Differences in adherence and motivation to HIV therapy--two independent assessments in 1998 and 2002

Natural history, with clinical, biochemical, and molecular characterization of classical homocystinuria in the Qatari population

Classical homocystinuria (HCU) is the most common inborn error of metabolism in Qatar, with an incidence of 1:1800, and is caused by the Qatari founder p.R336C mutation in the CBS gene. This study describes the natural history and clinical manifestations of HCU in the Qatari population. A single center study was performed between 2016 and 2017 in 126 Qatari patients, from 82 families. Detailed clinical and biochemical data were collected, and Stanford-Binet intelligence, quality of life and adherence to treatment assessments were conducted prospectively. Patients were assigned to one of three groups, according to the mode of diagnosis: (a) late diagnosis group (LDG), (b) family screening group (FSG), and (c) newborn screening group (NSG). Of the 126 patients, 69 (55%) were in the LDG, 44 (35%) in the NSG, and 13 (10%) in the FSG. The leading factors for diagnosis in the LDG were ocular manifestations (49%), neurological manifestations (45%), thromboembolic events (4%), and hyperactivity and behavioral changes (1%). Both FSG and NSG groups were asymptomatic at time of diagnosis. NSG had significantly higher intelligence quotient, quality of life, and adherence values compared with the LDG. The LDG and FSG had significantly higher methionine levels than the NSG. The LDG also had significantly higher total homocysteine levels than the NSG and FSG. Regression analysis confirmed these results even when adjusting for age at diagnosis, current age, or adherence. These findings increase the understanding of the natural history of HCU and highlight the importance of early diagnosis and treatment. SYNOPSIS: A study in 126 Qatari patients with HCU, including biochemical, clinical, and other key assessments, reveals that patients with a late clinical diagnosis have a poorer outcome, hereby highlighting the importance of early diagnosis and treatment.

Variation in Adherence Measures to Imatinib Therapy

PURPOSE

The introduction of tyrosine kinase inhibitors has transformed the care of patients with chronic myeloid leukemia, with survival approaching that of healthy individuals. Current-day challenges in chronic myeloid leukemia care include adherence to tyrosine kinase inhibitor therapy. We studied adherence from resource-constrained settings and tried to analyze the factors responsible for nonadherence in these individuals. We also correlated adherence to current molecular status.

PATIENTS AND METHODS

This was a single-center, cross-sectional, observational study from north India. It consisted of a questionnaire-based survey in which a one-to-one interview technique was used by trained nursing staff administering the Modified Morisky Adherence Scale (MMAS-9) questionnaire. Adherence was also measured on the basis of physician's assessment. JMP 13.0.0 was used for statistical analysis.

RESULTS

A total of 333 patients with a median age of 42 years were included in the study. The median BCR-ABL/ABL ratio (IS) was 0.175 (0.0 to 98.0). The mean MMAS-9 score was 11 ± 2. Adherence was seen in 54.95% on the basis of MMAS-9, whereas physician's assessment reported adherence in 90.39% of patients. Using the χ2 test, no relationship was found between the two assessment techniques. There was a significant relationship between major molecular response status and adherence by physician's assessment and MMAS-9 ( P < .001). Bivariate analysis by logistic fit showed a good relation between the MMAS-9 score and the BCR-ABL/ABL ratio (IS), χ2 (1,220) = 135.45 ( P < .001). On multivariate analysis, enrolment in the Novartis Oncology Access program (a patient assistance program) was significantly associated with adherence ( P = .012).

CONCLUSION

This study highlights the lack of adherence in real-world settings and the various factors responsible. Such studies are important from a public health services perspective in various settings around the world because they may lead to corrective action being taken at the institutional level.

Is Adherence to Imatinib Mesylate Treatment Among Patients with Chronic Myeloid Leukemia Associated with Better Clinical Outcomes in Qatar?

BACKGROUND

Despite the revolutionary success of introducing tyrosine kinase inhibitors (TKIs), such as imatinib mesylate (IM), for treating chronic myeloid leukemia (CML), a substantial proportion of patients' treatments fail.

AIM

This study investigates the correlation between patient adherence and failure of TKIs' treatment in a follow-up study.

METHODS

This is a follow-up study of a new cohort of CML patients. Adherence to IM is assessed using the Medication Event Monitoring System (MEMS 6 TrackCap, AARDEX Ltd). The 9-item Morisky Medication Adherence Scale, medication possession ratio (MPR) calculation, and the electronic medical records are used for identifying potential factors that influence adherence. Clinical outcomes are assessed according to the European Leukemia Net 2013 guidelines via reverse transcriptase quantitative polymerase chain reaction measurement of the level of BCR-ABL1 transcripts in peripheral blood. Response is classified at the hematological, cytogenetic, and molecular levels into optimal, suboptimal, or failure.

RESULTS

A total of 36 CML patients (5 citizens and 31 noncitizen residents) consented to participate in the study. The overall mean MEMS score was 89. Of the 36 patients, 22 (61%) were classified as adherent (mean: 95) and 14 (39%) were classified as nonadherent (mean: 80.2). Adherent patients were significantly more likely to obtain optimal response (95%) compared to the nonadherent group (14.3%; P < 0.0001). The rate of poor adherence was as high as 39% using MEMS, which correlates with 37% treatment failure rate. The survey results show that 97% of patients increased the IM dose by themselves when they felt unwell and 31% of them took the missing IM dose when they remembered. Other factors known to influence adherence show that half of patients developed one or more side effects, 65% of patients experienced lack of funds, 13% of patients declared unavailability of the drug in the NCCCR pharmacy, and 72% of patients believed that IM would cure the disease. The MPR results reveal that 16% of patients had poor access to treatment through the hospital pharmacy.

DISCUSSION AND CONCLUSION

This is the first prospective study to evaluate CML patients' adherence and response to IM in Qatar. The high rate of treatment failure observed in Qatar is explained by poor adherence. An economic factor (unaffordable drug prices) is one of the main causes of nonadherence and efforts should be made locally to improve access to medication for cancer diseases. Other risk factors associated with poor adherence could be improved by close monitoring and dose adjustment. Monitoring risk factors for poor adherence and patient education that include direct communication between the health-care teams, doctors, nurses, pharmacists, and patients are essential components for maximizing the benefits of TKI therapy and could rectify this problem. The preliminary results show that patients' response to treatment may be directly linked to patients' adherence to treatment. However, further in-depth and specific analysis may be necessary in a larger cohort.

Examining the interplay between depression, motivation, and antiretroviral therapy adherence: a social cognitive approach

A large body of research identifies depressive symptoms as a barrier to optimal antiretroviral therapy (ART) adherence, whereas treatment motivation has been characterized as a facilitator. There is evidence, however, that these patterns may not hold for some ART patients despite the widespread use of motivational techniques aimed at promoting adherence. Little is known about how the interplay between different levels of depressive symptoms and variations in the types and levels of motivation may influence ART adherence. The purpose of this study was to examine the relationship between depressive symptoms, two types of motivation, and adherence, with self-efficacy as a mediator. The sample consisted of 121 ART patients who reported various levels of depressive symptoms (mean age = 41 years; 84% African-American; and 68% female). Path analysis revealed that self-efficacy fully mediated the relationship between the three predictor variables (depressive symptoms, intrinsic motivation, and extrinsic motivation) and adherence, χ²(3, N = 121) = .78, RMSEA = .00, SRMR = .02, CFI = 1.00, NNFI = 1.06. Findings suggest that interventions using motivational techniques to build adherence among patients with varying levels of depressive symptoms should address the role of treatment self-efficacy to improve their effectiveness.

The 8-item Morisky Medication Adherence Scale translated in German and validated against objective and subjective polypharmacy adherence measures in cardiovascular patients

RATIONALE, AIMS AND OBJECTIVES

To translate in German the 8-item Morisky Medication Adherence Scale (MMAS-8D). To validate it against objective and subjective measures of adherence in cardiovascular patients with polypharmacy.

METHODS

A standard forward-backward procedure was used to translate the MMAS-8 into German. Validation took place on a convenience sample of ambulatory patients on chronic antiplatelet therapy between June 2010 and June 2011. Objective adherence was obtained from electronically monitored multi-drug punch cards. Internal consistency was assessed using Cronbach's alpha coefficient, construct validity using exploratory factor analyses and correlations between MMAS-8D and related measures. Convergent validity was assessed with a subjective questionnaire about beliefs about medicines (BMQ Specific, two sub-scales).

RESULTS

A total of 70 patients were included (mean age 65.7 ± 9.9 years; 31.4% women). The mean score of the MMAS-8D was 7.5 (SD 0.8; range 4.5-8). Moderate internal consistency (alpha = 0.31) was observed due to multidimensionality of the scale. Factor analysis yielded four components that accounted for 71.7% of the total variance. Convergent validity was supported by significant correlations with BMQ Necessity (r = 0.31, P < 0.01), BMQ Concerns (r = -0.16, P < 0.05) and with electronic adherence reports (U-values 44 and 471, P < 0.05). Platelet aggregation values were within therapeutic range for 80% of the patients. Blood values of the antiplatelet agent within therapeutic range were associated with a higher MMAS-8D score (U-value 125, P < 0.05).

CONCLUSIONS

The German MMAS-8 appears to be a reliable instrument to catch medication adherence in cardiovascular patients. It may be useful in patients with chronic therapy for detecting non-adherence.

Frequency and predictors of patient deviation from prescribed opioids and barriers to opioid pain management in patients with advanced cancer

CONTEXT

Approximately 80% of patients with advanced cancer report pain and receive opioids. Information is limited about deviations from prescribed opioid doses and barriers to pain control, but poor opioid adherence has been reported in 49%-70% of patients.

OBJECTIVES

To evaluate the frequency and severity of self-reported opioid deviation and barriers to opioid pain management in outpatients with advanced cancer.

METHODS

We surveyed 198 patients and collected pain scores (0-10), prescribed opioid dose, confidential patient-reported opioid prescription dose and intake (as long as there was no severe opioid deviation), barriers to pain management (Barriers Questionnaire-II [BQ-II]) scores, and adherence scores. Opioid deviation was defined as <70% or >130% of the prescribed dose.

RESULTS

Median patient age was 55 years; 91 (46%) were female. Median pain intensity and morphine equivalent daily dose were 4 (interquartile range=3-7) and 120mg (interquartile range=45-270mg), respectively. Prescribed and patient-reported prescribed doses were highly correlated for regular (r=0.90, P<0.001) and regular plus breakthrough opioid intake (r=0.94, P<0.001). Nineteen (9.6%) patients deviated. Deviation was more frequent in males (P=0.039) and nonwhites (P=0.0270). Nonwhite patients had higher scores on the BQ-II than white patients (P=0.038). Low adherence scores were significantly associated with higher BQ-II scores (1.99±0.80) for lower motivation score vs. 1.61±0.77 for higher score, P=0.007; and 2.13±0.79 for lower knowledge score vs. 1.57±0.72 for higher score, P=0.001.

CONCLUSION

Very few patients reported dose deviations, which were mostly toward lower dose. More research is necessary to better characterize the frequency and predictors of opioid deviation in this population.

Good adherence to imatinib therapy among patients with chronic myeloid leukemia--a single-center observational study

Previous studies have suggested that adherence to imatinib therapy can be an obstacle among patients with chronic myeloid leukemia (CML). We studied adherence to imatinib therapy among CML patients treated at the Sahlgrenska University Hospital. We identified all CML patients that were alive at the 1st of January 2010 (n = 70). Nineteen patients were excluded due to a history of allogenic hematopoietic stem cell transplantation, and nine were excluded due to treatment with other tyrosine kinase inhibitors. Thirty-eight out of 42 patients (90%) treated with imatinib accepted inclusion in the study. The patients were interviewed in a structured way, and adherence was evaluated in a standardized way using the nine-item Morisky Medication Adherence Scale that ranges from 1 to 13. A Morisky score ≤10 indicates nonadherence and ≥11 indicates adherence. In addition, predefined follow-up questions were asked to identify factors known to influence adherence to therapy. In contrast to previous studies, our patients showed good adherence to imatinib therapy with a mean Morisky score of 12.3 out of 13 (range, 9-13). The interviews revealed factors known to predict adherence to therapy, namely being well informed and having frequent contact with a single hematologist. Furthermore, the patients had easy access to the treating clinic and felt that they took part in decisions concerning their disease and treatment. We show that adherence to imatinib can be very good in CML patients, and we suggest that simple measures such as increased patient information and continuity of care will increase adherence in patients with CML.

Assessing treatment motivation among patients receiving antiretroviral therapy: a multidimensional approach

Using multidimensional scaling (MDS) analysis, this study examined how patient conceptualisations of treatment motivation compare with theoretically based assumptions used in current assessment approaches. Patients undergoing antiretroviral therapy for HIV/AIDS (n=39) rated for similarity between all possible pairings of 23 treatment descriptions, including descriptors of intrinsic, extrinsic, approach and avoidance motivation. MDS analyses revealed that patient perceptions of intrinsic and extrinsic motivations often differ from those based on definitions derived from common interpretations of self-determination theory. Findings also showed that patients reported motivation for avoiding treatment when they associated their medication regimens with side effects and other negatively valenced outcomes. The study describes new applications of MDS in assessing how patients perceive the relationship between treatment behaviours and specific forms of motivation, such as intrinsic and extrinsic motivations. In addition, the study suggests how MDS may be used to develop behavioural strategies aimed at helping patients follow their regimens consistently by identifying treatment conceptualisations and contexts that facilitate or impede adherence.

Readiness: the state of the science (or the lack thereof)

HIV treatment guidelines state that patients' readiness should be assessed before initiating highly active antiretroviral therapy (HAART) to assure adherence. None of the guidelines provide a way to measure readiness. Therefore, this article sought to review the literature on readiness to determine if there was a viable predictor of adherence. Twenty-seven articles were reviewed. Nine described studies that examined the relationship between a measure of readiness and HAART adherence. No readiness measure demonstrated clinical utility as a predictor of adherence. Study flaws included small sample sizes (only one study >100 patients), short follow-up periods (all ≤1 year and six were ≤5 months, four ≤1 month), measures of readiness that related poorly to adherence, and inconsistent adherence measures (eight different measures were used by the researchers). Neither the guidelines nor the literature will help clinicians judge who should initiate HAART and who should delay treatment.

Receiving a pharmaceutical care service compared to receiving standard pharmacy service in Sweden--How do patients differ with regard to perceptions of medicine use and the pharmacy encounter?

BACKGROUND

Qualitative research has shown that gaining control of medicine treatment and increased feelings of safety and empowerment are central concepts in patients' perceptions of a pharmaceutical care (PC) service provided in Sweden. However, little is known about any unique differences among patients receiving PC versus standard pharmacy services (SSs) and the impact of these services on patient-perceived outcomes.

OBJECTIVE

To describe and compare patients who had previously received a PC service and patients who had received a SS with regard to their perceptions of medicine use and the pharmacy encounter.

METHODS

Cross-sectional survey design comparing matched groups of patients who were previously elected to receive a PC service or who had received SS. Patients who were 60 years or older and used 5 or more prescription medicines concomitantly were included in the survey. Questionnaires included questions about perceptions of safety in drug therapy, general health, drug-related problems (DRPs), medication beliefs, adherence, and experiences of pharmacy encounters.

RESULTS

Patients receiving the PC service used more prescription medicines, reported poorer self-reported health, and less perceived safety in their medicine therapy than did patients in SS. PC patients reported that they felt safer with medications, felt a genuine interest from the pharmacist, received important information, and felt more prepared to see the doctor after having spoken to the pharmacist than did patients in SS. DRPs reported to a greater extent by patients receiving the PC service included difficulties opening containers, worries about side effects, experiences of side effects, worries about drug-drug interactions, and inadequate treatment effects. Adherence and medication beliefs showed no statistical difference between groups.

CONCLUSION

Patients receiving a PC service are a worried, vulnerable, and information-seeking group. When compared with patients receiving SS, the PC patients are more insecure about their medicine therapy, although talking to a pharmacist increased their self-reported feelings of safety and provided better preparation for visits to the doctor.

Psychometric properties of the Thai version of the 8-item Morisky Medication Adherence Scale in patients with type 2 diabetes

BACKGROUND

A self-reporting questionnaire is the most convenient and cheapest way to assess medication adherence. A new 8-item self-reported Morisky Medication Adherence Scale (MMAS) has been developed and has shown better psychometric properties than the original 4-item Morisky scale.

OBJECTIVE

To examine the validity, including convergent known-groups and construct validity, and reliability, including internal consistency and test-retest reliability, of the MMAS in Thai patients with type 2 diabetes.

METHODS

The data were derived from a cross-sectional study. In a convenience sample, 303 type 2 diabetic outpatients were interviewed at the General Police Hospital in Bangkok, Thailand, between January and June 2007. Face-to-face interviews included MMAS, medication adherence visual analog scale (MA-VAS), and sociodemographic data. Medical records were reviewed for clinical data such as hemoglobin A(1C) (A1C) levels.

RESULTS

Internal consistency reliability was moderate (Cronbach's alpha = 0.61), whereas the test-retest reliability of the MMAS was excellent (intraclass correlation coefficient = 0.83; p < 0.001). Concerning convergent validity, the MMAS had a high correlation with the 3-item Morisky scale (r = 0.77; p < 0.01) and a medium correlation with the MA-VAS (r = 0.57; p < 0.01). Regarding known-groups validity, a significant association between MMAS and A1C levels was found (chi(2) = 6.7; p < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value of the MMAS were 51%, 64%, 71%, and 43%, respectively. Our factor analysis showed that the MMAS had 3 dimensions including forgetting to take medications, stopping medications when feeling better or worse, and the complexity of the drug regimen.

CONCLUSIONS

The 8-item MMAS can be a tool to aid in assessing medication adherence in diabetes. The poor sensitivity can be improved by increasing the number of the response choices and the cut-off score of the scale and by using specific words in some items. A modified Thai version of the 8-item MMAS may be needed.

A structural equation modeling approach to the concepts of adherence and readiness in antiretroviral treatment

OBJECTIVE

The objective of this secondary analysis of data from a cross-sectional, nation-wide survey, was to test a hypothesized model with two latent concepts (readiness and adherence), based on the theory of trigger events. A secondary objective was to compare this model with two simpler models, without the concept of readiness.

METHODS

Data consisted of a consecutive sample of 828 HIV patients > or = 18 years on antiretroviral treatment at 30 out of 32 HIV Clinics in Sweden (response rate 97.5%). Structural equation modeling (SEM) was used to test the models against the empirical data. Chi2 test was used to compare fit between models.

RESULTS

The hypothesized model, with two latent concepts (readiness and adherence), fitted the data best (chi(2)=223.508, d.f.=129, p-value<0.0001, GFI=0.970, CFI=0.913, RMSEA=0.030), and significantly better than the models with adherence as the only latent concept.

CONCLUSION

Although the SEM technique could not rule out that other models might also fit the data equally well, the hypothesized model, where readiness and adherence were two separate latent concepts, fitted data the best. This supports readiness as a distinct factor that influences adherence and hence treatment outcome. Increased attention should therefore be attached to interventions that focus on the individual' readiness for behavioural change, i.e. factors amendable to change and that can be addressed by the patients themselves.

PRACTICE IMPLICATIONS

Based on these results it seems necessary to shift focus from adherence to readiness, especially in conditions where treatment can be postponed such as antiretroviral treatment.