in CBT and represent a promising first step toward the development of methods to study and optimize learning of CBT so as to improve patient outcomes.

Survey of risk factors for osteoporosis and osteoprotective behaviors among patients with epilepsy

The prevalence of risk factors for osteoporosis in persons with epilepsy, patients' awareness of their risk, and their engagement in osteoprotective behaviors were assessed in this study. Two hundred and sixty patients with epilepsy (F=51.5%, average age=42) completed a survey tool. Of 106 patients with a dual energy X-ray absorptiometry (DXA) result, 52% had low bone mineral density, and 11% had osteoporosis. The results suggest that the majority of patients with epilepsy do not engage in bone-protective behaviors. Those who have undergone a DXA scan may be more likely to take calcium and vitamin D supplementation compared with those who did not undergo a DXA scan, but they do not engage in other osteoprotective behaviors. Many patients did not accurately report their DXA results, indicating that better patient education is warranted.

Poor agreement between self-reported diagnosis and bone mineral density results in the identification of osteoporosis

Osteoporosis is a major health concern, estimated to affect millions worldwide. Bone mineral density (BMD) assessment is not practical for many large-scale epidemiological studies resulting in the reliance of self-report methods to ascertain diagnostic information. The aim of the study was to assess the validity of self-reported diagnosis of osteoporosis in a population-based study. This study examined data collected from 906 men and 843 women participating in the Geelong Osteoporosis Study. Osteoporosis was self-reported and compared against results of BMD scans of the hip and spine. Validity was examined by calculating sensitivity, specificity, positive predictive value, negative predictive value, and kappa statistic. Osteoporosis was self-reported by 118 (6.7%) participants and identified using BMD results for 64 (3.7%) participants. Specificity and negative predictive value were good (95.1% and 96.0%, respectively), whereas sensitivity and positive predictive value were poor (35.9% and 31.4%, respectively). The overall level of agreement (kappa) was 0.29. The results changed only slightly when we included participants with osteopenia and adult fracture as osteoporotic. Reliance on self-report methods to ascertain osteoporosis status is not recommended.

Improving bone mineral density reporting to patients with an illustration of personal fracture risk

Background

To determine patients’ preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations.

Methods

Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration.

Results

Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most “clear,” “clean,” and “easy to read”. The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category.

Conclusions

Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference.

Trial Registration

ClinicalTrials.gov Identifier: NCT01507662

Memory for therapy in bipolar disorder and comorbid insomnia

OBJECTIVE

To examine the extent to which patients recall the contents of therapy from 1 session to the next and to determine whether recall is associated with treatment outcome.

METHOD

Thirty interepisode individuals with bipolar disorder and comorbid insomnia (ages 21-62 years, 56.7% women, 56.7% Caucasian) participated in a randomized controlled trial of psychotherapies. Patients received either cognitive behavior therapy for insomnia (CBTI-BP; n = 17) or psychoeducation (PE; n = 13). At the beginning of each weekly session, patients freely recalled as many therapy points (i.e., distinct ideas, principles, and experiences) as they could from their previous session. After each session, therapists recorded a list of all therapy points delivered. Treatment outcome was measured via the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Patient-Reported Outcome Measurement Info System-Sleep, and Quality of Life-Sleep (QOL-Sleep), administered pre- and posttreatment, and treatment evaluation questions administered posttreatment.

RESULTS

Patients recalled 19.6% to 36.9% of therapy points listed by therapists. Raw numbers of therapy points recalled were positively correlated with reductions in ISI scores and gains in QOL-Sleep and with most treatment evaluation questions. Percentages of therapy points recalled were positively correlated with gains in QOL-Sleep but with no other sleep outcome measures or any of the treatment evaluation questions. Patients in CBTI-BP recalled more therapy points than did those in PE but did not differ in the percentages of points recalled.

CONCLUSIONS

Memory for therapy is poor. The amount of content recalled is positively associated with treatment outcome. Enhancing memory for therapy might play a key role in improving treatment outcome.

Improving Outcome of Psychosocial Treatments by Enhancing Memory and Learning

Mental disorders are prevalent and can lead to significant impairment. Some progress has been made toward establishing treatments; however, effect sizes are small to moderate, gains may not persist, and many patients derive no benefit. Our goal is to highlight the potential for empirically supported psychosocial treatments to be improved by incorporating insights from cognitive psychology and research on education. Our central question is: If it were possible to improve memory for the content of sessions of psychosocial treatments, would outcome substantially improve? We leverage insights from scientific knowledge on learning and memory to derive strategies for transdiagnostic and transtreatment cognitive support interventions. These strategies can be applied within and between sessions and to interventions delivered via computer, the Internet, and text message. Additional novel pathways to improving memory include improving sleep, engaging in exercise, and using imagery. Given that memory processes change across the lifespan, services to children and older adults may benefit from different types and amounts of cognitive support.

Abandoned acid? Understanding adherence to bisphosphonate medications for the prevention of osteoporosis among older women: a qualitative longitudinal study

BACKGROUND

There is significant morbidity and mortality caused by the complications of osteoporosis, for which ageing is the greatest epidemiological risk factor. Preventive medications to delay osteoporosis are available, but little is known about motivators to adhere to these in the context of a symptomless condition with evidence based on screening results.

AIM

To describe key perceptions that influence older women's adherence and persistence with prescribed medication when identified to be at a higher than average risk of fracture.

DESIGN OF STUDY

A longitudinal qualitative study embedded within a multi-centre trial exploring the effectiveness of screening for prevention of fractures.

SETTING

Primary care, Norfolk. United Kingdom.

METHODS

Thirty older women aged 70-85 years of age who were offered preventive medication for osteoporosis and agreed to undertake two interviews at 6 and 24 months post-first prescription.

RESULTS

There were no overall predictors of adherence which varied markedly over time. Participants' perceptions and motivations to persist with medication were influenced by six core themes: understanding adherence and non-adherence, motivations and self-care, appraising and prioritising risk, anticipating and managing side effects, problems of understanding, and decision making around medication. Those engaged with supportive professionals could better tolerate and overcome barriers such as side-effects.

CONCLUSIONS

Many issues are raised following screening in a cohort of women who have not previously sought advice about their bone health. Adherence to preventive medication for osteoporosis is complex and multifaceted. Individual participant understanding, choice, risk and perceived need all interact to produce unpredictable patterns of usage and acceptability. There are clear implications for practice and health professionals should not assume adherence in any older women prescribed medication for the prevention of osteoporosis. The beliefs and motivations of participants and their healthcare providers regarding the need to establish acceptable medication regimes is key to promoting and sustaining adherence.

FRAX provides robust fracture prediction regardless of socioeconomic status

We investigated the fracture risk assessment tool (FRAX) Canada calibration and discrimination according to income quintile in 51,327 Canadian women, with and without a competing mortality framework. Our data show that, under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of socioeconomic status (SES).

INTRODUCTION

FRAX® predicts 10-year fracture risk. Social factors may independently affect fracture risk. We investigated FRAX calibration and discrimination according to SES.

METHODS

Women aged ≥50 years with baseline femoral neck bone mineral density (BMD) were identified from the Manitoba Bone Density Program, Canada (n = 51,327), 1996-2011. Mean household income, extracted from 2006 census files, was categorized into quintiles. Ten-year fracture probabilities were calculated using FRAX Canada. Incident non-traumatic fractures were studied in relation to income quintile in adjusted Cox proportional hazards models. We compared observed versus predicted fractures with and without a competing mortality framework.

RESULTS

During mean 6.2 ± 3.7 years of follow up, there were 6,392 deaths, 3,723 women with ≥1 major osteoporotic fracture (MOF), and 1,027 with hip fractures. Lower income was associated with higher risk for death, MOF, and hip fracture in adjusted models (all p < 0.005). More women in income quintile 1 (lowest) versus quintile 5 experienced death (19 vs. 8%), MOF (10 vs. 6%), or hip fracture (3.0 vs. 1.3 %) (all p ≤ 0.001). Adjustment for competing mortality mitigated the effect of SES on FRAX calibration, and good calibration was observed. FRAX provided good fracture discrimination for MOF and hip fracture within each income quintile (all p < 0.001). Area under the curve was slightly lower for income quintiles 1 versus 5 for FRAX with BMD to predict MOF (0.68, 95% CI 0.66-0.70 vs. 0.71, 95% CI 0.69-0.74) and hip fracture (0.79, 95% CI 0.76-0.81 vs. 0.87, 95% CI 0.84-0.89).

CONCLUSION

Increased fracture risk in individuals of lower income is offset by increased mortality. Under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of SES.

Developing a bone mineral density test result letter to send to patients: a mixed-methods study

PURPOSE

To use a mixed-methods approach to develop a letter that can be used to notify patients of their bone mineral density (BMD) results by mail that may activate patients in their bone-related health care.

PATIENTS AND METHODS

A multidisciplinary team developed three versions of a letter for reporting BMD results to patients. Trained interviewers presented these letters in a random order to a convenience sample of adults, aged 50 years and older, at two different health care systems. We conducted structured interviews to examine the respondents' preferences and comprehension among the various letters.

RESULTS

A total of 142 participants completed the interview. A majority of the participants were female (64.1%) and white (76.1%). A plurality of the participants identified a specific version of the three letters as both their preferred version (45.2%; P<0.001) and as the easiest to understand (44.6%; P<0.01). A majority of participants preferred that the letters include specific next steps for improving their bone health.

CONCLUSION

Using a mixed-methods approach, we were able to develop and optimize a printed letter for communicating a complex test result (BMD) to patients. Our results may offer guidance to clinicians, administrators, and researchers who are looking for guidance on how to communicate complex health information to patients in writing.

May you never forget what is worth remembering: the relation between recall of medical information and medication adherence in patients with inflammatory bowel disease

BACKGROUND

Nurses play an important role in educating patients with inflammatory bowel disease (IBD) about immunosuppressive or biological therapy during prescribing consultations. The education for immunosuppressive or biological therapy often contains complex information. Poor medication intake behavior can be a result of poor information recall, which is often caused by complex information.

OBJECTIVES

The aim of this study is to measure information recall by IBD patients, and to investigate the relationship between recall and medication intake behavior.

METHODS

Data collection took place from September 2009 until March 2012. Eight nurses at six Dutch hospitals and 68 IBD patients participated in this study. Prescribing consultations were videotaped and patients completed surveys immediately after the consultation and after three weeks. Information recall was based on the actual communication in video recordings of the consultations. Medication intake behavior was measured by self-report.

RESULTS

Issues most frequently discussed were side effects and how patients had to administer their medication. IBD patients could reproduce half of the information. Recall of medical information was a significant predictor for self-reported medication intake behavior (β=0.37, p=0.007), indicating that higher recall of medical information relates to improved self-reported medication intake behavior.

CONCLUSIONS

This study revealed a significant relation between IBD patients' recall and self-reported medication intake behavior. When educating IBD patients about their newly prescribed medication, providers should consider recall-promoting techniques to increase medication intake behavior.

Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review

BACKGROUND

To investigate adherence and patient-specific factors associated with poor compliance with osteoporosis regimens among men.

METHODS

In this retrospective chart review study, we collected data on male patients with osteoporosis treated in accordance with therapeutic recommendations. Adherence was determined by the compliance and persistence of those patients who had been dispensed an osteoporosis regimen after an index prescription. All osteoporosis regimens were considered equivalent for the purpose of investigating adherence.

RESULTS

The prescriptions of 333 males met the inclusion criteria for data collection. The mean age was 68.6 ± 10.4 years. The median medication possession ratio (MPR, %) at years 1 and 2 was 90.1% (interquartile range (IQR) 19-100) and 53.7% (IQR 10.4-100), respectively; 52.3% of male patients at year 1 and 37.5% at year 2 had good compliance (defined as a MPR≧80%). The 1- and 2-year persistence rates were 45.9% and 30.0%, respectively. Patient-specific factors associated with poor compliance (MPR < 80%) during year 1 were first prescriptions given by orthopedists (odds ratio (OR) = 2.67; 95% confidence interval (CI) = 1.58-4.53; adjusted OR = 2.30, 95% CI = 1.26-4.22, p = 0.007). Male patients with rheumatoid arthritis (RA) (OR = 0.22, 95% CI = 0.06-0.78, adjusted OR = 0.19, 95% CI = 0.04-0.81, p = 0.025) and baseline bone mineral density (BMD) measurements (OR = 0.52, 95% CI = 0.32-0.85; adjusted OR = 0.51; 95% CI = 0.28-0.93, p = 0.029) were less likely to have poor compliance.

CONCLUSIONS

Adherence to osteoporosis regimens in males was suboptimal in our study. Poor compliance was more likely in prescription of the first anti-osteoporotic regimen by an orthopedist. Men with RA and BMD measurements before therapy had a lower risk of non-adherence. Healthcare professionals need to target patients with specific factors to improve adherence to osteoporotic regimens.

Osteoporosis medication adherence: physician perceptions vs. patients' utilization

Few data are available on physician perceptions of osteoporosis medication adherence. This study compared physician-estimated medication adherence with adherence calculated from their patients' pharmacy claims. Women aged ≥45 years, with an osteoporosis-related pharmacy claim between January 1, 2005 and August 31, 2008, and continuous coverage for ≥12 months before and after first (index) claim, were identified from a commercial health plan population. Prescribing physicians treating ≥5 of these patients were invited to complete a survey on their perception of medication adherence and factors affecting adherence in their patients. Pharmacy claims-based medication possession ratio (MPR) was calculated for the 12-month post-index period for each patient. Physicians who overestimated the percentage of adherent (MPR ≥0.8) patients by ≥10 points were considered "optimistic". Logistic regression assessed physician characteristics associated with optimistic perception of adherence. A total of 376 (17.2%) physicians responded to the survey; 62.0% were male, 58.2% were aged 45 to 60 years, 55.3% had ≥20 years of practice, and 35.4% practiced in an academic setting. Participating physicians prescribed osteoporosis medications for 2748 patients with claims data (mean [SD] age of 62.0 [10.6] years). On average, physicians estimated 67.2% of their patients to be adherent; however, only 40% of patients were actually adherent based on pharmacy data. Optimistic physicians (73.4%) estimated 71.9% of patients to be adherent while only 32.2% of their patients were adherent based on claims data. Physicians in academic settings were more likely to be optimistic than community-based physicians (odds ratio 1.69, 95% CI: 1.01, 2.85). Overestimation of medication adherence may impede physicians' ability to provide high quality care for their osteoporosis patients.

A systematic literature review of psychosocial and behavioral factors associated with initial medication adherence: a report of the ISPOR medication adherence & persistence special interest group

OBJECTIVES

Numerous factors influencing medication adherence in chronically ill patients are well documented, but the paucity of studies concerning initial treatment course experiences represents a significant knowledge gap. As interventions targeting this crucial first phase can affect long-term adherence and outcomes, an international panel conducted a systematic literature review targeting behavioral or psychosocial risk factors.

METHODS

Eligible published articles presenting primary data from 1966 to 2011 were abstracted by independent reviewers through a validated quality instrument, documenting terminology, methodological approaches, and factors associated with initial adherence problems.

RESULTS

We identified 865 potentially relevant publications; on full review, 24 met eligibility criteria. The mean Nichol quality score was 47.2 (range 19-74), with excellent reviewer concordance (0.966, P < 0.01). The most prevalent pharmacotherapy terminology was initial, primary, or first-fill adherence. Articles described the following factors commonly associated with initial nonadherence: patient characteristics (n = 16), medication class (n = 12), physical comorbidities (n = 12), pharmacy co-payments or medication costs (n = 12), health beliefs and provider communication (n = 5), and other issues. Few studies reported health system factors, such as pharmacy information, prescribing provider licensure, or nonpatient dynamics.

CONCLUSIONS

Several methodological challenges synthesizing the findings were observed. Despite implications for continued medication adherence and clinical outcomes, relatively few articles directly examined issues associated with initial adherence. Notwithstanding this lack of information, many observed factors associated with nonadherence are amenable to potential interventions, establishing a solid foundation for appropriate ongoing behaviors. Besides clarifying definitions and methodology, future research should continue investigating initial prescriptions, treatment barriers, and organizational efforts to promote better long-term adherence.

Patient recall of surgical information after day case knee arthroscopy

PURPOSE

Day case knee arthroscopy is frequently performed on dedicated lists designed to optimise the throughput of patients. This could affect patient recall of clinical information with clinical, ethical and medicolegal consequences. The purpose of this study was to assess patient recall after knee arthroscopy and identify potential contributory factors.

METHODS

Seventy-two patients undergoing day case knee arthroscopy were provided with information about their surgery post-operatively and tested for recall of the information prior to discharge. All patients underwent cognitive assessment when information was delivered and again when tested. Patient recall was correlated with demographic and anaesthetic factors and a multivariate regression model was used to identify risk factors for reduced recall.

RESULTS

Recall overall was poor. Significant independent risk factors for reduced recall were reduced cognitive state at the time of information delivery and a shorter time between surgery and information delivery. Duration of anaesthesia, use of sedatives and use of opiate analgesia were not significantly correlated with recall.

CONCLUSIONS

Information recall after day case knee athroscopy may be suboptimal. Allowing more time between surgery and information delivery may improve recall. However, this may be difficult during the course of a busy list and surgeons should consider using additional techniques to improve patient recall after surgery to reduce the risk of patient anxiety or non-compliance.

LEVEL OF EVIDENCE

IV.

Adherence with medications used to treat osteoporosis: behavioral insights

Non-persistence (never starting or stopping medication prematurely) and non-compliance (taking medication inappropriately) with fracture prevention medication among those at high risk of fracture remain significant barriers to optimal reduction of osteoporotic fractures. Current research suggest that for patients to persist and comply with prescriptions for fracture prevention medication, they need to believe that they are at significant risk of fracture, that the prescribed medication can safely reduce their risk of fracture without exposing them to long-term harm, that equally effective non-medicinal therapies are not available, and that they can successfully execute medication use in the context of their daily task demands. Further research is needed to understand; a) the mental models of osteoporosis, fractures, and medications used to treat osteoporosis that patients employ when making decisions as to whether or not to take fracture prevention medication; and b) how patients arbitrage information from various sources (health care providers, family, friends, and other sources) to formulate their beliefs about osteoporosis and medications used to treat it.

Awareness of osteoporosis, risk and protective factors and own diagnostic status: a cross-sectional study

We conducted a cross-sectional study of the understanding on osteoporosis amongst community-dwelling geriatric patients. Patient understanding on the pathology, risk factors and its complications was suboptimal, but better amongst women and persons with diagnosed osteoporosis. Improving patient osteoporosis education may lead to improved compliance with preventive and therapeutic measures.

PURPOSE

Osteoporosis is often preventable and treatable. Establishing levels of understanding in an Irish population will help inform future public and patient education.

METHODS

We conducted a cross-sectional survey of 126 randomly selected geriatric day hospital patients, interviewing next of kin where abbreviated mental test score was <6. Questions assessed awareness of (1) basic pathology, (2) predisposing and protective factors, (3) complications and (4) personal osteoporosis status and treatment.

RESULTS

Participants included 103 patients and 23 carers; 78.6 % were female; patients' mean age was 81.6 years. Of the patients surveyed, 87.3 % had heard of osteoporosis; 56.1 % knew affected bone; and 30.2 % were cognisant of architectural change. About 65.9 % reported that a doctor had never discussed the condition; 92.9 % correctly identified whether diagnosed with osteoporosis, and >96 % correctly identified their treatment status. Rates of risk factor identification were as follows: 88.9 % for ageing, 83.8 % female gender, 65.1 % smoking, 62.4 % low BMI and 51.6 % alcohol excess; <10 % identified other risk factors. Awareness of complications ranged from 91.3 % for fractures to 44.4 % for height loss. Awareness of protective factors (calcium/vitamin D-rich food, medication and exercise) was >85 % for each. More women had heard of osteoporosis (p = 0.02), knew affected bone (p = 0.005) and recognised gender as a risk factor (p = 0.015) and pain (p = 0.05) or kyphosis (p = 0.014) as complications. Osteoporotic patients (N = 38) were more likely to know it as affected bone (p = 0.006). Amongst patients surveyed [abbreviated mental test score (AMTS) 6-10], AMTS score did not predict understanding. Age did not predict understanding, nor were next of kin more likely to understand osteoporosis than patients.

CONCLUSION

There is scope for enhancing patient osteoporosis education, which may improve compliance with preventive and therapeutic measures.

The PAADRN study: a design for a randomized controlled practical clinical trial to improve bone health

INTRODUCTION

To describe the rationale and design of an NIH funded randomized controlled trial: the Patient Activation after DXA Result Notification (PAADRN) study. The aim of this trial is to evaluate the effect that a direct mailing of Dual-Energy X-ray Absorptiometry (DXA) results from bone density testing centers to patients will have on patients' knowledge, treatment and self-efficacy.

METHODS

We will enroll approximately 7500 patients presenting for DXA at three study sites, the University of Iowa, the University of Alabama at Birmingham, and Kaiser Permanente of Atlanta, Georgia. We will randomize providers (and their respective patients) to either the intervention arm or usual care. Patients randomized to the intervention group will receive a letter with their DXA results and an educational brochure, while those randomized to usual care will receive their DXA results according to standard practice. The seven discrete outcomes are changes from baseline to 12-weeks and/or 52-weeks post-DXA in: (1) guideline concordant pharmacologic and non-pharmacologic therapy; (2) knowledge of DXA results; (3) osteoporosis-specific knowledge; (4) general health-related quality of life; (5) satisfaction with bone-related health care, (6) patient activation; and, (7) osteoporosis-specific self-efficacy.

CONCLUSION

This trial will offer evidence of the impact of a novel approach-direct-to-patient mailing of test results-to improve patient activation in their bone health care. The results will inform clinical practice for the communication of DXA and other test results.

Treatment satisfaction and persistence among postmenopausal women on osteoporosis medications: 12-month results from POSSIBLE US™

SUMMARY

Women in POSSIBLE US™ who expressed greater treatment satisfaction at study entry were more likely to persist with osteoporosis therapy over a 1-year period. Lower satisfaction among women with moderate/severe side effects increased the risk of discontinuation/switching by 67%. Treatment satisfaction and side effect experience influence osteoporosis medication adherence.

INTRODUCTION

Non-adherence is common among women using postmenopausal osteoporosis (PMO) medications. We describe the association between treatment satisfaction, measured with the Treatment Satisfaction Questionnaire for Medication (TSQM), and the risk of discontinuation/switching PMO medications using patient-reported data from a large, longitudinal cohort study.

METHODS

Data from 2,405 participants in the Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US™) Study were evaluated. Cox proportional hazards regression was used to estimate hazard ratios (HR) for the association between treatment satisfaction at study entry and self-reported discontinuation/switching of pharmacologic PMO medications over a 1-year follow-up period. Logistic regression was used to evaluate relationships between treatment satisfaction, lifestyle behaviors, and compliance with bisphosphonate dosing instructions.

RESULTS

Median TSQM scores were highest (indicating greatest satisfaction) for the side effects domain [n = 1,182; median = 87.5 (Q1 = 75.0, Q3 = 100.0)] and lowest for global satisfaction [n = 2,340; median = 64.0 (Q1 = 55.7, Q3 = 77.7)]. Median scores decreased for the side effects and global satisfaction domains as patient-reported side effect severity increased. Women with higher satisfaction were less likely to discontinue/switch medications than women with lower scores (adjusted HRs for convenience 0.73, 95% CI = 0.63-0.85; effectiveness 0.82, 95% CI = 0.70-0.97; and global satisfaction 0.73, 95% CI = 0.63-0.85). Lower treatment satisfaction was particularly influential among women who reported moderate/severe side effects (HR = 0.60, 95% CI = 0.37-0.97).

CONCLUSIONS

Lower treatment satisfaction was associated with a 22% (1/0.82) to 67% (1/0.60) increased risk of discontinuation/switching osteoporosis medication during 1 year of follow-up.

Breast cancer patients' recall of receiving patient assistance services

Background

The objective of this study was to assess factors that affect breast cancer patients’ recall of patient assistance services.

Methods

We surveyed newly-diagnosed breast cancer patients and compared recall of receiving patient assistance services at 2 weeks and 6 months in a patient-assistance randomized controlled trial aimed to connect women to such programs. The intervention group received information about assistance programs targeted to their practical, psychosocial, and/or informational needs; the control group received a Department of Health pamphlet about breast cancer and its treatment, including a list of patient assistance services.

Findings

Of 333 women, 210 (63%) reported informational, 183 (55%) psychosocial and 177 (53%) practical needs. At 2 weeks, 96% (202/210) of women with informational needs reported receiving informational material but at 6 months, recall dropped to 69% (140/210). All women whose informational needs were met recalled receiving information, compared to 31% whose needs were unmet (p < 0.0001). Of 109 intervention patients with psychosocial or practical needs, 77% (79) contacted a program specified in their action plan at 2 weeks. However, at 6 months, only 39% (31/79) recalled contacting a program. Women without recall were less likely to report having their needs met (6% vs. 58%; p < 0.001).

Conclusions

Recall of patient assistance services is strongly related to having needs met. Use of patient surveys to evaluate utilization or impact of such programs should be used with caution due to poor patient recall.

Clinical Trials # NCT00233077

http://www.clinicaltrials.gov/ct2/show/NCT00233077?term=Nina+Bickell&rank=2

Osteoporosis pharmacotherapy following bone densitometry: importance of patient beliefs and understanding of DXA results

SUMMARY

Persistence with osteoporosis therapy remains low and identification of factors associated with better persistence is essential in preventing osteoporosis and fractures. In this study, patient understanding of dual energy X-ray absorptiometry (DXA) results and beliefs in effects of treatment were associated with treatment initiation and persistence.

INTRODUCTION

The purpose of this study is to examine patient understanding of their DXA results and evaluate factors associated with initiation of and persistence with prescribed medication in first-time users of anti-osteoporotic agents. Self-reported DXA results reflect patient understanding of diagnosis and may influence acceptance of osteoporosis therapy. To improve patient understanding of DXA results, we provided written information to patients and their referring general practitioner (GP), and evaluated factors associated with osteoporosis treatment initiation and 1-year persistence.

METHODS

Information on diagnosis was mailed to 1,000 consecutive patients and their GPs after DXA testing. One year after, a questionnaire was mailed to all patients to evaluate self-report of DXA results, drug initiation and 1-year persistence. Quadratic weighted kappa was used to estimate agreement between self-report and actual DXA results. Multivariable logistic regression was used to evaluate predictors of understanding of diagnosis, and correlates of treatment initiation and persistence.

RESULTS

A total of 717 patients responded (72%). Overall, only 4% were unaware of DXA results. Agreement between self-reported and actual DXA results was very good (κ = 0.83); younger age and glucocorticoid use were associated with better understanding. Correctly reported DXA results was associated with treatment initiation (OR 4.3, 95% CI 1.2-15.1, p = 0.02), and greater beliefs in drug treatment benefits were associated with treatment initiation (OR 1.4, 95%CI 1.1-1.9, p = 0.006) and persistence with therapy (OR 1.8, 95% CI 1.2-2.7, p = 0.006).

CONCLUSION

Our findings suggest that written information provides over 80% of patients with a basic understanding of their DXA results. Communicating results in writing may improve patient understanding thereby also improve osteoporosis management and prevention.

Adherence to osteoporosis drugs and fracture prevention: no evidence of healthy adherer bias in a frail cohort of seniors

We examined new users of osteoporosis drugs among seniors in Pennsylvania and found no evidence of healthy adherer bias on observed associations between adherence to treatment and non-vertebral fracture risk; we document fracture reduction with better adherence to bisphosphonates, yet no fracture reduction with better adherence to calcitonin or raloxifene.

INTRODUCTION

We examined the potential for "healthy adherer bias" when studying the effects of adherence to osteoporosis pharmacotherapy on fracture risk. Based on clinical trial evidence, bisphosphonates, calcitonin, and raloxifene reduce vertebral fracture risk; yet only bisphosphonates are documented to reduce non-vertebral fracture risk.

METHODS

This is a cohort study of older women in Pennsylvania who initiated osteoporosis drugs between 1995 and 2005. We included new users of bisphosphonates, calcitonin, and raloxifene. Adherence was categorized based on a measure of compliance as high [proportion of days covered (PDC) ≥ 80%], intermediate (50% < PDC < 80%), or low (PDC ≤ 50%) according to a 180-day ascertainment period. Non-vertebral fracture rates within 365 days after the ascertainment period were compared between adherence categories (reference = low) using Cox proportional hazard models and adjusting for fracture risk factors. Primary and secondary prevention cohorts were examined separately. Adherence to calcitonin and raloxifene were control analyses.

RESULTS

We found little difference in fracture rates between levels of adherence to calcitonin, bisphosphonates for primary prevention, or raloxifene for secondary prevention. We document lower fracture rates among high versus low adherent bisphosphonate users for secondary prevention (HR = 0.53, 95%CI = 0.38-0.74) and higher fracture rates among high versus low adherent raloxifene users for primary prevention (HR = 2.01, 95%CI = 1.04-3.87).

CONCLUSIONS

We document little evidence of healthy adherer bias when studying the association between better adherence to osteoporosis drugs and fracture risk reduction, with only better adherence to bisphosphonates reducing fracture risk. The higher fracture risk among highly adherent raloxifene users for primary prevention is likely due to residual confounding.

The BMD muddle: the disconnect between bone densitometry results and perception of bone health

We conducted a phenomenological qualitative study to examine fracture patients' interpretations of their most recent bone densitometry results and perceptions of their current bone health. English-speaking outpatients who had sustained a fragility fracture in the previous 18-24 mo and reported having at least 1 previous bone mineral density (BMD) test were eligible. Data were collected through semistructured interviews in patients' homes. Patients were asked to describe their most recent BMD test results and perception of their bone health status based on these results. Eighteen patients (14 women and 4 men) aged 49-82 yr were recruited. BMD results showed bone density in patients to be normal (n=4), osteopenic (n=9), and osteoporotic (n=5). A correct diagnosis was recalled by 6 patients. Two common interpretations of BMD test results emerged: (1) no news was considered to be good news (n=9) and (2) evidence of compromised bone health was not considered to be serious or accurate (n=6). Medication adherence did not appear to be associated with perception of bone health or actual BMD results. Patients' perceptions of their current bone health did not correspond to the results of their most recent BMD test. Standardized bone densitometry reporting may improve patients' understanding of their bone health.