Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control

The role of affective temperaments in self-care and medication adherence among individuals with bipolar disorder: a moderation analysis

Background

Affective temperament, defined as the fundamental predisposition from which normal affective states originate or as the constitutional core of personality, play a crucial role in mood disorders, particularly bipolar disorders. Understanding the relationship between temperaments, treatment adherence, and self-care is crucial for effective management and improved clinical results.

Objectives

This study aims to (1) assess the correlation between affective temperaments and treatment adherence, (2) investigate the relationship between affective temperaments and self-care abilities, (3) identify predictors of treatment adherence, and (4) explore the moderating effect of self-care on the relationship between treatment adherence and depressive temperament in individuals with bipolar disorder.

Methods

A cross-sectional study was conducted with 231 individuals diagnosed with bipolar disorder (BD) type I (N=160) and type II (N=71). The participants were evaluated using the following psychometric tools: Temperament Evaluation of Memphis, Pisa, and San Diego (TEMPS) to assess affective temperaments, Personal and Social Performance Scale (PSP) to evaluate social functioning and self-care abilities, and Morisky Medication Adherence Scale (MMAS) to measure treatment adherence. The study involved statistical analyses to examine correlations, identify predictors, and explore moderating effects.

Results

The findings revealed significant correlations between affective temperaments and both treatment adherence and self-care abilities. Specifically, hyperthymic temperament was positively associated with higher treatment adherence, whereas cyclothymic and depressive temperaments were linked to lower adherence. Self-care abilities were found to mediate the relationship between depressive temperament and treatment adherence, suggesting that improved self-care can enhance adherence in individuals with depressive temperament.

Conclusions

Affective temperaments significantly influence treatment adherence and self-care abilities in individuals with bipolar disorder. The mediating role of self-care highlights the importance of developing targeted interventions to improve self-care practices, thereby enhancing treatment adherence and overall well-being. Personalized treatment strategies based on temperament assessments could lead to better clinical outcomes and quality of life for individuals with bipolar disorder.

Assessment of Non-Adherence to Anti-TB Drugs and Associated Factors Among Patients Attending TB Treatment Centers During COVID-19 Pandemic in Mogadishu, Somalia: A Cross-Sectional Study

Background

The COVID-19 pandemic's first wave and subsequent lockdowns disrupted global healthcare systems, significantly impacting essential services including tuberculosis (TB) care. Non-adherence to anti-TB drugs is a critical concern, leading to treatment failure, drug resistance, and increased morbidity and mortality. This study assessed the rate and determinants of non-adherence to TB treatment among patients at TB centers during the first wave of the pandemic.

Material and Methods

A cross-sectional study was conducted from June 15 to July 30, 2020, involving 255 TB patients at three centers in Mogadishu. Data were gathered using the Morisky Medication Adherence Scale-8 (MMAS-8) through structured interviews and analyzed using descriptive statistics and binary logistic regression.

Results

The study found a 34.5% non-adherence rate during the pandemic. Key reasons for non-adherence included forgetting to take medication (33%), feeling well (29%), experiencing side effects (18%), and fear of contracting COVID-19 (16%). Significant factors associated with non-adherence were age groups 25-34 years (OR = 2.96, p = 0.024) and 35-44 years (OR = 4.55, p = 0.005), unemployment (OR = 2.57, p = 0.037), smoking (OR = 3.49, p = 0.029), tobacco use (OR = 4.15, p = 0.034), proximity to a health facility (OR = 0.44, p = 0.033), perception of healthcare providers as very friendly (OR = 0.24, p = 0.031) or friendly (OR = 0.45, p = 0.023), being in the continuous treatment phase (OR = 3.2, p < 0.001), and experiencing adverse treatment effects (OR = 2.42, p = 0.003).

Conclusion

Non-adherence to anti-tuberculosis treatment was notably high in Mogadishu during the first wave of the pandemic, necessitating targeted interventions to improve adherence.

Determinants of stroke among adult hypertensive patients on follow up in Addis Ababa public hospitals, Ethiopia: A case control study

BACKGROUND

Stroke is a non-communicable disease that causes sudden global or focal neurological disorders. It is one of the major public causes of morbidity and mortality in low- and middle-income countries, including Ethiopia. Early identification of the determinants and prompt intervention remains critical to reduce morbidity and mortality from stroke.

OBJECTIVE

The study aimed to identify determinants of stroke among adult hypertensive patients on follow up in Addis Ababa public hospitals, Ethiopia.

METHODS

Unmatched case-control study design was conducted among 326(109 cases and 217 controls) study participants in Addis Ababa public hospitals from September 1-30, 2021. The cases were adult hypertensive patients who developed a stroke and the controls were adult hypertensive patients. The study participants were selected by consecutive sampling technique. Pretested structured interviewer assisted questionnaire and checklist were used to collect data. Data were entered into Epi data version 3.1; exported and analysed by SPSS version 23. All independent variables with p-value < 0.25 in the bi-variable logistic regression analysis were entered into multivariable logistic regression analysis. Finally, variables with p-value <0.05 were considered as determinants of the stroke.

RESULTS

In this study, current cigarette smoker(AOR = 5.55, 95% CI: 2.48, 12.43), current alcohol drinker(AOR = 4.27, 95% CI: 1.94, 9.38), medication non-compliance(AOR = 3.23, 95% CI: 1.62, 6.44), uncontrolled systolic blood pressure (AOR = 3.42, 95% CI: 1.64, 7.16), uncontrolled diastolic blood pressure(AOR = 4.29, 95% CI: 2.06, 8.93), high low density lipoprotein(AOR = 6.89, 95% CI: 3.57, 13.35) and diabetic mellitus(AOR = 3.25, 95% CI: 1.58, 6.69) were more likely to develop a stroke.

CONCLUSION AND RECOMMENDATION

Cigarette smoking, alcohol use, non-adherence to medication, uncontrolled systolic pressure, uncontrolled diastolic blood pressure, high low-density lipoprotein, and diabetic mellitus were determinants of stroke. Providing health education about lifestyle changes and the consequences of hypertension at all follow-up is very important.

Adherence to oral anticoagulants in patients with non-valvular atrial fibrillation: the role of patients' characteristics and out-of-pocket payments

BACKGROUND

Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq's private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients.

RESEARCH DESIGN AND METHODS

This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq's southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p < 0.05 was considered statistically significant.

RESULTS

The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income (p = 0.001), number of daily pills (p = 0.006), and OACs' average monthly cost (p = 0.011).

CONCLUSION

Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

Cost-Effectiveness of Sotagliflozin in SOLOIST-WHF

BACKGROUND

The efficacy of sotagliflozin in patients with diabetes and recent worsening of heart failure was shown in the SOLOIST-WHF trial. However, the cost-effectiveness of sotagliflozin in these patients has not been previously investigated.

OBJECTIVES

The authors sought to determine the cost-effectiveness of sotagliflozin in patients with diabetes and recent worsening of heart failure.

METHODS

Based on SOLOIST-WHF trial data (N = 1,222), the authors constructed a Markov model to estimate the lifetime impact of sotagliflozin from a U.S. health care sector perspective. Cost data were sourced from the National Inpatient Sample. Life expectancy was modeled from census data and modified by the mortality rate in SOLOIST-WHF. Fatal and nonfatal event rates were carried forward from the trial data. Utility was assessed from the published reports.

RESULTS

Lifetime quality-adjusted life-years (QALYs) were 4.43 and 4.04 in the sotagliflozin and placebo groups, respectively, and lifetime costs were $220,113 and $188,198 in the sotagliflozin and placebo groups, respectively. The point estimate incremental cost-effectiveness ratio was $81,823 per QALY gained. The probability of being cost-effective was 3.6%, 67.5%, and 89.4% at willingness-to-pay thresholds of $50,000, $100,000, and $150,000, respectively, per QALY gained.

CONCLUSIONS

In patients with diabetes and recent worsening of heart failure, sotagliflozin is cost-effective in the U.S. using commonly accepted willingness-to-pay thresholds. (Effect of Sotagliflozin on Cardiovascular Events in Participants With Type 2 Diabetes Post Worsening Heart Failure [SOLOIST-WHF]; NCT03521934).

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Genetic Risk and Coronary Artery Calcium in Personalizing Antihypertensive Treatment: A Pooled Cohort Analysis

OBJECTIVE

To assess the role of the systolic blood pressure polygenic risk score (SBP-PRS) in antihypertensive treatment initiation and its comparative efficacy with coronary artery calcium (CAC) scores.

PATIENTS AND METHODS

This retrospective cohort study included participants with whole genome sequencing data who underwent CAC scanning between 1971 and 2008, were free of prevalent cardiovascular disease (CVD), and were not taking antihypertensive medications. The cohort was stratified by blood pressure (BP) treatment group and SBP-PRS (low/intermediate, first and second tertiles; high, third tertile) and CAC score (0 vs >0) subgroups. The primary outcome was the first occurence of adjudicated coronary heart disease, heart failure, or stroke during 10-year follow-up. The 10-year number needed to treat (NNT) to prevent 1 event of the primary outcome was estimated. A relative risk reduction of 25% for the primary outcome based on the treatment effect of intensive control (SBP <120 mm Hg) of hypertension in SPRINT (Systolic Blood Pressure Intervention Trial) was used for estimating the NNT.

RESULTS

Among the 5267 study participants, the median age was 59 years (interquartile range, 51-68 years); 2817 (53.5%) were women and 2880 (54.7%) were non-White individuals. Among 1317 individuals with elevated BP/low-risk stage 1 hypertension not recommended treatment, the 10-year incidence rate of the primary outcome was 5.6% for low/intermediate SBP-PRS and 6.3% for high SBP-PRS with NNTs of 63 and 59, respectively. Similarly, the 10-year incidence rate of the primary outcome was 2.9% for CAC score 0 and 9.7% for CAC score greater than 0, with NNTs of 117 and 37, respectively.

CONCLUSION

Including genetic information in risk estimation of individuals with elevated BP/low-risk stage 1 hypertension has modest value in the initiation of antihypertensive therapy. Genetic risk and CAC both have efficacy in personalizing antihypertensive therapy.

Integrating decision modeling and machine learning to inform treatment stratification

There is increasing interest in moving away from "one size fits all (OSFA)" approaches toward stratifying treatment decisions. Understanding how expected effectiveness and cost-effectiveness varies with patient covariates is a key aspect of stratified decision making. Recently proposed machine learning (ML) methods can learn heterogeneity in outcomes without pre-specifying subgroups or functional forms, enabling the construction of decision rules ('policies') that map individual covariates into a treatment decision. However, these methods do not yet integrate ML estimates into a decision modeling framework in order to reflect long-term policy-relevant outcomes and synthesize information from multiple sources. In this paper, we propose a method to integrate ML and decision modeling, when individual patient data is available to estimate treatment-specific survival time. We also propose a novel implementation of policy tree algorithms to define subgroups using decision model output. We demonstrate these methods using the SPRINT (Systolic Blood Pressure Intervention Trial), comparing outcomes for "standard" and "intensive" blood pressure targets. We find that including ML into a decision model can impact the estimate of incremental net health benefit (INHB) for OSFA policies. We also find evidence that stratifying treatment using subgroups defined by a tree-based algorithm can increase the estimates of the INHB.

Apixaban plasma concentrations before and after catheter ablation for atrial fibrillation

BACKGROUND

Catheter ablation in patients with atrial fibrillation is associated with a transient increase in thromboembolic risk and adequate anticoagulation is highly important. When patients are anticoagulated with apixaban, monitoring of plasma concentrations of the drug is not routinely performed. This study aimed to assess the influence of clinical patient characteristics, concomitant drug treatment and self-reported adherence on apixaban concentrations, and to describe the intra- and inter-individual variability in apixaban concentrations in this group of patients. Method Apixaban concentrations from 141 patients were measured in plasma one week before ablation and two, six and ten weeks after ablation, employing ultra-high performance liquid chromatography coupled with tandem mass spectrometry. In samples not obtained at trough, apixaban concentrations were adjusted to trough levels. Self-reported adherence was registered by means of the 8-item Morisky Medication Adherence Scale before and after ablation.

RESULTS

There were statistically significant, positive correlations between apixaban concentrations and increased age, female sex, lower glomerular filtration rate, higher CHA2DS2-VASc score, use of cytochrome P450 3A4 and/or p-glycoprotein inhibitors, and use of amiodarone. Self-reported adherence was generally high. The mean intra-individual and inter-individual coefficients of variation were 29% and 49%, respectively.

CONCLUSION

In patients undergoing catheter ablation for atrial fibrillation, age, sex, renal function, interacting drugs and cerebrovascular risk profile were all associated with altered plasma apixaban concentration. In this group of patients with a generally high self-reported adherence, intra-individual variability was modest, but the inter-individual variability was substantial, and similar to those previously reported in other patient apixaban-treated populations. If a therapeutic concentration range is established, there might be a need for a more flexible approach to apixaban dosing, guided by therapeutic drug monitoring.

Effect of medication adherence on quality of life, activation measures, and health imagine in the elderly people: a cross-sectional study

BACKGROUND

Usually, old age brings a poor quality of life due to illness and frailty. To prolong their lives and ensure their survival, all elderly patients with chronic diseases must adhere to their medications. In our study, we investigate medication adherence for elderly patients and its impact on the general health of the patient.

METHODS

We implemented a cross-sectional survey-based study with four sections in April 2022 in Saudi Arabia. Data about the participants' demographic characteristics, the Morisky Medication Adherence Scale, Patient Activation Measure (PAM) 13, and EQ-5D-5 L.

RESULTS

A total of 421 patients participated in this study, their mean age was 60.4 years, and most of them were males. Most of our population is living independently 87.9%. The vast majority of people have a low adherence record in the Morisky Medication Adherence Scale (8-MMAS) classes (score = < 6). Moreover, the average PAM13 score is 51.93 (Level2) indicating a low level of confidence and sufficient knowledge to take action. Our analysis showed a significant correlation between socioeconomic status and medication adherence. Also, there was an association between housing status and medication adherence. On the other hand, we found no correlation between medication adherence and quality of life (QOL) by EQ-5D-5 L.

CONCLUSION

Medication adherence is directly affected by living arrangements, as patients who live with a caretaker who can remind them to take their medications at the appropriate times have better medication adherence than those who live alone. Medication adherence was also significantly influenced by socioeconomic status, perhaps as a result of psychological effects and the belief of the lower-salaried population that they would be unable to afford the additional money required to cure any comorbidities that arose as a result of the disease. On the other hand, we did not find any correlation between medication adherence and quality of life. Finally, awareness of the necessity of adherence to medication for the elderly is essential.

Nonadherence to oral cancer chemotherapy in hepatocellular carcinoma: prevalence and predictive factors in Vietnam

PURPOSE

Standard oral cancer chemotherapy (OCT) or targeted therapy (OTT) has expanded the treatment methods for hepatocellular carcinoma (HCC). However, its principal nonadherence causes a reduction in efficacy. We aimed to evaluate the status of nonadherence and influencing factors among outpatient patients with HCC.

PATIENTS AND METHODS

In 2021, a prospective observational study was conducted on 384 patients with either old or newly diagnosed HCC treated with OTT. Nonadherence to OCT was determined using the eight-item Morisky Medication Adherence Scale, with a score < 6 points. The patients were finished with a six-month follow-up investigation by questionnaires.

RESULTS

54,8% of HCC outpatients were nonadherent to OCT, with a mean Morisky score of 5.19. They dropped out of the treatment mainly because of drug side effects, such as fatigue (72.4%), hand-foot syndrome (42.7%), diarrhea (38.3%), nausea (25%), insomnia (24.7%), abdominal pain (12%), and anxiety about these adverse events (65.9%). Additionally, financial difficulties and low relative copayments were significantly correlated with the noncompliant treatment of patients (OR = 2.29, 95% CI = 1.32-3.98, P = 0.003; OR = 4.36, 95% CI = 0.95-19.93, P = 0.039, respectively). Moreover, inadequate individual information about the clinical course, the art of treatment, and medication usage instructions were suggestive barriers to adherence to treatment (OR = 1.96, 95% CI = 1.08-3.55, P = 0.024; OR = 1.86, 95% CI = 1.1-3.14, P = 0.02; OR = 2.34, 95% CI = 1.29-4.26, P = 0.004, respectively). Finally, a low level of trust in doctors was an essential factor in nonadherence (Mean of the Anderson Trust in Physician Scale scores counted 38.12 vs. 43.97, respectively for non-adherence vs. adherence, P = 0.00001).

CONCLUSIONS

This study suggests a high rate of primary nonadherence to standard oral targeted therapy among HCC outpatient patients because of drug side effects, patient awareness of treatment, and lack of confidence in healthcare providers. Close supervision, proper medication instructions, appropriate dosage reductions, and comprehensive patient counseling might be necessary to control nonadherence.

Factors Influencing Therapeutic Non-Adherence Behavior Among Patients with Type 2 Diabetes in Two Public Hospitals in the Gambia: A Cross-Sectional Study

Background

Type 2 Diabetes Mellitus (DM) is a significant public health problem in The Gambia. While therapeutic non-adherence is widely recognized as a common and costly problem, very little is known about therapeutic adherence behavior among patients with diabetes in The Gambia.

Purpose

The objective of this study was to determine the prevalence and factors that influence diabetic therapeutic non-adherence behavior among patients with type 2 diabetes in The Gambia.

Methods

A cross-sectional study design was used, and participants were recruited from Edward Francis Small Teaching Hospital (EFSTH) and Kanifing General Hospital (KGH). The sample size of 145 patients with type 2 diabetes was included and data was collected using a structured questionnaire. Adherence to anti-diabetic medications was measured using the Morisky Medications Adherence Scale (MMAS-8). Logistic regression was used to determine the factors associated with diabetic therapeutic non-adherence.

Results

The prevalence of non-adherence to anti-diabetic treatment was 27.6%. Perceived barrier (forgetfulness, long-term medication use, and medication side effects) to diabetic treatment (OR = 0.265, 95% CI: 0.113-0.621, p = 0.041) was statistically significantly associated with non-adherence to anti-diabetic treatment. However, the frequency of doctor's visits (OR = 0.310, 95% CI: 0.046-2.111) was not significantly associated with non-adherence to anti-diabetic treatment.

Conclusion

The rate of non-adherence to antidiabetic treatment in this study was high. Perceived barriers to antidiabetic treatment such as forgetfulness, long-term medication use, and medication side effects influenced therapeutic non-adherence to antidiabetic treatment. While interventions should focus on how to eliminate these barriers, health education on diabetic self-care may help reinforce the importance of medication adherence to prevent complications.

Adherence to antihypertensive medication and its associated factors among patients with hypertension attending a tertiary hospital in Kathmandu, Nepal

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of premature mortality and morbidity globally. Despite the evidences of the availability of effective treatment for hypertension, its management remains suboptimal. Medication adherence is the most crucial factor for blood pressure control. It is important to identify the factors associated with adherence to antihypertensive treatment for better management. Hence, this study assessed the level of antihypertensive medication adherence and its associated factors among patients with hypertension visiting a tertiary-level hospital in Kathmandu, Nepal. An analytical cross-sectional study was carried out among 308 diagnosed patients with hypertension who were prescribed antihypertensive medication. The Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence. Data was collected through face-to-face interviews and analysed using SPSS v26. A bivariate and multivariate logistic regression model was used to assess the factors associated with low medication adherence. More than half (61%) of the study participants had moderate to high levels of medication adherence. Upon bivariate analysis, there was a significant association between presence of side effects, blood pressure status, forgetfulness, high cost, fear of taking medicine lifelong and irregular follow-up with a low level of adherence. Upon multivariate the logistic regression analysis, forgetfulness [Adjusted Odd's Ratio (AOR) 22.5, 95% Confidence Interval(CI) 10.56-47.86], high cost (AOR 3.8, 95%CI 1.25-11.60) and fear of taking medicines lifelong (AOR 6.04, 95%CI 2.96-12.33) were found to be associated factors of low level of adherence. There is an urgency to develop evidence-based strategies to improve the level of adherence to antihypertensive medications among patients with hypertension. Strategies like reminder messaging, setting alarms, expanding the scope of national health insurance and proper counselling to reduce fear could help to improve medication adherence. Hence, the feasibility and effectiveness of such intervention should be explored in future studies.

Treatment Adherence and Health Status of Patients With COPD Under Treatment With Salmeterol/Fluticasone via the Elpenhaler® Device: The AHEAD Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a heterogeneous progressive lung condition characterized by long-term respiratory symptoms and airflow limitation. Appropriate bronchodilation is the cornerstone of COPD treatment, leading to better health status as well as benefits in prognosis and mortality.

METHODS

In the current open, noninterventional, observational study, 716 patients diagnosed with COPD of variable severity were administered a fixed-dose combination (FDC) of fluticasone propionate and salmeterol (500 + 50 mcg) through the Elpenhaler® device. The patients' adherence to treatment (based on the MMAS-8 [8-item Morisky Medication Adherence Scale]) and health status (based on the CCQ [Clinical COPD Questionnaire]) were assessed at the beginning of the study and at the end of the 3-month follow-up period.

RESULTS

The mean ± SD MMAS-8 score at 1 and 3 months was 6.12 ± 1.89 and 6.45 ± 1.80, respectively, indicating medium adherence overall; however, there was a statistically significant increase of 0.33 units in the MMAS-8 score at the end of the follow-up (paired t-test p < 0.0001), suggestive of an improvement in adherence throughout the study. Higher adherence was associated with better health status at baseline, which further improved by the end of the follow-up. Moreover, we observed a statistically significant decrease of 1.07 points (p < 0.0001) in the mean CCQ total score from the baseline (CCQ score = 2.2 ± 1.00) until the end of the study follow-up (CCQ score = 1.13 ± 0.67). Similar conclusions were also drawn in the mean domain scores regarding symptoms (score equal to 1.36 ± 0.72, decrease by 1.18) as well as functional and mental state (scores equal to 0.86 ± 0.73 and 1.20 ± 0.88, decrease by 1.04 and 1.00, respectively, p < 0.0001). Similarly, when patients were stratified into subgroups with and without comorbidities, the former group showed an increase of 7% in the patients with medium to high adherence during the course of the study. In the same patient subgroup, there was a notable decrease in CCQ score by 1.18 points (p < 0.0001) during the study.

CONCLUSIONS

The administration of FDC of fluticasone propionate and salmeterol, (500 + 50 mcg) via the Elpenhaler® device for COPD, resulted in a well-maintained or slight increase in treatment adherence and a subsequent benefit in health status, which further persisted after 3 months of treatment.

Pharmacokinetic Comparison of a Fixed-Dose Combination of Candesartan Cilexetil/Amlodipine/Atorvastatin Versus Co-administration of Individual Formulations in Healthy Participants

INTRODUCTION

Fixed-dose combinations (FDCs) of angiotensin II receptor blockers, calcium channel blockers, and statins are conventional therapeutic interventions prescribed for cardiovascular diseases. This study aimed at drawing a comparison between the pharmacokinetics and safety of an FDC and the corresponding individual formulations in healthy subjects.

METHODS

A randomized, open-label, single-dose, three-sequence, three-period, partially repeated crossover study was conducted with a cohort of healthy volunteers. A 14-day washout period was maintained between each of the three periods. In this study, candesartan cilexetil, amlodipine, and atorvastatin was administered orally as FDCs of 16/10/40 mg in study 1 and 16/5/20 mg in study 2. The maximum plasma concentration (Cmax) and area under the plasma concentration-time curve from time zero to the time of the last quantifiable concentration (AUClast) of candesartan, amlodipine, and atorvastatin were estimated as the geometric mean ratios (GMRs) and 90% confidence intervals (CIs) of the FDC to individual formulations. If the within-subject coefficient of variation (CVwr) of Cmax was greater than 0.3, the bioequivalence (BE) range calculated using the reference-scaled average bioequivalence was used to assess whether the 90% CI was within the BE range.

RESULTS

The GMRs (90% CIs) for the AUClast for candesartan and amlodipine were 0.9612 (0.9158-1.0089)/0.9965 (0.9550-1.0397) and 1.0033 (0.9800-1.0271)/1.0067 (0.9798-1.0344), and the GMRs (90% CIs) for Cmax were 0.9600 (0.8953-1.0294)/0.9851 (0.9368-1.0359) and 1.0198 (0.9950-1.0453)/1.0003 (0.9694-1.0321) in studies 1 and 2, respectively. The extended BE ranges calculated from the CVwr of the Cmax of atorvastatin were 0.7814-1.2797 and 0.7415-1.3485, respectively. The GMRs (90% CIs) for the AUClast of atorvastatin were 1.0532 (1.0082-1.1003)/1.0252 (0.9841-1.0680), and the GMRs (90% CIs) for Cmax were 1.0630 (0.9418-1.1997)/0.9888 (0.8792-1.1120) in studies 1 and 2, respectively.

CONCLUSION

The Cmax and AUClast values of candesartan cilexetil/amlodipine/atorvastatin 16/10/40 mg and 16/5/20 mg, respectively, were within the BE ranges. There were no clinically significant differences in safety between the two formulations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, study 1: NCT04478097; study 2: NCT04627207.

Knowledge, attitude, and practice toward postoperative self-management among kidney transplant recipients

BACKGROUND

Patient involvement is crucial to the success of kidney transplants. This study aimed to investigate the knowledge, attitude, and practice (KAP) toward postoperative self-management among kidney transplant recipients.

METHODS

A web-based cross-sectional study was conducted in Ruijin Hospital (Shanghai, China) between March 24, 2023, and April 15, 2023 in kidney transplant recipients. A questionnaire was designed to collect data about the characteristics of the participants and their KAP toward postoperative self-management. KAP scores were calculated based on participants' responses, using predefined scoring criteria tailored to evaluate each dimension of KAP effectively.

RESULTS

A total of 483 valid questionnaires were collected, including 189 (39.13%) participants aged between 46 and 60 years. The mean score of knowledge, attitude and practice were 23.44 ± 4.87 (possible range: 0-28), 43.59 ± 2.65 (possible range: 10-50), 52.52 ± 4.64 (possible range: 0-58), respectively. The multivariate analysis showed knowledge scores (OR = 1.15, 95% CI = 1.10-1.20, p < 0.001), attitude scores (OR = 1.22, 95% CI = 1.12-1.32, p < 0.001) and undergone transplantation within 1 year (OR = 3.92, 95% CI = 1.60-9.63, p = 0.003) were independently associated with good practice. Knowledge scores (OR = 1.06, 95% CI = 1.02-1.10, p = 0.003), attitude scores (OR = 1.16, 95% CI = 1.08-1.25, p < 0.001), aged 16-35 years (OR = 0.38, 95% CI = 0.18-0.78, p = 0.009), underwent a single kidney transplant surgery (OR = 3.97, 95% CI = 1.28-12.38, p = 0.017) were independently associated with medication adherence.

CONCLUSIONS

Kidney transplant recipients had good knowledge, positive attitude and good practice toward postoperative self-management. Implementing personalized education, psychological support, and close monitoring strategies is recommended to optimize postoperative self-management in kidney transplant recipients.

Assessment of Medication Adherence Among Patients With Hypertension and Diabetes Mellitus in a Tertiary Healthcare Center: A Descriptive Study

Introduction Effective management of diabetes and hypertension requires a comprehensive approach, including dietary adjustments, physical activity, routine screening for complications, and adherence to medication. Proper adherence to pharmacotherapy is essential for maintaining glycemic control and managing blood pressure. Non-adherence can result in increased complications, higher healthcare costs, and greater morbidity and mortality. This study aimed to evaluate the sociodemographic profile and medication adherence among adults with diabetes and hypertension, focusing on those undergoing treatment. The objective was to determine the extent of adherence and identify factors that influence adherence among patients with type 2 diabetes mellitus (T2DM) and hypertension. Methods A community-based study was conducted on patients with T2DM and/or hypertension in both rural and urban areas of Bhopal, specifically those attending JK Hospital, Bhopal, Madhya Pradesh, India. Participants were selected using a simple random sampling method. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8), a validated tool for measuring patient adherence behavior. Results The study included 300 participants, of whom 68% (n=204) were male and 32% (n=96) were female. The average age of the participants was 57.52±10.3 years. Among the 300 patients, 9% (n=27) had high adherence to medication, 24.7% (n=74) had moderate adherence, and 66.3% (n=199) had low adherence. Conclusions Effective strategies must include targeted patient education on medication costs, side effects, and the long-term benefits of adherence. Integrating technological aids like smartphone apps may enhance adherence. Patients who adhere closely to their regimens are more likely to achieve better control over blood pressure and glycated hemoglobin (HbA1c) levels, underscoring the critical importance of adherence in managing chronic conditions effectively.

Update of the clinical guideline for hypertension diagnosis and treatment in Iran

BACKGROUND

This article introduces the updated version of the Iranian guideline for the diagnosis and treatment of hypertension in adults. The initial version of the national guideline was developed in 2011 and updated in 2014. Among the reasons necessitating the update of this guideline were the passage of time, the incompleteness of the scopes, the limitation of the target group, and more important is the request of the ministry of health in Iran.

METHOD

The members of the guideline updating group, after reviewing the original version and the new evidence, prepared 10 clinical questions regarding hypertension, and based on the evidence found from the latest scientific documents, provided recommendations or suggestions to answer these questions.

RESULT

According to the updated guideline, the threshold for office prehypertension diagnosis should be considered the systolic blood pressure (SBP) of 130-139 mmHg and/or the diastolic blood pressure (DBP) of 80-89 mmHg, and in adults under 75 years of age without comorbidities, the threshold for office hypertension diagnosis should be SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg. The goal of treatment in adults who lack comorbidities and risk factors is SBP < 140 mmHg and DBP < 90 mmHg. The first-line treatment recommended in people with prehypertension is lifestyle modification, while for those with hypertension, pharmacotherapy along with lifestyle modification. The threshold to start drug therapy is determined at SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg, and the first-line treatment is considered a drug or a combined pill of antihypertensive drugs, including ACEIs, ARBs, thiazide and thiazide-like agents, or CCBs. At the beginning of the pharmacotherapy, the Guideline Updating Group members suggested studying serum electrolytes, creatinine, lipid profile, fasting sugar, urinalysis, and an electrocardiogram. Regarding the visit intervals, monthly visits are suggested at the beginning of the treatment or in case of any change in the type or dosage of the drug until achieving the treatment goal, followed by every 3-to-6-month visits. Moreover, to reduce further complications, it was suggested that healthcare unit employees use telehealth strategies.

CONCLUSIONS

In this guideline, specific recommendations and suggestions have been presented for adults and subgroups like older people or those with cardiovascular disease, diabetes mellitus, chronic kidney disease, and COVID-19.

Effects of a Planned Web-Based Educational Intervention Based on the Health Belief Model for Patients With Ischemic Stroke in Promoting Secondary Prevention During the COVID-19 Lockdown in China: Quasi-Experimental Study

Background

Some common modified vascular risk factors remain poorly controlled among stroke survivors, and educational programs may help improve these conditions.

Objective

This study aimed to evaluate the effect of a planned web-based educational intervention based on the health belief model (HBM) in promoting secondary prevention among patients with ischemic stroke.

Methods

An evaluation-blinded quasi-experimental trial with a historical control group was conducted. Patients admitted from March to June 2020 were assigned to the historical control group, and patients admitted from July to October 2020 were assigned to the intervention group. The control group received routine health management. The intervention group received 6 additional sessions based on the HBM via Tencent Meeting, an audio and video conferencing application, within 3 months after discharge. Sessions were held every 2 weeks, with each session lasting approximately 40 minutes. These sessions were conducted in small groups, with about 8 to 10 people in each group. The primary outcomes were changes in blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), and the proportion of patients achieving the treatment target. The secondary outcomes were medication adherence, assessed with the Morisky Medicine Adherence Scale (MMAS), and disability, assessed with the modified Rankin scale.

Results

In total, 315 patients experiencing their first-ever stroke were analyzed. More patients in the intervention group had controlled BP (41.9% vs 28.4%; adjusted odds ratio [aOR] 1.93; P=.01), LDL-C (83.1% vs 67.7%; aOR 2.66; P=.001), and HbA1c (91.9% vs 83.9%; aOR: 3.37; P=.04) levels as well as a significant postintervention decrease in the systolic BP (adjusted β -3.94; P=.02), LDL-C (adjusted β -0.21; P=.008), and HbA1c (adjusted β -0.27; P<.001), compared with control groups. Significant between-group differences were observed in medication adherence (79.4% vs 63.2%; aOR 2.31; P=.002) but not in favorable functional outcomes.

Conclusions

A web-based education program based on the HBM may be more effective than current methods used to educate patients having strokes on optimal vascular risk factors and medication adherence.

The analysis of factors affecting medication adherence in patients with myasthenia gravis: a cross-sectional study

Background

Clinically, patients with myasthenia gravis are generally treated with drugs to improve their physical condition, and poor medication adherence can hinder their recovery. Many studies have shown the importance of medication adherence for effective treatment. Various factors may affect a patient's medication adherence; however, studies concerning medication adherence in patients with myasthenia gravis are rare.

Objectives

This study aimed to identify the factors related to medication adherence in patients with myasthenia gravis, and determine the possibility of predicting medication adherence.

Methods

This cross-sectional observational study was conducted among inpatients and outpatients with myasthenia gravis of the First Affiliated Hospital of Guangzhou University of Chinese Medicine in China. Data on patient demographics, disease-related characteristics, and medical treatment were collected. We evaluated medication adherence of the patients using the Morisky Medication Adherence Scale-8, Beliefs about Medicines Questionnaire, and the Self-efficacy for Appropriate Medication Use Scale.

Results

We distributed 200 questionnaires and finally retrieved 198 valid questionnaires. A total of 139 (70.2%) women participated in this study, and 81 (40.9%) among the 198 participants were aged 40-59 years. In total, 103 (52.0%) participants exhibited bad adherence to pharmacological treatment, and factors such as taking medication irregularly [odds ratio (OR) = 0.242, 95% CI = 0.093-0.627], the necessity of taking medicine (OR = 1.286, 95% CI = 1.142-1.449), the concerns of taking medicine (OR = 0.890, 95% CI = 0.801-0.988), and the self-efficacy for taking medications under difficult circumstances (OR = 1.194, 95% CI = 1.026-1.389) had statistically significant impacts on medication adherence.

Conclusion

Our study shows that taking medication irregularly and concerns of taking medicine are the risk factors for medication adherence. Meanwhile, the necessity of talking medicine and self-efficacy for taking medications under difficult circumstances are the protective factors for medication adherence. Our findings can help medical staff to enhance patients' medication adherence by informing patients necessary medical knowledge, emphasizing the necessity for medication, relieving patients' concerns regarding medication, and improving the self-efficacy for taking medications under difficult circumstances.

Building and Validation of an Acute Event Prediction Model for Severe Mental Disorders

Background

The global incidence of acute events in psychiatric patients is intensifying, and models to successfully predict acute events have attracted much attention.

Objective

To explore the influence factors of acute incident severe mental disorders (SMDs) and the application of Rstudio statistical software, and build and verify a nomogram prediction model.

Methods

SMDs were taken as research objects. The questionnaire survey method was adopted to collect data. Patients with acute event independent factors were screened. R software multivariable Logistic regression model was constructed and a nomogram was drawn.

Results

A total of 342 patients with SMDs were hospitalized, and the number of patients who encountered acute events was 64, which accounted for 18.70% of all patients. Statistical significances were found in many aspects (all P ˂ 0.05). Such aspects included Medication adherence, disease diagnosis, marital status, caregivers, social support and the hospitalization environment (odds ratio (OR) = 4.08, 11.62, 12.06, 10.52, 0.04 and 0.61, respectively) were independent risk factors for the acute events of patients with SMDs. The prediction model was modeled, and the AUC was 0.77 and 0.80. The calibration curve shows that the model has good calibration. The clinical decision curve shows that the model has a good clinical effect.

Conclusion

The constructed risk prediction model shows good prediction effectiveness in the acute events of patients with SMDs, which is helpful for the early detection of clinical mental health staff at high risk of acute events.

Latent Profile Analysis of Medication Beliefs in Patients with Type 2 Diabetes in the Hospital-Home Transition and Comparison with Medication Adherence

Background

The treatment of Type 2 Diabetes Mellitus (T2DM) is a protracted and arduous process. Medication, being a universally crucial therapeutic measure, underscores the significance of medication adherence in managing the disease effectively. Medication beliefs have emerged as a significant predictor of adherence, attracting considerable scholarly attention in recent years. However, there remains a paucity of research utilizing individual-centered approaches to explore medication beliefs among the T2DM population during the hospital-home transition, leaving the relationship between these beliefs and medication adherence unclear.

Purpose

To investigate latent categories of medication beliefs among patients with T2DM during the transition from hospital to home, and to analyze variations in medication adherence across these categories of patients.

Patients and methods

Between August 2022 and September 2023, this study selected 304 patients with a pre-discharge diagnosis of T2DM as study subjects from a tertiary hospital in Dongguan City. The patients' profiles were assessed comprehensively via the Sociodemographic and Clinical Characteristics Questionnaire, alongside the Chinese version of Beliefs about Medicines Questionnaire-Specific and Morisky Medication Adherence Scale-8. The present study conducted latent profile analysis using Mplus 7.4 software and analyzed the influencing factors of different medication belief categories and their differences in medication adherence using SPSS 26.0 software.

Results

The medication beliefs of 304 patients were rated at 3.36±5.24 points, while medication adherence scored 6.23±1.56 points. The medication beliefs were classified into four categories: moderate necessity - low to moderate concern group (40.13%), high necessity - low concern group (9.54%), moderate necessity - moderate to high concern group (19.08%), and moderate necessity - high concern group (31.25%). Age, monthly per capita household income, and place of residence emerged as influential factors for the four categories. Moreover, the disparity in medication adherence among these categories demonstrated statistical significance (P < 0.001).

Conclusion

The medication beliefs of patients were classified into four distinct categories, and variations in medication adherence were evident across these categories. The high necessity - low concern group demonstrated the highest medication adherence scores, while the moderate necessity - high concern group exhibited the lowest scores. Healthcare providers are advised to tailor personalized medication belief enhancement programs based on patients' homogeneous beliefs, addressing specific issues encountered by each category. This approach aims to ensure optimal medication adherence across diverse medical and social environments, effectively improving patient prognosis and enhancing quality of life.

Development of a Health Behavioral Digital Intervention for Patients With Hypertension Based on an Intelligent Health Promotion System and WeChat: Randomized Controlled Trial

BACKGROUND

The effectiveness of timely medication, physical activity (PA), a healthy diet, and blood pressure (BP) monitoring for promoting health outcomes and behavioral changes among patients with hypertension is supported by a substantial amount of literature, with "adherence" playing a pivotal role. Nevertheless, there is a lack of consistent evidence regarding whether digital interventions can improve adherence to healthy behaviors among individuals with hypertension.

OBJECTIVE

The aim was to develop a health behavioral digital intervention for hypertensive patients (HBDIHP) based on an intelligent health promotion system and WeChat following the behavior change wheel (BCW) theory and digital micro-intervention care (DMIC) model and assess its efficacy in controlling BP and improving healthy behavior adherence.

METHODS

A 2-arm, randomized trial design was used. We randomly assigned 68 individuals aged >60 years with hypertension in a 1:1 ratio to either the control or experimental group. The digital intervention was established through the following steps: (1) developing digital health education materials focused on adherence to exercise prescriptions, Dietary Approaches to Stop Hypertension (DASH), prescribed medication, and monitoring of BP; (2) using the BCW theory to select behavior change techniques; (3) constructing the intervention's logic following the guidelines of the DMIC model; (4) creating an intervention manual including the aforementioned elements. Prior to the experiment, participants underwent physical examinations at the community health service center's intelligent health cabin and received intelligent personalized health recommendations. The experimental group underwent a 12-week behavior intervention via WeChat, while the control group received routine health education and a self-management manual. The primary outcomes included BP and adherence indicators. Data analysis was performed using SPSS, with independent sample t tests, chi-square tests, paired t tests, and McNemar tests. A P value <.05 was considered statistically significant.

RESULTS

The final analysis included 54 participants with a mean age of 67.24 (SD 4.19) years (n=23 experimental group, n=31 control group). The experimental group had improvements in systolic BP (-7.36 mm Hg, P=.002), exercise time (856.35 metabolic equivalent [MET]-min/week, P<.001), medication adherence (0.56, P=.001), BP monitoring frequency (P=.02), and learning performance (3.23, P<.001). Both groups experienced weight reduction (experimental: 1.2 kg, P=.002; control: 1.11 kg, P=.009) after the intervention. The diet types and quantities for both groups (P<.001) as well as the subendocardial viability ratio (0.16, P=.01) showed significant improvement. However, there were no statistically significant changes in other health outcomes.

CONCLUSIONS

The observations suggest our program may have enhanced specific health outcomes and adherence to health behaviors in older adults with hypertension. However, a longer-term, larger-scale trial is necessary to validate the effectiveness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://www.chictr.org.cn/showprojEN.html?proj=172782.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/46883.

Design and validation of a new questionnaire with a gender perspective to measure medication adherence for secondary prevention of ischaemic heart disease: study protocol

INTRODUCTION AND OBJECTIVES

Only about 50% of chronic patients in high-income countries adhere to their treatment. There are methods to measure medication adherence but none of them can be considered optimal. This study will aim to design and validate a questionnaire to measure medication adherence in patients with ischaemic heart disease using a direct method as a gold-standard adherence measure and taking into account the gender perspective. Moreover, the profile of low adherence in these patients will be determined.

METHODS AND ANALYSIS

First study phase consists on the questionnaire design following the next steps: identification of the dimensions, definition of the target population, questionnaire items and order, response coding, questionnaire instructions, content validity by experts and understandability. In the second phase, a cross-sectional study will be performed to end the questionnaire development and validate it. Four hundred and forty patients (50% female) with acute coronary syndrome receiving treatment within the previous 12 months will be included. Patient will answer the initial questionnaire and adherence to aspirin and statin will be measured using a direct method (drug concentration analysis in blood) and other questionnaires. From the set of preselected questionnaire items, those most closely associated with the gold standard measure will be selected using multivariate statistics.

ETHICS AND DISSEMINATION

All participants gave their written informed consent before participating in the study. The study protocol follows the recommendations of the Declaration of Helsinki and was approved by the ethics committees of the three participating centres. The results of this study will be displayed at national and international conferences and in peer-reviewed scientific journals.

Factors Related to Treatment Non-Adherence Among Caregivers of Pediatric and Adolescent Growth Hormone Deficiency Patients in Japan

Background

About one-third of caregivers of pediatric or adolescent growth hormone deficiency (pGHD) patients in Japan have reported poor treatment adherence. However, few studies have examined factors related to adherence for that group.

Objective

The aim of this study is to consider factors related to poor adherence to daily treatment among caregivers of pGHD patients in Japan.

Methods

A cross-sectional survey was conducted among caregivers of pGHD patients in Japan. Caregivers were asked about demographic and treatment characteristics, health literacy, treatment satisfaction, opinions about treatment, and treatment adherence. Health literacy was assessed using the 14-item health literacy scale (HLS-14). Adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8). Statistical association with adherence was considered using Chi-square and Student's t-testing. An exploratory factor analysis (EFA) and K-means cluster analysis was conducted to consider the influence of treatment satisfaction and opinions concerning treatment on adherence.

Results

Responses were collected from 112 caregivers. The caregiver's age being 30-39 years old, the primary caregiver being male, the primary caregiver being employed, and low functional health literacy for the caregiver were associated with poor adherence. Patients being pre-elementary school age was also associated with poor adherence. Low satisfaction with drug treatment and/or their device and communication with healthcare professionals (HCPs), and lack of agreement with the importance of treatment management (eg, keeping injection records, getting informed about the disease/therapy, reporting non-adherence, and sticking to an administration schedule), were also associated with poor adherence.

Conclusion

Strategies to improve treatment adherence among caregivers of pGHD patients in Japan should consider the age, gender, and employment status of the caregiver - as well as their functional literacy. Improvement in satisfaction with the drug or device used, better communication with HCPs, and greater awareness of the importance of treatment management, may also lead to better adherence.

A Mobile Applet for Assessing Medication Adherence and Managing Adverse Drug Reactions Among Patients With Cancer: Usability and Utility Study

BACKGROUND

Medication adherence and the management of adverse drug reactions (ADRs) are crucial to the efficacy of antitumor drugs. A WeChat applet, also known as a "Mini Program," is similar to the app but has marked advantages. The development and use of a WeChat applet makes follow-up convenient for patients with cancer.

OBJECTIVE

This study aimed to assess the usability and utility of a newly developed WeChat applet, "DolphinCare," among patients with cancer in Shanghai.

METHODS

A qualitative methodology was used to obtain an in-depth understanding of the experiences of patients with cancer when using DolphinCare from the usability and utility aspects. The development phase consisted of 2 parts: alpha and beta testing. Alpha testing combined the theory of the Fogg Behavior Model and the usability model. Alpha testing also involved testing the design of DolphinCare using a conceptual framework, which included factors that could affect medication adherence and ADRs. Beta testing was conducted using in-depth interviews. In-depth interviews allowed us to assist the patients in using DolphinCare and understand whether they liked or disliked DolphinCare and found it useful.

RESULTS

We included participants who had an eHealth Literacy Scale (eHEALS) score of ≥50%, and a total of 20 participants were interviewed consecutively. The key positive motivators described by interviewers were to be reminded to take their medications and to alleviate their ADRs. The majority of the patients were able to activate and use DolphinCare by themselves. Most patients indicated that their trigger to follow-up DolphinCare was the recommendation of their known and trusted health care professionals. All participants found that labels containing the generic names of their medication and the medication reminders were useful, including timed pop-up push notifications and text alerts. The applet presented the corresponding information collection forms of ADRs to the patient to fill out. The web-based consultation system enables patients to consult pharmacists or physicians in time when they have doubts about medications or have ADRs. The applet had usabilities and utilities that could improve medication adherence and the management of ADRs among patients with cancer.

CONCLUSIONS

This study provides preliminary evidence regarding the usability and utility of this type of WeChat applet among patients with cancer, which is expected to be promoted for managing follow-up among other patients with other chronic disease.

Association Between Self-Reported Medication Adherence and Therapeutic Inertia in Hypertension: A Secondary Analysis of SPRINT (Systolic Blood Pressure Intervention Trial)

BACKGROUND

Therapeutic inertia (TI), failure to intensify antihypertensive medication when blood pressure (BP) is above goal, remains prevalent in hypertension management. The degree to which self-reported antihypertensive adherence is associated with TI with intensive BP goals remains unclear.

METHODS AND RESULTS

Cross-sectional analysis was performed of the 12-month visit of participants in the intensive arm of SPRINT (Systolic Blood Pressure Intervention Trial), which randomized adults to intensive (<120 mm Hg) versus standard (<140 mm Hg) systolic BP goals. TI was defined as no increase in antihypertensive regimen intensity score, which incorporates medication number and dose, when systolic BP is ≥120 mm Hg. Self-reported adherence was assessed using the 8-Item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (MMAS-8 score <6), medium (MMAS-8 score 6 to <8), and high (MMAS-8 score 8). Poisson regressions estimated prevalence ratios (PRs) and 95% CIs for TI associated with MMAS-8. Among 1009 intensive arm participants with systolic BP >120 mm Hg at the 12-month visit (mean age, 69.6 years; 35.2% female, 28.8% non-Hispanic Black), TI occurred in 50.8% of participants. Participants with low adherence (versus high) were younger and more likely to be non-Hispanic Black or smokers. The prevalence of TI among patients with low, medium, and high adherence was 45.0%, 53.5%, and 50.4%, respectively. After adjustment, neither low nor medium adherence (versus high) were associated with TI (PR, 1.11 [95% CI, 0.87-1.42]; PR, 1.08 [95% CI, 0.84-1.38], respectively).

CONCLUSIONS

Although clinician uncertainty about adherence is often cited as a reason for why antihypertensive intensification is withheld when above BP goals, we observed no evidence of an association between self-reported adherence and TI.

Effectiveness of Hypertension Management Strategies in SPRINT-Eligible US Adults: A Simulation Study

BACKGROUND

Despite reducing cardiovascular disease (CVD) events and death in SPRINT (Systolic Blood Pressure Intervention Trial), intensive systolic blood pressure goals have not been adopted in the United States. This study aimed to simulate the potential long-term impact of 4 hypertension management strategies in SPRINT-eligible US adults.

METHODS AND RESULTS

The validated Blood Pressure Control-Cardiovascular Disease Policy Model, a discrete event simulation of hypertension care processes (ie, visit frequency, blood pressure [BP] measurement accuracy, medication intensification, and medication adherence) and CVD outcomes, was populated with 25 000 SPRINT-eligible US adults. Four hypertension management strategies were simulated: (1) usual care targeting BP <140/90 mm Hg (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care), (2) intensive care per the SPRINT protocol targeting BP <120/90 mm Hg (SPRINT intensive), (3) usual care targeting guideline-recommended BP <130/80 mm Hg (American College of Cardiology/American Heart Association usual care), and (4) team-based care added to usual care and targeting BP <130/80 mm Hg. Relative to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, among the 18.1 million SPRINT-eligible US adults, an estimated 138 100 total CVD events could be prevented per year with SPRINT intensive, 33 900 with American College of Cardiology/American Heart Association usual care, and 89 100 with team-based care. Compared with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, SPRINT intensive care was projected to increase treatment-related serious adverse events by 77 600 per year, American College of Cardiology/American Heart Association usual care by 33 300, and team-based care by 27 200.

CONCLUSIONS

As BP control has declined in recent years, health systems must prioritize hypertension management and invest in effective strategies. Adding team-based care to usual care may be a pragmatic way to manage risk in this high-CVD-risk population.

Cost-Effectiveness of Icosapent Ethyl in REDUCE-IT USA: Results From Patients Randomized in the United States

BACKGROUND

In 3146 REDUCE-IT USA (Reduction of Cardiovascular Events With Icosapent Ethyl Intervention Trial USA) participants, icosapent ethyl (IPE) reduced first and total cardiovascular events by 31% and 36%, respectively, over 4.9 years of follow-up.

METHODS AND RESULTS

We used participant-level data from REDUCE-IT USA, 2021 US costs, and IPE costs ranging from $4.59 to $11.48 per day, allowing us to examine a range of possible medication costs. The in-trial analysis was participant-level, whereas the lifetime analysis used a Markov model. Both analyses considered value from a US health sector perspective. The incremental cost-effectiveness ratio (incremental costs divided by incremental quality-adjusted life-years) of IPE compared with standard care (SC) was the primary outcome measure. There was incremental gain in quality-adjusted life-years with IPE compared with SC using in-trial (3.28 versus 3.13) and lifetime (10.36 versus 9.83) horizons. Using an IPE cost of $4.59 per day, health care costs were lower with IPE compared with SC for both in-trial ($29 420 versus $30 947) and lifetime ($216 243 versus $219 212) analyses. IPE versus SC was a dominant strategy in trial and over the lifetime, with 99.7% lifetime probability of an incremental cost-effectiveness ratio <$50 000 per quality-adjusted life-year gained. At a medication cost of $11.48 per day, the cost per quality-adjusted life-year gained was $36 208 in trial and $9582 over the lifetime.

CONCLUSIONS

In this analysis, at $4.59 per day, IPE offers better outcomes than SC at lower costs in trial and over a lifetime and is cost-effective at $11.48 per day for conventional willingness-to-pay thresholds. Treatment with IPE should be strongly considered in US patients like those enrolled in REDUCE-IT USA.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01492361.

Direct oral anticoagulant concentrations and adherence in stroke patients

No therapeutic ranges linking drug concentrations of apixaban and rivaroxaban to clinical outcomes have been defined. We investigated whether direct oral anticoagulant (DOAC) concentrations among patients admitted to hospital with symptoms of stroke differed between those later verified to suffer an ischaemic cerebrovascular event (stroke or transient ischaemic attack) and those having other diagnoses (control group). Serum concentrations in 102 patients on DOAC for atrial fibrillation (84%) and thromboembolic disease (16%) were measured within 24 h of the acute event, employing ultra-high performance liquid chromatography with tandem mass spectrometry. We converted all concentrations to standardized trough levels. DOAC concentrations were lower in the 64 patients with verified ischaemic cerebrovascular event than in the 30 controls, 255 ± 155 versus 329 ± 144 nmol/L (p = 0.029), despite no statistically significant difference in self-reported adherence and daily dosages. Calculated concentrations were 5.4-596 nmol/L (median = 229 nmol/L) in the ischaemic stroke group and 41-602 nmol/L (median = 316 nmol/L) in controls. CHA2 DS2 -VASc score was significantly higher in the ischaemic stroke group than in controls (4.9 ± 1.6 versus 4.1 ± 1.7; p = 0.007). These results may suggest that patients with high cerebrovascular risk might benefit from higher DOAC levels than those with a lower risk.

Social determinants of blood pressure control in a middle-income country in Latin America

Blood pressure (BP) control is a key intervention to decrease cardiovascular diseases (CVD), the main cause of death in low and middle-income countries (MIC). Scarce data on the determinants of BP control in Latin America are available. Our objective is to explore the role of gender, age, education, and income as social determinants of BP control in Argentina, a MIC with a universal health care system. We evaluated 1184 persons in two hospitals. Blood pressure was measured using automatic oscillometric devices. We selected those patients treated for hypertension. The average BP of less than 140/90 mmHg was considered a controlled BP. We found 638 hypertensive individuals, of whom 477 (75%) were receiving antihypertensive drugs, and of those, 248 (52%) had controlled BP. The prevalence of low education was more frequent in uncontrolled patients (25.3% vs. 16.1%; P < .01). We did not find association between household income, gender, and BP control. Older patients had less BP control (44% of those older than 75 years vs. 60.9% of those younger than 40; test for trend P < .05). Multivariate regression indicates low education (OR 1.71 95% CI [1.05, 2.79]; P = .03) and older age (OR 1.01; 95% IC [1.00, 1.03]) as independent predictors of the lack of BP control. We conclude that rates of BP control are low in Argentina. In a MIC with a universal health care system low education and old age but not household income are independent predictors of the lack of BP control.

A Machine Learning Model to Predict Patients' Adherence Behavior and a Decision Support System for Patients With Metastatic Breast Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Adherence to oral anticancer treatments is critical in the disease trajectory of patients with breast cancer. Given the impact of nonadherence on clinical outcomes and the associated economic burden for the health care system, finding ways to increase treatment adherence is particularly relevant.

OBJECTIVE

The primary end point is to evaluate the effectiveness of a decision support system (DSS) and a machine learning web application in promoting adherence to oral anticancer treatments among patients with metastatic breast cancer. The secondary end point is to collect a set of new physical, psychological, social, behavioral, and quality of life predictive variables that could be used to refine the preliminary version of the machine learning model to predict patients' adherence behavior.

METHODS

This prospective, randomized controlled study is nested in a large-scale international project named "Enhancing therapy adherence among metastatic breast cancer patients" (Pfizer 65080791), aimed to develop a predictive model of nonadherence and associated DSS and guidelines to foster patients' engagement and therapy adherence. A web-based DSS named TREAT (treatment adherence support) was developed using a patient-driven approach, with 4 sections, that is, Section A: Metastatic Breast Cancer; Section B: Adherence to Cancer Therapies; Section C: Promoting Adherence; and Section D: My Adherence Diary. Moreover, a machine learning-based web application was developed to predict patients' risk factors of adherence to anticancer treatment, specifically pertaining to physical status and comorbid conditions, as well as short and long-term side effects. Overall, 100 patients consecutively admitted at the European Institute of Oncology (IEO) at the Division of Medical Senology will be enrolled; 50 patients with metastatic breast cancer will be exposed to the DSS and machine learning web application for 3 months (experimental group), and 50 patients will not be exposed to the intervention (control group). Each participant will fill a weekly medication diary and a set of standardized self-reports evaluating psychological and quality of life variables (Adherence Attitude Inventory, Beck Depression Inventory-II, Brief Pain Inventory, 13-item Sense of Coherence scale, Brief Italian version of Cancer Behavior Inventory, European Organization for Research and Treatment of Cancer Quality of Life 23-item Breast Cancer-specific Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, 8-item Morisky Medication Adherence Scale, State-Trait Anxiety Inventory forms I and II, Big Five Inventory, and visual analogue scales evaluating risk perception). The 3 assessment time points are T0 (baseline), T1 (1 month), T2 (2 months), and T3 (3 months). This study was approved by the IEO ethics committee (R1786/22-IEO 1907).

RESULTS

The recruitment process started in May 2023 and is expected to conclude on December 2023.

CONCLUSIONS

The contribution of machine learning techniques through risk-predictive models integrated into DSS will enable medication adherence by patients with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06161181; https://clinicaltrials.gov/study/NCT06161181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48852.

Examining the potential impacts of intensive blood pressure treatment on the socioeconomic inequity in hypertension prevalence in China: a nationally representative cross-sectional study

Few studies focused on the equity of hypertension prevalence before and after the diagnostic threshold change. The study aimed to analyze the 130/80 mmHg hypertension diagnostic threshold on the equity of hypertension prevalence in China. The baseline survey data from the China Health and Retirement Longitudinal Study (CHARLS) conducted from 2011 to 2012 were utilized to evaluate the impact of the 130/80 mmHg diagnostic threshold on the equity of hypertension prevalence in China using the concentration index and its decomposition which was an index reflecting the health inequality caused by social and economic factors. The prevalence of hypertension was 41.56% and 57.33% under the diagnostic thresholds of 140/90 mmHg and 130/80 mmHg, respectively. The concentration index for hypertension prevalence in China was -0.017 (95%CI: -0.028, -0.006) under the 140/90 mmHg threshold and -0.010 (95%CI: -0.018, -0.002) under the 130/80 mmHg threshold. Concentration index decomposition analysis of hypertension prevalence diagnosed at both diagnostic thresholds showed that age, BMI, and economic status contributed more to the inequitable situation of hypertension prevalence. Higher age, higher BMI, and poorer economic status increased the inequity of hypertension prevalence. No significant difference in the increase in hypertension among individuals of different economic status after implementing the blood pressure control standard (130/80 mmHg), and the prevalence of hypertension in the region did not show a significant bias towards the low economic status population. Therefore, implementing this standard will not increase the risk of hypertension prevalence biased toward people of low economic status. Implementing the 130/80 mmHg diagnostic threshold will not increase the risk of hypertension prevalence biased towards people of low economic status.

The Impact of Psychosomatic Factors on Treatment Adherence of Acute Myocardial Infarction Survivors; A Two-Year Follow-Up Study

Backgroud

Because of the important role of adhering to treatment to reduce major adverse cardiovascular events and mortality, studying the factors affecting treatment adherence (TA) is warranted. This study aimed to identify the impact of psychosomatic factors on adhering to treatment among patients with acute myocardial infarction.

Materials and Methods

This is a cohort study as a part of the Isfahan ST-segment-elevated Myocardial Infarction Cohort Study. Psychosomatic factors such as health anxiety, illness denial, irritable mood, and demoralization were assessed among 867 patients at the first visit. The patients were followed for 2 years; TA and major adverse cardiovascular events were checked annually in survivors.

Results

The results from binary logistic regression applied to find the association between TA and psychosomatic factors showed that the patients with health anxiety, irritable mood, and demoralization were significantly poor adherent to treatment (odds ratio [95% confidence interval]: 1.39 [1.02, 2.73], 1.51 [1.02, 2.37], and 1.66 [1.02, 2.91]), respectively. The associations remained the same when adjusted for various potential confounders.

Conclusions

Psychosomatic factors played an essential role in adhering to treatment among patients with acute myocardial infarction. As a result, appropriate psychological interventions may help the patients adhere to their treatment better.

Cost-effectiveness of drug treatment for young and middle-aged stage 1 hypertensive patients with high risk

Background

Drug treatment was recommended for stage 1 hypertensive patients (blood pressure of 130-139 / 80-89 millimetres of mercury (mmHg)) with high cardiovascular disease (CVD) risk in the 2017 Hypertension Clinical Practice Guidelines, 2018 Chinese guidelines and 2021 World Health Organization guidelines, but not in other guidelines. However, evidence on the cost-effectiveness of drug treatment among young and middle-aged patients remains scarce. This study aimed to compare the cost-effectiveness of drug treatment vs. non-drug treatment for stage 1 hypertensive patients aged <60 years with high CVD risk.

Methods

A microsimulation model projected quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios for drug treatment from a societal perspective. Transition probabilities were estimated from the Kailuan study with a sample size of 34 093 patients aged <60 years with high CVD risk. Costs and health utilities were obtained from the Kailuan study, national statistics reports and published literature.

Results

Over a 15-year time horizon, the model predicted that drug treatment generated QALY of 9.36 and was associated with expected costs of 3735 US dollars ($) compared with 9.07 and $3923 produced by non-drug treatment among stage 1 hypertensive patients, resulting in a cost-saving for drug treatment. At a willingness-to-pay threshold of $10439/QALY (one gross domestic product (GDP) per capita in 2020), drug treatment had a 99.99% probability of being cost-effective for 10 000 samples of probabilistic sensitivity analysis. Sensitivity analyses by different values of transition probability, cost, utility and discount rate did not appreciably change the results. Shortening the time horizon to the average follow-up period of eight years resulted in ICER of $189/QALY for drug treatment (<1 × GDP/QALY).

Conclusions

Our results suggested that drug treatment was a dominant strategy for stage 1 hypertensive patients aged <60 years with high CVD risk in China, which may provide evidence for policymakers and clinicians when weighing the pros and cons of drug treatment for young and middle-aged stage 1 hypertensive patients.

Elderly and aged asthma have different characteristics: results of a multicenter study

Background/aim

Characteristics of asthma in the elderly population is not well-known. The aim of the present study was to evaluate asthma in the elderly population, to compare disease characteristics between patients diagnosed <60 (aged asthma) and ≥60 (elderly asthma) years of age.

Materials and methods

The study was a prospective, multicenter, cross-sectional type. A questionnaire was filled out to patients 60 years of age and over, that have been followed for asthma for at least 3 months. Asthma Control Test (ACT), eight-item Morisky Medication Adherence Scale (MMAS-8) was filled out, inhaler device technique was assessed.

Results

A total of 399 patients were included from 17 tertiary care centers across the country. Mean age was 67.11 years and 331 (83%) were female. The age at asthma diagnosis was ≥60 in 146 (36.6%) patients. Patients diagnosed ≥60 years were older (p < 0.001), had higher education level (p < 0.001), more commonly had first-degree relative with asthma (p = 0.038), asthma related comorbidities (p = 0.009) and accompanying rhinitis/rhinosinusitis (p = 0.005), had better asthma control (p = 0.001), were using less controller medications (p = 0.014). Inhaler technique was correct in 37% of the patients with no difference in between the groups. Treatment compliance was better in elderly asthma patients (p < 0.001). In the multivariate logistic regression analysis, having well-controlled asthma (odds ratio = 1.61, CI = 1.04-2.51), and high medication adherence rate (odds ratio = 2.43, CI = 1.48-4.0) were associated with being in the elderly asthma group.

Conclusion

The characteristics of asthma are different among patients aged 60 years and over which seems to be related to onset age of asthma. In our cohort, the elderly asthma patients had higher education level, and treatment adherence and asthma control was better. Patients diagnosed ≥60 years of age did not have more severe disease.

Relationship Between Asthma Control Status and Health-Related Quality of Life in Japan: A Cross-Sectional Mixed-Methods Study

INTRODUCTION

There is limited information regarding multidimensional relationships between asthma control and health-related quality of life (HRQoL), work productivity, and asthma symptom burden in Japan. Furthermore, systematic qualitative investigations about asthma burden have not been performed.

METHODS

This cross-sectional, mixed-methods study included Japanese patients (≥ 20 years) with asthma adherent to inhaled corticosteroids/long-acting β2-agonists (ICS/LABA). The primary endpoint was impact of asthma on HRQoL, measured using the Asthma Health Questionnaire-33 (AHQ-33). Secondary endpoints were cough burden (Japanese-adapted Leicester Cough Questionnaire [J-LCQ]) and impact of asthma on work/activities (asthma-specific Work Productivity and Activity Impairment Questionnaire [WPAI:Asthma]). Quantitative data were assessed for the overall population and for well-controlled (WC) and not well-controlled (NWC) asthma subgroups. Qualitative verbal interviews further assessed the impact of NWC asthma on patients' HRQoL; emergent themes were extracted using thematic analyses.

RESULTS

Of 454 patients, 45.2% (n = 205) had NWC asthma. Patients with NWC asthma had significantly worse asthma- and cough-related HRQoL across all AHQ-33 and J-LCQ domains and significantly greater work and activity impairment versus patients with WC asthma, across all assessed WPAI:Asthma domains. AHQ-33 total score was highly correlated with J-LCQ total and domain scores (r = - 0.8132 to r = - 0.7407). Nine themes emerged from qualitative interviews and confirmed that patients with NWC asthma had considerable HRQoL impairment due to asthma symptoms.

CONCLUSIONS

Patients with NWC asthma had higher symptom burden and worse HRQoL than patients with WC asthma, despite ICS/LABA adherence. Cough burden correlated with HRQoL, suggesting cough may be one of the key markers to inform treatment strategy for patients with asthma.

Sequenced treatment alternatives to relieve adolescent depression (STAR-AD): a multicentre open-label randomized controlled trial protocol

BACKGROUND

Adolescent major depressive disorder (MDD) is a prevalent mental health problem with low treatment success rates. Whether fluoxetine or fluoxetine combined with cognitive-behavioural therapy (CBT) is the more effective initial treatment for adolescent MDD remains controversial, and few studies have investigated whether treatment switching or augmentation is preferred when the initial treatment is not working well.

METHODS

We developed a multicentre open-label Sequential Multiple Assignment Randomized Trial (SMART) design, consisting of two phases lasting 8 weeks each. In phase 1 (at baseline), patients will be recruited and grouped in fluoxetine group or fluoxetine combined with CBT group by patient self-selection. In phase 2 (after 8 weeks of treatment), the nonresponders will be randomly assigned to six groups, in which participants will switch to sertraline, vortioxetine, or duloxetine or added aripiprazole, olanzapine, or lithium carbonate to fluoxetine. After the full 16 weeks of treatment, we will assess the long-term sustainability of the treatment effects by evaluating participants during their subsequent naturalistic treatment. The primary outcome will be the response rate, determined by the Children's Depression Rating Scale-Revised (CDRS-R). Secondary outcomes include the change in scores on the Beck Depression Inventory (BDI), the Screen for Child Anxiety-Related Emotional Disorders (SCARED) and the Safe Assessment.

DISCUSSION

The results from this study will aid clinicians in making informed treatment selection decisions for adolescents with MDD.

TRIAL REGISTRATION

This protocol was registered at ClinicalTrials.gov with Identifier: NCT05814640.

Effects of a Community Health Worker-Led Health Literacy Intervention on Lifestyle Modification Among Patients With Hypertension and Diabetes in the City of Harare, Zimbabwe: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Hypertension and diabetes are among the most common noncommunicable diseases in Zimbabwe. These 2 conditions are largely prevented and controlled by lifestyle modifications, such as healthy eating habits, physical activity, and avoiding the use of tobacco and alcohol.

OBJECTIVE

This study aims to evaluate the effects of a community health worker (CHW)-led health literacy intervention on lifestyle modification among patients with diabetes and hypertension in the City of Harare, Zimbabwe, in terms of (1) adherence to recommended lifestyle changes, (2) blood pressure and blood glucose levels, and (3) medication adherence.

METHODS

This is a 6-month-long cluster randomized controlled trial, which will be conducted in primary health care clinics in the city of Harare. A total of 14 clinics will be randomly allocated into either the intervention or control group. A total of 680 (49 participants per clinic) adult patients with hypertension and diabetes will be enrolled for the trial. Participants in the intervention arm will receive a simple health literacy intervention on lifestyle modification, which will be delivered by trained CHWs, while those in the control arm will receive usual care. The intervention consists of 4 face-to-face interactive educational sessions and monthly support visits by trained CHWs and will be carried out over a period of 6 months. The primary study outcomes will be blood pressure and blood glucose levels and levels of adherence to the recommended lifestyle modifications. Other outcomes will include adherence to medication. Data management and analysis will be done using Epi Info software, and the data will be analyzed using the intention-to-treat principle.

RESULTS

Recruitment of study participants commenced on June 1, 2023, and was completed on July 30, 2023. Baseline data are being collected after participants' recruitment, and the final data collection will be completed by January 31, 2024.

CONCLUSIONS

There is an information dearth regarding the effectiveness of CHW-led interventions for the management and control of hypertension in Zimbabwe. Our study offers an opportunity to show the effectiveness of CHWs in addressing the gaps in the management of hypertension and diabetes. The findings from our study will provide crucial evidence on the effectiveness and feasibility of a simple intervention delivered by CHWs in resource-constrained areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47512.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT

Background

Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed.

Objectives

To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption.

Design

Multicentre, three-arm, parallel-group, randomised controlled clinical trial.

Setting

Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands).

Participants

Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate.

Interventions

(1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation.

Main outcome measures

Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule.

Results

Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported.

Limitations

The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted.

Conclusions

Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate.

Future work

Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence.

Trial registration

This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Comprehension of Nonvalvular Atrial Fibrillation and Anticoagulant Adherence in Elderly Patients in a Subcohort Study of the All Nippon Atrial Fibrillation in the Elderly Registry

In this subcohort study of the ANAFIE (All Nippon Atrial Fibrillation In the Elderly) Registry enrolling >30,000 Japanese elderly (aged ≥75 years) patients with nonvalvular atrial fibrillation (NVAF), we assessed the association between patient comprehension of NVAF and adherence to anticoagulant therapy with clinical outcomes. Data from 1,968 patients evaluated for NVAF comprehension by a questionnaire consisting of 4 key questions, and 2,362 patients who completed the Morisky Medication Adherence Scale-8 questionnaire were analyzed. Overall, NVAF comprehension was low (81.9% had <3 points), and compared with high comprehension (score ≥3), low comprehension (0 points: 42.1%) was associated with poor prognosis, nonsignificantly higher risk of stroke or systemic embolic event (adjusted hazard ratio [aHR] 2.60 [95% confidence interval 0.97 to 6.94, p = 0.057]), all-cause death (aHR 1.71 [0.96 to 3.04, p = 0.069]), and significantly higher risk of net clinical outcome (composite of stroke/systemic embolic events, major bleeding, and all-cause death) (aHR 1.63 [1.04 to 2.54, p = 0.032]). Adherence to anticoagulant therapy assessed by Morisky Medication Adherence Scale-8 was high (64.9% had high adherence; 29.2%, had medium adherence), but compared with high adherence (score 8), low adherence (score <6: 5.9%) was associated with poor prognosis, significantly higher risk of ischemic stroke (aHR 2.95 [1.08 to 8.04, p = 0.035]), all-cause death (aHR 1.93 [1.16 to 3.21, p = 0.011]), and net clinical outcome (aHR 1.75 [1.12 to 2.75, p = 0.015]). Overall, NVAF comprehension and adherence showed a weak correlation to anticoagulant therapy at baseline (correlation coefficient 0.049). In conclusion, low NVAF comprehension and low anticoagulant adherence were associated with poor clinical outcomes in elderly patients with NVAF.

Family-centered empowerment approach to optimize phosphate management among hemodialysis patients: an experimental study

BACKGROUND

This study aimed to investigate the effect of a family-centered empowerment program on hyperphosphatemia management.

METHOD

This experimental study was performed on 80 randomly selected eligible patients with hyperphosphatemia undergoing hemodialysis. Patients were assigned randomly to two groups of family-centered empowerment program (FCEPG) and control group (CG) by coin toss (40 people per group). Data collection tools were the researcher-made Phosphate Control Knowledge Scale, the researcher-made Adherence to Dietary Restriction of Phosphorus Intake Scale, the eight-item Morisky Medication Adherence Scale, and serum phosphorus measurements. Data were collected before the intervention, one month, and three months after the intervention. Patients in FCEPG participated in a family-centered empowerment program. The statistical significance level was considered to be 0.05.

RESULTS

Inter-group comparisons showed no significant difference between FCEPG and CG in terms of the mean score of knowledge of phosphate control, adherence to dietary restriction of phosphorus intake, adherence to medication, and the mean serum phosphorus level before the empowerment program, but showed significant differences between them in these respects at one month after the program and three months after the program (p < 0.05). Intra-group comparisons showed a significant difference in FCEPG between the mean and standard deviation of all four variables before the empowerment program and the corresponding values one month and three months after the program (P < 0.05).

CONCLUSION

The findings of this study can be used in various fields of healthcare in the hospital and community.

Advanced Messaging Intervention for Medication Adherence and Clinical Outcomes Among Patients With Cancer: Randomized Controlled Trial

BACKGROUND

Medication adherence is crucial for improving clinical outcomes in the treatment of patients with cancer. The lack of adherence and adverse drug reactions can reduce the effectiveness of cancer therapy including the quality of life. The commonly used intervention methods for medication adherence continue to evolve, and the age of fifth-generation (5G) messaging has arrived.

OBJECTIVE

In this study, we conducted a prospective, pilot randomized controlled trial to evaluate the effect of 5G messaging on medication adherence and clinical outcomes among patients with cancer in China.

METHODS

The research population was patients with nonsmall cell lung cancer undergoing pemetrexed chemotherapy who require regular folic acid (FA) and vitamin B12 supplements. The intervention and control groups were assigned to 5G messaging and second-generation (2G) messaging, respectively. The patients' medication adherence and quality of life were assessed at baseline and 1-month and 3-month time points. Moreover, the chemotherapy-related hematologic or nonhematologic toxicities, as well as the serum levels of FA and vitamin B12, were measured.

RESULTS

Of the 567 patients assessed for eligibility between January and May 2021, a total of 154 (27.2%) patients were included. Overall, 80 were randomized to the control group and 74 to the intervention group. The odds of adherence in the 5G messaging intervention group were significantly higher than the control group at the 1-month (62/69, 90% vs 56/74, 76%; adjusted odds ratio 2.67, 95% CI 1.02-7.71) and 3-month (50/60, 83% vs 48/64, 75%; adjusted odds ratio 2.36, 95% CI 1.00-5.23) time points. Correspondingly, the FA and vitamin B12 serum levels of patients in the 5G messaging group were higher than those of the control group. Regarding hematologic toxicities, only the incidence of leukopenia in the intervention group was lower than that in the control group (25/80, 31% in the control group vs 12/74, 16% in the intervention group; P=.04). There were no differences in nonhematologic toxicities and quality of life between the 2 groups.

CONCLUSIONS

In summary, we conclude that compared with conventional 2G text-based messaging, a 5G messaging intervention can better improve medication adherence and clinical outcome among patients with cancer.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200058188; https://www.chictr.org.cn/showproj.html?proj=164489.

Impact of web application support versus standard management on adherence with adjuvant hormone therapy in patients treated for breast cancer: the WEBAPPAC study

BACKGROUND

Non-metastatic breast cancer treatment is mainly based on surgery, with or without chemotherapy, radiotherapy and/or hormone therapy. To reduce the risk of hormone receptor positive (HR+) disease recurrence, hormone therapy is prescribed for at least 5 years. It may induce adverse drug reactions (ADRs) as joint pain, sexual dysfunction, weight increase, fatigue, mood disorders and vasomotor symptoms. Around 30-40% of patients withhold hormone therapy within 5 years after initiation. Based on encouraging results of mobile health in patient follow-up, we developed a web-application addressed for breast cancer patients initiating adjuvant hormonal therapy and aimed to assess its impact on hormone therapy adherence, ADRs management, and health-related quality of life.

METHODS

The WEBAPPAC trial is a randomized, open-label, prospective, single-center phase 3 study aiming to assess the interest of a web-application support as compared to standard management among breast cancer patients initiating hormone therapy. The main endpoint is the proportion of patients with hormone therapy adherence failure within 18 months after treatment start, in each arm. Eligible patients will be 1:1 randomized between the WEBAPPAC web-application support (experimental arm,) or standard support (control arm), with stratification on type of hormone therapy (Aromatase inhibitor or Tamoxifen). We plan to enroll 438 patients overall. Failure to hormone therapy will be assessed using the Morisky 8-item self-questionnaire (MMSA8), patient adherence logbook, and medical consultations. Secondary outcomes include hormone therapy adherence at 6 months, pain (Visual Analogue Scale and Brief Pain Inventory), quality of life (EORTC QLQ-C30 and BR23 self-questionnaires), anxiety and depression (Hospital and Depression Scale), and return to work and/or daily activities. The user experience with the WEBAPPAC web-application will be assessed using the System Usability Scale (SUS) questionnaire.

DISCUSSION

Hormone therapy discontinuation or adherence failure in breast cancer patients may be indirectly related to an increased risk of recurrence. A better control of medication adherence, through the detection of side effects and some proposed actions trying to reduce them, appears therefore essential to limit the risk of disease recurrence. The WEBAPPAC web-application thus aims better monitoring and allowing higher level of responsiveness in case of ADRs, thus improving treatment adherence.

TRIAL REGISTRATION

NCT04554927, registered September 18, 2020.

PROTOCOL VERSION

Version 2.1 dated from December 21, 2021.

Estimated Population Health Benefits of Intensive Systolic Blood Pressure Treatment Among SPRINT-Eligible US Adults

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated an intensive (<120 mm Hg) vs. standard (<140 mm Hg) systolic blood pressure (SBP) goal lowered cardiovascular disease (CVD) risk. Estimating the effect of intensive SBP lowering among SPRINT-eligible adults most likely to benefit can guide implementation efforts.

METHODS

We studied SPRINT participants and SPRINT-eligible participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study and National Health and Nutrition Examination Surveys (NHANES). A published algorithm of predicted CVD benefit with intensive SBP treatment was used to categorize participants into low, medium, or high predicted benefit. CVD event rates were estimated with intensive and standard treatment.

RESULTS

Median age was 67.0, 72.0, and 64.0 years in SPRINT, SPRINT-eligible REGARDS, and SPRINT-eligible NHANES participants, respectively. The proportion with high predicted benefit was 33.0% in SPRINT, 39.0% in SPRINT-eligible REGARDS, and 23.5% in SPRINT-eligible NHANES. The estimated difference in CVD event rate (standard minus intensive) was 7.0 (95% confidence interval [CI] 3.4-10.7), 8.4 (95% CI 8.2-8.5), and 6.1 (95% CI 5.9-6.3) per 1,000 person-years in SPRINT, SPRINT-eligible REGARDS participants, and SPRINT-eligible NHANES participants, respectively (median 3.2-year follow-up). Intensive SBP treatment could prevent 84,300 (95% CI 80,800-87,920) CVD events per year in 14.1 million SPRINT-eligible US adults; 29,400 and 28,600 would be in 7.0 million individuals with medium or high predicted benefit, respectively.

CONCLUSIONS

Most of the population health benefit from intensive SBP goals could be achieved by treating those characterized by a previously published algorithm as having medium or high predicted benefit.

Persistence to rivaroxaban therapy for stroke prevention in clinical practice in Italy: Rationale and design of the RITMUS-AF prospective observational cohort study

Background

Non-valvular atrial fibrillation (NVAF) is a cardiac rhythm disturbance that increases the risk of stroke and is highly prevalent in Europe and Italy, increasingly with advancing age. Oral anticoagulation is a key component of stroke prevention in patients with NVAF, yet withdrawal or interruption of anticoagulation may transiently increase the risk of embolic events. Treatment persistence to anticoagulation is an important metric but one that is not well studied in patients with NVAF in Italy. The RITMUS-AF study aims to evaluate the persistence with rivaroxaban treatment for stroke prevention in patients with NVAF in Italy.

Methods

RITMUS-AF is a prospective, observational cohort study of patients with NVAF in hospital cardiology departments with a non-vitamin K antagonist oral anticoagulant surveillance program across all 20 regions of Italy. The study population comprises consecutively screened, consenting patients with NVAF naïve to and newly treated with rivaroxaban for stroke prevention in routine clinical practice. The target enrollment is 800 patients; each patient will be followed for a maximum duration of 24 months. The primary endpoint is the proportion of patients who discontinue rivaroxaban treatment. Secondary endpoints are reasons for rivaroxaban discontinuation, dose changes and reasons for changes, switches to alternative therapies and the reasons for these decisions, and self-reported adherence. Data analyses will be exploratory and descriptive.

Conclusion

RITMUS-AF will help to address the limited data in Italian clinical practice on treatment persistence and reasons for drug interruptions in patients with NVAF on rivaroxaban.

Association between office visit intervals and long-term cardiovascular risk in hypertensive patients

Hypertension is a chronic disease that requires long-term follow-up in many patients, however, optimal visit intervals are not well-established. This study aimed to evaluate the incidences of major cardiovascular events (MACEs) according to visit intervals. We analyzed data from 9894 hypertensive patients in the Korean Hypertension Cohort, which enrolled and followed up 11,043 patients for over 10 years. Participants were classified into five groups based on their median visit intervals (MVIs) during the 4-year period and MACEs were compared among the groups. The patients were divided into clinically relevant MVIs of one (1013; 10%), two (1299; 13%), three (2732; 28%), four (2355; 24%), and six months (2515; 25%). The median follow-up period was 5 years (range: 1745 ± 293 days). The longer visit interval groups did not have an increased cumulative incidence of MACE (12.9%, 11.8%, 6.7%, 5.9%, and 4%, respectively). In the Cox proportional hazards model, those in the longer MVI group had a smaller hazard ratio (HR) for MACEs or all-cause death: 1.77 (95% confidence interval [CI], 1.45-2.17), 1.7 (95% CI: 1.41-2.05), 0.90 (95% CI: 0.74-1.09) and 0.64 (95% CI: 0.52-0.79), respectively (Reference MVI group of 75-104 days). In conclusion, a follow-up visits with a longer interval of 3-6 months was not associated with an increased risk of MACE or all-cause death in hypertensive patients. Therefore, once medication adjustment is stabilized, a longer interval of 3-6 months is reasonable, reducing medical expenses without increasing the risk of cardiovascular outcomes.

Cost-Effectiveness of Pharmacotherapy for the Treatment of Obesity in Adolescents

Importance

Antiobesity pharmacotherapy is recommended for adolescents ages 12 years and older with obesity. Several medications have been approved by the US Food and Drug Administration for adolescent use, but the most cost-effective medication remains unclear.

Objective

To estimate the cost-effectiveness of lifestyle counseling alone and as adjunct to liraglutide, mid-dose phentermine and topiramate (7.5 mg phentermine and 46 mg topiramate), top-dose phentermine and topiramate (15 mg phentermine and 92 mg topiramate), or semaglutide among adolescent patients with obesity.

Design, Setting, and Participants

This economic evaluation used a microsimulation model to project health and cost outcomes of lifestyle counseling alone and adjunct to liraglutide, mid-dose phentermine and topiramate, top-dose phentermine and topiramate, or semaglutide over 13 months, 2 years, and 5 years among a hypothetical cohort of 100 000 adolescents with obesity, defined as an initial body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 37. Model inputs were derived from clinical trials, published literature, and national sources. Data were analyzed from April 2022 to July 2023.

Exposures

Lifestyle counseling alone and as adjunct to liraglutide, mid-dose phentermine and topiramate, top-dose phentermine and topiramate, or semaglutide.

Main Outcomes and Measures

The main outcome was quality-adjusted life years (QALYs), costs (2022 US dollars), and incremental cost-effectiveness ratios (ICERs), with future costs and QALYs discounted 3.0% annually. A strategy was considered cost-effective if the ICER was less than $100 000 per QALY gained. The preferred strategy was determined as the strategy with the greatest increase in QALYs while being cost-effective. One-way and probabilistic sensitivity analyses were used to assess parameter uncertainty.

Results

The model simulated 100 000 adolescents at age 15 with an initial BMI of 37, of whom 58 000 (58%) were female. At 13 months and 2 years, lifestyle counseling was estimated to be the preferred strategy. At 5 years, top-dose phentermine and topiramate was projected to be the preferred strategy with an ICER of $56 876 per QALY gained vs lifestyle counseling. Semaglutide was projected to yield the most QALYs, but with an unfavorable ICER of $1.1 million per QALY gained compared with top-dose phentermine and topiramate. Model results were most sensitive to utility of weight reduction and weight loss of lifestyle counseling and top-dose phentermine and topiramate.

Conclusions and Relevance

In this economic evaluation of pharmacotherapy for adolescents with obesity, top-dose phentermine and topiramate as adjunct to lifestyle counseling was estimated to be cost-effective after 5 years. Long-term clinical trials in adolescents are needed to fully evaluate the outcomes of pharmacotherapy, especially into adulthood.