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Thompson AA, Iyer A, Mayfield CK, Petrigliano FA, Nicholson LT, Liu JN. Harms Reporting in Randomized Controlled Trials Underpinning the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for Distal Radius Fractures. J Hand Surg Am 2023:S0363-5023(23)00139-9. [PMID: 37097262 DOI: 10.1016/j.jhsa.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/22/2023] [Accepted: 03/09/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE The purpose of this study was to measure the harms-related reporting among randomized controlled trials (RCTs) cited as supporting evidence for the American Academy of Orthopaedic Surgeons clinical practice guidelines regarding the management of distal radius fractures. METHODS We adhered to the guidance for reporting metaresearch and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines throughout the course of this investigation. We used the American Academy of Orthopaedic Surgeons clinical practice guidelines for distal radius fractures available on Orthoguidelines.org. A linear regression analysis was conducted to model the relationship between the year of publication and the total Consolidated Standards of Reporting Trials percentage adherence over time. RESULTS Thirty-five RCTs were included in the final sample. The average number of Consolidated Standards of Reporting Trials Extension for Harms items adequately reported across all included RCTs was 9.2 (9.2/18, 50.9%). None of the included trials adequately reported all 18 items. Ten items had a compliance of more than 50% (10/18, 55.6%), 4 items had a compliance of 20%-50% (4/18, 22.2%), and 4 items had a compliance of less than 20% (4/18, 22.2%). The results of the linear regression model showed no significant improvement in Consolidated Standards of Reporting Trials Harms reporting over time. CONCLUSIONS Adverse events are incompletely reported among RCTs cited as supporting evidence for American Academy of Orthopaedic Surgeons clinical practice guidelines for the management of distal radius fractures. CLINICAL RELEVANCE Given our findings, specific attention should be paid to improving the standardization of the classification of adverse events to facilitate ease in the reporting process.
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Affiliation(s)
- Ashley A Thompson
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA.
| | - Avinash Iyer
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA
| | - Cory K Mayfield
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA
| | - Frank A Petrigliano
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA
| | - Luke T Nicholson
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA
| | - Joseph N Liu
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA
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2
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Effectiveness of a structured pharmacist-delivered intervention for patients post-acute coronary syndromes on all-cause hospitalizations and cardiac-related hospital readmissions: a prospective quasi-experimental study. Int J Clin Pharm 2023:10.1007/s11096-023-01538-4. [PMID: 36795303 DOI: 10.1007/s11096-023-01538-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/05/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity in Qatar and globally. AIM The primary objective of the study was to evaluate the effectiveness of a structured clinical pharmacist-delivered intervention on all-cause hospitalizations and cardiac-related readmissions in patients with ACS. METHOD A prospective quasi-experimental study was conducted at Heart Hospital in Qatar. Discharged ACS patients were allocated to one of three study arms: (1) an intervention group (received a structured clinical pharmacist-delivered medication reconciliation and counselling at discharge, and two follow-up sessions at 4 weeks and 8 weeks post-discharge), (2) a usual care group (received the general usual care at discharge by clinical pharmacists) or, (3) a control group (discharged during weekends or after clinical pharmacists' working hours). Follow-up sessions for the intervention group were designed to re-educate and counsel patients about their medications, remind them about the importance of medication adherence, and answer any questions they may have. At the hospital, patients were allocated into one of the three groups based on intrinsic and natural allocation procedures. Recruitment of patients took place between March 2016 and December 2017. Data were analyzed based on intention-to-treat principles. RESULTS Three hundred seventy-three patients were enrolled in the study (intervention = 111, usual care = 120, control = 142). Unadjusted results showed that the odds of 6-month all-cause hospitalizations were significantly higher among the usual care (OR 2.034; 95% CI: 1.103-3.748, p = 0.023) and the control arms (OR 2.704; 95% CI: 1.456-5.022, p = 0.002) when compared to the intervention arm. Similarly, patients in the usual care arm (OR 2.304; 95% CI: 1.122-4.730, p = 0.023) and the control arm (OR 3.678; 95% CI: 1.802-7.506, p ≤ 0.001) had greater likelihood of cardiac-related readmissions at 6 months. After adjustment, these reductions were only significant for cardiac-related readmissions between control and intervention groups (OR 2.428; 95% CI: 1.116-5.282, p = 0.025). CONCLUSION This study demonstrated the impact of a structured intervention by clinical pharmacists on cardiac-related readmissions at 6 months post-discharge in patients post-ACS. The impact of the intervention on all-cause hospitalization was not significant after adjustment for potential confounders. Large cost-effective studies are required to determine the sustained impact of structured clinical pharmacist-provided interventions in ACS setting. TRIAL REGISTRATION Clinical Trials: NCT02648243 Registration date: January 7, 2016.
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3
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Garcia RA, Spertus JA, Benton MC, Jones PG, Mark DB, Newman JD, Bangalore S, Boden WE, Stone GW, Reynolds HR, Hochman JS, Maron DJ. Association of Medication Adherence With Health Outcomes in the ISCHEMIA Trial. J Am Coll Cardiol 2022; 80:755-765. [PMID: 35981820 PMCID: PMC10548342 DOI: 10.1016/j.jacc.2022.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/27/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial randomized participants with chronic coronary disease (CCD) to guideline-directed medical therapy with or without angiography and revascularization. The study examined the association of nonadherence with health status outcomes. OBJECTIVES The study sought to compare 12-month health status outcomes of adherent and nonadherent participants with CCD with an a priori hypothesis that nonadherent patients would have better health status if randomized to invasive management. METHODS Self-reported medication-taking behavior was assessed at randomization with a modified 4-item Morisky-Green-Levine Adherence Scale, and participants were classified as adherent or nonadherent. Twelve-month health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ-7) summary score (SS), which ranges from 0 to 100 (higher score = better). The association of adherence with outcomes was evaluated using Bayesian proportional odds models, including an interaction by study arm (conservative vs invasive). RESULTS Among 4,480 randomized participants, 1,245 (27.8%) were nonadherent at baseline. Nonadherent participants had worse baseline SAQ-7 SS in both conservative (72.9 ± 19.3 vs 75.6 ± 18.4) and invasive (71.0 ± 19.8 vs 74.2 ± 18.7) arms. In adjusted analyses, adherence was associated with higher 12-month SAQ-7 SS in both treatment groups (mean difference in SAQ-7 SS with conservative treatment = 1.6 [95% credible interval: 0.3-2.9] vs with invasive management = 1.9 [95% credible interval: 0.8-3.1]), with no interaction by treatment. CONCLUSIONS More than 1 in 4 participants reported medication nonadherence, which was associated with worse health status in both conservative and invasive treatment strategies at baseline and 12 months. Strategies to improve medication adherence are needed to improve health status outcomes in CCD, regardless of treatment strategy. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- R Angel Garcia
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John A Spertus
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - Mary C Benton
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Philip G Jones
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan D Newman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - William E Boden
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gregg W Stone
- Department of Medicine (Cardiology) and Population Health Science and Policy, Mount Sinai Hospital, New York, New York, USA
| | - Harmony R Reynolds
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Judith S Hochman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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4
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Udumyan R, Botteri E, Jerlstrom T, Montgomery S, Smedby KE, Fall K. Beta-blocker use and urothelial bladder cancer survival: a Swedish register-based cohort study. Acta Oncol 2022; 61:922-930. [PMID: 35881046 DOI: 10.1080/0284186x.2022.2101902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Recent observational studies linked β-adrenergic receptor blocker use with improved survival in patients with several cancer types, but there is no information on the potential effects of β-blockers in patients with bladder cancer. Literature from pre-clinical studies is also limited, but urothelial cancer can exhibit significant overexpression of β-adrenergic receptors relative to normal urothelial tissue, suggesting that urothelial cancer may benefit from β-blockade therapy. We thus aimed to explore the possible association between β-blocker use and bladder cancer-specific mortality (BCSM) among patients with urothelial bladder cancer. MATERIAL AND METHODS Patients diagnosed during 2006-2014 and identified from the Swedish Cancer Register (n = 16,669) were followed until 31 December 2015. Cox regression was used to evaluate the association of β-blockers dispensed within 90 days prior to cancer diagnosis with BCSM (primary outcome) and all-cause mortality, while controlling for socio-demographic factors, tumor characteristics, comorbidity, other medications and surgical procedures. Hazard ratios (HR) with 95% confidence intervals (CI) were reported. RESULTS Overall, β-blocker use was associated with lower BCSM [HR 0.88 (95%CI 0.81-0.96)]. Especially use of nonselective β-blockers showed a clear inverse association in comparison with both nonuse [0.66 (0.50-0.86)] and use of other antihypertensive medications [0.72 (0.54-0.95)]. The inverse association was most pronounced among patients with locally advanced/metastatic disease: [0.35 (0.18-0.68)]. A lower-magnitude inverse association was observed for selective β-blocker use [0.91 (0.83-0.99)]. Largely similar inverse associations were observed for hydrophilic [0.82 (0.70-0.95)] and lipophilic [0.91 (0.83-1.00)] β-blocker use. CONCLUSION β-blocker use, particularly of the nonselective type, was associated with lower BCSM, especially in patients with locally advanced/metastatic urothelial bladder cancer.
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Affiliation(s)
- Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Edoardo Botteri
- Department of Research, Cancer Registry of Norway, Oslo, Norway.,Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Tomas Jerlstrom
- Department of Urology, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Karin E Smedby
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Katja Fall
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Mongin D, Lauper K, Finckh A, Frisell T, Courvoisier DS. Accounting for missing data caused by drug cessation in observational comparative effectiveness research: a simulation study. Ann Rheum Dis 2022; 81:729-736. [PMID: 35027398 PMCID: PMC8995805 DOI: 10.1136/annrheumdis-2021-221477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022]
Abstract
Objectives To assess the performance of statistical methods used to compare the effectiveness between drugs in an observational setting in the presence of attrition. Methods In this simulation study, we compared the estimations of low disease activity (LDA) at 1 year produced by complete case analysis (CC), last observation carried forward (LOCF), LUNDEX, non-responder imputation (NRI), inverse probability weighting (IPW) and multiple imputations of the outcome. All methods were adjusted for confounders. The reasons to stop the treatments were included in the multiple imputation method (confounder-adjusted response rate with attrition correction, CARRAC) and were either included (IPW2) or not (IPW1) in the IPW method. A realistic simulation data set was generated from a real-world data collection. The amount of missing data caused by attrition and its dependence on the ‘true’ value of the data missing were varied to assess the robustness of each method to these changes. Results LUNDEX and NRI strongly underestimated the absolute LDA difference between two treatments, and their estimates were highly sensitive to the amount of attrition. IPW1 and CC overestimated the absolute LDA difference between the two treatments and the overestimation increased with increasing attrition or when missingness depended on disease activity at 1 year. IPW2 and CARRAC produced unbiased estimations, but IPW2 had a greater sensitivity to the missing pattern of data and the amount of attrition than CARRAC. Conclusions Only multiple imputation and IPW2, which considered both confounding and treatment cessation reasons, produced accurate comparative effectiveness estimates.
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Affiliation(s)
- Denis Mongin
- Department of Medicine, University of Geneva, Geneva, Switzerland
| | - Kim Lauper
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Axel Finckh
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Frisell
- Department of medicine Solna, Karolinska institute, Stockholm, Sweden
| | - Delphine Sophie Courvoisier
- Department of Medicine, University of Geneva, Geneva, Switzerland.,Division of Rheumatology, Beau Sejour Hospital, Geneva University Hospitals, Geneva, Switzerland
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6
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Tajabadi M, Goran Orimi H, Ramzgouyan MR, Nemati A, Deravi N, Beheshtizadeh N, Azami M. Regenerative strategies for the consequences of myocardial infarction: Chronological indication and upcoming visions. Biomed Pharmacother 2021; 146:112584. [PMID: 34968921 DOI: 10.1016/j.biopha.2021.112584] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Heart muscle injury and an elevated troponin level signify myocardial infarction (MI), which may result in defective and uncoordinated segments, reduced cardiac output, and ultimately, death. Physicians apply thrombolytic therapy, coronary artery bypass graft (CABG) surgery, or percutaneous coronary intervention (PCI) to recanalize and restore blood flow to the coronary arteries, albeit they were not convincingly able to solve the heart problems. Thus, researchers aim to introduce novel substitutional therapies for regenerating and functionalizing damaged cardiac tissue based on engineering concepts. Cell-based engineering approaches, utilizing biomaterials, gene, drug, growth factor delivery systems, and tissue engineering are the most leading studies in the field of heart regeneration. Also, understanding the primary cause of MI and thus selecting the most efficient treatment method can be enhanced by preparing microdevices so-called heart-on-a-chip. In this regard, microfluidic approaches can be used as diagnostic platforms or drug screening in cardiac disease treatment. Additionally, bioprinting technique with whole organ 3D printing of human heart with major vessels, cardiomyocytes and endothelial cells can be an ideal goal for cardiac tissue engineering and remarkable achievement in near future. Consequently, this review discusses the different aspects, advancements, and challenges of the mentioned methods with presenting the advantages and disadvantages, chronological indications, and application prospects of various novel therapeutic approaches.
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Affiliation(s)
- Maryam Tajabadi
- School of Metallurgy and Materials Engineering, Iran University of Science and Technology (IUST), Narmak, Tehran 16844, Iran
| | - Hanif Goran Orimi
- School of Metallurgy and Materials Engineering, Iran University of Science and Technology (IUST), Narmak, Tehran 16844, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Roya Ramzgouyan
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Alireza Nemati
- Department of Biomedical Engineering, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Niloofar Deravi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Nima Beheshtizadeh
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mahmoud Azami
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
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Abstract
Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.
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Affiliation(s)
- Steven T Simon
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vinay Kini
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew E Levy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - P Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
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8
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Khan NA, Torralba KD, Aslam F. Missing data in randomised controlled trials of rheumatoid arthritis drug therapy are substantial and handled inappropriately. RMD Open 2021; 7:rmdopen-2021-001708. [PMID: 34330848 PMCID: PMC8327847 DOI: 10.1136/rmdopen-2021-001708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/11/2021] [Indexed: 11/11/2022] Open
Abstract
Objectives To analyse the amount, reporting and handling of missing data, approach to intention-to-treat (ITT) principle application and sensitivity analysis utilisation in randomised clinical trials (RCTs) of rheumatoid arthritis (RA). To assess the trend in such reporting 10 years apart (2006 and 2016). Methods Parallel group drug therapy RA RCTs with a clinical primary endpoint. Results 176 studies enrolling a median of 160 (IQR 62–339) patients were eligible. In terms of actual analysis: 81 (46%) RCTs conducted ITT, 42 (23.9%) conducted modified ITT while 53 (30.1%) conducted non-ITT analysis. Only 58 of 97 (59.8%) RCTs reporting an ITT analysis actually performed it. The median (IQR) numbers of participants completing the trial and included in analysis for primary outcome were 86% (74%–91%) and 100% (97.1%–100%), respectively. 53 (32.7%) and 65 (40.1%) RCTs had >20% and 10%–20% missing primary outcome data, respectively. Missing data handling was unreported by 58 of 171 (33.9%) RCTs. When reported, vast majority used simple imputation methods. No significant trend towards improved reporting was seen between 2006 and 2016. Sensitivity analysis numerically improved from 2006 to 2016 (14.7% vs 21.4%). Conclusions There is significant discrepancy in the reported and the actual performed analysis in RA drug therapy RCTs. Nearly one-third of RCTs had >20% missing data. The reporting and methods of missing data handling remain inadequate with high usage of non-preferred simple imputation methods. Sensitivity analysis utilisation was low. No trend towards better missing data reporting and handling was seen.
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Affiliation(s)
- Nasim A Khan
- Rheumatology Section, CHI St Vincent Little Rock Diagnostic Clinic, Little Rock, Arkansas, USA
| | - Karina D Torralba
- Division of Rheumatology, Loma Linda University, Loma Linda, California, USA
| | - Fawad Aslam
- Divison of Rheumatology, Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
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9
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Yoo TK, Park SH, Do Han K, Chae BJ. Cardiovascular events and mortality in a population-based cohort initially diagnosed with ductal carcinoma in situ. BMC Cancer 2021; 21:735. [PMID: 34174850 PMCID: PMC8236151 DOI: 10.1186/s12885-021-08494-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/09/2021] [Indexed: 01/05/2023] Open
Abstract
Background Ductal carcinoma in situ (DCIS) patients are usually diagnosed through cancer screening programs, suggesting a healthy user effect. In this population-based cohort, we assessed the risk of cardiovascular events and mortality in DCIS patients. Methods Using the Korean National Health Insurance Service database, 13,740 women, who were initially diagnosed with DCIS between 2007 and 2013, were analyzed. A control group was matched according to age and the year of diagnosis at a 3:1 ratio (n = 41,220). Follow-up was performed until 2016. Subgroup analysis was performed according to the subsequent diagnosis of invasive breast cancer within 1 year: pure DCIS and DCIS+Invasive group. Results DCIS patients were more likely to have underlying diseases, higher incomes, and to live in urban districts compared to the control group. Women diagnosed of DCIS had lower myocardial infarct risk (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.46–0.90) and lower stroke risk (HR 0.77; 95% CI 0.60–0.98) compared to the control group. This trend of lower risk was sustained after adjusting for age, income, residence and comorbidities. The mortality rate was similar between the control group and pure DCIS patients but was higher in the DCIS+Invasive group (HR 1.63; 95% CI 1.34–1.98). However, after adjusting for age, income, residence and comorbidities, mortality did not differ between the control group and DCIS+Invasive group (HR 0.99; 95% CI 0.78–1.24). Conclusions DCIS patients were at lower risk for MI and stroke compared to a control group despite a higher rate of comorbidities, which may reflect changes in health behaviour. The importance of managing pre-existing comorbidities along with DCIS treatment should be emphasized. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08494-0.
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Affiliation(s)
- Tae-Kyung Yoo
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.,Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Sang Hyun Park
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Kyung Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, 06978, Republic of Korea
| | - Byung Joo Chae
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Kangnam-Gu, Seoul, 06531, South Korea.
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10
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Treatment adherence in tyrosinemia type 1 patients. Orphanet J Rare Dis 2021; 16:256. [PMID: 34082789 PMCID: PMC8173906 DOI: 10.1186/s13023-021-01879-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While therapeutic advances have significantly improved the prognosis of patients with hereditary tyrosinemia type 1 (HT1), adherence to dietary and pharmacological treatments is essential for an optimal clinical outcome. Poor treatment adherence is well documented among patients with chronic diseases, but data from HT1 patients are scarce. This study evaluated pharmacological and dietary adherence in HT1 patients both directly, by quantifying blood levels nitisinone (NTBC) levels and metabolic biomarkers of HT1 [tyrosine (Tyr), phenylalanine (Phe), and succinylacetone]; and indirectly, by analyzing NTBC prescriptions from hospital pharmacies and via clinical interviews including the Haynes-Sackett (or self-compliance) test and the adapted Battle test of patient knowledge of the disease. RESULTS This observational study analyzed data collected over 4 years from 69 HT1 patients (7 adults and 62 children; age range, 7 months-35 years) who were treated with NTBC and a low-Tyr, low-Phe diet. Adherence to both pharmacological and, in particular, dietary treatment was poor. Annual data showed that NTBC levels were lower than recommended in more than one third of patients, and that initial Tyr levels were high (> 400 µM) in 54.2-64.4% of patients and exceeded 750 µM in 25.8% of them. Remarkably, annual normalization of NTBC levels was observed in 29.4-57.9% of patients for whom serial NTBC determinations were performed. Poor adherence to dietary treatment was more refractory to positive reinforcement: 36.2% of patients in the group who underwent multiple analyses per year maintained high Tyr levels during the entire study period, and, when considering each of the years individually this percentage ranged from 75 to 100% of them. Indirect methods revealed percentages of non-adherent patients of 7.3 and 15.9% (adapted Battle and Haynes tests, respectively). CONCLUSIONS Despite initially poor adherence to pharmacological and especially dietary treatment among HT1 patients, positive reinforcement at medical consultations resulted in a marked improvement in NTBC levels, indicating the importance of systematic positive reinforcement at medical visits.
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11
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Medication non-adherence in chronic kidney disease: a mixed-methods review and synthesis using the theoretical domains framework and the behavioural change wheel. J Nephrol 2021; 34:1091-1125. [PMID: 33559850 DOI: 10.1007/s40620-020-00895-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/28/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Medication non-adherence is a well-recognised issue in chronic diseases but data in patients with chronic kidney disease (CKD) not receiving kidney replacement therapy (KRT) remains limited. This review summarised the prevalence of medication non-adherence and assessed determinants and outcomes associated with it in adults with CKD, not on KRT. METHOD We searched PubMed, Embase, PsychInfo, Web of Science, and Cochrane (CENTRAL) for studies published until January 2020. Pooled prevalence of medication non-adherence was reported. Determinants of adherence-identified from quantitative and qualitative studies-were mapped into the theoretical domains framework and interventions proposed using the behavioural change wheel. RESULTS Twenty-seven studies (22 quantitative and 5 qualitative) were included. The pooled prevalence of medication non-adherence was 39% (95% CI 30-48%). Nine studies reported association between non-adherence and outcomes, including blood pressure, disease progression, adverse events, and mortality. Modifiable determinants of non-adherence were mapped into 11 of the 14 Theoretical Domains Framework-of which, six appeared most relevant. Non-adherence decisions were usually due to lack of knowledge on CKD, comorbidities, and medications; polypharmacy and occurrence of medication side effects; changes in established routines such as frequent medication changes; higher medication cost, poor accessibility to medications, services and facilities; inadequate patient-healthcare professional communication; and forgetfulness. Using the behavioural change wheel, we identified several areas where interventions can be directed to improve medication adherence. CONCLUSION Medication non-adherence is common in adults with CKD, not on KRT and may lead to poor outcomes. Evidence synthesis using mixed study designs was crucial in identifying determinants of non-adherence, drawing on a parsimonious approach from behaviour science. PROSPERO REGISTRATION CRD42020149983.
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Per-Treatment Post Hoc Analysis of Clinical Trial Outcomes With Tolvaptan in ADPKD. Kidney Int Rep 2021; 6:1032-1040. [PMID: 33912753 PMCID: PMC8071614 DOI: 10.1016/j.ekir.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction In pivotal trials of patients with autosomal dominant polycystic kidney disease at risk of rapid progression, tolvaptan slowed estimated glomerular filtration rate (eGFR) decline in early-to-moderate (TEMPO 3:4 [NCT00428948]) and moderate- to late-stage (REPRISE [NCT02160145]) chronic kidney disease (CKD). Discontinuation was less frequent in REPRISE (15.0%) than TEMPO 3:4 (23.0%), given that in REPRISE, only subjects who tolerated tolvaptan 60/30 mg daily initiated the double-blind phase. We evaluated whether the greater treatment effect in REPRISE was attributable to different completion rates. Methods We conducted post hoc analyses of TEMPO 3:4 and REPRISE completers, defined as subjects who took trial drug to the end of the treatment period in TEMPO 3:4 (3 years) or REPRISE (1 year). Efficacy (rate of change in eGFR for tolvaptan vs. placebo) was analyzed as in each trial. Subjects from TEMPO 3:4 and REPRISE were also matched by propensity score for age, gender, and baseline eGFR to explore potential additional determinants of treatment effect. Results The annualized tolvaptan treatment effect in TEMPO 3:4 completers (difference vs. placebo of 0.98 ml/min per 1.73 m2/y) and REPRISE completers (difference of 1.23) was similar to that of the respective total trial populations (TEMPO 3:4: 0.94; REPRISE: 1.27). The treatment effect of tolvaptan was also similar between matched subjects. Conclusion Greater treatment completion rate did not drive greater treatment effect in REPRISE. The more advanced CKD of REPRISE subjects may be more relevant. More rapid decline in kidney function in later-stage CKD enabled the effects of tolvaptan to be more easily discerned.
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Abstract
INTRODUCTION Although clinical practice guidelines (CPG) identify first, second- and third-line mood stabilizer (MS) treatments, they rarely define clinical response to prophylaxis or the core issues to be considered. This project aimed to develop a template for describing how clinical response may be classified and a framework to assist decision-making and monitoring of response in day-to-day practice. METHOD A scoping exercise was undertaken followed by narrative synthesis of (a) qualitative and quantitative definitions of MS response applied in clinical and research practice and (b) potential confounders (eg, non-adherence; tolerability issues) of relevance to routine practice, for example, the concepts are applicable to individuals with bipolar disorder for whom sustained remission is a less realistic goal. Expert consensus was employed to develop a taxonomy of response and key concepts that inform clinical judgements about MS response. RESULTS Five core constructs can be used to systematize clinical judgements regarding MS response and its monitoring: (a) quantitative, qualitative and/or patient-reported outcome measures (PROMS), (b) personalized assessment of the acceptable benefit-to-harm ratio of a proposed treatment, (c) adequacy of treatment exposure (dose, duration, therapeutic monitoring and adherence), (d) illness activity pre- and post-MS initiation, and (e) other potential confounders (co-prescription of MS; polypharmacy) or protective factors (eg, psychosocial factors). CONCLUSIONS This heuristic framework might be used as a teaching aid or by clinicians who wish to take a more systematic approach to developing shared criteria for judging MS response that better match patient expectations and preferences. Heuristic approaches also allow seamless introduction of new evidence.
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Affiliation(s)
- Jan Scott
- Institute of Neuroscience, Newcastle University, Newcastle, UK.,Université Paris Diderot and INSERM UMRS1144, Paris, France
| | - Bruno Etain
- Université Paris Diderot and INSERM UMRS1144, Paris, France.,Département de Psychiatrie et de Médecine Addictologique, AP-HP, GH Saint-Louis-Lariboisière-F. Widal, Paris, France
| | - Andrew Nierenberg
- The Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Frank Bellivier
- Université Paris Diderot and INSERM UMRS1144, Paris, France.,Département de Psychiatrie et de Médecine Addictologique, AP-HP, GH Saint-Louis-Lariboisière-F. Widal, Paris, France
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Murray EJ. Editorial: Demystifying the Placebo Effect. Am J Epidemiol 2021; 190:2-9. [PMID: 32719871 DOI: 10.1093/aje/kwaa162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
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Affiliation(s)
- Joseph R. Dettori
- Spectrum Research, Inc, Steilacoom, WA, USA,Joseph R. Dettori, Spectrum Research, Inc, PO Box
88998, Steilacoom, WA 98388, USA.
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Murray EJ, Claggett BL, Granger B, Solomon SD, Hernán MA. Adherence-adjustment in placebo-controlled randomized trials: An application to the candesartan in heart failure randomized trial. Contemp Clin Trials 2020; 90:105937. [PMID: 31982649 DOI: 10.1016/j.cct.2020.105937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The per-protocol effect provides important information in randomized trials with incomplete adherence. Yet, because valid estimation typically requires adjustment for prognostic factors that predict adherence, per-protocol effect estimates are often met with skepticism. In placebo-controlled trials, however, the validity of adjustment can be indirectly verified by demonstrating no association between adherence and the outcome among the placebo arm. Here, we describe a two-stage procedure in which we first adjust for time-varying adherence in the placebo arm and then use a similar procedure to estimate the per-protocol effect. METHODS We use the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) randomized trial. First, we compare adherers versus non-adherers in the placebo arm, adjusting for pre- and post-randomization variables. Second, we use models validated in the placebo arm to estimate the per-protocol effect of adherence to candesartan versus placebo in the full trial. FINDINGS We successfully estimated no association between adherence and mortality in the placebo arm; hazard ratio: 0.91 (95% CI: 0.51, 2.52). We then estimated the per-protocol effect under two sets of protocol-defined stopping criteria after adjustment for post-randomization confounders. The mortality hazard ratio estimates ranged from 0.91 to 0.93 for the per-protocol effect estimates, similar to the intention-to-treat effect estimates. INTERPRETATION Adherence adjustment in the CHARM trial is feasible when appropriate assumptions about missing data and confounding are made. These assumptions cannot be verified but can be supported through the use of placebo-arm adherence assessment.
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Affiliation(s)
- Eleanor J Murray
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Brian L Claggett
- Department of Non-invasive Cardiology, Harvard Medical School, Boston, MA, USA
| | | | - Scott D Solomon
- Department of Non-invasive Cardiology, Harvard Medical School, Boston, MA, USA
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
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Rodriguez F, Maron DJ, Knowles JW, Virani SS, Lin S, Heidenreich PA. Association of Statin Adherence With Mortality in Patients With Atherosclerotic Cardiovascular Disease. JAMA Cardiol 2020; 4:206-213. [PMID: 30758506 DOI: 10.1001/jamacardio.2018.4936] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Statins decrease mortality in those with atherosclerotic cardiovascular disease (ASCVD), but statin adherence remains suboptimal. Objective To determine the association between statin adherence and mortality in patients with ASCVD who have stable statin prescriptions. Design, Setting, and Participants This retrospective cohort analysis included patients who were between ages 21 and 85 years and had 1 or more International Classification of Diseases, Ninth Revision, Clinical Modification codes for ASCVD on 2 or more dates in the previous 2 years without intensity changes to their statin prescription who were treated within the Veterans Affairs Health System between January 1, 2013, and April 2014. Exposures Statin adherence was defined by the medication possession ratio (MPR). Adherence levels were categorized as an MPR of less than 50%, 50% to 69%, 70% to 89%, and 90% or greater. For dichotomous analyses, adherence was defined as an MPR of 80% or greater. Main Outcomes and Measures The primary outcome was death of all causes adjusted for demographic and clinical characteristics, as well as adherence to other cardiac medications. Results Of 347 104 eligible adults with ASCVD who had stable statin prescriptions, 5472 (1.6%) were women, 284 150 (81.9%) were white, 36 208 (10.4%) were African American, 16 323 (4.7%) were Hispanic, 4093 (1.2%) were Pacific Islander, 1293 (0.4%) were Native American, 1145 (0.3%) were Asian, and 1794 (0.5%) were other races. Patients taking moderate-intensity statin therapy were more adherent than patients taking high-intensity statin therapy (odds ratio [OR], 1.18; 95% CI, 1.16-1.20). Women were less adherent (OR, 0.89; 95% CI, 0.84-0.94), as were minority groups. Younger and older patients were less likely to be adherent compared with adults aged 65 to 74 years. During a mean (SD) of 2.9 (0.8) years of follow-up, there were 85 930 deaths (24.8%). Compared with the most adherent patients (MPR ≥ 90%), patients with an MPR of less than 50% had a hazard ratio (HR; adjusted for clinical characteristics and adherence to other cardiac medications) of 1.30 (95% CI, 1.27-1.34), those with an MPR of 50% to 69% had an HR of 1.21 (95% CI, 1.18-1.24), and those with an MPR of 70% to 89% had an HR of 1.08 (95% CI, 1.06-1.09). Conclusions and Relevance Using a national sample of Veterans Affairs patients with ASCVD, we found that a low adherence to statin therapy was associated with a greater risk of dying. Women, minorities, younger adults, and older adults were less likely to adhere to statins. Our findings underscore the importance of finding methods to improve adherence.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - David J Maron
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Joshua W Knowles
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Salim S Virani
- Michael E. DeBakey Veterans Affairs Medical Center, Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Shoutzu Lin
- Veterans Affairs Health System, Palo Alto, California
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California.,Veterans Affairs Health System, Palo Alto, California
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Udumyan R, Montgomery S, Fang F, Valdimarsdottir U, Hardardottir H, Ekbom A, Smedby KE, Fall K. Beta-Blocker Use and Lung Cancer Mortality in a Nationwide Cohort Study of Patients with Primary Non-Small Cell Lung Cancer. Cancer Epidemiol Biomarkers Prev 2019; 29:119-126. [PMID: 31641010 DOI: 10.1158/1055-9965.epi-19-0710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/21/2019] [Accepted: 10/16/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND β-Adrenergic receptor blockers have been associated with improved survival among patients with different types of malignancies, but available data for patients with non-small cell lung cancer (NSCLC) are contradictory and limited to small hospital-based studies. We therefore aimed to investigate whether β-blocker use at the time of cancer diagnosis is associated with lung cancer mortality in the largest general population-based cohort of patients with NSCLC to date. METHODS For this retrospectively defined nationwide cohort study, we used prospectively collected data from Swedish population and health registers. Through the Swedish Cancer Register, we identified 18,429 patients diagnosed with a primary NSCLC between 2006 and 2014 with follow-up to 2015. Cox regression was used to estimate the association between β-blocker use at time of cancer diagnosis ascertained from the Prescribed Drug Register and cancer-specific mortality identified from the Cause of Death Register. RESULTS Over a median follow-up of 10.2 months, 14,994 patients died (including 13,398 from lung cancer). Compared with nonuse, β-blocker use (predominantly prevalent use, 93%) was not associated with lung cancer mortality [HR (95% confidence interval): 1.01 (0.97-1.06)]. However, the possibility that diverging associations for specific β-blockers and some histopathologic subtypes exist cannot be excluded. CONCLUSIONS In this nationwide cohort of patients with NSCLC, β-blocker use was not associated with lung cancer mortality when assessed in aggregate in the total cohort, but evidence for some β-blockers is less conclusive. IMPACT Our results do not indicate that β-blocker use at lung cancer diagnosis reduces the cancer-specific mortality rate in patients with NSCLC.
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Affiliation(s)
- Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Fang Fang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Unnur Valdimarsdottir
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Center of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Hronn Hardardottir
- Center of Public Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Respiratory Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Anders Ekbom
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Karin E Smedby
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Hematology Clinic, Karolinska University Hospital, Stockholm, Sweden
| | - Katja Fall
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Möllenkamp M, Zeppernick M, Schreyögg J. The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review. Health Policy 2019; 123:1199-1209. [PMID: 31676042 DOI: 10.1016/j.healthpol.2019.09.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022]
Abstract
In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types' effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency. We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm. In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.
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Affiliation(s)
- Meilin Möllenkamp
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany.
| | - Maike Zeppernick
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
| | - Jonas Schreyögg
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
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20
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Lowinger MB, Ormes JD, Su Y, Small JH, Williams RO, Zhang F. How broadly can poly(urethane)-based implants be applied to drugs of varied properties? Int J Pharm 2019; 568:118550. [DOI: 10.1016/j.ijpharm.2019.118550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/02/2023]
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Khatib R, Marshall K, Silcock J, Forrest C, Hall AS. Adherence to coronary artery disease secondary prevention medicines: exploring modifiable barriers. Open Heart 2019; 6:e000997. [PMID: 31354954 PMCID: PMC6615814 DOI: 10.1136/openhrt-2018-000997] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 06/13/2019] [Indexed: 12/17/2022] Open
Abstract
Background Non-adherence to secondary prevention medicines (SPMs) among patients with coronary artery disease (CAD) remains a challenge in clinical practice. This study attempted to identify actual and potential modifiable barriers to adherence that can be addressed in cardiology clinical practice. Methods This was a cross-sectional, postal survey-based study of the medicines-taking experience of patients with CAD treated at a secondary/tertiary care centre. All participants had been on SPM for ≥3 months. Results In total, 696 eligible patients were sent the survey and 503 responded (72.3%). The median age was 70 years, and 403 (80.1%) were male; the median number of individual daily doses of all medicines was 6. The rate of non-adherence to at least one SPM was 43.5% (n=219), but 53.3% of reported non-adherence was to only one SPM. Statins contributed to 66.7% and aspirin to 61.7% of overall non-adherence identified by the Single Question (SQ) tool. In 30.8% of non-adherent patients (n=65), this was at least partly intentional. Barriers included forgetfulness (84.9%; n=186), worry that medicines will do more harm than good (33.8%; n=74), feeling hassled about medicines taking (18.7%; n=41), feeling worse when taking medicines (14.2%; n=31) and not being convinced of the benefit of medicines (9.1%; n=20). In a multivariate analysis, modifiable factors associated with overall non-adherence included being prescribed aspirin (OR: 2.22; 95% CI: 1.18 to 4.17), having specific concern about SPM (OR: 1.12; 95% CI: 1.07 to 1.18) and issues with repeat prescriptions (OR: 2.48; 95% CI: 1.26 to 4.90). Different factors were often associated with intentional versus unintentional non-adherence. Conclusions Using appropriate self-report tools, patients share actual and potential modifiable barriers to adherence that can be addressed in clinical practice. Non-adherence behaviour was selective. Most non-adherence was driven by forgetfulness, concern about the harm caused by SPM and practical barriers.
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Affiliation(s)
- Rani Khatib
- Medicines Management & Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Kay Marshall
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Jon Silcock
- Bradford School of Pharmacy, University of Bradford, Bradford, UK
| | - Claire Forrest
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Alistair S Hall
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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22
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Exploring the relationship of digital information sources and medication adherence. Comput Biol Med 2019; 109:303-310. [DOI: 10.1016/j.compbiomed.2019.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/15/2019] [Accepted: 04/20/2019] [Indexed: 12/28/2022]
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Pierre-Victor D, Pinsky PF. Association of Nonadherence to Cancer Screening Examinations With Mortality From Unrelated Causes: A Secondary Analysis of the PLCO Cancer Screening Trial. JAMA Intern Med 2019; 179:196-203. [PMID: 30592477 PMCID: PMC6439655 DOI: 10.1001/jamainternmed.2018.5982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Patient nonadherence to chronic disease prevention guidelines is associated with increased mortality. Nonadherence to offered cancer screening tests may be associated with mortality among middle-aged and older adults. OBJECTIVE To evaluate the association between nonadherence to cancer screening tests and mortality in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening trial, excluding mortality from cancers studied in the trial. DESIGN, SETTING, AND PARTICIPANTS Randomization at 10 US screening centers occurred from November 8, 1993, to July 2, 2001. Original follow-up was through 13 years or December 31, 2009. Participants were re-consented to further follow-up starting May 18, 2011, and were observed until December 31, 2012. Protocol screening tests for the PLCO Cancer Screening trial intervention arm participants (N = 77 443) included chest radiographs and flexible sigmoidoscopy for both sexes, prostate-specific antigen tests and digital rectal examinations for men, and cancer antigen 125 tests and transvaginal ultrasonography for women. At baseline, participants completed a self-administered questionnaire. The cohort was classified into those receiving all sex-specified PLCO Cancer Screening trial screening tests at baseline (fully adherent), those receiving some but not all baseline tests (partially adherent), and those receiving no baseline tests (nonadherents). Secondary analysis was ad hoc in the original trial protocol. Statistical analysis was conducted from November 24, 2017, to August 29, 2018. MAIN OUTCOMES AND MEASURES Mortality was ascertained via mailed annual study update questionnaires and searches of the National Death Index. Cox proportional hazards regression was used to analyze the association between mortality and adherence, controlling for various covariates. RESULTS Of 77 443 participants in the intervention arm, 64 567 (29 537 women and 35 030 men; mean [SD] age, 62.3 [5.3] years) were included in the analysis based on consenting to trial participation before randomization and being eligible for all screening tests. Overall, 55 065 participants (85.3%) were adherent, 2548 (3.9%) were partially adherent, and 6954 (10.8%) were nonadherent with the baseline screening protocol. Within 10 years of follow-up, the hazard ratio of mortality, excluding deaths from cancers studied in the PLCO Cancer Screening trial and controlling only for age, sex, and race/ethnicity (model 1), was 1.73 (95% CI, 1.60-1.89) for nonadherent compared with fully adherent participants and 1.36 (95% CI, 1.19-1.54) for partially compared with fully adherent participants. After adjustment for medical risk factors for mortality and behavioral-related factors (model 2), the hazard ratio decreased to 1.46 (95% CI, 1.34-1.59) for nonadherent compared with fully adherent participants. CONCLUSIONS AND RELEVANCE Among participants in a screening trial for multiple cancers, a nonadherence behavior profile marked by nonadherence to protocol screenings was associated with higher overall mortality (excluding deaths from cancers studied in the trial). The generalizability of this finding to routine clinical practice should be assessed. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00002540.
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Affiliation(s)
| | - Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
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Friesen P. Placebos as a Source of Agency: Evidence and Implications. Front Psychiatry 2019; 10:721. [PMID: 31708807 PMCID: PMC6824097 DOI: 10.3389/fpsyt.2019.00721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Bioethical discussions surrounding the use of placebos in clinical practice have long revolved around the moral permissibility of deceiving a patient if it is likely to benefit them. While these discussions have been insightful and productive, they reinforce the notion that placebo effects can only be induced through deception. This paper challenges this notion, looking beyond the paradigmatic clinical encounter involving deceptive placebos and towards many other routes that bring about placebo effects. After briefly describing the bioethical terrain surrounding the deceptive use of placebos in clinical practice, section 1 offers an examination of the various mechanisms known to contribute to placebo effects: classical conditioning, expectations, affective pathways, open-label placebo treatments, and additional factors that do not fall easily into a single category. The following section explores how each of these routes can be harnessed to bring about clinical benefits without the use of deception. This provides grounding for reconceiving of the placebo effect as a clinical tool that is not always in conflict with patient autonomy and can even be seen as a source of agency. In the final section, implications of the shift away from seeing placebos as necessarily deceptive are discussed. These include the necessity of looking beyond the clinical encounter and mainstream medicine as the primary sites of placebo responses, how important acknowledging the limits of placebo effects will be when we do so, as well as the difficulties of disentangling agency, responsibility, and blame within medicine.
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Affiliation(s)
- Phoebe Friesen
- Biomedical Ethics Unit, Social Studies of Medicine, McGill University, Canada
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25
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Harborow PW, Ogden J. The Effectiveness of An Acupuncturist Working in General Practice – An Audit. Acupunct Med 2018; 22:214-20; discussion 220. [PMID: 15628779 DOI: 10.1136/aim.22.4.214] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This audit was based in general practice and examined 49 consecutive referrals to a UK trained traditional Chinese acupuncturist. It aimed to assess the type of patients referred to an acupuncturist, subsequent changes in health status, whether the effectiveness of acupuncture was related to the type of presenting problem and to examine which factors were predictive of the success of acupuncture. The referred patients had a wide variety of conditions which were categorised as to whether or not there was empirical evidence from trials of responsiveness to acupuncture (evidence based vs non evidence based). Patients completed measures of their health status prior to treatment and at two and six month follow ups. In addition, the referring GP's beliefs about the prognosis of the problem and the therapist's and patient's expectations of success were measured at baseline. The results showed that referred patients reported poorer health status than a historical sample of general practice patients and that they showed significant improvements in all aspects of health status following acupuncture. In particular, patients showed improved energy, pain, emotional reactions, sleep and reduced social isolation at two months which were maintained at six months. Physical mobility was improved at six months. In addition, the results indicated that the best predictors of effectiveness were the therapist's and patient's expectations of success at baseline. Effectiveness was not related to the category of condition (evidence based or not) nor to the GP's expectations about the prognosis of the condition. The results are discussed in terms of implications for the role of acupuncture in General Practice and selectively targeting patients who would be responsive to such an approach.
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Affiliation(s)
- Patrick W Harborow
- Department of General Practice, Guys, Kings and St Thomas' School of Medicine, King's College, London
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Litchfield I, Jones LL, Moiemen N, Andrews N, Greenfield S, Mathers J. The role of self-management in burns aftercare: a qualitative research study. Burns 2018; 45:825-834. [PMID: 30545694 DOI: 10.1016/j.burns.2018.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 10/17/2018] [Accepted: 10/23/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION For severe burns patient care presents a considerable challenge, necessitating an integrated multi-disciplinary approach that utilises a range of treatments. The period of care post-discharge can be lengthy and complex, and include scar management, occupational and physiotherapies, psychological support, and further surgery. How successfully the patient negotiates this complex care regimen is critical to their long-term recovery and in doing so they would appear to employ approaches recognised as "self-management" in other chronic conditions. However their exact nature and how they are used has yet to be explicitly explored amongst chronic burn patients. METHODS Semi-structured interviews were conducted with 24 patients to discuss their experiences of long-term burn treatment as part of a broader mixed- methods feasibility study of the use of pressure garment therapy in preventing hypertrophic scarring after burn injury. The topic guide included questions on the patient experience of their care post discharge, including pressure garment therapy and other scar management techniques; and their expectations and experiences of treatment and recovery. The data were analysed using an established framework of self-management processes. RESULTS Burns patients employ many of the same processes of self-management as those experiencing more widely recognised chronic diseases or illnesses. This is despite the prospect of gradual improvement amongst burns patients absent in those with incurable chronic conditions. The key processes of self-management they share are the ability to focus on their illness needs, activate the appropriate resources and coming to terms with the consequences of living with either the physical or psychological consequences of their condition. CONCLUSION Modern burn care is technologically advanced and delivered by a highly trained, multi-disciplinary team, yet the level of its success relies on the ability of the patient to independently fulfil a number of health-related tasks and activities once leaving hospital. Considering the potential cost-savings to health services and the prospect of improved outcomes for patients capable of self-management our work is an important first step in more precisely understanding the use of self-management amongst burns patients, and the level of implicit or explicit support currently offered by their care providers.
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Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Laura L Jones
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Naiem Moiemen
- The Scar Free Foundation Centre for Burns Research, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Nicole Andrews
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
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Fredericksen RJ, Yang FM, Gibbons LE, Edwards TC, Brown S, Fitzsimmons E, Alperovitz-Bichell K, Godfrey M, Wang A, Church A, Gutierrez C, Paez E, Dant L, Loo S, Walcott M, Mugavero MJ, Mayer KH, Mathews WC, Patrick DL, Crane PK, Crane HM. Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care. Res Social Adm Pharm 2018; 15:1168-1176. [PMID: 30327183 DOI: 10.1016/j.sapharm.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Providers are often unaware of poor adherence to prescribed medications for their patients with chronic diseases. OBJECTIVE To develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers. Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH. KEY RESULTS Behavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4-16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability. CONCLUSION Measures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.
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Affiliation(s)
- R J Fredericksen
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - F M Yang
- Augusta University, 1120 15th Street Augusta, GA, 30912, USA
| | - L E Gibbons
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - T C Edwards
- University of Washington, Quality of Life Group, Box 359455, Seattle, WA, 98195, USA
| | - S Brown
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - E Fitzsimmons
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | | | - M Godfrey
- Beaufort Jasper Hampton Comprehensive Health Services, 1520 Grays Highway, Ridgeland, SC, 29936, USA
| | - A Wang
- Chase Brexton Health Care, 5500 Knoll N Dr #370, Columbia, MD, 21045, USA
| | - A Church
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - C Gutierrez
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - E Paez
- University of California-San Diego, The Owen Clinic, 4168 Front Street, San Diego, CA, 92103, USA
| | - L Dant
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - S Loo
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - M Walcott
- University of Alabama-Birmingham, 1917 Clinic, Community Care Building, 908 South 20th Street, Birmingham, AL, 35294, USA
| | - M J Mugavero
- University of Alabama-Birmingham, 1917 Clinic, Community Care Building, 908 South 20th Street, Birmingham, AL, 35294, USA
| | - K H Mayer
- Fenway Community Health, 1340 Boylston Street, Boston, MA, 02215, USA
| | - W C Mathews
- University of California-San Diego, The Owen Clinic, 4168 Front Street, San Diego, CA, 92103, USA
| | - D L Patrick
- University of Washington, Quality of Life Group, Box 359455, Seattle, WA, 98195, USA
| | - P K Crane
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
| | - H M Crane
- University of Washington, Center for AIDS Research, 325 Ninth Avenue, Box 359931, Seattle, WA, 98104, USA
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Medication Adherence Mediates the Relationship Between Heart Failure Symptoms and Cardiac Event-Free Survival in Patients With Heart Failure. J Cardiovasc Nurs 2018; 33:40-46. [PMID: 28591004 DOI: 10.1097/jcn.0000000000000427] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF) symptoms such as dyspnea are common and may precipitate hospitalization. Medication nonadherence is presumed to be associated with symptom exacerbations, yet how HF symptoms, medication adherence, and hospitalization/death are related remains unclear. OBJECTIVE The aim of this study was to explore the relationships among HF symptoms, medication adherence, and cardiac event-free survival in patients with HF. METHODS At baseline, patient demographics, clinical data, and HF symptoms were collected in 219 patients with HF. Medication adherence was monitored using the Medication Event Monitoring System. Patients were followed for up to 3.5 years to collect hospitalization and survival data. Logistic regression and survival analyses were used for the analyses. RESULTS Patients reporting dyspnea or ankle swelling were more likely to have poor medication adherence (P = .05). Poor medication adherence was associated with worse cardiac event-free survival (P = .006). In Cox regression, patients with HF symptoms had 2 times greater risk for a cardiac event than patients without HF symptoms (P = .042). Heart failure symptoms were not a significant predictor of cardiac event-free survival after entering medication adherence in the model (P = .091), indicating mediation. CONCLUSIONS Medication adherence was associated with fewer HF symptoms and lower rates of hospitalization and death. It is important to develop interventions to improve medication adherence that may reduce HF symptoms and high hospitalization and mortality in patients with HF.
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Alvarez C, Saint-Pierre C, Herskovic V, Sepúlveda M. Analysis of the Relationship between the Referral and Evolution of Patients with Type 2 Diabetes Mellitus. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1534. [PMID: 30036937 PMCID: PMC6068730 DOI: 10.3390/ijerph15071534] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/10/2018] [Accepted: 07/13/2018] [Indexed: 12/30/2022]
Abstract
Type 2 Diabetes Mellitus (T2DM) is a chronic disease that has risen in prominence in recent years and can cause serious complications. Several studies show that the level of adherence to different types of treatment has a direct correlation with the positive evolution of chronic diseases. While such studies relate to patient adherence to medication, those that concern adherence to medical appointments do not distinguish between the different disciplines that attend to or refer patients. This study analyses the relationship between adherence to referrals made by three distinct disciplines (doctors, nurses, and nutritionists) and the results of HbA1c tests from a sample of 2290 patients with T2DM. The aim is to determine whether a relationship exists between patient improvement and the frequency with which they attend scheduled appointments in a timely manner, having been previously referred from or to a particular discipline. Results showed that patients tended to be more adherent when their next appointment is with a doctor, and less adherent when it is with a nurse or nutritionist. Furthermore, patients that remained stable had higher rates of adherence, whereas those with lower adherence tended to be more decompensated. The results can enable healthcare professionals to monitor patients and place particular emphasis on those who do not attend their scheduled appointments in a timely manner.
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Affiliation(s)
- Camilo Alvarez
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Cecilia Saint-Pierre
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Valeria Herskovic
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Marcos Sepúlveda
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
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Bachur C, Singer B, Hayes-Conroy A, Horwitz RI. Social Determinants of Treatment Response. Am J Med 2018; 131:480-483. [PMID: 29421690 DOI: 10.1016/j.amjmed.2018.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 01/27/2023]
Abstract
Socioeconomic status is consistently linked to population health and specifically to the finding that there is decreasing health associated with decreasing social position. Despite the substantial literature, an analogous literature that is focused on clinical practice, and especially consideration of the individual, is almost nonexistent. Even in the absence of these data, physicians routinely incorporate patient life experience (biography) into their estimation of a patient's clinical trajectory (prognosis) and when making therapeutic decisions. Some advances have occurred that strengthen the evidence base, such as the US Food and Drug Administration decision to show all results from randomized controlled trials on newly approved drugs by age, sex, and race. In this article we review the current status of research on the impact of social determinants of treatment response and illustrate the important role of the therapeutic context in both research and practice. Examples are provided in which a patient's "biography" alters treatment response in subgroups of the population studied. We also provide examples in which multi-omic data and biographical information in a single individual can illuminate the clinical expression of disease. Finally, we suggest a research agenda that would better support physicians who use social and behavioral features as important elements in their decision making in clinical care.
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Affiliation(s)
- Catherine Bachur
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | | | | | - Ralph I Horwitz
- Temple Transformative Medicine Institute, Lewis Katz School of Medicine, Temple University, Philadelphia, Pa.
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31
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A Ventricular Assist Device Recipient and Suicidality: Multidisciplinary Collaboration With a Psychiatrically Distressed Patient. J Cardiovasc Nurs 2018; 32:135-139. [PMID: 26422637 DOI: 10.1097/jcn.0000000000000293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ventricular assist device (VAD) recipients are at high risk of depression and anxiety, and poor psychosocial functioning is associated with worse medical outcomes. PURPOSE We present a case of a 31-year-old depressed patient who demonstrated passive suicidal behavior through multiple episodes of noncompliance, including temporarily discontinuing warfarin (Coumadin) several months after VAD implantation. The patient's psychosocial and medical histories and outcomes are presented. CONCLUSIONS This case underscores the importance of pre-VAD as well and ongoing psychosocial evaluation and management for this unique patient population. CLINICAL IMPLICATIONS Medical teams who are treating patients with cardiovascular disease who are under consideration for VAD or heart transplantation need to be aware of the multitude of ways in which patients can express depressed and suicidal mood and work with a multidisciplinary team to treat such symptoms to optimize patients' success with VAD/heart transplantation.
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32
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Cedillo-Couvert EA, Ricardo AC, Chen J, Cohan J, Fischer MJ, Krousel-Wood M, Kusek JW, Lederer S, Lustigova E, Ojo A, Porter AC, Sharp LK, Sondheimer J, Diamantidis C, Wang X, Roy J, Lash JP. Self-reported Medication Adherence and CKD Progression. Kidney Int Rep 2018; 3:645-651. [PMID: 29854972 PMCID: PMC5976857 DOI: 10.1016/j.ekir.2018.01.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 01/16/2018] [Accepted: 01/25/2018] [Indexed: 02/01/2023] Open
Abstract
Introduction In the general population, medication nonadherence contributes to poorer outcomes. However, little is known about medication adherence among adults with chronic kidney disease (CKD). We evaluated the association of self-reported medication adherence with CKD progression and all-cause death in patients with CKD. Methods In this prospective observational study of 3305 adults with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, the baseline self-reported medication adherence was assessed by responses to 3 questions and categorized as high, medium, and low. CKD progression (50% decline in eGFR or incident end-stage renal disease) and all-cause death were measured using multivariable Cox proportional hazards. Results Of the patients, 68% were categorized as high adherence, 17% medium adherence, and 15% low adherence. Over a median follow-up of 6 years, there were 969 CKD progression events and 675 deaths. Compared with the high-adherence group, the low-adherence group experienced increased risk for CKD progression (hazard ratio = 1.27, 95% confidence interval = 1.05, 1.54) after adjustment for sociodemographic and clinical factors, cardiovascular medications, number of medication types, and depressive symptoms. A similar association existed between low adherence and all-cause death, but did not reach standard statistical significance (hazard ratio = 1.14 95% confidence interval = 0.88, 1.47). Conclusion Baseline self-reported low medication adherence was associated with an increased risk for CKD progression. Future work is needed to better understand the mechanisms underlying this association and to develop interventions to improve adherence.
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Affiliation(s)
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Janet Cohan
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Michael J Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA.,Department of Medicine, Jesse Brown VAMC, Chicago, Illinois, USA.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Marie Krousel-Wood
- Department of Medicine and Epidemiology, Tulane University, New Orleans, Louisiana, USA; Research Division, Ochsner Health System, New Orleans, Louisiana, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Swati Lederer
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA.,Department of Medicine, Jesse Brown VAMC, Chicago, Illinois, USA.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Eva Lustigova
- Department of Medicine and Epidemiology, Tulane University, New Orleans, Louisiana, USA; Research Division, Ochsner Health System, New Orleans, Louisiana, USA
| | - Akinlolu Ojo
- Department of Medicine, University of Arizona, Phoenix, Arizona, USA
| | - Anna C Porter
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Lisa K Sharp
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - James Sondheimer
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Clarissa Diamantidis
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xue Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Roy
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
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Arbuckle C, Tomaszewski D, Aronson BD, Brown L, Schommer J, Morisky D, Linstead E. Evaluating Factors Impacting Medication Adherence Among Rural, Urban, and Suburban Populations. J Rural Health 2018; 34:339-346. [DOI: 10.1111/jrh.12291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/19/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Cody Arbuckle
- Mathematics and Computer Science, Schmid College of Science and Technology; Chapman University; Orange California
| | - Daniel Tomaszewski
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy; Chapman University; Irvine California
| | - Benjamin D. Aronson
- Department of Pharmacy Practice, College of Pharmacy; Ohio Northern University; Ada Ohio
| | - Lawrence Brown
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy; Chapman University; Irvine California
| | - Jon Schommer
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy; University of Minnesota; Minneapolis Minnesota
| | - Donald Morisky
- Department of Community Health Sciences, Fielding School of Public Health; University of California; Los Angeles California
| | - Erik Linstead
- Mathematics and Computer Science, Schmid College of Science and Technology; Chapman University; Orange California
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Myers B, Mitchell C, Whitty JA, Donovan P, Coombes I. Prescribing and medication communication on the post-take ward round. Intern Med J 2017; 47:454-457. [PMID: 28401716 DOI: 10.1111/imj.13280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 07/14/2016] [Accepted: 09/10/2016] [Indexed: 11/28/2022]
Abstract
Gaps in communication between medical officers and poor planning are associated with prescribing errors and may result in patient harm. This study describes medication communication on post-take ward rounds (PTWR). Over 6 weeks on 24 PTWR, 130 patients, prescribed 1244 medications, were observed. Of these, 811 (65%) medications were discussed, with 249 discussions (relating to 126 medications) being 'in-depth'. Of 191 planned medication-related actions, 38 (20%) were not implemented by the end of the PTWR and 21 (11%) by time of discharge from hospital. This study suggests that the level of medication communication and subsequent actions are suboptimal. Processes to improve this situation should be explored.
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Affiliation(s)
- Brooke Myers
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.,Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Charles Mitchell
- Centre for Safe and Effective Prescribing, University of Queensland, Brisbane, Queensland, Australia
| | - Jenny A Whitty
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Peter Donovan
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ian Coombes
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
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McCoy CE. Understanding the Intention-to-treat Principle in Randomized Controlled Trials. West J Emerg Med 2017; 18:1075-1078. [PMID: 29085540 PMCID: PMC5654877 DOI: 10.5811/westjem.2017.8.35985] [Citation(s) in RCA: 357] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 08/18/2017] [Accepted: 08/21/2017] [Indexed: 11/24/2022] Open
Abstract
Clinicians, institutions, and policy makers use results from randomized controlled trials to make decisions regarding therapeutic interventions for their patients and populations. Knowing the effect the intervention has on patients in clinical trials is critical for making both individual patient as well as population-based decisions. However, patients in clinical trials do not always adhere to the protocol. Excluding patients from the analysis who violated the research protocol (did not get their intended treatment) can have significant implications that impact the results and analysis of a study. Intention-to-treat analysis is a method for analyzing results in a prospective randomized study where all participants who are randomized are included in the statistical analysis and analyzed according to the group they were originally assigned, regardless of what treatment (if any) they received. This method allows the investigator (or consumer of the medical literature) to draw accurate (unbiased) conclusions regarding the effectiveness of an intervention. This method preserves the benefits of randomization, which cannot be assumed when using other methods of analysis. The risk of bias is increased whenever treatment groups are not analyzed according to the group to which they were originally assigned. If an intervention is truly effective (truth), an intention-to-treat analysis will provide an unbiased estimate of the efficacy of the intervention at the level of adherence in the study. This article will review the “intention-to-treat” principle and its converse, “per-protocol” analysis, and illustrate how using the wrong method of analysis can lead to a significantly biased assessment of the effectiveness of an intervention.
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Affiliation(s)
- C Eric McCoy
- University of California, Irvine, School of Medicine and Medical Center, Department of Emergency Medicine, Orange, California
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36
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Wabe N, Wiese MD. Treating rheumatoid arthritis to target: physician and patient adherence issues in contemporary rheumatoid arthritis therapy. J Eval Clin Pract 2017; 23:486-493. [PMID: 27650675 DOI: 10.1111/jep.12620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/10/2016] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
Abstract
Development of the treat-to-target (T2T) strategy, the process whereby drug therapy is adjusted until the therapeutic goal is achieved, has revolutionized how rheumatoid arthritis (RA) patients are treated. With the advent of T2T, the management of RA is more effective than ever, with the possibility of remission and other favorable clinical and patient-reported outcomes. Effective implementation of a T2T strategy in routine clinical practice mainly depends on the long-term commitment of physician and patient to T2T treatment recommendations. However, as T2T is a complex process involving aggressive early management with several steps of therapy modifications requiring frequent close monitoring of disease activity and drug toxicities, it may be more liable to suboptimal adherence in real-life clinical practice. The aim of the review is to present key issues related to patient medication adherence and physician adherence to the current RA treatment recommendations and their importance in optimizing the outcome of treatment in RA treated according to T2T strategy.
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Affiliation(s)
- Nasir Wabe
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Michael D Wiese
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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38
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Cobretti MR, Page RL, Linnebur SA, Deininger KM, Ambardekar AV, Lindenfeld J, Aquilante CL. Medication regimen complexity in ambulatory older adults with heart failure. Clin Interv Aging 2017; 12:679-686. [PMID: 28442898 PMCID: PMC5396835 DOI: 10.2147/cia.s130832] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM). PATIENTS AND METHODS Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool. RESULTS The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications. CONCLUSION Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.
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Affiliation(s)
| | - Robert L Page
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | | | - Amrut V Ambardekar
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO
| | - JoAnn Lindenfeld
- Advanced Heart Failure and Cardiac Transplant Program, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
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Du L, Cheng Z, Zhang Y, Li Y, Mei D. The impact of medication adherence on clinical outcomes of coronary artery disease: A meta-analysis. Eur J Prev Cardiol 2017; 24:962-970. [PMID: 28436725 DOI: 10.1177/2047487317695628] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Liping Du
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Zhongwei Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Yuxuan Zhang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Ying Li
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Dan Mei
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
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40
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Rockhold F. Comments on 'Estimands in clinical trials - broadening the perspective'. Stat Med 2017; 36:24-26. [PMID: 27917552 DOI: 10.1002/sim.7164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Frank Rockhold
- Duke Clinical Research Institute, 2400, Pratt St, Durham, NC 27705
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Salari A, Hasandokht T, Mahdavi-Roshan M, Kheirkhah J, Gholipour M, Pouradollah Tootkaoni M. Risk factor control, adherence to medication and follow up visit, five years after coronary artery bypass graft surgery. J Cardiovasc Thorac Res 2016; 8:152-157. [PMID: 28210470 PMCID: PMC5304097 DOI: 10.15171/jcvtr.2016.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction: Inadequate adherence to medication and follow up visits were proposed correlated with cardiovascular mortality and complications. This study was planned to evaluate medication and follow up adherence and risk factor control in patients with coronary artery disease 5 years after coronary artery bypass grafting (CABG). Methods: In this retrospective cohort study, adult patients who underwent CABG in 2010 were enrolled. Conventional and probable risk factor control and adherence to medication and follow up visits were assessed. Results: 196 patients were recruited to the study. Uncontrolled blood pressure, blood glucose and low-density lipoprotein (LDL)were reported in 48%, 61% and 32% of patients, respectively. More than 63% of former smokers restarted smoking during 6-12 months after bypass. Poor medication adherence was present in 10.7% in the study population. The last follow up visit time for 30% of patients was later than 12 months after CABG. Conclusion: Poor risk factors control and adherence to follow up visits was common among patients undergoing CABG.
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Affiliation(s)
- Arsalan Salari
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Tolou Hasandokht
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
- Community Medicine Department, Faculty Of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Marjan Mahdavi-Roshan
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
- Community Medicine Department, Faculty Of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Jalal Kheirkhah
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mahboueh Gholipour
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mahsa Pouradollah Tootkaoni
- Guilan Interventional Cardiovascular Research Center, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
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Collop N, Stierer TL, Shafazand S. SAVE Me From CPAP. J Clin Sleep Med 2016; 12:1701-1704. [PMID: 27855746 DOI: 10.5664/jcsm.6366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/03/2016] [Indexed: 11/13/2022]
Affiliation(s)
- Nancy Collop
- Emory Sleep Center, Emory University, Atlanta, GA
| | - Tracy L Stierer
- Johns Hopkins Center for Sleep at Howard County General Hospital, Johns Hopkins University, Baltimore, MD
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Abstract
This study examined the prevalence of depression based on scores of 200 patients with acute coronary syndrome on the Emotion Profile Index of Plutchik and its relationship with the type of acute coronary syndrome and the severity of ischemic heart disease. Patients with acute coronary syndrome scored higher on depression than the control group. There was no difference in scores on Depression by type of acute coronary syndrome and no significant mean differences on Depression for patients with and without left ventricular failure. Patients with acute myocardial infarction and ventricular fibrillation scored lower on Depression than other patients with acute myocardial infarction and control group. This study supports the view that patients with acute myocardial infarction and ventricular fibrillation and lower scores on Depression have good prognosis during hospitalization and maybe for the long term.
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Affiliation(s)
- Damir Kozmar
- Department of Medicine, University of J. J. Strossmayer Osijek, Clinical Hospital Osijek, Croatia
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Hartogsohn I. Set and setting, psychedelics and the placebo response: An extra-pharmacological perspective on psychopharmacology. J Psychopharmacol 2016; 30:1259-1267. [PMID: 27852960 DOI: 10.1177/0269881116677852] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Placebo response theory and set and setting theory are two fields which examine how non-biological factors shape the response to therapy. Both consider factors such as expectancy, preparation and beliefs to be crucial for understanding the extra-pharmacological processes which shape the response to drugs. Yet there are also fundamental differences between the two theories. Set and setting concerns itself with response to psychoactive drugs only; placebo theory relates to all therapeutic interventions. Placebo theory is aimed at medical professionals; set and setting theory is aimed at professionals and drug users alike. Placebo theory is primarily descriptive, describing how placebo acts; set and setting theory is primarily prescriptive, educating therapists and users on how to control and optimize the effects of drugs. This paper examines how placebo theory and set and setting theory can complement and benefit each other, broadening our understanding of how non-biological factors shape response to drugs and other treatment interventions.
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Affiliation(s)
- Ido Hartogsohn
- Science, Technology and Society Program, Bar Ilan University, Ramat Gan, Israel
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Caspard H, Chan AK, Walker AM. Determinants of the Differences in Ldl-Cholesterol After Initiation of Statin Treatment. Ann Pharmacother 2016; 40:21-6. [PMID: 16317108 DOI: 10.1345/aph.1g315] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Randomized clinical trials may not accurately predict drug benefit in clinical practice because the patients and conditions of therapy almost always differ between those settings. Objective: To determine whether differences in low-density lipoprotein cholesterol (LDL-C) time curves between clinical trial results and usual care experience after initiation of statin therapy could be explained fully in terms of observable characteristics of patients and practice in usual care. Methods: We compared LDL-C measurements for 3 years after initiation of statin treatment in individuals enrolled in a health maintenance organization (HMO), with enrollees in the active treatment arm of the CARE (Cholesterol and Recurrent Events) trial. Analysis of the determinants of variation in LDL-C in the HMO cohort was used to adjust the crude results to the distribution of patient and treatment characteristics in the trial. Results: The mean percent decrease in LDL-C was lower in the HMO cohort (n = 1245) than in the clinical trial at the end of each 6-month period, with the difference diminishing over time. Adjustment of the HMO time curve to the baseline characteristics of the clinical trial cohort did not significantly change the mean estimates at any time point. Assuming optimal adherence in the HMO cohort raised the curve over time, with 95% confidence intervals including the means observed in CARE after 18 months. Fixing treatment to pravastatin 40 mg/day, as in CARE, brought the estimates in the HMO cohort very close to those of the clinical trial, with 95% confidence intervals including the means observed in CARE at all time points. Conclusions: Treatment selection, dosing, and adherence under usual care were the primary reasons for which improvements in LDL-C in practice fell short of expectations that are based on clinical trial findings for statin therapy. Beginning with a low dose of statins and titrating to a satisfactory response can delay effective treatment by 18 months or more. Poor adherence accounts for a further substantial shortfall from maximal effect. Differences between trial populations and the general population of statin users with respect to age, gender, and baseline LDL-C have no measurable impact on discrepancies between predicted and observed LDL-C improvement in usual practice.
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Affiliation(s)
- Herve Caspard
- Department of US Medical Affairs, Sanofi-Aventis, Bridgewater, NJ 08807-0977, USA.
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Zidan A, Awaisu A, Kheir N, Mahfoud Z, Kaddoura R, AlYafei S, El Hajj MS. Impact of a pharmacist-delivered discharge and follow-up intervention for patients with acute coronary syndromes in Qatar: a study protocol for a randomised controlled trial. BMJ Open 2016; 6:e012141. [PMID: 27864247 PMCID: PMC5129077 DOI: 10.1136/bmjopen-2016-012141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Acute coronary syndrome (ACS) is one of the leading causes of morbidity and mortality worldwide. Secondary cardiovascular risk reduction therapy (consisting of an aspirin, a β-blocker, an ACE inhibitor or an angiotensin II receptor blocker and a statin) is needed for all patients with ACS. Less than 80% of patients with ACS in Qatar use this combination after discharge. This study is aimed to evaluate the effectiveness of clinical pharmacist-delivered intervention at discharge and tailored follow-up postdischarge on decreasing hospital readmissions, emergency department (ED) visits and mortality among patients with ACS. METHODS AND ANALYSIS A prospective, randomised controlled trial will be conducted at the Heart Hospital in Qatar. Patients are eligible for enrolment if they are at least 18 years of age and are discharged from any non-surgical cardiology service with ACS. Participants will be randomised into 1 of 3 arms: (1) 'control' arm which includes patients discharged during weekends or after hours; (2) 'clinical pharmacist delivered usual care at discharge' arm which includes patients receiving the usual care at discharge by clinical pharmacists; and (3) 'clinical pharmacist-delivered structured intervention at discharge and tailored follow-up postdischarge' arm which includes patients receiving intensive structured discharge interventions in addition to 2 follow-up sessions by intervention clinical pharmacists. Outcomes will be measured by blinded research assistants at 3, 6 and 12 months after discharge and will include: all-cause hospitalisations and cardiac-related hospital readmissions (primary outcome), all-cause mortality including cardiac-related mortality, ED visits including cardiac-related ED visits, adherence to medications and treatment burden. Percentage of readmissions between the 3 arms will be compared on intent-to-treat basis using χ2 test with Bonferroni's adjusted pairwise comparisons if needed. ETHICS AND DISSEMINATION The study was ethically approved by the Qatar University and the Hamad Medical Corporation Institutional Review Boards. The results shall be disseminated in international conferences and peer-reviewed publications. TRIALS REGISTRATION NUMBER NCT02648243; pre-results.
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Affiliation(s)
- Amani Zidan
- Clinical Pharmacy and Practice Section, Qatar University College of Pharmacy, Doha, Qatar
| | - Ahmed Awaisu
- Clinical Pharmacy and Practice Section, Qatar University College of Pharmacy, Doha, Qatar
| | - Nadir Kheir
- Clinical Pharmacy and Practice Section, Qatar University College of Pharmacy, Doha, Qatar
| | | | | | | | - Maguy Saffouh El Hajj
- Clinical Pharmacy and Practice Section, Qatar University College of Pharmacy, Doha, Qatar
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Using Animation to Improve Recovery from Acute Coronary Syndrome: A Randomized Trial. Ann Behav Med 2016; 50:108-18. [PMID: 26497696 DOI: 10.1007/s12160-015-9736-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
UNLABELLED Background: Recovery from myocardial infarction has been associated with patients' perceptions of damage to their heart. New technologies offer a way to show patients animations that may foster more accurate perceptions and encourage medication adherence, increased exercise and faster return to activities. PURPOSE The purpose of this study was to investigate the effects of a brief animated intervention delivered at the patients' bedside on perceptions and recovery in acute coronary syndrome patients. METHODS Seventy acute coronary syndrome patients were randomly assigned to the intervention or standard care alone. Illness perceptions, medication beliefs and recovery outcomes were measured. RESULTS Post-intervention, the intervention group had significantly increased treatment control perceptions and decreased medication harm beliefs and concerns. Seven weeks later, intervention participants had significantly increased treatment control and timeline beliefs, decreased symptoms, lower cardiac avoidance, greater exercise and faster return to normal activities compared to control patients. CONCLUSIONS A brief animated intervention may be clinically effective for acute coronary syndrome patients (Trial-ID: ACTRN12614000440628).
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Risks associated with permanent discontinuation of blood pressure-lowering medications in patients with type 2 diabetes. J Hypertens 2016; 34:781-7. [PMID: 26938813 DOI: 10.1097/hjh.0000000000000841] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The associations of discontinuation of the study medication on major outcomes were assessed in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation Trial. METHODS ADVANCE was a factorial randomized controlled trial of blood pressure lowering (a fixed combination of perindopril and indapamide vs. placebo) and intensive glucose control (vs. standard glucose control) in patients with type 2 diabetes. Patients who permanently discontinued the randomized blood pressure-lowering medication during the study period (n = 1557) were compared with others (n = 9583). Cox's proportional hazards models were used to estimate the effects of the discontinuation on the risks of macrovascular events, microvascular events together and separately and all-cause mortality, using discontinuation as a time-dependent covariate. RESULTS In multivariable analyses, discontinuation was associated with increased risks of combined macro and microvascular events (hazard ratio 2.24, 95% CI 1.96-2.57), macrovascular events (3.23, 2.75-3.79), microvascular events (1.38, 1.11-1.71), and all-cause mortality (7.99, 6.92-9.21) compared to continuing administration of randomized medications during the trial period, which were highest in the first year after discontinuation. These associations were similar in active and placebo groups, except in the first year after discontinuation during which event rates were lower in the active group than in the placebo group (P ≤ 0.01). CONCLUSION Discontinuation of study medication is a potent risk marker for identifying high-risk patients. Thus it is important that clinicians seek to identify such patients early after discontinuation of treatment. Although some short-term residual effects of previous active treatment can be expected, patients who discontinue require further urgent investigation and management.
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Lijfering WM, Biedermann JS, Kruip MJ, Leebeek FW, Rosendaal FR, Cannegieter SC. Can we prevent venous thrombosis with statins: an epidemiologic review into mechanism and clinical utility. Expert Rev Hematol 2016; 9:1023-1030. [DOI: 10.1080/17474086.2016.1245137] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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50
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Forestal DA, Klaiman TA, Peterson AM, Heller DA. Initial Medication Adherence in the Elderly Using PACE Claim Reversals: A Pilot Study. J Manag Care Spec Pharm 2016; 22:1046-50. [PMID: 27579826 PMCID: PMC10398187 DOI: 10.18553/jmcp.2016.22.9.1046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Medicare Modernization Act, with its requirements for Medicare Part D to comply with electronic prescribing (e-prescribing), bolstered the adoption of e-prescribing, which increased to 73% in 2013. Therefore, understanding whether electronic prescriptions are less likely to be picked up is important as e-prescribing continues to be emphasized. OBJECTIVE To assess whether prescription origin is among the factors associated with initial medication adherence, using claim reversals as a proxy measure. METHODS A cross-sectional study was completed using a sample of reversed claims from the Pharmaceutical Assistance Contract for the Elderly (PACE) program for September 2014. The total number of reversed claims for new prescriptions (15,966) was categorized by prescription origin (written, telephone, electronic, fax, and pharmacy). Using a chi-square analysis, the reversed claims were compared among prescription origin to determine if there is a difference in the proportion of electronic prescriptions reversed compared with those from other origins. RESULTS When compared with all other prescription origins, electronic prescriptions (E) were more likely to be reversed at day 0 (E = 50%, any other [AO] = 49%, P < 0.05) and after day 0 (E = 58%, AO = 42%, P < 0.05). CONCLUSIONS Electronic prescriptions are associated with a higher rate of claim reversals and may reflect poorer initial adherence. Electronic prescriptions may more likely be forgotten or not picked up because they were not presented to the pharmacy by the patient. The growing adoption of electronic prescriptions merits particular attention, since it may be a factor in initial medication adherence in the elderly. DISCLOSURES This study was not supported by any funding. Peterson reports advisory board and consultancy fees from IMS Health and Pfizer and employment by Genentech. Klaiman is currently employed by AccessMatters. No other financial or other conflicts of interests were reported. Study concept and design were primarily contributed by Forestal, along with Klaiman and Peterson. Heller took the lead in data collection, along with Forestal, and data interpretation was performed by Forestal, Klaiman, and Peterson. Forestal, Klaiman, and Heller were responsible for manuscript preparation.
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Affiliation(s)
- Doris A Forestal
- 1 University of the Sciences in Philadelphia, Philadelphia, Pennsylvania
| | - Tamar A Klaiman
- 1 University of the Sciences in Philadelphia, Philadelphia, Pennsylvania
| | - Andrew M Peterson
- 1 University of the Sciences in Philadelphia, Philadelphia, Pennsylvania
| | - Debra A Heller
- 2 Magellan Medicaid Administration/PACE, Harrisburg, Pennsylvania
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