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Dawson S, Girling CJ, Cowap L, Clark-Carter D. Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 3:CD013766. [PMID: 36989170 PMCID: PMC10054300 DOI: 10.1002/14651858.cd013766.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Adherence to treatment, including inhaled therapies, is low in people with cystic fibrosis (CF). Although psychological interventions for improving adherence to inhaled therapies in people with CF have been developed, no previous published systematic review has evaluated the evidence for efficacy of these interventions. OBJECTIVES The primary objective of the review was to assess the efficacy of psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis (CF). The secondary objective was to establish the most effective components, or behaviour change techniques (BCTs), used in these interventions. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched databases (PubMed; PsycINFO; EBSCO; Scopus; OpenGrey), trials registries (World Health Organization International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), and the reference lists of relevant articles and reviews, with no restrictions on language, year or publication status. Date of search: 7 August 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different types of psychological interventions for improving adherence to inhaled therapies in people with CF of any age, or comparing psychological interventions with usual care. We included quasi-RCTs if we could reasonably assume that the baseline characteristics were similar in both groups. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and completed data extraction, risk of bias assessments, and BCT coding (using the BCT Taxonomy v1) for all included trials. We resolved any discrepancies by discussion, or by consultation with a third review author as necessary. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 10 trials (1642 participants) in the review (children and adolescents in four trials; adults in five trials; and children and adults in one trial). Nine trials compared a psychological intervention with usual care; we could combine data from some of these in a number of quantitative analyses. One trial compared a psychological intervention with an active comparator (education plus problem-solving (EPS)). We identified five ongoing trials. Psychological interventions were generally multi-component and complex, containing an average of 9.6 BCTs (range 1 to 28). The two most commonly used BCTs included 'problem-solving' and 'instruction on how to perform the behaviour'. Interventions varied in their type, content and mode of delivery. They included a problem-solving intervention; a paper-based self-management workbook; a telehealth intervention; a group training programme; a digital intervention comprising medication reminders and lung function self-monitoring; a life-coaching intervention; a motivational interviewing (MI) intervention; a brief MI intervention (behaviour change counselling); and a digital intervention combined with behaviour change sessions. Intervention duration ranged from 10 weeks to 12 months. Assessment time points ranged from six to eight weeks up to 23 months. Psychological interventions compared with usual care We report data here for the 'over six months and up to 12 months' time point. We found that psychological interventions probably improve adherence to inhaled therapies (primary outcome) in people with CF compared with usual care (mean difference (MD) 9.5, 95% confidence interval (CI) 8.60 to 10.40; 1 study, 588 participants; moderate-certainty evidence). There was no evidence of a difference between groups in our second primary outcome, treatment-related adverse events: anxiety (MD 0.30, 95% CI -0.40 to 1.00; 1 study, 535 participants), or depression (MD -0.10, 95% CI -0.80 to 0.60; 1 study, 534 participants), although this was low-certainty evidence. For our secondary outcomes, there was no evidence of a difference between groups in terms of lung function (forced expiratory volume in one second (FEV1) % predicted MD 1.40, 95% CI -0.20 to 3.00; 1 study, 556 participants; moderate-certainty evidence); number of pulmonary exacerbations (adjusted rate ratio 0.96, 95% CI 0.83 to 1.11; 1 study, 607 participants; moderate-certainty evidence); or respiratory symptoms (MD 0.70, 95% CI -2.40 to 3.80; 1 study, 534 participants; low-certainty evidence). However, psychological interventions may improve treatment burden (MD 3.90, 95% CI 1.20 to 6.60; 1 study, 539 participants; low-certainty evidence). The overall certainty of the evidence ranged from low to moderate across these outcomes. Reasons for downgrading included indirectness (current evidence included adults only whereas our review question was broader and focused on people of any age) and lack of blinding of outcome assessors. Psychological interventions compared with an active comparator For this comparison the overall certainty of evidence was very low, based on one trial (n = 128) comparing an MI intervention to EPS for 12 months. We are uncertain whether an MI intervention, compared with EPS, improves adherence to inhaled therapies, lung function, or quality of life in people with CF, or whether there is an effect on pulmonary exacerbations. The included trial for this comparison did not report on treatment-related adverse events (anxiety and depression). We downgraded all reported outcomes due to small participant numbers, indirectness (trials included only adults), and unclear risk of bias (e.g. selection and attrition bias). AUTHORS' CONCLUSIONS Due to the limited quantity of trials included in this review, as well as the clinical and methodological heterogeneity, it was not possible to identify an overall intervention effect using meta-analysis. Some moderate-certainty evidence suggests that psychological interventions (compared with usual care) probably improve adherence to inhaled therapies in people with CF, without increasing treatment-related adverse events, anxiety and depression (low-certainty evidence). In future review updates (with ongoing trial results included), we hope to be able to establish the most effective BCTs (or 'active ingredients') of interventions for improving adherence to inhaled therapies in people with CF. Wherever possible, investigators should make use of the most objective measures of adherence available (e.g. data-logging nebulisers) to accurately determine intervention effects. Outcome reporting needs to be improved to enable combining or separation of measures as appropriate. Likewise, trial reporting needs to include details of intervention content (e.g. BCTs used); duration; intensity; and fidelity. Large trials with a longer follow-up period (e.g. 12 months) are needed in children with CF. Additionally, more research is needed to determine how to support adherence in 'under-served' CF populations.
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Affiliation(s)
- Sophie Dawson
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Carla-Jane Girling
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Innovation Centre, Sheffield, UK
| | - Lisa Cowap
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - David Clark-Carter
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
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2
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Savant AP, McColley SA. Cystic fibrosis year in review 2019: Section 3 multisystem-based care and research. Pediatr Pulmonol 2023; 58:697-703. [PMID: 33210843 DOI: 10.1002/ppul.25158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022]
Abstract
During the year 2019, numerous research studies and other reports were published that are interesting and instructive to professionals who care for people with cystic fibrosis (CF) and their families. This report is the third of 3 CF year in review articles and focuses on the multisystem manifestations of CF care. Previous articles have addressed cystic fibrosis transmembrane regulator modulators and reports on CF pulmonary disease and airway infections. It is an exciting time to be involved in care and research that aims to improve care for people with CF and their families.
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Affiliation(s)
- Adrienne P Savant
- Division of Pulmonary Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana, USA.,Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Clinical Research, Stanley Manne Children's Research Institute, Chicago, Illinois, USA.,Division of Pulmonary Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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3
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Viprey M, Mougeot F, Dima AL, Haesebaert J, Occelli P, Durieu I, Rouzé H, Reynaud Q, Touzet S. A Participatory Approach Involving Patients with Cystic Fibrosis and Healthcare Professionals for the Co-Design of an Adherence-Enhancing Intervention Toolkit. Patient Prefer Adherence 2023; 17:995-1004. [PMID: 37063606 PMCID: PMC10103710 DOI: 10.2147/ppa.s389792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/22/2023] [Indexed: 04/18/2023] Open
Abstract
Purpose Cystic fibrosis (CF) is an inherited life-shortening disease involving a significant treatment burden. Few interventions have been proven effective in improving adherence, and of these fewer have been adopted for implementation. Patient participation in research is increasingly desired in developing relevant health care services. A participatory approach was implemented in an adult CF center to co-design an adherence-enhancing intervention toolkit. We aimed to report on the participatory process and the results regarding the co-designed intervention. Patients and Methods Two focus group sessions and four working sessions were conducted at 4-week intervals with three healthcare professionals (HCP; physician, nurse, physiotherapist), eight patients, and two researchers (sociologist, public health pharmacist). The two initial focus group sessions were dedicated to the collection of narratives about CF treatment experiences to identify drivers of adherence. The next four working sessions were dedicated to the reflection on solutions that could alleviate the difficulties identified and be used in current clinical practice. The researchers observed during all sessions the interactions between participants, group dynamics, and process of implementation of the collective reflection. Results The process facilitated an active participation of patients and HCP, who contributed equally to the intervention development. The co-design adherence-enhancing intervention toolkit consisted in a self-questionnaire to be completed by patients before the medical consultation and used as a communication support during the consultation, plus a toolkit of solutions to be proposed by the HCP for each barrier identified by patients, and to be followed up during the next consultation. Conclusion This study demonstrated that a participatory approach involving CF patients and HCP lead to the development of an adherence-enhancing intervention toolkit, using a 6-session format; the benefits of the co-designed intervention on the medication adherence have yet to be tested in a multicenter, open-label study in 3 centers in France.
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Affiliation(s)
- Marie Viprey
- Hospices Civils de Lyon, Pôle Santé Publique, Service des Données de Santé, Lyon, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Correspondence: Marie Viprey, Hospices Civils de Lyon, Service des Données de Santé, 162 Avenue Lacassagne, Lyon, 69003, France, Tel +33 4 72 11 51 39, Fax +33 4 72 11 57 20, Email
| | | | - Alexandra Lelia Dima
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Julie Haesebaert
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Pauline Occelli
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Isabelle Durieu
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Centre de Référence Adulte de la Mucoviscidose, Pierre Bénite, France
| | - Héloïse Rouzé
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Quitterie Reynaud
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Centre de Référence Adulte de la Mucoviscidose, Pierre Bénite, France
| | - Sandrine Touzet
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Santé au Travail, Lyon, France
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4
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Sandler RD, Wildman MJ. The CFHealthHub Learning Health System: Using Real-Time Adherence Data to Support a Community of Practice to Deliver Continuous Improvement in an Archetypal Long-Term Condition. Healthcare (Basel) 2022; 11:healthcare11010020. [PMID: 36611480 PMCID: PMC9818500 DOI: 10.3390/healthcare11010020] [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: 09/29/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
CFHealthHub is a learning health system active in over 50% of adult CF Centres in England, supporting people with CF to develop habits of self-care around adherence to preventative inhaled therapy. This is achieved through the delivery of a behaviour change intervention, alongside collection of objective adherence data. As is common to long-term conditions, adherence to prescribed therapy is low, despite clear evidence of beneficial long-term impact on outcomes. This article explains how CFHealthHub is underpinned by coherent conceptual frameworks. We discuss how application of implementation and quality improvement strategies has facilitated CFHealthHub's progression from a pilot study to a large, randomised control trial and now to a learning health system, becoming embedded within routine care. CFHealthHub is now able to support real-time health technology assessments, quality improvement and research trials and is in the process of being implemented in routine clinical care across participating centres.
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Affiliation(s)
- Robert D. Sandler
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield S5 7AU, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield S1 4DA, UK
- Correspondence:
| | - Martin J. Wildman
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield S5 7AU, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield S1 4DA, UK
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5
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Gabel ME, Fox CK, Grimes RA, Lowman JD, McDonald CM, Stallings VA, Michel SH. Overweight and cystic fibrosis: An unexpected challenge. Pediatr Pulmonol 2022; 57 Suppl 1:S40-S49. [PMID: 34738328 DOI: 10.1002/ppul.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/06/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
Achieving a healthy weight balance has been a central focus of care for people who have cystic fibrosis (CF). Over the years, the emphasis has primarily been on promoting weight gain to optimize pulmonary outcomes. With continued improvements in CF care, including highly effective CF modulators available for many people, the CF community is now experiencing a new challenge: addressing the concern that some people are gaining weight excessively. While at this time, we do not know to what extent overweight and obesity will affect health outcomes for people with CF, it is likely that excessive weight gain may have negative health impacts similar to those seen in the general population. In this paper, we review the history of nutritional guidelines for people with CF, as well as more recent trends toward overweight and obesity for some. A multidisciplinary approach is needed to collaboratively start the oftentimes difficult conversation regarding excessive weight gain, and to identify resources to help people achieve and maintain a healthy weight through diet, exercise, and behavioral modification.
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Affiliation(s)
- Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Claudia K Fox
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rachel A Grimes
- Department of Psychiatry, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - John D Lowman
- Department of Physical Therapy, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Catherine M McDonald
- Department of Clinical Nutrition, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Virginia A Stallings
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Suzanne H Michel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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6
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Richards B, Osborne SR, Simons M. Introducing a MAP for adherence care in the paediatric cystic fibrosis clinic: a multiple methods implementation study. BMC Health Serv Res 2022; 22:109. [PMID: 35078462 PMCID: PMC8790869 DOI: 10.1186/s12913-021-07373-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with cystic fibrosis are required to adhere to a burdensome daily treatment regimen. Comprehensive adherence protocols can support more consistent use of adherence interventions and improve treatment adherence rates. This study aimed to explore the feasibility, acceptability, and appropriateness of implementing an adherence protocol into the outpatient cystic fibrosis clinic of a tertiary, paediatric hospital. METHODS This implementation study employed a pre-post observation design, using multiple methods. Focus groups and semi-structured interviews were conducted pre-implementation to understand clinician and consumer perspectives on adherence care. A multicomponent adherence protocol (including multidisciplinary written treatment plans, digital mental health screening and customised communication tools) was then implemented as standard care for a three-month implementation phase. Quantitative data was collected throughout using purpose-designed audit tools and surveys. The Replicating Effective Practice (REP) Framework guided the implementation process. Analysis was informed by The Consolidated Framework for Implementation Research (CFIR) to identify factors that support or challenge the integration of adherence protocols into standard care. RESULTS Thirteen clinicians, eight parents and two adolescents participated in focus groups or interviews that informed development of the tailored multicomponent adherence protocol for implementation. Medical chart audits demonstrated that the protocol was used with 44-57% of eligible consumers three months after introduction. Eighteen clinicians and five consumers participated in post-implementation phase questionnaires. The protocol was considered acceptable and appropriate to clinicians and consumers. Changes in clinicians' practice behaviour were short-lived peaks in response to targeted intervention strategies throughout the implementation phase, such as audit and feedback. CONCLUSIONS An adherence protocol is not an "off the shelf" solution to the adherence challenge in a hospital outpatient setting. Despite the tailored adherence protocol being considered appropriate and acceptable to clinicians and consumers, low fidelity indicates limited feasibility in the outpatient clinic setting, where multi-disciplinary members are all considered responsible for adherence care interventions. Key implementation factors and strategies to consider prior to introducing an adherence protocol are described. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12619001730190 (Retrospectively registered).
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Affiliation(s)
- Bianca Richards
- Occupational Therapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, Queensland, 4101, Australia
| | - Sonya R Osborne
- School of Nursing and Midwifery, Faculty of Health, Engineering, and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, 11 Salisbury Road, Ipswich, Queensland, 4305, Australia.
- Australian Centre for Health Services Innovation (AusHSI), School of Public Health and Social Work, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Queensland, 4059, Australia.
| | - Megan Simons
- Occupational Therapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, Queensland, 4101, Australia
- Centre for Children's Burns and Trauma Research, The University of Queensland, Child Health Research Centre, 62 Graham Street, South Brisbane, Queensland, 4101, Australia
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7
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Izem R, McCarter R. Randomized and non-randomized designs for causal inference with longitudinal data in rare disorders. Orphanet J Rare Dis 2021; 16:491. [PMID: 34814939 PMCID: PMC8609847 DOI: 10.1186/s13023-021-02124-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
In the United States, approximately 7000 rare diseases affect 30 million patients, and only 10% of these diseases have existing therapies. Sound study design and causal inference methods are essential to demonstrate the therapeutic efficacy, safety, and effectiveness of new therapies. In the rare diseases setting, several factors challenge the use of typical parallel control designs: the small patient population size, genotypic and phenotypic diversity, and the complexity and incomplete understanding of the disorder’s progression. Repeated measures, when spaced appropriately relative to disease progression and exploited in design and analysis, can increase study power and reduce variability in treatment effect estimation. This paper reviews these longitudinal designs and draws the parallel between some new and existing randomized studies in rare diseases and their less well-known controlled observational study designs. We show that self-controlled randomized crossover and N-of-1 designs have similar considerations as the observational case series and case-crossover designs. Also, randomized sequential designs have similar considerations to longitudinal cohort studies using sequential matching or weighting to control confounding. We discuss design and analysis considerations for valid causal inference and illustrate them with examples of analyses in multiple rare disorders, including urea cycle disorder and cystic fibrosis.
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Affiliation(s)
- Rima Izem
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA.
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA
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Wildman MJ, O’Cathain A, Hind D, Maguire C, Arden MA, Hutchings M, Bradley J, Walters SJ, Whelan P, Ainsworth J, Tappenden P, Buchan I, Elliott R, Nicholl J, Elborn S, Michie S, Mandefield L, Sutton L, Hoo ZH, Drabble SJ, Lumley E, Beever D, Navega Biz A, Scott A, Waterhouse S, Robinson L, Hernández Alava M, Sasso A. An intervention to support adherence to inhaled medication in adults with cystic fibrosis: the ACtiF research programme including RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background
People with cystic fibrosis frequently have low levels of adherence to inhaled medications.
Objectives
The objectives were to develop and evaluate an intervention for adults with cystic fibrosis to improve adherence to their inhaled medication.
Design
We used agile software methods to develop an online platform. We used mixed methods to develop a behaviour change intervention for delivery by an interventionist. These were integrated to become the CFHealthHub intervention. We undertook a feasibility study consisting of a pilot randomised controlled trial and process evaluation in two cystic fibrosis centres. We evaluated the intervention using an open-label, parallel-group randomised controlled trial with usual care as the control. Participants were randomised in a 1 : 1 ratio to intervention or usual care. Usual care consisted of clinic visits every 3 months. We undertook a process evaluation alongside the randomised controlled trial, including a fidelity study, a qualitative interview study and a mediation analysis. We undertook a health economic analysis using both a within-trial and model-based analysis.
Setting
The randomised controlled trial took place in 19 UK cystic fibrosis centres.
Participants
Participants were people aged ≥ 16 years with cystic fibrosis, on the cystic fibrosis registry, not post lung transplant or on the active transplant list, who were able to consent and not using dry-powder inhalers.
Intervention
People with cystic fibrosis used a nebuliser with electronic monitoring capabilities. This transferred data automatically to a digital platform. People with cystic fibrosis and clinicians could monitor adherence using these data, including through a mobile application (app). CFHealthHub displayed graphs of adherence data as well as educational and problem-solving information. A trained interventionist helped people with cystic fibrosis to address their adherence.
Main outcome measures
Randomised controlled trial – adjusted incidence rate ratio of pulmonary exacerbations meeting the modified Fuchs criteria over a 12-month follow-up period (primary outcome); change in percentage adherence; and per cent predicted forced expiratory volume in 1 second (key secondary outcomes). Process evaluation – percentage fidelity to intervention delivery, and participant and interventionist perceptions of the intervention. Economic modelling – incremental cost per quality-adjusted life-year gained.
Results
Randomised controlled trial – 608 participants were randomised to the intervention (n = 305) or usual care (n = 303). To our knowledge, this was the largest randomised controlled trial in cystic fibrosis undertaken in the UK. The adjusted rate of exacerbations per year (primary outcome) was 1.63 in the intervention and 1.77 in the usual-care arm (incidence rate ratio 0.96, 95% confidence interval 0.83 to 1.12; p = 0.638) after adjustment for covariates. The adjusted difference in mean weekly normative adherence was 9.5% (95% confidence interval 8.6% to 10.4%) across 1 year, favouring the intervention. Adjusted mean difference in forced expiratory volume in 1 second (per cent) predicted at 12 months was 1.4% (95% confidence interval –0.2% to 3.0%). No adverse events were related to the intervention. Process evaluation – fidelity of intervention delivery was high, the intervention was acceptable to people with cystic fibrosis, participants engaged with the intervention [287/305 (94%) attended the first intervention visit], expected mechanisms of action were identified and contextual factors varied between randomised controlled trial sites. Qualitative interviews with 22 people with cystic fibrosis and 26 interventionists identified that people with cystic fibrosis welcomed the objective adherence data as proof of actions to self and others, and valued the relationship that they built with the interventionists. Economic modelling – the within-trial analysis suggests that the intervention generated 0.01 additional quality-adjusted life-years at an additional cost of £865.91 per patient, leading to an incremental cost-effectiveness ratio of £71,136 per quality-adjusted life-year gained. This should be interpreted with caution owing to the short time horizon. The health economic model suggests that the intervention is expected to generate 0.17 additional quality-adjusted life-years and cost savings of £1790 over a lifetime (70-year) horizon; hence, the intervention is expected to dominate usual care. Assuming a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, the probability that the intervention generates more net benefit than usual care is 0.89. The model results are dependent on assumptions regarding the duration over which costs and effects of the intervention apply, the impact of the intervention on forced expiratory volume in 1 second (per cent) predicted and the relationship between increased adherence and drug-prescribing levels.
Limitations
Number of exacerbations is a sensitive and valid measure of clinical change used in many trials. However, data collection of this outcome in this context was challenging and could have been subject to bias. It was not possible to measure baseline adherence accurately. It was not possible to quantify the impact of the intervention on the number of packs of medicines prescribed.
Conclusions
We developed a feasible and acceptable intervention that was delivered to fidelity in the randomised controlled trial. We observed no statistically significant difference in the primary outcome of exacerbation rates over 12 months. We observed an increase in normative adherence levels in a disease where adherence levels are low. The magnitude of the increase in adherence may not have been large enough to affect exacerbations.
Future work
Given the non-significant difference in the primary outcome, further research is required to explore why an increase in objective normative adherence did not reduce exacerbations and to develop interventions that reduce exacerbations.
Trial registration
Work package 3.1: Current Controlled Trials ISRCTN13076797. Work packages 3.2 and 3.3: Current Controlled Trials ISRCTN55504164.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Iain Buchan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Public Health and Policy, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Rachel Elliott
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Stuart Elborn
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Laura Mandefield
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Zhe Hui Hoo
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Lumley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Aline Navega Biz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anne Scott
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Louisa Robinson
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Alessandro Sasso
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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9
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Wildman MJ, O'Cathain A, Maguire C, Arden MA, Hutchings M, Bradley J, Walters SJ, Whelan P, Ainsworth J, Buchan I, Mandefield L, Sutton L, Tappenden P, Elliott RA, Hoo ZH, Drabble SJ, Beever D. Self-management intervention to reduce pulmonary exacerbations by supporting treatment adherence in adults with cystic fibrosis: a randomised controlled trial. Thorax 2021; 77:461-469. [PMID: 34556552 PMCID: PMC9016257 DOI: 10.1136/thoraxjnl-2021-217594] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/15/2021] [Indexed: 12/02/2022]
Abstract
Introduction Recurrent pulmonary exacerbations lead to progressive lung damage in cystic fibrosis (CF). Inhaled medications (mucoactive agents and antibiotics) help prevent exacerbations, but objectively measured adherence is low. We investigated whether a multi-component (complex) self-management intervention to support adherence would reduce exacerbation rates over 12 months. Methods Between October 2017 and May 2018, adults with CF (aged ≥16 years; 19 UK centres) were randomised to the intervention (data-logging nebulisers, a digital platform and behavioural change sessions with trained clinical interventionists) or usual care (data-logging nebulisers). Outcomes included pulmonary exacerbations (primary outcome), objectively measured adherence, body mass index (BMI), lung function (FEV1) and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Analyses were by intent to treat over 12 months. Results Among intervention (n=304) and usual care (n=303) participants (51% female, median age 31 years), 88% completed 12-month follow-up. Mean exacerbation rate was 1.63/year with intervention and 1.77/year with usual care (adjusted ratio 0.96; 95% CI 0.83 to 1.12; p=0.64). Adjusted mean differences (95% CI) were in favour of the intervention versus usual care for objectively measured adherence (9.5% (8.6% to 10.4%)) and BMI (0.3 (0.1 to 0.6) kg/m2), with no difference for %FEV1 (1.4 (−0.2 to 3.0)). Seven CFQ-R subscales showed no between-group difference, but treatment burden reduced for the intervention (3.9 (1.2 to 6.7) points). No intervention-related serious adverse events occurred. Conclusions While pulmonary exacerbations and FEV1 did not show statistically significant differences, the intervention achieved higher objectively measured adherence versus usual care. The adherence difference might be inadequate to influence exacerbations, though higher BMI and lower perceived CF treatment burden were observed.
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Affiliation(s)
- Martin J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK .,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Iain Buchan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK.,Department of Public Health and Policy, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Laura Mandefield
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rachel A Elliott
- Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Zhe Hui Hoo
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
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10
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Davis CS, Cogen JD. Can clinical benefits of modulators effectively 'modulate' adherence in people with CF? Thorax 2021; 76:854-855. [PMID: 33863830 DOI: 10.1136/thoraxjnl-2021-216974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Chelsea S Davis
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
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11
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Arden MA, Hutchings M, Whelan P, Drabble SJ, Beever D, Bradley JM, Hind D, Ainsworth J, Maguire C, Cantrill H, O'Cathain A, Wildman M. Development of an intervention to increase adherence to nebuliser treatment in adults with cystic fibrosis: CFHealthHub. Pilot Feasibility Stud 2021; 7:1. [PMID: 33390191 PMCID: PMC7780635 DOI: 10.1186/s40814-020-00739-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 11/30/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition in which daily therapies to maintain lung health are critical, yet treatment adherence is low. Previous interventions to increase adherence have been largely unsuccessful and this is likely due to a lack of focus on behavioural evidence and theory alongside input from people with CF. This intervention is based on a digital platform that collects and displays objective nebuliser adherence data. The purpose of this paper is to identify the specific components of an intervention to increase and maintain adherence to nebuliser treatments in adults with CF with a focus on reducing effort and treatment burden. METHODS Intervention development was informed by the Behaviour Change Wheel (BCW) and person-based approach (PBA). A multidisciplinary team conducted qualitative research to inform a needs analysis, selected, and refined intervention components and methods of delivery, mapped adherence-related barriers and facilitators, associated intervention functions and behaviour change techniques, and utilised iterative feedback to develop and refine content and processes. RESULTS Results indicated that people with CF need to understand their treatment, be able to monitor adherence, have treatment goals and feedback and confidence in their ability to adhere, have a treatment plan to develop habits for treatment, and be able to solve problems around treatment adherence. Behaviour change techniques were selected to address each of these needs and were incorporated into the digital intervention developed iteratively, alongside a manual and training for health professionals. Feedback from people with CF and clinicians helped to refine the intervention which could be tailored to individual patient needs. CONCLUSIONS The intervention development process is underpinned by a strong theoretical framework and evidence base and was developed by a multidisciplinary team with a range of skills and expertise integrated with substantial input from patients and clinicians. This multifaceted development strategy has ensured that the intervention is usable and acceptable to people with CF and clinicians, providing the best chance of success in supporting people with CF with different needs to increase and maintain their adherence. The intervention is being tested in a randomised controlled trial across 19 UK sites.
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Affiliation(s)
- M A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, 2.03a Heart of the Campus, Collegiate Crescent Campus, Sheffield, S10 2BQ, UK.
| | - M Hutchings
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - P Whelan
- Health eResearch Centre-Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9GB, UK
| | - S J Drabble
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - D Beever
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - J M Bradley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - J Ainsworth
- Health eResearch Centre-Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9GB, UK
| | - C Maguire
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - H Cantrill
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - A O'Cathain
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - M Wildman
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
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12
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Multi-dimensional clinical phenotyping of a national cohort of adult cystic fibrosis patients. J Cyst Fibros 2020; 20:91-96. [PMID: 32948498 DOI: 10.1016/j.jcf.2020.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cystic Fibrosis (CF) is a multi-systemic disorder resulting from genetic variation in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene which can result in bronchiectasis, chronic sinusitis, pancreatic malabsorption, cholestatic liver disease and distal intestinal obstructive syndrome. This study generates multi-dimensional clinical phenotypes that capture the complexity and spectrum of the disease manifestations seen in adult CF patients using statistically robust techniques. METHODS Pre-transplant clinical data from adult (age ≥18 years) CF patients (n = 992) seen in six regionally distinct US CF centers between 1/1/2014 and 6/30/2015 were included. Demographic, spirometry, nutritional, microbiological and therapy data were used to generate clusters using the Random Forests statistical-learning and Partitioning around Medoids (PAM) clustering algorithms. Five commonly measured demographic, physiological and nutritional parameters were needed to create the final phenotypes that are highly similar to a regionally matched group of patients from the CF Foundation Patient Registry RESULTS: This approach identified high-risk phenotypes with expected characteristics including high rates of pancreatic insufficiency, diabetes and Pseudomonas aeruginosa colonization. It also identified unexpected populations including a) a male-dominated, well-nourished group with good lung function with a high prevalence of severe genotypes (i.e. 60% subjects had two minimal function CFTR variations), b) and an older, "survivor" phenotype that had high rates of chronic P. aeruginosa infection. CONCLUSIONS This study identified recognizable phenotypes that capture the clinical complexity in a statistically robust manner and which may aide in the identification of specific genetic and environmental factors responsible for these disease manifestation patterns.
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13
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Muther EF, Butcher JL, Riekert KA. Understanding Treatment Adherence in Cystic Fibrosis: Challenges and Opportunities. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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