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Sherman AC, O'Brien CE, Simonton-Atchley S. A Longitudinal Study of Adherence among Cystic Fibrosis Patients: Associations with Gratitude Over the Course of One Year. Int J Behav Med 2024:10.1007/s12529-024-10306-1. [PMID: 38914922 DOI: 10.1007/s12529-024-10306-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Daily airway clearance therapy (ACT) is a critical aspect of treatment in cystic fibrosis (CF), but poor adherence is a prominent concern. Identifying factors that might enhance or diminish adherence is a priority for treatment centers. Gratitude, a generalized tendency to notice and appreciate positive facets of experience, is a psychosocial resource that has commanded growing research interest. This longitudinal study examined whether gratitude at baseline was associated with ongoing or persistent ACT adherence over the course of a year. METHODS Trait gratitude was evaluated at baseline using a validated measure, among adults receiving care at a regional CF treatment center. Self-reported adherence to ACT was assessed at baseline, 6 months, and 12 months using the Cystic Fibrosis Treatment Questionnaire. Average age of participants was 27.2 years, 45.5% were women, and 19.7% had severe disease. RESULTS In multivariable logistic regression models that accounted for disease severity (Forced Expiratory Volume1% predicted) and other clinical and demographic variables, individuals with higher baseline gratitude were significantly more likely to demonstrate persistent adherence over the course of the year. Gratitude remained predictive after additionally adjusting for other well-known psychosocial resource variables (social support and emotional well-being). CONCLUSION This is among the first demonstrations that gratitude is associated with persistent self-reported adherence to treatment over time. Findings suggest that gratitude may be important psychosocial resource for adults with CF, as they contend with complex, highly burdensome treatment regimens. Further research is warranted to examine these relationships and their impact on downstream health outcomes.
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Affiliation(s)
- Allen C Sherman
- Behavioral Medicine Division, University of Arkansas for Medical Sciences, Behavioral Medicine, #756 4301 W. Markham Street, Little Rock, AR, 72205, USA.
| | - Catherine E O'Brien
- College of Pharmacy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stephanie Simonton-Atchley
- Behavioral Medicine Division, University of Arkansas for Medical Sciences, Behavioral Medicine, #756 4301 W. Markham Street, Little Rock, AR, 72205, USA
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Main E, Rand S. Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis. Cochrane Database Syst Rev 2023; 5:CD002011. [PMID: 37144842 PMCID: PMC10161870 DOI: 10.1002/14651858.cd002011.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is an inherited life-limiting disorder. Over time persistent infection and inflammation within the lungs contribute to severe airway damage and loss of respiratory function. Chest physiotherapy, or airway clearance techniques (ACTs), are integral in removing airway secretions and initiated shortly after CF diagnosis. Conventional chest physiotherapy (CCPT) generally requires assistance, while alternative ACTs can be self-administered, facilitating independence and flexibility. This is an updated review. OBJECTIVES To evaluate the effectiveness (in terms of respiratory function, respiratory exacerbations, exercise capacity) and acceptability (in terms of individual preference, adherence, quality of life) of CCPT for people with CF compared to alternative ACTs. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 26 June 2022. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials (including cross-over design) lasting at least seven days and comparing CCPT with alternative ACTs in people with CF. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. pulmonary function tests and 2. number of respiratory exacerbations per year. Our secondary outcomes were 3. quality of life, 4. adherence to therapy, 5. cost-benefit analysis, 6. objective change in exercise capacity, 7. additional lung function tests, 8. ventilation scanning, 9. blood oxygen levels, 10. nutritional status, 11. mortality, 12. mucus transport rate and 13. mucus wet or dry weight. We reported outcomes as short-term (seven to 20 days), medium-term (more than 20 days to up to one year) and long-term (over one year). MAIN RESULTS We included 21 studies (778 participants) comprising seven short-term, eight medium-term and six long-term studies. Studies were conducted in the USA (10), Canada (five), Australia (two), the UK (two), Denmark (one) and Italy (one) with a median of 23 participants per study (range 13 to 166). Participant ages ranged from newborns to 45 years; most studies only recruited children and young people. Sixteen studies reported the sex of participants (375 males; 296 females). Most studies compared modifications of CCPT with a single comparator, but two studies compared three interventions and another compared four interventions. The interventions varied in the duration of treatments, times per day and periods of comparison making meta-analysis challenging. All evidence was very low certainty. Nineteen studies reported the primary outcomes forced expiratory volume in one second (FEV1)and forced vital capacity (FVC), and found no difference in change from baseline in FEV1 % predicted or rate of decline between groups for either measure. Most studies suggested equivalence between CCPT and alternative ACTs, including positive expiratory pressure (PEP), extrapulmonary mechanical percussion, active cycle of breathing technique (ACBT), oscillating PEP devices (O-PEP), autogenic drainage (AD) and exercise. Where single studies suggested superiority of one ACT, these findings were not corroborated in similar studies; pooled data generally concluded that effects of CCPT were comparable to those of alternative ACTs. CCPT versus PEP We are uncertain whether CCPT improves lung function or has an impact on the number of respiratory exacerbations per year compared with PEP (both very low-certainty evidence). There were no analysable data for our secondary outcomes, but many studies provided favourable narrative reports on the independence achieved with PEP mask therapy. CCPT versus extrapulmonary mechanical percussion We are uncertain whether CCPT improves lung function compared with extrapulmonary mechanical percussions (very low-certainty evidence). The annual rate of decline in average forced expiratory flow between 25% and 75% of FVC (FEF25-75) was greater with high-frequency chest compression compared to CCPT in medium- to long-term studies, but there was no difference in any other outcome. CCPT versus ACBT We are uncertain whether CCPT improves lung function compared to ACBT (very low-certainty evidence). Annual decline in FEF25-75 was worse in participants using the FET component of ACBT only (mean difference (MD) 6.00, 95% confidence interval (CI) 0.55 to 11.45; 1 study, 63 participants; very low-certainty evidence). One short-term study reported that directed coughing was as effective as CCPT for all lung function outcomes, but with no analysable data. One study found no difference in hospital admissions and days in hospital for exacerbations. CCPT versus O-PEP We are uncertain whether CCPT improves lung function compared to O-PEP devices (Flutter device and intrapulmonary percussive ventilation); however, only one study provided analysable data (very low-certainty evidence). No study reported data for number of exacerbations. There was no difference in results for number of days in hospital for an exacerbation, number of hospital admissions and number of days of intravenous antibiotics; this was also true for other secondary outcomes. CCPT versus AD We are uncertain whether CCPT improves lung function compared to AD (very low-certainty evidence). No studies reported the number of exacerbations per year; however, one study reported more hospital admissions for exacerbations in the CCPT group (MD 0.24, 95% CI 0.06 to 0.42; 33 participants). One study provided a narrative report of a preference for AD. CCPT versus exercise We are uncertain whether CCPT improves lung function compared to exercise (very low-certainty evidence). Analysis of original data from one study demonstrated a higher FEV1 % predicted (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004), FVC (MD 7.83, 95% CI 2.48 to 13.18; P = 0.004) and FEF25-75 (MD 7.05, 95% CI 3.15 to 10.95; P = 0.0004) in the CCPT group; however, the study reported no difference between groups (likely because the original analysis accounted for baseline differences). AUTHORS' CONCLUSIONS We are uncertain whether CCPT has a more positive impact on respiratory function, respiratory exacerbations, individual preference, adherence, quality of life, exercise capacity and other outcomes when compared to alternative ACTs as the certainty of the evidence is very low. There was no advantage in respiratory function of CCPT over alternative ACTs, but this may reflect insufficient evidence rather than real equivalence. Narrative reports indicated that participants prefer self-administered ACTs. This review is limited by a paucity of well-designed, adequately powered, long-term studies. This review cannot yet recommend any single ACT above others; physiotherapists and people with CF may wish to try different ACTs until they find an ACT that suits them best.
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Affiliation(s)
- Eleanor Main
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sarah Rand
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
- School of Physiotherapy, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Abstract
BACKGROUND Cystic fibrosis (CF) is an inherited progressive life-limiting disease characterised by the build-up of abnormally thick, sticky mucus affecting mostly the lungs, pancreas, and digestive system. Airway clearance techniques (ACTs), traditionally referred to as chest physiotherapy, are recommended as part of a complex treatment programme for people with CF. The aim of an ACTs is to enhance mucociliary clearance and remove viscous secretions from the airways within the lung to prevent distal airway obstruction. This reduces the infective burden and associated inflammatory effects on the airway epithelia. There are a number of recognised ACTs, none of which have shown superiority in improving short-term outcomes related to mucus transport. This systematic review, which has been updated regularly since it was first published in 2000, considers the efficacy of ACTs compared to not performing any ACT in adults and children with CF. It is important to continue to review this evidence, particularly the long-term outcomes, given the recent introduction of highly effective modulator therapies and the improved health outcomes and potential changes to CF management associated with these drugs. OBJECTIVES To determine the effectiveness and acceptability of airway clearance techniques compared to no airway clearance techniques or cough alone in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings, to 17 October 2022. We searched ongoing trials registers (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) to 7 November 2022. SELECTION CRITERIA We included randomised or quasi-randomised studies that compared airway clearance techniques (chest physiotherapy) with no airway clearance techniques or spontaneous cough alone in people with CF. DATA COLLECTION AND ANALYSIS Both review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of the included studies. We used GRADE methodology to assess the certainty of the evidence. MAIN RESULTS We included 11 cross-over studies (153 participants) and one parallel study (41 participants). There were differences between studies in how the interventions were delivered, with several intervention groups combining more than one ACT. One study used autogenic drainage; five used conventional chest physiotherapy; nine used positive expiratory pressure (PEP), with one study varying the water pressure between arms; three studies used oscillating PEP; two used exercise; and two used high-frequency chest wall oscillation (HFCWO). Of the 12 included studies, 10 were single-treatment studies, and two delivered the intervention over two consecutive days (once daily in one study, twice daily in the second). This substantial heterogeneity in the treatment interventions precluded pooling of data for meta-analysis. Blinding of participants, caregivers, and clinicians is impossible in airway clearance studies; we therefore judged all studies at unclear risk of performance bias. Lack of information in eight studies made assessment of risk of bias unclear for most other domains. We rated the certainty of evidence as low or very low due to the short-term cross-over trial design, small numbers of participants, and uncertain risk of bias across most or all domains. Six studies (84 participants) reported no effect on pulmonary function variables following intervention; but one study (14 participants) reported an improvement in pulmonary function following the intervention in some of the treatment groups. Two studies reported lung clearance index: one (41 participants) found a variable response to treatment with HFCWO, whilst another (15 participants) found no effect on lung clearance index with PEP therapy (low-certainty evidence). Five studies (55 participants) reported that ACTs, including coughing, increased radioactive tracer clearance compared to control, while a further study (eight participants) reported no improvement in radioactive tracer clearance when comparing PEP to control, although coughing was discouraged during the PEP intervention. We rated the certainty of evidence on the effect of ACTs on radioactive tracer clearance as very low. Four studies (46 participants) investigated the weight of mucus cleared from the lungs and reported greater secretions during chest physiotherapy compared to a control. One study (18 participants) reported no differences in sputum weight (very low-certainty evidence). AUTHORS' CONCLUSIONS The evidence from this review shows that ACTs may have short-term effects on increasing mucus transport in people with CF. All included studies had short-term follow-up; consequently, we were unable to draw any conclusions on the long-term effects of ACTs compared to no ACTs in people with CF. The evidence in this review represents the use of airway clearance techniques in a CF population before widespread use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Further research is needed to determine the effectiveness and acceptability of airway clearance in those treated with highly effective CFTR modulators.
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Affiliation(s)
- Louise Warnock
- Oxford Adult Cystic Fibrosis Centre, Oxford Centre for Respiratory Medicine, The Churchill Hospital, Oxford, UK
| | - Alison Gates
- Oxford Adult Cystic Fibrosis Centre, Oxford Centre for Respiratory Medicine, The Churchill Hospital, Oxford, UK
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Dawson S, Girling CJ, Cowap L, Clark-Carter D. Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 3:CD013766. [PMID: 36989170 PMCID: PMC10054300 DOI: 10.1002/14651858.cd013766.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Adherence to treatment, including inhaled therapies, is low in people with cystic fibrosis (CF). Although psychological interventions for improving adherence to inhaled therapies in people with CF have been developed, no previous published systematic review has evaluated the evidence for efficacy of these interventions. OBJECTIVES The primary objective of the review was to assess the efficacy of psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis (CF). The secondary objective was to establish the most effective components, or behaviour change techniques (BCTs), used in these interventions. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched databases (PubMed; PsycINFO; EBSCO; Scopus; OpenGrey), trials registries (World Health Organization International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), and the reference lists of relevant articles and reviews, with no restrictions on language, year or publication status. Date of search: 7 August 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different types of psychological interventions for improving adherence to inhaled therapies in people with CF of any age, or comparing psychological interventions with usual care. We included quasi-RCTs if we could reasonably assume that the baseline characteristics were similar in both groups. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and completed data extraction, risk of bias assessments, and BCT coding (using the BCT Taxonomy v1) for all included trials. We resolved any discrepancies by discussion, or by consultation with a third review author as necessary. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 10 trials (1642 participants) in the review (children and adolescents in four trials; adults in five trials; and children and adults in one trial). Nine trials compared a psychological intervention with usual care; we could combine data from some of these in a number of quantitative analyses. One trial compared a psychological intervention with an active comparator (education plus problem-solving (EPS)). We identified five ongoing trials. Psychological interventions were generally multi-component and complex, containing an average of 9.6 BCTs (range 1 to 28). The two most commonly used BCTs included 'problem-solving' and 'instruction on how to perform the behaviour'. Interventions varied in their type, content and mode of delivery. They included a problem-solving intervention; a paper-based self-management workbook; a telehealth intervention; a group training programme; a digital intervention comprising medication reminders and lung function self-monitoring; a life-coaching intervention; a motivational interviewing (MI) intervention; a brief MI intervention (behaviour change counselling); and a digital intervention combined with behaviour change sessions. Intervention duration ranged from 10 weeks to 12 months. Assessment time points ranged from six to eight weeks up to 23 months. Psychological interventions compared with usual care We report data here for the 'over six months and up to 12 months' time point. We found that psychological interventions probably improve adherence to inhaled therapies (primary outcome) in people with CF compared with usual care (mean difference (MD) 9.5, 95% confidence interval (CI) 8.60 to 10.40; 1 study, 588 participants; moderate-certainty evidence). There was no evidence of a difference between groups in our second primary outcome, treatment-related adverse events: anxiety (MD 0.30, 95% CI -0.40 to 1.00; 1 study, 535 participants), or depression (MD -0.10, 95% CI -0.80 to 0.60; 1 study, 534 participants), although this was low-certainty evidence. For our secondary outcomes, there was no evidence of a difference between groups in terms of lung function (forced expiratory volume in one second (FEV1) % predicted MD 1.40, 95% CI -0.20 to 3.00; 1 study, 556 participants; moderate-certainty evidence); number of pulmonary exacerbations (adjusted rate ratio 0.96, 95% CI 0.83 to 1.11; 1 study, 607 participants; moderate-certainty evidence); or respiratory symptoms (MD 0.70, 95% CI -2.40 to 3.80; 1 study, 534 participants; low-certainty evidence). However, psychological interventions may improve treatment burden (MD 3.90, 95% CI 1.20 to 6.60; 1 study, 539 participants; low-certainty evidence). The overall certainty of the evidence ranged from low to moderate across these outcomes. Reasons for downgrading included indirectness (current evidence included adults only whereas our review question was broader and focused on people of any age) and lack of blinding of outcome assessors. Psychological interventions compared with an active comparator For this comparison the overall certainty of evidence was very low, based on one trial (n = 128) comparing an MI intervention to EPS for 12 months. We are uncertain whether an MI intervention, compared with EPS, improves adherence to inhaled therapies, lung function, or quality of life in people with CF, or whether there is an effect on pulmonary exacerbations. The included trial for this comparison did not report on treatment-related adverse events (anxiety and depression). We downgraded all reported outcomes due to small participant numbers, indirectness (trials included only adults), and unclear risk of bias (e.g. selection and attrition bias). AUTHORS' CONCLUSIONS Due to the limited quantity of trials included in this review, as well as the clinical and methodological heterogeneity, it was not possible to identify an overall intervention effect using meta-analysis. Some moderate-certainty evidence suggests that psychological interventions (compared with usual care) probably improve adherence to inhaled therapies in people with CF, without increasing treatment-related adverse events, anxiety and depression (low-certainty evidence). In future review updates (with ongoing trial results included), we hope to be able to establish the most effective BCTs (or 'active ingredients') of interventions for improving adherence to inhaled therapies in people with CF. Wherever possible, investigators should make use of the most objective measures of adherence available (e.g. data-logging nebulisers) to accurately determine intervention effects. Outcome reporting needs to be improved to enable combining or separation of measures as appropriate. Likewise, trial reporting needs to include details of intervention content (e.g. BCTs used); duration; intensity; and fidelity. Large trials with a longer follow-up period (e.g. 12 months) are needed in children with CF. Additionally, more research is needed to determine how to support adherence in 'under-served' CF populations.
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Affiliation(s)
- Sophie Dawson
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Carla-Jane Girling
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Innovation Centre, Sheffield, UK
| | - Lisa Cowap
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - David Clark-Carter
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
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Raywood E, Shannon H, Filipow N, Tanriver G, Stanojevic S, Kapoor K, Douglas H, O'Connor R, Murray N, Black B, Main E. Quantity and quality of airway clearance in children and young people with cystic fibrosis. J Cyst Fibros 2023; 22:344-351. [PMID: 36210322 DOI: 10.1016/j.jcf.2022.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/27/2022] [Accepted: 09/19/2022] [Indexed: 05/01/2023]
Abstract
Children and young people with CF (CYPwCF) get advice about using positive expiratory pressure (PEP) or oscillating PEP (OPEP) devices to clear sticky mucus from their lungs. However, little is known about the quantity (number of treatments, breaths, or sets) or quality (breath pressures and lengths) of these daily airway clearance techniques (ACTs) undertaken at home. This study used electronic pressure sensors to record real time breath-by-breath data from 145 CYPwCF (6-16y) during routine ACTs over 2 months. ACT quantity and quality were benchmarked against individual prescriptions and accepted recommendations for device use. In total 742,084 breaths from 9,081 treatments were recorded. Individual CYPwCF maintained consistent patterns of ACT quantity and quality over time. Overall, 60% of CYPwCF did at least half their prescribed treatments, while 27% did fewer than a quarter. About 77% of pre-teens did the right number of daily treatments compared with only 56% of teenagers. CYPwCF usually did the right number of breaths. ACT quality (recommended breath length and pressure) varied between participants and depended on device. Breath pressures, lengths and pressure-length relationships were significantly different between ACT devices. PEP devices encouraged longer breaths with lower pressures, while OPEP devices encouraged shorter breaths with higher pressures. More breaths per treatment were within advised ranges for both pressure and length using PEP (30-31%) than OPEP devices (1-3%). Objective measures of quantity and quality may help to optimise ACT device selection and support CYPwCF to do regular effective ACTs.
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Affiliation(s)
- Emma Raywood
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Harriet Shannon
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Nicole Filipow
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Gizem Tanriver
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sanja Stanojevic
- Community Health and Epidemiology, Dalhousie University Halifax, Canada
| | - Kunal Kapoor
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Helen Douglas
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK; Paediatric Cystic Fibrosis Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Rachel O'Connor
- Paediatric Cystic Fibrosis Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Nicky Murray
- Paediatric Cystic Fibrosis Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Bridget Black
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Eleanor Main
- Physiotherapy, UCL Great Ormond Street Institute of Child Health, London, UK.
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Wilson LM, Saldanha IJ, Robinson KA. Active cycle of breathing technique for cystic fibrosis. Cochrane Database Syst Rev 2023; 2:CD007862. [PMID: 36727723 PMCID: PMC9893420 DOI: 10.1002/14651858.cd007862.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND People with cystic fibrosis (CF) experience chronic airway infections as a result of mucus buildup within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an update of a previously published review. OBJECTIVES To compare the clinical effectiveness of ACBT with other airway clearance therapies in CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched clinical trials registries and the reference lists of relevant articles and reviews. Date of last search: 29 March 2021. SELECTION CRITERIA We included randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing ACBT with other airway clearance therapies in CF. DATA COLLECTION AND ANALYSIS Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study. We used GRADE to assess our confidence in the evidence assessing quality of life, participant preference, adverse events, forced expiratory volume in one second (FEV1) % predicted, forced vital capacity (FVC) % predicted, sputum weight, and number of pulmonary exacerbations. MAIN RESULTS Our search identified 99 studies, of which 22 (559 participants) met the inclusion criteria. Eight randomised controlled studies (259 participants) were included in the analysis; five were of cross-over design. The 14 remaining studies were cross-over studies with inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged from six to 63 years (mean age 18.7 years). In 13 studies follow up lasted a single day. However, there were two long-term randomised controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis. Included studies compared ACBT with autogenic drainage, airway oscillating devices (AOD), high-frequency chest compression devices, conventional chest physiotherapy (CCPT), positive expiratory pressure (PEP), and exercise. We found no difference in quality of life between ACBT and PEP mask therapy, AOD, other breathing techniques, or exercise (very low-certainty evidence). There was no difference in individual preference between ACBT and other breathing techniques (very low-certainty evidence). One study comparing ACBT with ACBT plus postural exercise reported no deaths and no adverse events (very low-certainty evidence). We found no differences in lung function (forced expiratory volume in one second (FEV1) % predicted and forced vital capacity (FVC) % predicted), oxygen saturation or expectorated sputum between ACBT and any other technique (very low-certainty evidence). There were no differences in the number of pulmonary exacerbations between people using ACBT and people using CCPT (low-certainty evidence) or ACBT with exercise (very low-certainty evidence), the only comparisons to report this outcome. AUTHORS' CONCLUSIONS There is little evidence to support or reject the use of the ACBT over any other airway clearance therapy and ACBT is comparable with other therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for people with cystic fibrosis such as quality of life and preference.
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Affiliation(s)
- Lisa M Wilson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ian J Saldanha
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Fındık BN, Kenis-Coskun Ö, Karadağ-Saygı E, Gökdemir Y, Ergenekon AP, Karadağ B. The safety and sustainability of bottle-pep therapy in pediatric patients with cystic fibrosis. Physiother Theory Pract 2023; 39:287-299. [PMID: 34878368 DOI: 10.1080/09593985.2021.2012859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Airway clearance techniques, which include positive expiratory pressure (PEP) devices, are essential in the pulmonary rehabilitation of cystic fibrosis (CF). Bottle-PEP is a low-cost but an effective alternative. OBJECTIVE The aim of this study is to document the sustainability and safety of Bottle-PEP therapy as a home rehabilitation aid. METHODS The study has been designed as a prospective case series. Patients with CF at the age of 6-18 years in acute exacerbation period were included in the study. Bottle-PEP training was given by a competent physiotherapist to those patients who did not use any method, and those who currently use another device were followed up with their existing devices. Thus, patients divided into two groups were followed up for 1 year. The patients were evaluated by phone every 2 weeks for exacerbation, regular and proper use of the device, and satisfaction during their follow-up. The patients were evaluated every 3 months with pulmonary function tests, 6-minute walking test (6MWT) and quality of life. RESULTS Thirty-four patients were included in the study. The acute exacerbation score of the patients was 4.5 in the Bottle-PEP group and 6 in the other group, showing no significant difference (p = .1). Treatment compliance scores were compared, the median value of the Bottle-PEP group was 24 the other group was 27 and there was no significant difference (p = .6). During follow-up of, there were no significant differences in FEV1, 6MWT and quality of life data (p > .05). CONCLUSION Bottle-PEP treatment is not different from other devices in terms of long-term usability and safety in patients diagnosed with cystic fibrosis.
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Affiliation(s)
- Büşra Nur Fındık
- Marmara University Medical Faculty Physical Medicine and Rehabilitation Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
| | - Özge Kenis-Coskun
- Marmara University Medical Faculty Physical Medicine and Rehabilitation Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
| | - Evrim Karadağ-Saygı
- Marmara University Medical Faculty Physical Medicine and Rehabilitation Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
| | - Yasemin Gökdemir
- Marmara University Medical Faculty Pediatric Pulmonology Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
| | - Almala Pınar Ergenekon
- Marmara University Medical Faculty Pediatric Pulmonology Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
| | - Bülent Karadağ
- Marmara University Medical Faculty Pediatric Pulmonology Department, Fevzi Cakmak Mah Muhsin Yazicioglu Cad Marmara Universitesi Pendik Eğitim ve Araştırma Hastanesi Pendik, Istanbul, Turkey
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8
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Gursli S, Quittner A, Jahnsen RB, Skrede B, Stuge B, Bakkeheim E. Airway clearance physiotherapy and health-related quality of life in cystic fibrosis. PLoS One 2022; 17:e0276310. [PMID: 36256673 PMCID: PMC9578613 DOI: 10.1371/journal.pone.0276310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/03/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Airway clearance physiotherapy is recommended in cystic fibrosis, but limited evidence exists to suggest how much treatment is enough. As a secondary analysis of a prior study investigating the safety, efficacy, and participants' perceptions of a novel airway clearance technique, specific cough technique (SCT) compared to forced expiration technique (FET), we aimed to evaluate whether the intervention was associated with changes in health-related quality of life (HRQoL). METHODS We conducted randomised, controlled individual trials with six adults (N-of-1 RCTs). Each trial included eight weeks of treatment, twice a week, using saline inhalation in horizontal positions, one with SCT and one with FET, in random order. Efficacy was measured by sputum wet weight (g) after each session. Perceived usefulness and preference were self-reported at the end of the study. Lung function was assessed at baseline and at the end of study. HRQoL was measured using the Cystic Fibrosis Questionnaire-Revised (CFQ-R) at baseline (week 1) and at completion of the study (week 8). Individual HRQoL scores (0-100) were coded and analysed using CFQ-R Software Program, version 2.0. RESULTS Patient-reported outcomes were completed by all subjects. Individual CFQ-R-Respiratory Symptoms Scores (CFQ-R-RSS) showed a positive change, meeting the minimal important difference (MID) ≥ 4 points in five participants and a negative change in one individual. A strong correlation (r = 0.94 (p<0.01) was found between total sputum weight (g) and the positive changes in CFQ-R-RSS, and between changes in lung function and CFQ-R-RSS (r = 0.84 (p = 0.04). CONCLUSION The airway clearance intervention was associated with clinically meaningful changes in patient-reported symptoms on the CFQ-R in the majority of the participants. This finding warrants further investigation regarding treatment, duration and frequency. A long-term study may reveal beneficial effects on other clinically meaningful endpoints, such as pulmonary exacerbations, high-resolution computed tomography scores and HRQoL. TRIAL REGISTRATION The study was registered in ClinicalTrials.gov, under the number NCT0 1266473.
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Affiliation(s)
- Sandra Gursli
- National Resource Centre for Cystic Fibrosis, Oslo University Hospital, Oslo, Norway
- * E-mail:
| | - Alexandra Quittner
- Miami Children’s Research Institute, Miami, Florida, United States of America
| | - Reidun Birgitta Jahnsen
- Department of Neurosciences for Children, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, CHARM, University of Oslo, Oslo, Norway
| | - Bjørn Skrede
- Department of Pulmonary Medicine, Oslo University Hospital, Oslo, Norway
| | - Britt Stuge
- Division of Orthopaedic Surgery, Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Egil Bakkeheim
- National Resource Centre for Cystic Fibrosis, Oslo University Hospital, Oslo, Norway
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9
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Pereira PC, de Lima CJ, Fernandes AB, Fernandes FB, Zângaro RA, Villaverde AB. Systemic Effects of Photobiomodulation on Blood Components in the Treatment of Community-Acquired Pneumonia. Photobiomodul Photomed Laser Surg 2022; 40:51-58. [PMID: 34935510 DOI: 10.1089/photob.2021.0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The analysis of the complete blood count (CBC) of patients with community-acquired pneumonia (CAP) is an essential practice both for diagnosing the disease and for evaluating the patient's clinical evolution. It is proposed in the present study to analyze the hematological alterations resulting from photobiostimulation using near-infrared light-emitting diodes (LEDs) in patients with CAP. Methods: This was a clinical, prospective, blinded, and descriptive longitudinal study that involved 21 patients undergoing CAP treatment who were divided into two groups: LED, 11 patients who were treated with infrared LED and conventional treatment; and CON (control), 10 patients who received only conventional treatment (antibiotic therapy and physiotherapy). Physiotherapy was applied before LED irradiation in the LED group. The patients' CBCs were obtained before and after treatment, and erythrocyte counts, hemoglobin and hematocrit concentrations, and leukocyte and platelet counts were assessed. The phototherapy was performed with a vest with an array of 300 LEDs (940 nm) mounted on an area of 36 × 58 cm and positioned in the patient's anterior thoracic and abdominal regions. The total power was 6 W, with 15 min of irradiation time. The patients were treated daily for seven consecutive days. Statistical analyses of the intra- and intergroups of CBC data were done using Student's t-test and one-way ANOVA (analysis of variance), respectively, both at the significance level of α = 0.05. Results: There was a statistically significant recovery difference after treatment in the LED group compared with the CON group for erythrocytes, hemoglobin, leukocytes, segmented and band neutrophils, lymphocytes, and monocytes (p < 0.05). The greatest differences between the LED and CON groups were lymphocyte count reduction (60% vs. 16%), erythrocyte increase (86% vs. 35%), and leukocyte reduction (28% vs. 15%). Conclusions: The hematologic components of CAP patients recovered their normal values faster with conventional treatment associated with infrared LED therapy, thus indicating greater treatment efficiency when compared with the conventional therapy. This study was registered with the Brazilian Registry of Clinical Trials (ReBeC) under Universal Trial Number (UTN) U1111-1229-1296 (2019/06/05).
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Affiliation(s)
- Pâmela Camila Pereira
- Institute of Biomedical Engineering, Anhembi Morumbi University (UAM), São José dos Campos, Brazil
- University Center of Itajubá-FEPI, Physiotherapy Department, Itajubá, Brazil
| | - Carlos José de Lima
- Institute of Biomedical Engineering, Anhembi Morumbi University (UAM), São José dos Campos, Brazil
- Center of Innovation, Technology and Education (CITE), São José dos Campos, Brazil
| | - Adriana Barrinha Fernandes
- Institute of Biomedical Engineering, Anhembi Morumbi University (UAM), São José dos Campos, Brazil
- Center of Innovation, Technology and Education (CITE), São José dos Campos, Brazil
| | | | - Renato Amaro Zângaro
- Institute of Biomedical Engineering, Anhembi Morumbi University (UAM), São José dos Campos, Brazil
- Center of Innovation, Technology and Education (CITE), São José dos Campos, Brazil
| | - Antonio Balbin Villaverde
- Institute of Biomedical Engineering, Anhembi Morumbi University (UAM), São José dos Campos, Brazil
- Center of Innovation, Technology and Education (CITE), São José dos Campos, Brazil
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10
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Andrews K, Smith M, Cox NS. Physiotherapy: At what cost? Parents experience of performing chest physiotherapy for infants with cystic fibrosis. J Child Health Care 2021; 25:616-627. [PMID: 33249885 DOI: 10.1177/1367493520976481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Physiotherapy is one of the most burdensome aspects of cystic fibrosis (CF) care. Healthcare requirements for older children with CF are reported to impact parental quality of life and physiotherapy adherence. How parents of infants experience performing chest physiotherapy as a part of CF care is unknown. This study aimed to explore the experience of performing chest physiotherapy for parents of infants with CF. In this study, 13 parents of infants (aged 1-2 years) with CF participated in one in-depth semi-structured interview and completed a daily diary for five days. Principles of hermeneutic phenomenology guided interpretation of interview transcripts, diary entries, and field notes. For these parents, being responsible for performing chest physiotherapy was an ever-present experience of pressure, doubt, and guilt. Managing chest physiotherapy resulted in sacrifices that were perceived by parents as an expected and necessary part of meeting the healthcare needs of their child. Despite perceived sacrifices, performing chest physiotherapy was also experienced by parents as an opportunity to positively impact the health of their child. Awareness of parental perceptions and experiences of chest physiotherapy in CF may enhance the personalization of physiotherapy and minimize burden.
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Affiliation(s)
- Kristen Andrews
- School of Community Health, 1109Charles Sturt University, Albury, NSW, Australia
| | - Megan Smith
- Faculty of Science, 1109Charles Sturt University, Albury, NSW, Australia
| | - Narelle S Cox
- Monash University & Institute for Breathing and Sleep, 2541Monash University, Australia
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11
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Gecili E, Brokamp C, Palipana A, Huang R, Andrinopoulou ER, Pestian T, Rasnick E, Keogh RH, Ni Y, Clancy JP, Ryan P, Szczesniak RD. Seasonal variation of lung function in cystic fibrosis: longitudinal modeling to compare a Midwest US cohort to international populations. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 776:145905. [PMID: 35125553 PMCID: PMC8813005 DOI: 10.1016/j.scitotenv.2021.145905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Characterizing seasonal trend in lung function in individuals with chronic lung disease may lead to timelier treatment of acute respiratory symptoms and more precise distinction between seasonal exposures and variability. Limited research has been conducted to assess localized seasonal fluctuation in lung function decline in individuals with cystic fibrosis (CF) in context with routinely collected demographic and clinical data. We conducted a longitudinal cohort study of 253 individuals aged 6-22 years with CF receiving care at a pediatric Midwestern US CF center with median (range) of follow-up time of 4.7 (0-9.95) years, implementing two distinct models to estimate seasonality effects. The outcome, lung function, was measured as percent-predicted of forced expiratory volume in 1 second (FEV1). Both models showed that older age, being male, using Medicaid insurance and having Pseudomonas aeruginosa infection corresponded to accelerated FEV1 decline. A sine wave model for seasonality had better fit to the data, compared to a linear model with categories for seasonality. Compared to international cohorts, seasonal fluctuations occurred earlier and with greater volatility, even after adjustment for ambient temperature. Average lung function peaked in February and dipped in August, and FEV1 fluctuation was 0.81 % predicted (95% CI: 0.52 to 1.1). Adjusting for temperature shifted the peak and dip to March and September, respectively, and decreased FEV1 fluctuation to 0.45 % predicted (95% CI: 0.08 to 0.82). Understanding localized seasonal variation and its impact on lung function may allow researchers to perform precision public health for lung diseases and disorders at the point-of-care level.
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Affiliation(s)
- Emrah Gecili
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Cole Brokamp
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Anushka Palipana
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
- Division of Statistics and Data Science, Department of Mathematics, University of Cincinnati, 155B McMicken Hall, Cincinnati, OH, USA
| | - Rui Huang
- Division of Statistics and Data Science, Department of Mathematics, University of Cincinnati, 155B McMicken Hall, Cincinnati, OH, USA
| | | | - Teresa Pestian
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Erika Rasnick
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Ruth H. Keogh
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Yizhao Ni
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, USA
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - John P. Clancy
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, USA
- Cystic Fibrosis Foundation, 4550 Montgomery Ave, Bethesda, MD, USA
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Patrick Ryan
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, USA
| | - Rhonda D. Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, USA
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA
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12
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Bingol I, Gokdemir Y, Yilmaz-Yegit C, Ergenekon P, Atag E, Bas Ikizoglu N, Erdem Eralp E, Evkaya A, Gencer K, Saygi EK, Karakoc F, Ersu R, Karadag B. Comparison of conventional chest physiotherapy and oscillatory positive expiratory pressure therapy in primary ciliary dyskinesia. Pediatr Pulmonol 2020; 55:3414-3420. [PMID: 32997437 DOI: 10.1002/ppul.25099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/22/2020] [Accepted: 09/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chest physiotherapy (CP) is a recommended treatment modality in primary ciliary dyskinesia (PCD). OBJECTIVE Primary aim was to compare the efficacy and safety of the conventional chest physiotherapy (CCP) and oscillatory positive expiratory pressure therapy (OPEPT). Secondary aims were to compare the exacerbation rate, time until the first exacerbation, patient compliance and comfort between the two CP methods. METHODS This is a 6 month randomized, controlled crossover trial. Patients >6 years of age with PCD were randomized into two groups, first group was assigned to OPEPT (Acapella®) for 3 months while second group was assigned to CCP. Groups were crossed over to the other modality after a 15-day washout period. Pulmonary function tests (PFTs) and compliance were monitored by monthly clinic visits. RESULTS There was a significant increase in FEV1 , FEF25-75 , and PEF values (p = .018, p = .020, and p = .016, respectively) in the OPEPT group and in FVC values (p = .007) in CCP group compared to baseline. However PFT increase at 3rd month was not superior to each other with both physiotherapy methods. Median acute pulmonary exacerbation rate and time period until the first exacerbation were similar in both groups (p = .821, p = .092, respectively). Comfort and effectiveness of OPEPT was higher than CCP according to patients (p = .029 and p = .042, respectively). There were no adverse effects with either therapy. CONCLUSIONS OPEPT was as effective as CCP in PCD patients. OPEPT was more comfortable and effective than CCP according to patients. OPEPT might be an efficient alternative method for airway cleareance in PCD patients.
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Affiliation(s)
- Ibrahim Bingol
- Division of Pediatrics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Cansu Yilmaz-Yegit
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Pinar Ergenekon
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Emine Atag
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Nilay Bas Ikizoglu
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ela Erdem Eralp
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ayca Evkaya
- Division of Physiotheraphy and Rehabilitation, School of Health Sciences, Maltepe University, Istanbul, Turkey
| | - Kardelen Gencer
- Division of Physical Medicine and Rehabilitation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Evrim K Saygi
- Division of Physical Medicine and Rehabilitation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Fazilet Karakoc
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Refika Ersu
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Bulent Karadag
- Division of Pediatric Pulmonology, School of Medicine, Marmara University, Istanbul, Turkey
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13
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Zang E, Max JT. Bayesian estimation and model selection in group-based trajectory models. Psychol Methods 2020; 27:347-372. [PMID: 33151722 DOI: 10.1037/met0000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We develop a Bayesian group-based trajectory model (GBTM) and extend it to incorporate dual trajectories and Bayesian model averaging for model selection. Our framework lends itself to many of the standard distributions used in GBTMs, including normal, censored normal, binary, and ordered outcomes. On the model selection front, GBTMs require the researcher to specify a functional relationship between time and the outcome within each latent group. These relationships are generally polynomials with varying degrees in each group, but can also include additional covariates or other functions of time. When the number of groups is large, the model space can grow prohibitively complex, requiring a time-consuming brute-force search over potentially thousands of models. The approach developed in this article requires just one model fit and has the additional advantage of accounting for uncertainty in model selection. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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14
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Szczesniak RD, Pestian T, Duan LL, Li D, Stamper S, Ferrara B, Kramer E, Clancy JP, Grossoehme D. Data driven decision making to characterize clinical personas of parents of children with cystic fibrosis: a mixed methods study. BMC Pulm Med 2020; 20:174. [PMID: 32552880 PMCID: PMC7301999 DOI: 10.1186/s12890-020-01202-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/28/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Beginning at a young age, children with cystic fibrosis (CF) embark on demanding care regimens that pose challenges to parents. We examined the extent to which clinical, demographic and psychosocial features inform patterns of adherence to pulmonary therapies and how these patterns can be used to develop clinical personas, defined as aspects of adherence barriers that are presented by parents and/or perceived by clinicians, in order to enhance personalized CF care delivery. METHODS We undertook an explanatory sequential mixed-methods study consisting of i) multivariate clustering to create clusters corresponding to parental adherence patterns (quantitative phase); ii) parental participant interviews to create clinical personas interpreted from clustering (qualitative phase). Clinical, demographic and psychosocial features were used in supervised clustering against clinical endpoints, which included adherence to airway clearance and aerosolized medications and self-efficacy score, which was used as a feature for modeling adherence. Clinical implications were developed for each persona by combing quantitative and qualitative data (integration phase). RESULTS The quantitative phase showed that the 87 parent participants were segmented into three distinct patterns of adherence based on use of aerosolized medication and practice of airway clearance. Patterns were primarily influenced by self-efficacy, distance to CF care center and child BMI percentile. The two key patterns that emerged for the self-efficacy model were most heavily influenced by distance to CF care center and child BMI percentile. Eight clinical personas were developed in the qualitative phase from parent and clinician participant feedback of latent components from these models. Findings from the integration phase include recommendations to overcome specific challenges with maintaining treatment regimens and increasing support from social networks. CONCLUSIONS Adherence patterns from multivariate models and resulting parent personas with their corresponding clinical implications have utility as clinical decision support tools and capabilities for tailoring intervention study designs that promote adherence.
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Affiliation(s)
- Rhonda D Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave (MLC 5041), Cincinnati, OH, 45229, USA. .,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Teresa Pestian
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave (MLC 5041), Cincinnati, OH, 45229, USA
| | - Leo L Duan
- Department of Statistics, University of Florida, Gainesville, FL, USA
| | - Dan Li
- Alzheimer's Therapeutic Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sophia Stamper
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Brycen Ferrara
- Division of Pediatric & Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth Kramer
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - John P Clancy
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Daniel Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH, USA
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15
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Abstract
BACKGROUND Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. This is an update of a previously published review. OBJECTIVES To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 29 July 2019. In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 15 August 2019. SELECTION CRITERIA Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. DATA COLLECTION AND ANALYSIS Two authors independently applied the inclusion criteria to publications, assessed the quality of the included studies and assessed the evidence using GRADE. MAIN RESULTS The searches identified 82 studies (330 references); 39 studies (total of 1114 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 13 studies did blind the outcome assessors. The quality of the evidence across all comparisons ranged from low to very low. Forced expiratory volume in one second was the most frequently measured outcome and while many of the studies reported an improvement in those people using a vibrating device compared to before the study, there were few differences when comparing the different devices to each other or to other airway clearance techniques. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure (low-quality evidence). There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices and due to the low- or very low-quality evidence, it is not clear whether these were due to the particular intervention. Participant satisfaction was reported in 13 studies but again with low- or very low-quality evidence and not consistently in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. AUTHORS' CONCLUSIONS There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, individual preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.There may also be a requirement to consider the cost implication of devices over other forms of equally advantageous airway clearance techniques. Using the GRADE method to assess the quality of the evidence, we judged this to be low or very low quality, which suggests that further research is very likely to have an impact on confidence in any estimate of effect generated by future interventions.
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Affiliation(s)
- Lisa Morrison
- West of Scotland Adult CF Unit, Queen Elizabeth University Hospital (The Southern General Hospital), Glasgow, UK
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16
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Muther EF, Butcher JL, Riekert KA. Understanding Treatment Adherence in Cystic Fibrosis: Challenges and Opportunities. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Wang X, Chen H, Essien E, Wu J, Serna O, Paranjpe R, Abughosh S. Medication Adherence to Antihypertensive Triple-Combination Therapy Among Patients Enrolled in a Medicare Advantage Plan. J Manag Care Spec Pharm 2019; 25:678-686. [PMID: 31134857 PMCID: PMC10397987 DOI: 10.18553/jmcp.2019.25.6.678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Approximately 32% (75 million) of adults have hypertension in the United States, leading to 1,100 daily deaths and costing more than $48 billion annually in medical expenditures. Approximately 25% of patients with hypertension require triple combination therapy to reach recommended blood pressure. Currently, only 3 single-pill triple-combination therapies are available in the market for the treatment of hypertension. Medication adherence has become a major concern for the health care system, and nonadherence is associated with higher risks of morbidity and mortality. OBJECTIVE To compare medication adherence rates among single-pill triple-combination therapy, free triple-combination therapy, and fixed-dose dual-combination therapy plus a third agent in hypertensive patients enrolled in a Medicare Advantage prescription drug plan using 2 adherence definitions. METHODS A retrospective cohort study was conducted using Cigna-HealthSpring's medical claims database from January 2014 to December 2016. Antihypertensive combination therapy users were classified into a single-pill triple-combination group, a fixed-dose dual-combination plus a third agent group, and a free triple-combination group. Adherence rates using proportion of days covered (PDC) were calculated for each group within a 1-year follow-up period using 2 definitions: a strict one requiring all antihypertensive agents during follow-up and a more relaxed definition requiring any antihypertensive agent during follow-up. Descriptive statistics were examined, and group differences were assessed using chi-square and analysis of variance. Multivariate logistic regression was conducted to control confounders of adherence using both definitions. RESULTS 10,836 triple-combination users were identified. In the multivariate model using the first definition, fixed-dose dual-combination plus a third agent was significantly associated with lower adherence compared with single-pill triple therapy (OR = 0.177; 95% CI = 0.119-0.263; P < 0.001). No significant difference was detected between single-pill triple-combination therapy in comparison with free-combination therapy. In the multivariate model using the second definition, fixed-dose dual-combination plus a third agent and free-combination therapy were significantly associated with better adherence in comparison with single-pill triple combination therapy (OR = 3.62, 95% CI = 2.59-5.05; OR = 4.31, 95% CI = 2.15-8.64, respectively). Younger age, female gender, language (Spanish), some comorbidities, and previous hospitalization had a negative effect on adherence. CONCLUSIONS Measuring adherence to multiple concurrent regimens is complicated and different adherence definitions can result in significant variations in adherence measures. Future research evaluating clinical outcomes with various definitions is needed. DISCLOSURES No outside funding supported this study. Abughosh reports grants from Sanofi, Regeneron, Valeant Pharmaceuticals, BMS/Pfizer, and PhRMA, not related to this study. Serna reports employement with CareAllies, a Cigna company. The other authors have no conflicts of interest to disclose.
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Affiliation(s)
- Xin Wang
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Ekere Essien
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Jun Wu
- Department of Pharmaceutical and Administrative Sciences, Presbyterian College School of Pharmacy, Clinton, South Carolina
| | - Omar Serna
- CareAllies, a Cigna company, Houston, Texas
| | - Rutugandha Paranjpe
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
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Wilson LM, Morrison L, Robinson KA. Airway clearance techniques for cystic fibrosis: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2019; 1:CD011231. [PMID: 30676656 PMCID: PMC6353051 DOI: 10.1002/14651858.cd011231.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cystic fibrosis is a life-limiting genetic condition in which thick mucus builds up in the lungs, leading to infections, inflammation, and eventually, deterioration in lung function. To clear their lungs of mucus, people with cystic fibrosis perform airway clearance techniques daily. There are various airway clearance techniques, which differ in terms of the need for assistance or equipment, and cost. OBJECTIVES To summarise the evidence from Cochrane Reviews on the effectiveness and safety of various airway clearance techniques in people with cystic fibrosis. METHODS For this overview, we included Cochrane Reviews of randomised or quasi-randomised controlled trials (including cross-over trials) that evaluated an airway clearance technique (conventional chest physiotherapy, positive expiratory pressure (PEP) therapy, high-pressure PEP therapy, active cycle of breathing techniques, autogenic drainage, airway oscillating devices, external high frequency chest compression devices and exercise) in people with cystic fibrosis.We searched the Cochrane Database of Systematic Reviews on 29 November 2018.Two review authors independently evaluated reviews for eligibility. One review author extracted data from included reviews and a second author checked the data for accuracy. Two review authors independently graded the quality of reviews using the ROBIS tool. We used the GRADE approach for assessing the overall strength of the evidence for each primary outcome (forced expiratory volume in one second (FEV1), individual preference and quality of life). MAIN RESULTS We included six Cochrane Reviews, one of which compared any type of chest physiotherapy with no chest physiotherapy or coughing alone and the remaining five reviews included head-to-head comparisons of different airway clearance techniques. All the reviews were considered to have a low risk of bias. However, the individual trials included in the reviews often did not report sufficient information to adequately assess risk of bias. Many trials did not sufficiently report on outcome measures and had a high risk of reporting bias.We are unable to draw definitive conclusions for comparisons of airway clearance techniques in terms of FEV1, except for reporting no difference between PEP therapy and oscillating devices after six months of treatment, mean difference -1.43% predicted (95% confidence interval -5.72 to 2.87); the quality of the body of evidence was graded as moderate. The quality of the body of evidence comparing different airway clearance techniques for other outcomes was either low or very low. AUTHORS' CONCLUSIONS There is little evidence to support the use of one airway clearance technique over another. People with cystic fibrosis should choose the airway clearance technique that best meets their needs, after considering comfort, convenience, flexibility, practicality, cost, or some other factor. More long-term, high-quality randomised controlled trials comparing airway clearance techniques among people with cystic fibrosis are needed.
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Affiliation(s)
- Lisa M Wilson
- Johns Hopkins UniversityEvidence‐based Practice CenterHampton House, 6th Floor624 North BroadwayBaltimoreMDUSA21205‐1901
| | - Lisa Morrison
- Queen Elizabeth University Hospital (The Southern General Hospital)West of Scotland Adult CF Unit1345 Govan RoadGlasgowUKG51 4TF
| | - Karen A Robinson
- Johns Hopkins UniversityDepartment of Medicine1830 E. Monument St., Suite 8068BaltimoreMDUSA21287
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Oates GR, Stepanikova I, Rowe SM, Gamble S, Gutierrez HH, Harris WT. Objective Versus Self-Reported Adherence to Airway Clearance Therapy in Cystic Fibrosis. Respir Care 2018; 64:176-181. [PMID: 30538158 DOI: 10.4187/respcare.06436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Historically, studies of adherence to airway clearance therapy in cystic fibrosis (CF) have relied on self-reporting. We compared self-reported airway clearance therapy adherence to actual usage data from home high-frequency chest wall compressions (HFCWC) vests and identified factors associated with overestimation of adherence in self-reports. METHODS Pediatric patients who perform airway clearance therapy with a HFCWC vest were eligible to participate. Objective adherence data were obtained from the HFCWC device, which records cumulative utilization time. Two readings at least 5 weeks apart were collected. Objective adherence was recorded as a ratio of mean-to-prescribed daily use (%). Self-reported adherence data were collected with a caregiver survey at enrollment. Adherence rates were categorized as low (< 35% of prescribed), moderate (36-79% of prescribed), and high (≥ 80% of prescribed). An overestimation was present when self-reported adherence was at least one category higher than objective adherence. RESULTS In the final sample (N = 110), mean adherence by usage data was 61%. Only 35% of subjects (n = 38) were highly adherent, and 28% (n = 31) were low adherent. In contrast, 65% of subjects (n = 72) reported high adherence and only 8% (n = 9) reported low adherence (P < .001). Nearly half of self-reports (46%) overestimated adherence. In a multiple regression analysis, overestimation was associated with multiple airway clearance therapy locations (odds ratio 7.13, 95% CI 1.16-43.72, P = .034) and prescribed daily use ≥ 60 min (odds ratio 3.85, 95% CI 1.08-13.76, P < .038). Among subjects with prescribed daily airway clearance therapy ≥ 60 min, the odds of overestimating adherence increased 3-fold (odds ratio 3.04, 95% CI 1.17-7.87, P = .02) in a lower-income (< $50,000/y) environment. CONCLUSIONS Self-reports overestimated actual adherence to airway clearance therapy, and the overestimation increased with treatment occurring in multiple households and prescribed therapy duration. Among participants with prescribed airway clearance therapy ≥ 60 min, overestimation increased with lower income. Objective measures of adherence are needed, particularly for lower-income children and those receiving treatments in multiple locations.
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Affiliation(s)
- Gabriela R Oates
- Division of Pediatric Pulmonary and Sleep Medicine, as well as the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Alabama.
| | - Irena Stepanikova
- Department of Sociology, University of Alabama at Birmingham and Research Center for Toxic Compounds in the Environment (RECETOX), Masaryk University, Czech Republic
| | - Steven M Rowe
- Division of Pediatric Pulmonary and Sleep Medicine, as well as the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Alabama.,Departments of Medicine and Cell Developmental and Integrative Biology, University of Alabama at Birmingham
| | | | - Hector H Gutierrez
- Division of Pediatric Pulmonary and Sleep Medicine, as well as the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Alabama
| | - William T Harris
- Division of Pediatric Pulmonary and Sleep Medicine, as well as the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Alabama
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20
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Balli F. Developing Digital Games to Address Airway Clearance Therapy in Children With Cystic Fibrosis: Participatory Design Process. JMIR Serious Games 2018; 6:e18. [PMID: 30463835 PMCID: PMC6282016 DOI: 10.2196/games.8964] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 06/25/2018] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Children affected with cystic fibrosis do respiratory exercises to release the mucus stuck in their lungs. OBJECTIVE The objective of our study was to develop prototypes of digital games that use breath pressure to make this daily physiotherapy more fun. METHODS We used a participatory design approach and organized short events to invite contributors from different disciplines to develop game prototypes. From the 6 prototypes, 3 were tested by 10 children during a prestudy. The source code of the games, of which 2 continue to be developed, has been released on the internet under fair use licenses. RESULTS We discuss 7 themes of importance in designing games for health, combining our experience with a review a posteriori of literature. CONCLUSIONS This study provides examples of games and their pitfalls as well as recommendations to create games for health in a participatory approach that enables everyone to improve and adapt the work done.
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Affiliation(s)
- Fabio Balli
- Breathing Games, Montreal, QC, Canada.,Concordia University, Montreal, QC, Canada
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21
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Selekman RE, Shapiro DJ, Boscardin J, Williams G, Craig JC, Brandström P, Pennesi M, Roussey-Kesler G, Hari P, Copp HL. Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis. Pediatrics 2018; 142:peds.2018-0119. [PMID: 29954832 PMCID: PMC6317567 DOI: 10.1542/peds.2018-0119] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Limited data exist regarding uropathogen resistance in randomized controlled trials of urinary tract infection (UTI) prevention and antibiotic prophylaxis. OBJECTIVE To assess the effect of prophylaxis on developing a multidrug-resistant first recurrent UTI among children with vesicoureteral reflux. DATA SOURCES Cochrane Kidney and Transplant Specialized Register through May 25, 2017. STUDY SELECTION Randomized controlled trials of patients ≤18 years of age with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis compared with no treatment or placebo with available antibiotic sensitivity profiles. DATA EXTRACTION Two independent observers abstracted data and assessed quality and validity per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Adjusted meta-analyses were performed by using a mixed-effects logistic regression model. RESULTS One thousand two hundred and ninety-nine patients contributed 224 UTIs. Patients treated with prophylaxis were more likely to have a multidrug-resistant infection (33% vs 6%, P < .001) and were more likely to receive broad-spectrum antibiotics (68% vs 49%, P = .004). Those receiving prophylaxis had 6.4 times the odds (95% confidence interval: 2.7-15.6) of developing a multidrug-resistant infection. One multidrug-resistant infection would develop for every 21 reflux patients treated with prophylaxis. LIMITATIONS Variables that may contribute to resistance such as medication adherence and antibiotic exposure for other illnesses could not be evaluated. CONCLUSIONS Prophylaxis increases the risk of multidrug resistance among recurrent infections. This has important implications in the risk-benefit assessment of prophylaxis as a management strategy and in the selection of empirical treatment of breakthrough infections in prophylaxis patients.
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Affiliation(s)
| | - Daniel J. Shapiro
- Boston Combined Residency Program, Boston Children’s Hospital and Boston Medical Center, Boston, Massachusetts
| | - John Boscardin
- Medicine, and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Gabrielle Williams
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan C. Craig
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Per Brandström
- Pediatric Uro-Nephrologic Center, Sahlgrenska Academy, University of Gothenburg and Queen Slivias Children’s Hospital, Gothenburg, Sweden
| | - Marco Pennesi
- Department of Pediatrics, Institute for Child and Maternal Health, University of Trieste, Trieste, Italy
| | | | - Pankaj Hari
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Matilde INE, Eid RAC, Nunes AF, Ambrozin ARP, Moura RH, Carnieli-Cazati D, Timenetsky KT. Bronchial hygiene techniques in patients on mechanical ventilation: what are used and why? ACTA ACUST UNITED AC 2018; 16:eAO3856. [PMID: 29694610 PMCID: PMC5968793 DOI: 10.1590/s1679-45082018ao3856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 10/02/2017] [Indexed: 11/22/2022]
Abstract
Objective To analyze and describe the maneuvers most commonly used in clinical practice by physical therapists and the reasons for choosing them. Methods A prospective multicenter study using a questionnaire. The sample consisted of physical therapists from five hospitals (three private hospitals, a teaching hospital and a public hospital). Results A total of 185 questionnaires were filled in. Most professionals had graduated 6 to 10 years before and over had over 10 years of intensive care unit experience. The most often used maneuvers were vibrocompression, hyperinflation, postural drainage, tracheal suction and motor mobilization. The most frequent reason for choosing these maneuvers was “I notice they are more efficient in clinical practice.” Conclusion Physical therapy is mostly based on individual experience acquired in the clinical practice, and not on the scientific literature.
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Oates GR, Hamby BW, Stepanikova I, Knight SJ, Bhatt SP, Hitchcock J, Schumann C, Dransfield MT. Social Determinants of Adherence to Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease. COPD 2017; 14:610-617. [PMID: 29020525 DOI: 10.1080/15412555.2017.1379070] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Adherence to pulmonary rehabilitation (PR) is low. Previous studies have focused on clinical predictors of PR completion. We aimed to identify social determinants of adherence to PR. A cross-sectional analysis of a database of COPD patients (N = 455) in an outpatient PR program was performed. Adherence, a ratio of attended-to-prescribed sessions, was coded as low (<35%), moderate (35-85%), and high (>85%). Individual-level measures included age, sex, race, BMI, smoking status, pack-years, baseline 6-minute walk distance (6MWD: <150, 150-249, ≥250), co-morbidities, depression, and prescribed PR sessions (≤20, 21-30, >30). Fifteen area-level measures aggregated to Census tracts were obtained from the U.S. Census after geocoding patients' addresses. Using exploratory factor analysis, a neighborhood socioeconomic disadvantage index was constructed, which included variables with factor loading >0.5: poverty, public assistance, households without vehicles, cost burden, unemployment, and minority population. Multivariate regression models were adjusted for clustering on Census tracts. Twenty-six percent of patients had low adherence, 23% were moderately adherent, 51% were highly adherent. In the best fitted full model, each decile increase in neighborhood socioeconomic disadvantage increased the risk of moderate vs high adherence by 14% (p < 0.01). Smoking tripled the relative risk of low adherence (p < 0.01), while each increase in 6MWD category decreased that risk by 72% (p < 0.01) and 84% (p < 0.001), respectively. These findings show that, relative to high adherence, low adherence is associated with limited functional capacity and current smoking, while moderate adherence is associated with socioeconomic disadvantage. The distinction highlights different pathways to suboptimal adherence and calls for tailored intervention approaches.
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Affiliation(s)
- Gabriela R Oates
- a Preventive Medicine , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Bryant W Hamby
- b Sociology , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Irena Stepanikova
- b Sociology , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Sara J Knight
- a Preventive Medicine , University of Alabama at Birmingham , Birmingham , AL , USA.,c Birmingham Veterans Affairs Medical Center , Birmingham , AL , USA
| | - Surya P Bhatt
- d Lung Health Center and Pulmonary, Allergy and Critical Care Medicine , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Jason Hitchcock
- e Cardiopulmonary Rehabilitation , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Christopher Schumann
- e Cardiopulmonary Rehabilitation , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Mark T Dransfield
- c Birmingham Veterans Affairs Medical Center , Birmingham , AL , USA.,d Lung Health Center and Pulmonary, Allergy and Critical Care Medicine , University of Alabama at Birmingham , Birmingham , AL , USA
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Abstract
BACKGROUND Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. This is an update of a previously published review. OBJECTIVES To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 27 April 2017.In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 26 April 2017. SELECTION CRITERIA Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. DATA COLLECTION AND ANALYSIS Two authors independently applied the inclusion criteria to publications and assessed the quality of the included studies. MAIN RESULTS The searches identified 76 studies (302 references); 35 studies (total of 1138 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 11 studies did blind the outcome assessors.Forced expiratory volume in one second was the most frequently measured outcome. One long-term study (seven months) compared oscillatory devices with either conventional physiotherapy or breathing techniques and found statistically significant differences in some lung function parameters in favour of oscillating devices. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure. There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices. Participant satisfaction was reported in 15 studies but this was not specifically in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence. AUTHORS' CONCLUSIONS There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, individual preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.There may also be a requirement to consider the cost implication of devices over other forms of equally advantageous airway clearance techniques. Using the GRADE method to assess the quality of the evidence, we judged this to be low or very low quality, which suggests that further research is very likely to have an impact on confidence in any estimate of effect generated by future interventions.
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Affiliation(s)
- Lisa Morrison
- Queen Elizabeth University Hospital (The Southern General Hospital)West of Scotland Adult CF Unit1345 Govan RoadGlasgowUKG51 4TF
| | - Stephanie Milroy
- Queen Elizabeth University Hospital1345 Govan RoadGlasgowUKG51 4TF
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25
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Mikesell CL, Kempainen RR, Laguna TA, Menk JS, Wey AR, Gaillard PR, Regelmann WE. Objective Measurement of Adherence to Out-Patient Airway Clearance Therapy by High-Frequency Chest Wall Compression in Cystic Fibrosis. Respir Care 2017; 62:920-927. [PMID: 28424226 DOI: 10.4187/respcare.05349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Objective measures of adherence to high-frequency chest wall compression (HFCWC), a form of airway clearance therapy for patients with cystic fibrosis, are lacking. We used a novel electronic monitoring device integrated into an HFCWC vest to measure adherence compared with self-reported adherence. We determined factors that influenced adherence and how adherence correlated with baseline pulmonary function and pulmonary exacerbations. METHODS Data were collected by direct measurement of date, time of day, and duration of HFCWC use to determine the number of daily treatments and daily duration of treatments. Chart review provided prescribed airway clearance therapy treatment and demographic and clinical information. Subject and caregiver report of the daily number of airway clearance therapy treatments was obtained by telephone interviews. Analysis used 2-sample and paired t test, analysis of variance, and linear regression. RESULTS Average adherence was 69%. Adherence was highest in children (82%, P = .02) and those receiving assistance with treatment (82%, P < .001). Subjects overestimated therapy duration from a mean ± SD of 127 ± 169% by adults to 19.2 ± 26.3% by parents or guardians of children. Average adherence decreased with increasing prescribed therapy time (P = .02). Average daily therapy time and adherence had significant positive associations with baseline FEV1 percent of predicted (P = .02 and P = .02, respectively) and negative associations with pulmonary exacerbations during the pre-study period and at baseline (P = .044 and P = .02, respectively). CONCLUSIONS Greater adherence to HFCWC measured directly by a novel recorder was associated with better baseline pulmonary function and fewer exacerbations in the pre-study and baseline period. Adherence decreased with age and prescribed therapy time and increased with therapy assistance. Self-report overestimation is large and thus not an accurate measure of adherence.
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Affiliation(s)
- Christina L Mikesell
- Children's Respiratory and Critical Care Specialists, Minneapolis, Minnesota.,Pediatric Pulmonology, University of Minnesota Cystic Fibrosis Center and Masonic Children's Hospital, Minneapolis, Minnesota
| | - Robert R Kempainen
- Pulmonary and Critical Care Medicine, Hennepin County Medical Center, and the University of Minnesota Cystic Fibrosis Center and Hospital, Minneapolis, Minnesota
| | - Theresa A Laguna
- Pediatric Pulmonology, University of Minnesota Cystic Fibrosis Center and Masonic Children's Hospital, Minneapolis, Minnesota
| | - Jeremiah S Menk
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Andrew R Wey
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Philippe R Gaillard
- Department of Mathematics and Statistics, Auburn University, Auburn, Alabama
| | - Warren E Regelmann
- Pediatric Pulmonology, University of Minnesota Cystic Fibrosis Center and Masonic Children's Hospital, Minneapolis, Minnesota.
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Narayanan S, Mainz JG, Gala S, Tabori H, Grossoehme D. Adherence to therapies in cystic fibrosis: a targeted literature review. Expert Rev Respir Med 2017; 11:129-145. [DOI: 10.1080/17476348.2017.1280399] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Jochen G. Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Smeet Gala
- Market Access Solutions LLC. (MKTXS), Raritan, NJ, USA
| | - Harold Tabori
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Daniel Grossoehme
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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27
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Braden MN, van Leer E. Effect of MP4 Therapy Videos on Adherence to Voice Therapy Home Practice in Children With Dysphonia. J Voice 2017; 31:114.e17-114.e23. [DOI: 10.1016/j.jvoice.2016.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/24/2016] [Accepted: 03/30/2016] [Indexed: 11/30/2022]
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Feiten TDS, Flores JS, Farias BL, Rovedder PME, Camargo EG, Dalcin PDTR, Ziegler B. Respiratory therapy: a problem among children and adolescents with cystic fibrosis. J Bras Pneumol 2016; 42:29-34. [PMID: 26982038 PMCID: PMC4805384 DOI: 10.1590/s1806-37562016000000068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/04/2015] [Indexed: 12/02/2022] Open
Abstract
Objective : To evaluate the level of self-reported adherence to physical therapy recommendations in pediatric patients (6-17 years) with cystic fibrosis (CF) and to ascertain whether the different levels of adherence correlate with pulmonary function, clinical aspects, and quality of life. Methods : This was a cross-sectional study. The patients and their legal guardians completed a questionnaire regarding adherence to physical therapy recommendations and a CF quality of life questionnaire. We collected demographic, spirometric, and bacteriological data, as well as recording the frequency of hospitalizations and Shwachman-Kulczycki (S-K) clinical scores. Results : We included 66 patients in the study. Mean age, FEV1 (% of predicted), and BMI were 12.2 ± 3.2 years, 90 ± 24%, and 18.3 ± 2.5 kg/m2, respectively. The patients were divided into two groups: high-adherence (n = 39) and moderate/poor-adherence (n = 27). No statistically significant differences were found between the groups regarding age, gender, family income, and total S-K clinical scores. There were statistically significant differences between the high-adherence group and the moderate/poor-adherence group, the latter showing lower scores for the "radiological findings" domain of the S-K clinical score (p = 0.030), a greater number of hospitalizations (p = 0.004), and more days of hospitalization in the last year (p = 0.012), as well as lower scores for the quality of life questionnaire domains emotion (p = 0.002), physical (p = 0.019), treatment burden (p < 0.001), health perceptions (p = 0.036), social (p = 0.039), and respiratory (p = 0.048). Conclusions : Low self-reported adherence to physical therapy recommendations was associated with worse radiological findings, a greater number of hospitalizations, and decreased quality of life in pediatric CF patients.
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Affiliation(s)
| | - Josani Silva Flores
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Bruna Luciano Farias
- Faculdade de Fisioterapia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | | | | | - Bruna Ziegler
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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29
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Lo-Ciganic WH, Donohue JM, Jones BL, Perera S, Thorpe JM, Thorpe CT, Marcum ZA, Gellad WF. Trajectories of Diabetes Medication Adherence and Hospitalization Risk: A Retrospective Cohort Study in a Large State Medicaid Program. J Gen Intern Med 2016; 31:1052-60. [PMID: 27229000 PMCID: PMC4978686 DOI: 10.1007/s11606-016-3747-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/18/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Numerous interventions are available to boost medication adherence, but the targeting of these interventions often relies on crude measures of poor adherence. Group-based trajectory models identify individuals with similar longitudinal prescription filling patterns. Identifying distinct adherence trajectories may be more useful for targeting interventions, although the association between adherence trajectories and clinical outcomes is unknown. OBJECTIVE To examine the association between adherence trajectories for oral hypoglycemics and subsequent hospitalizations among diabetes patients. DESIGN Retrospective cohort study. PATIENTS A total of 16,256 Pennsylvania Medicaid enrollees, non-dually eligible for Medicare, initiating oral hypoglycemics between 2007 and 2009. MAIN MEASURES We used group-based trajectory models to identify trajectories of oral hypoglycemics in the 12 months post-treatment initiation, using monthly proportion of days covered (PDC) as the adherence measure. Multivariable Cox proportional hazard models were used to examine the association between trajectories and time to first diabetes-related hospitalization/emergency department (ED) visits in the following year. We used the C-index to compare prediction performance between adherence trajectories and dichotomous cutpoints (annual PDC <80 vs. ≥80 %). RESULTS The mean annual PDC was 0.58 (SD 0.32). Seven trajectories were identified: perfect adherers (9 % of the cohort), nearly perfect adherers (31.4 %), moderate adherers (21.0 %), low adherers (11.0 %), late discontinuers (6.8 %), early discontinuers (9.7 %), and non-adherers with only one fill (11.1 %). Compared to perfect adherers, trajectories of moderate adherers (HR = 1.48, 95 % CI 1.25, 1.75), low adherers (HR = 1.51, 95 % CI 1.25, 1.83), and non-adherers with only one fill (HR = 1.35, 95 % CI 1.09, 1.67) had greater risk of diabetes-related hospitalizations/ED visits. Predictive accuracy was improved using trajectories compared to dichotomized cutpoints (C-index = 0.714 vs. 0.652). CONCLUSIONS Oral hypoglycemic treatment trajectories were highly variable in this large Medicaid cohort. Low and moderate adherers and those filling only one prescription had a modestly higher risk of hospitalizations/ED visits compared to perfect adherers. Trajectory models may be valuable in identifying specific non-adherence patterns for targeting interventions.
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Affiliation(s)
- Wei-Hsuan Lo-Ciganic
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA.
| | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bobby L Jones
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Subashan Perera
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Walid F Gellad
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Librero J, Sanfélix-Gimeno G, Peiró S. Medication Adherence Patterns after Hospitalization for Coronary Heart Disease. A Population-Based Study Using Electronic Records and Group-Based Trajectory Models. PLoS One 2016; 11:e0161381. [PMID: 27551748 PMCID: PMC4995009 DOI: 10.1371/journal.pone.0161381] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 08/04/2016] [Indexed: 11/23/2022] Open
Abstract
Objective To identify adherence patterns over time and their predictors for evidence-based medications used after hospitalization for coronary heart disease (CHD). Patients and Methods We built a population-based retrospective cohort of all patients discharged after hospitalization for CHD from public hospitals in the Valencia region (Spain) during 2008 (n = 7462). From this initial cohort, we created 4 subcohorts with at least one prescription (filled or not) from each therapeutic group (antiplatelet, beta-blockers, ACEI/ARB, statins) within the first 3 months after discharge. Monthly adherence was defined as having ≥24 days covered out of 30, leading to a repeated binary outcome measure. We assessed the membership to trajectory groups of adherence using group-based trajectory models. We also analyzed predictors of the different adherence patterns using multinomial logistic regression. Results We identified a maximum of 5 different adherence patterns: 1) Nearly-always adherent patients; 2) An early gap in adherence with a later recovery; 3) Brief gaps in medication use or occasional users; 4) A slow decline in adherence; and 5) A fast decline. These patterns represented variable proportions of patients, the descending trajectories being more frequent for the beta-blocker and ACEI/ARB cohorts (16% and 17%, respectively) than the antiplatelet and statin cohorts (10% and 8%, respectively). Predictors of poor or intermediate adherence patterns were having a main diagnosis of unstable angina or other forms of CHD vs. AMI in the index hospitalization, being born outside Spain, requiring copayment or being older. Conclusion Distinct adherence patterns over time and their predictors were identified. This may be a useful approach for targeting improvement interventions in patients with poor adherence patterns.
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Affiliation(s)
- Julián Librero
- Health Services Research Unit, Center for Public Health Research (CSISP-FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Center for Public Health Research (CSISP-FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- * E-mail:
| | - Salvador Peiró
- Health Services Research Unit, Center for Public Health Research (CSISP-FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is the most common genetic, life-shortening illness among white populations. Management of the disease requires a complex, time-consuming treatment regimen. The purpose of this review is to highlight current research examining the psychological burden of CF, including psychological distress, social challenges, treatment burden, and adherence to daily treatments. RECENT FINDINGS Individuals with CF and their parent caregivers report elevated symptoms of depression and anxiety. Recent international guidelines (Cystic Fibrosis Foundation and European Cystic Fibrosis Society) recommend annual screening of these symptoms using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales. Symptoms of depression have been associated with decreased adherence, lower quality of life, and higher healthcare costs. Adherence to pulmonary medications has been found to be 50% or less and decreases with age. Poor adherence has been associated with higher healthcare costs, more frequent hospitalizations, and worse quality of life. SUMMARY Individuals with CF face unique challenges that can lead to psychological burden. Screening for these symptoms and developing effective interventions to improve adherence are the key targets for the next 5 years of research.
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Sylvain C, Lamothe L, Berthiaume Y, Rabasa-Lhoret R. How patients' representations of cystic fibrosis-related diabetes inform their health behaviours. Psychol Health 2016; 31:1129-44. [PMID: 27112101 DOI: 10.1080/08870446.2016.1183008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although diabetes is a frequent complication of cystic fibrosis (CF), patients' behaviours tend not to comply with best practice recommendations. Using Leventhal's Common-Sense Model, we address this issue by exploring patients' representations of CF-related diabetes (CFRD) to better understand the discrepancy between patients' expected and observed health behaviours. METHODS Semi-structured individual interviews were conducted with patients (n = 39) in six CF clinics in Quebec, Canada. These interviews were part of a larger research project on screening and management practices for CFRD. RESULTS Illness representations differed between two groups of interviewed patients: (1) one group had either CF without dysglycemia or CF with impaired glucose tolerance; and (2) the other group had CFRD. Both representations were internally consistent and encompassed Leventhal's five dimensions of illness representation: illness identity, cause, timeline, consequences and control. CONCLUSIONS Patients require specific information on CFRD. The screening phase could be a crucial time to help patients adjust their representations to fit the reality of CFRD.
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Affiliation(s)
- Chantal Sylvain
- a School of Rehabilitation , Université de Sherbrooke, Centre for Action in Work Disability Prevention and Rehabilitation (CAPRIT) , Longueuil , Canada
| | - Lise Lamothe
- b School of Public Health , Université de Montréal, Université de Montréal Public Health Research Institute (IRSPUM) , Montréal , Canada
| | - Yves Berthiaume
- c Department of medicine , Université de Montréal, Institut de Recherches Cliniques de Montréal (IRCM) , Montréal , Canada
| | - Rémi Rabasa-Lhoret
- d Department of Nutrition , Université de Montréal, Institut de Recherches Cliniques de Montréal (IRCM) , Montréal , Canada
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Grossoehme DH, Szczesniak RD, Mrug S, Dimitriou SM, Marshall A, McPhail GL. Adolescents' Spirituality and Cystic Fibrosis Airway Clearance Treatment Adherence: Examining Mediators. J Pediatr Psychol 2016; 41:1022-32. [PMID: 27037417 DOI: 10.1093/jpepsy/jsw024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/05/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Adolescent cystic fibrosis (CF) treatment adherence is a significant multidimensional issue. Using the Theory of Reasoned Action (TRA), this study examined the role of spiritual factors in adherence. METHODS Forty-five 11-19-year-olds diagnosed with CF completed questionnaires concerning psychosocial, spiritual, and adherence-related constructs and Daily Phone Diaries to calculate treatment adherence. Exploratory Factor Analysis identified two spiritual factors used in subsequent analyses. The mediating roles of attitude toward the treatment's value (utility), subjective behavioral norms (the product of perceived behavioral norms and one's motivation to comply with them), self-efficacy for completing the treatments and treatment intentions in the relationship between spiritual factors and treatment adherence were tested with path analysis. RESULTS Lower 'spiritual struggle' and greater 'engaged spirituality' predicted treatment attitude (utility) and subjective behavioral norms, which, together with self-efficacy, predicted treatment intentions. Finally, treatment intentions predicted airway clearance adherence. CONCLUSIONS Findings were consistent with the TRA. Engaged spirituality supports pro-adherence determinants and behavior. Spiritual struggle's negative associations with outcomes warrant screening and intervention.
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Affiliation(s)
| | - Rhonda D Szczesniak
- Division of Pulmonary Medicine Division Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center
| | - Sylvie Mrug
- Department of Psychology, University of Alabama - Birmingham
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Adherence Determinants in Cystic Fibrosis: Cluster Analysis of Parental Psychosocial, Religious, and/or Spiritual Factors. Ann Am Thorac Soc 2016; 12:838-46. [PMID: 25803407 DOI: 10.1513/annalsats.201408-379oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
RATIONALE Cystic fibrosis is a progressive disease requiring a complex, time-consuming treatment regimen. Nonadherence may contribute to an acceleration of the disease process. Spirituality influences some parental healthcare behaviors and medical decision-making. OBJECTIVES We hypothesized that parents of children with cystic fibrosis, when classified into groups based on adherence rates, would share certain psychosocial and religious and/or spiritual variables distinguishing them from other adherence groups. METHODS We conducted a multisite, prospective, observational study focused on parents of children younger than 13 years old at two cystic fibrosis center sites (Site 1, n= 83; Site 2, n = 59). Religious and/or spiritual constructs, depression, and marital adjustment were measured by using previously validated questionnaires. Determinants of adherence included parental attitude toward treatment, perceived behavioral norms, motivation, and self-efficacy. Adherence patterns were measured with the Daily Phone Diary, a validated instrument used to collect adherence data. Cluster analysis identified discrete adherence patterns, including parents' completion of more treatments than prescribed. MEASUREMENTS AND MAIN RESULTS For airway clearance therapy, four adherence groups were identified: median adherence rates of 23%, 52%, 77%, and 120%. These four groups differed significantly for parental depression, sanctification of their child's body, and self-efficacy. Three adherence groups were identified for nebulized medications: median adherence rates of 35%, 82%, and 130%. These three groups differed significantly for sanctification of their child's body and self-efficacy. CONCLUSIONS Our results indicated that parents in each group shared psychosocial and religious and/or spiritual factors that differentiated them. Therefore, conversations about adherence likely should be tailored to baseline adherence patterns. Development of efficacious religious and/or spiritual interventions that promote adherence by caregivers of children with cystic fibrosis may be useful.
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Abstract
BACKGROUND Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. This is an updated version of previously published reviews. OBJECTIVES To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 02 June 2015. SELECTION CRITERIA Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone. DATA COLLECTION AND ANALYSIS Both authors independently assessed study eligibility, extracted data and assessed the risk of bias in the included studies. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible. MAIN RESULTS The searches identified 157 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed. Blinding of participants, caregivers or clinicians in airway clearance studies is impossible; therefore this was not considered as a high risk of bias in the included studies. Lack of protocol data made assessment of risk of bias unclear for the majority of other criteria.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups. AUTHORS' CONCLUSIONS The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.
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Affiliation(s)
- Louise Warnock
- Oxford Centre for Respiratory Medicine, The Churchill HospitalOxford Adult Cystic Fibrosis CentreOld RoadHeadingtonOxfordUKOX3 7LJ
| | - Alison Gates
- Oxford Centre for Respiratory Medicine, The Churchill HospitalOxford Adult Cystic Fibrosis CentreOld RoadHeadingtonOxfordUKOX3 7LJ
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Oates GR, Stepanikova I, Gamble S, Gutierrez HH, Harris WT. Adherence to airway clearance therapy in pediatric cystic fibrosis: Socioeconomic factors and respiratory outcomes. Pediatr Pulmonol 2015; 50:1244-52. [PMID: 26436321 PMCID: PMC4871693 DOI: 10.1002/ppul.23317] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/08/2015] [Accepted: 09/14/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The evidence linking socioeconomic status (SES) and adherence in cystic fibrosis (CF) is inconclusive and focused on medication uptake. We examined associations between SES, adherence to airway clearance therapy (ACT), and CF respiratory outcomes. STUDY DESIGN Socioeconomic, clinical, and adherence data of CF patients (N = 110) at a single CF Center were evaluated in this cross-sectional observational study. SES was operationalized as maternal and paternal education and household income. Adherence to ACT was measured with utilization data from the high-frequency chest wall oscillation (HFCWO) device over 4-6 weeks. Statistical modeling was used to test three hypotheses: (H1) Higher SES is associated with higher ACT adherence; (H2) Higher SES is associated with better respiratory outcomes; and (H3) ACT adherence mediates the relationship between SES and respiratory outcomes. RESULTS In multinomial logistic regression, maternal college education, annual income >$50,000, and more adults in the household were independently related to better adherence (P < 0.05). Paternal college education, income >$100,000, and lack of exposure to smoking were independently related to higher lung function (P < 0.05). Current adherence to ACT with HFCWO was not associated with lung function over 12 months. CONCLUSIONS SES is associated both with ACT adherence and respiratory outcomes in pediatric CF patients. However, the link between SES and respiratory outcomes in this study was not mediated by adherence to ACT with HFCWO. These data emphasize the importance of socioeconomic resources and household environment for CF health. Family socio-demographic profiles can help identify patients at increased risk for ACT nonadherence.
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Affiliation(s)
- Gabriela R Oates
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Irena Stepanikova
- Department of Sociology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Hector H Gutierrez
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - William T Harris
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
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Sanfélix-Gimeno G, Rodríguez-Bernal CL, Hurtado I, Baixáuli-Pérez C, Librero J, Peiró S. Adherence to oral anticoagulants in patients with atrial fibrillation-a population-based retrospective cohort study linking health information systems in the Valencia region, Spain: a study protocol. BMJ Open 2015; 5:e007613. [PMID: 26482766 PMCID: PMC4611755 DOI: 10.1136/bmjopen-2015-007613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adherence to oral anticoagulation (OAC) treatment, vitamin K antagonists or new oral anticoagulants, is an essential element for effectiveness. Information on adherence to OAC in atrial fibrillation (AF) and the impact of adherence on clinical outcomes using real-world data barely exists. We aim to describe the patterns of adherence to OAC over time in patients with AF, estimate the associated factors and their impact on clinical events, and assess the same issues with conventional measures of primary and secondary adherence-proportion of days covered (PDC) and persistence-in routine clinical practice. METHODS AND ANALYSIS This is a population-based retrospective cohort study including all patients with AF treated with OAC from 2010 to date in Valencia, Spain; data will be obtained from diverse electronic records of the Valencia Health Agency. PRIMARY OUTCOME MEASURE adherence trajectories. SECONDARY OUTCOMES (1) primary non-adherence; (2) secondary adherence: (a) PDC, (b) persistence. Clinical outcomes: hospitalisation for haemorrhagic or thromboembolic events and death during follow-up. ANALYSIS (1) description of baseline characteristics, adherence patterns (trajectory models or latent class growth analysis models) and conventional adherence measures; (2) logistic or Cox multivariate regression models, to assess the associations between adherence measures and the covariates, and logistic multinomial regression models, to identify characteristics associated with each trajectory; (3) Cox proportional hazard models, to assess the relationship between adherence and clinical outcomes, with propensity score adjustment applied to further control for potential confounders; (4) to estimate the importance of different healthcare levels in the variations of adherence, logistic or Cox multilevel regression models. ETHICS AND DISSEMINATION This study has been approved by the corresponding Clinical Research Ethics Committee. We plan to disseminate the project's findings through peer-reviewed publications and presentations at relevant health conferences. Policy reports will also be prepared in order to promote the translation of our findings into policy and clinical practice.
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Affiliation(s)
- G Sanfélix-Gimeno
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C L Rodríguez-Bernal
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - I Hurtado
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C Baixáuli-Pérez
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - J Librero
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - S Peiró
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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Affiliation(s)
- Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, Caen University Hospital, Caen, France
- Normandy University, Caen, France
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Sawicki GS, Heller KS, Demars N, Robinson WM. Motivating adherence among adolescents with cystic fibrosis: youth and parent perspectives. Pediatr Pulmonol 2015; 50:127-36. [PMID: 24616259 PMCID: PMC4160425 DOI: 10.1002/ppul.23017] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 02/09/2014] [Indexed: 11/06/2022]
Abstract
As advances in the care of individuals with cystic fibrosis (CF) have resulted in improved survival, therapeutic regimens for treatment of CF have become increasingly complex. This high treatment burden poses challenges to chronic disease self-management, particularly amongst adolescents. The aim of this qualitative study was to understand the barriers and facilitators of adherence to chronic CF therapies as perceived by adolescents with CF and their parents. In a series of structured interviews with 18 youth and their parents, we explored issues related to daily routines, youth and parental roles regarding chronic therapy, and motivators for adherence. All interviews were audio-recorded and coded for themes and patterns. Reported barriers to adherence included time pressures, competing priorities, heightened awareness of disease trajectory, privacy concerns, and lack of perceived consequences from non-adherence. Identified facilitators for adherence included recognizing the importance of therapies, developing strong relationships with care teams, establishing structured routines, and focusing on shifting responsibilities from a parent to their adolescent child. The themes uncovered by these interviews identify areas for intervention and support by clinical programs seeking to improve adherence and self-management strategies for adolescents with CF.
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Affiliation(s)
- Gregory S Sawicki
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
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Quittner AL, Zhang J, Marynchenko M, Chopra PA, Signorovitch J, Yushkina Y, Riekert KA. Pulmonary medication adherence and health-care use in cystic fibrosis. Chest 2014; 146:142-151. [PMID: 24480974 DOI: 10.1378/chest.13-1926] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Poor treatment adherence is common in cystic fibrosis (CF) and may lead to worse health outcomes and greater health-care use. This study evaluated associations of adherence to pulmonary medications, age, health-care use, and cost among patients with CF. METHODS Patients with CF aged ≥ 6 years were identified in a national commercial claims database. A 12-month medication possession ratio (MPR) was computed for each pulmonary medication and then averaged for a composite MPR (CMPR) for each patient. The CMPR was categorized as low (< 0.50), moderate (0.50-0.80), or high (≥ 0.80). Annual health-care use and costs were measured during the first and second year and compared across adherence categories by multivariable modeling. RESULTS Mean CMPR for the sample (N = 3,287) was 48% ± 31%. Age was inversely related to CMPR. In the concurrent year, more CF-related hospitalizations were observed among patients with low (event rate ratio [ERR], 1.35; 95% CI, 1.15-1.57) and moderate (ERR, 1.25; 95% CI, 1.05-1.48) vs high adherence; similar associations were observed for all-cause hospitalizations and CF-related and all-cause acute care use (hospitalizations + ED) in the concurrent and subsequent year. Rates of CF-related and all-cause outpatient visits did not differ by adherence. Low and moderate adherence predicted higher concurrent health-care costs by $14,211 ($5,557-$24,371) and $8,493 (-$1,691 to $19,709), respectively, compared with high adherence. CONCLUSIONS Worse adherence to pulmonary medications was associated with higher acute health-care use in a national, privately insured cohort of patients with CF. Addressing adherence may reduce avoidable health-care use.
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Affiliation(s)
| | - Jie Zhang
- Novartis Pharmaceuticals Corp, East Hanover, NJ
| | | | | | | | | | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
BACKGROUND Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. OBJECTIVES To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 13 January 2014. SELECTION CRITERIA Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. DATA COLLECTION AND ANALYSIS Two authors independently applied the inclusion criteria to publications and assessed the quality of the included studies. MAIN RESULTS The searches identified 68 studies with a total of 288 references; 35 studies (total of 1050 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, furthermore data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 10 studies did blind the outcome assessors.Forced expiratory volume in one second was the most frequently measured outcome. One long-term study (seven months) compared oscillatory devices with either conventional physiotherapy or breathing techniques and found statistically significant differences in some lung function parameters in favour of oscillating devices. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure. There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices. Participant satisfaction was reported in 15 studies but this was not specifically in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence. AUTHORS' CONCLUSIONS There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, patient preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.
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Affiliation(s)
- Lisa Morrison
- West of Scotland Adult CF Unit, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, UK, G12 0YN
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Goldbeck L, Fidika A, Herle M, Quittner AL. Psychological interventions for individuals with cystic fibrosis and their families. Cochrane Database Syst Rev 2014; 2014:CD003148. [PMID: 24941199 PMCID: PMC7388585 DOI: 10.1002/14651858.cd003148.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND With increasing survival estimates for individuals with cystic fibrosis, long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adaptation and health-related quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES To determine whether psychological interventions for people with cystic fibrosis provide significant psychosocial and physical benefits in addition to standard medical care. SEARCH METHODS Studies were identified from two Cochrane trials registers (Cystic Fibrosis and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search of the Cystic Fibrosis and Genetic Disorders Group's register: 19 December 2013.Most recent search of the Depression, Anxiety and Neurosis Group's register: 12 November 2013. SELECTION CRITERIA Randomised controlled studies of a broad range of psychological interventions evaluating subjective and objective health outcomes, such as quality of life or pulmonary function, in individuals of all ages with cystic fibrosis and their immediate family. We were interested in psychological interventions, including psychological methods within the scope of psychotherapeutic or psychosomatic mechanism of action (e.g. cognitive behavioural, cognitive, family systems or systemic, psycho-dynamic, or other, e.g. supportive, relaxation, or biofeedback), which were aimed at improving psychological and psychosocial outcomes (e.g. quality of life, levels of stress or distress, psychopathology, etc.), adaptation to disease management and physiological outcomes. DATA COLLECTION AND ANALYSIS Three authors were involved in selecting the eligible studies and two of these authors assessed their risk of bias. MAIN RESULTS The review includes 16 studies (eight new studies included in this update) representing data from 556 participants. Studies are diverse in their design and their methods. They cover interventions with generic approaches, as well as interventions developed specifically to target disease-specific symptoms and problems in people with cystic fibrosis. These include cognitive behavioural interventions to improve adherence to nutrition or psychosocial adjustment, cognitive interventions to improve adherence or those associated with decision making in lung transplantation, a community-based support intervention and other interventions, such as self-hypnosis, respiratory muscle biofeedback, music therapy, dance and movement therapy, and a tele-medicine intervention to support patients awaiting transplantation.A substantial proportion of outcomes relate to adherence, changes in physical status or other specific treatment concerns during the chronic phase of the disease.There is some evidence that behavioural interventions targeting nutrition and growth in children (4 to 12 years) with cystic fibrosis are effective in the short term. Evidence was found that providing a structured decision-making tool for patients considering lung transplantation improves patients' knowledge of and expectations about the transplant, and reduces decisional conflict in the short term. One study about training in biofeedback-assisted breathing demonstrated some evidence that it improved some lung function measurements. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS Currently, insufficient evidence exists on psychological interventions or approaches to support people with cystic fibrosis and their caregivers, although some of the studies were promising. Due to the heterogeneity between studies, more of each type of intervention are needed to support preliminary evidence. Multicentre studies, with consequent funding implications, are needed to increase the sample size of these studies and enhance the statistical power and precision to detect important findings. In addition, multicentre studies could improve the generalisation of results by minimizing centre or therapist effects. Psychological interventions should be targeted to illness-specific symptoms or behaviours to demonstrate efficacy.
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Affiliation(s)
- Lutz Goldbeck
- Dptm. Child and Adolescent Psychiatry/Psychotherapy, University Clinic Ulm, Steinhoevelstr. 5, Ulm, Baden-Württemberg, Germany, D-89075
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Li Y, Zhou H, Cai B, Kahler KH, Tian H, Gabriel S, Arcona S. Group-based trajectory modeling to assess adherence to biologics among patients with psoriasis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:197-208. [PMID: 24748809 PMCID: PMC3986333 DOI: 10.2147/ceor.s59339] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Proportion of days covered (PDC), a commonly used adherence metric, does not provide information about the longitudinal course of adherence to treatment over time. Group-based trajectory model (GBTM) is an alternative method that overcomes this limitation. METHODS The statistical principles of GBTM and PDC were applied to assess adherence during a 12-month follow-up in psoriasis patients starting treatment with a biologic. The optimal GBTM model was determined on the basis of the balance between each model's Bayesian information criterion and the percentage of patients in the smallest group in each model. Variables potentially predictive of adherence were evaluated. RESULTS In all, 3,249 patients were included in the analysis. Four GBTM adherence groups were suggested by the optimal model, and patients were categorized as demonstrating continuously high adherence, high-then-low adherence, moderate-then-low adherence, or consistently moderate adherence during follow-up. For comparison, four PDC groups were constructed: PDC Group 4 (PDC ≥75%), PDC Group 3 (25%≤ PDC <50%), PDC Group 2 (PDC <25%), and PDC Group 1 (50%≤ PDC <75%). Our findings suggest that the majority of patients (97.9%) from PDC Group 2 demonstrated moderate-then-low adherence, whereas 96.4% of patients from PDC Group 4 showed continuously high adherence. The remaining PDC-based categorizations did not capture patients with uniform adherence behavior based on GBTM. In PDC Group 3, 25.3%, 17.2%, and 57.5% of patients exhibited GBTM-defined consistently moderate adherence, moderate-then-low adherence, or high-then-low adherence, respectively. In PDC Group 1, 70.8%, 23.6%, and 5.7% of patients had consistently moderate adherence, high-then-low adherence, and continuously high adherence, respectively. Additional analyses suggested GBTM-based categorization was best predicted by patient age, sex, certain comorbidities, and particular drug use. CONCLUSION GBTM is a more appropriate way to model dynamic behaviors and offers researchers an alternative to more traditional drug adherence measurements.
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Affiliation(s)
- Yunfeng Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Beilei Cai
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Haijun Tian
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Susan Gabriel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Steve Arcona
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Abstract
The purpose of this review was to identify current terms and definitions used to identify and describe children and adolescents who require technology. A total of 400 articles published from January 2000 through May 2012 were reviewed; 26 articles met the inclusion criteria. The review included only primary research studies that focused on a child and adolescent sample (birth to 18 years old) who required technology. Current terms and definitions used to describe children and adolescents who require technology include technology and complex care. Technology is a constant in both terminology and definitions, and it differentiates this population from the general population of children with chronic illness and special health care needs. This review highlights the need for better, more detailed descriptions of the population of children and adolescents who require technology in their daily lives.
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Warnock L, Gates A, van der Schans CP. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database Syst Rev 2013:CD001401. [PMID: 24006212 DOI: 10.1002/14651858.cd001401.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chest physiotherapy is widely used in people with cystic fibrosis in order to clear mucus from the airways. OBJECTIVES To determine the effectiveness and acceptability of chest physiotherapy compared to no treatment or spontaneous cough alone to improve mucus clearance in cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 04 February 2013. SELECTION CRITERIA Randomised or quasi-randomised clinical studies in which a form of chest physiotherapy (airway clearance technique) were taken for consideration in people with cystic fibrosis compared with either no physiotherapy treatment or spontaneous cough alone. DATA COLLECTION AND ANALYSIS Both authors independently assessed study eligibility, extracted data and assessed study quality. There was heterogeneity in the published outcomes, with variable reporting which meant pooling of the data for meta-analysis was not possible. MAIN RESULTS The searches identified 144 studies, of which eight cross-over studies (data from 96 participants) met the inclusion criteria. There were differences between studies in the way that interventions were delivered, with several of the intervention groups combining more than one treatment modality. One included study looked at autogenic drainage, six considered conventional chest physiotherapy, three considered oscillating positive expiratory pressure, seven considered positive expiratory pressure and one considered high pressure positive expiratory pressure. Of the eight studies, six were single-treatment studies and in two, the treatment intervention was performed over two consecutive days (once daily in one, twice daily in the other). This enormous heterogeneity in the treatment interventions prevented any meta-analyses from being performed.Four studies, involving 28 participants, reported a higher amount of expectorated secretions during chest physiotherapy as compared to a control. One study, involving 18 participants, reported no significant differences in sputum weight. In five studies radioactive tracer clearance was used as an outcome variable. In three of these (28 participants) it was reported that chest physiotherapy, including coughing, increased radioactive tracer clearance as compared to the control period. One study (12 participants) reported increased radioactive tracer clearance associated with all interventions compared to control, although this was only reported to have reached significance for postural drainage with percussion and vibrations; and the remaining study (eight participants) reported no significant difference in radioactive tracer clearance between chest physiotherapy, without coughing, compared to the control period. Three studies, involving 42 participants reported no significant effect on pulmonary function variables following intervention; but one further study did report significant improvement in pulmonary function following the intervention in some of the treatment groups. AUTHORS' CONCLUSIONS The results of this review show that airway clearance techniques have short-term effects in the terms of increasing mucus transport. No evidence was found on which to draw conclusions concerning the long-term effects.
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Affiliation(s)
- Louise Warnock
- Oxford Adult Cystic Fibrosis Centre, Oxford Centre for Respiratory Medicine, The Churchill Hospital, Old Road, Headington, Oxford, UK, OX3 7LJ
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Using group-based trajectory modeling to examine heterogeneity of symptom burden in patients with head and neck cancer undergoing aggressive non-surgical therapy. Qual Life Res 2013; 22:2331-9. [PMID: 23475689 DOI: 10.1007/s11136-013-0380-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2013] [Indexed: 11/12/2022]
Abstract
PURPOSE Treatment-related symptom burden varies significantly among patients undergoing radiotherapy or chemoradiotherapy, yet such variation is typically not reflected in the results from single-group studies. We applied group-based trajectory modeling (GBTM) to describe the heterogeneity of symptom burden among patients with head and neck cancer and to identify subgroups with distinct symptom-development trajectories. METHODS Patients (n = 130) were recruited pretherapy and rated multiple symptoms weekly for 10 weeks via the M. D. Anderson Symptom Inventory. With the mean of five most severe symptoms over time as an outcome measure, GBTM was used to identify patient subgroups with distinct symptom trajectories. Linear mixed-effects modeling (LMM) was applied to compare with GBTM's ability to describe the longitudinal symptom data. RESULTS The five most severe symptoms were problems with taste, difficulty swallowing or chewing, problems with mucus, fatigue, and dry mouth. A two-group GBTM model identified 68 % of patients as having high symptom burden, associated with older age, worse baseline performance status, and chemoradiotherapy treatment. A four-group GBTM model generated one stable group (4 % of patients) and three groups varying in symptom severity with both linear and quadratic functions over time. LMM revealed symptom-change patterns similar to that produced by GBTM but was inferior in identifying risk factors for high symptom burden. CONCLUSIONS For cancer patients undergoing aggressive therapy, GBTM is capable of identifying various symptom-burden trajectories and provides severity groupings that will aid research and may be of clinical utility. These results may be generalizable to other cancer types and treatments.
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McIlwaine MP, Alarie N, Davidson GF, Lands LC, Ratjen F, Milner R, Owen B, Agnew JL. Long-term multicentre randomised controlled study of high frequency chest wall oscillation versus positive expiratory pressure mask in cystic fibrosis. Thorax 2013; 68:746-51. [PMID: 23407019 DOI: 10.1136/thoraxjnl-2012-202915] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Positive expiratory pressure (PEP) is the most commonly used method of airway clearance (AC) in Canada for patients with cystic fibrosis (CF) whereas, in some countries, high frequency chest wall oscillation (HFCWO) is the preferred form of AC. There have been no long-term studies comparing the efficacy of HFCWO and PEP in the CF population. OBJECTIVES To determine the long-term efficacy of HFCWO compared with PEP mask therapy in the treatment of CF as measured by the number of pulmonary exacerbations (PEs). METHODS A randomised controlled study was performed in 12 CF centres in Canada. After a 2-month washout period, subjects were randomised to perform either HFCWO or PEP mask therapy for 1 year. RESULTS 107 subjects were enrolled in the study; 51 were randomised to PEP and 56 to HFCWO. There were 19 dropouts within the study period, of which 16 occurred prior to or at the time of randomisation. There were significant differences between the groups in the mean number of PEs (1.14 for PEP vs 2.0 for HFCWO) and time to first PE (220 days for PEP vs 115 days for HFCWO, p=0.02). There was no significant difference in lung function, health-related quality of life scores or patient satisfaction scores between the two groups. PEP mask therapy required a shorter treatment time. CONCLUSIONS The results of this study favour PEP and do not support the use of HFCWO as the primary form of AC in patients with CF. CLINICAL TRIAL REGISTRATION NUMBER NCT00817180.
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Affiliation(s)
- Maggie Patricia McIlwaine
- Division of Paediatric Respirology and Department of Physiotherapy, Cystic Fibrosis Clinic, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
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Association of impaired linear growth and worse neurodevelopmental outcome in infants with single ventricle physiology: a report from the pediatric heart network infant single ventricle trial. J Pediatr 2013; 162:250-6.e2. [PMID: 22939929 PMCID: PMC3547153 DOI: 10.1016/j.jpeds.2012.07.048] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/21/2012] [Accepted: 07/20/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To describe neurodevelopmental outcomes in infants with single ventricle (SV) physiology and determine factors associated with worse outcomes. STUDY DESIGN Neurodevelopmental outcomes for infants with SV enrolled in a multicenter drug trial were assessed at 14 months of age using the Bayley Scales of Infant Development-II. Multivariable regression analysis was used to identify factors associated with worse outcomes. RESULTS Neurodevelopmental testing was performed at 14 ± 1 months in 170/185 subjects in the trial. Hypoplastic left heart syndrome was present in 59% and 75% had undergone the Norwood operation. Mean Psychomotor Developmental Index (PDI) and mental developmental index (MDI) were 80 ± 18 and 96 ± 14, respectively, (normal 100 ± 15, P < .001 for each). Group-based trajectory analysis provided a 2-group model ("high" and "low") for height z-score trajectory and brain type natriuretic peptide (BNP) trajectory. The predicted PDI scores were 15 points higher in the "high" height z-score trajectory compared with the "low" cluster (P < .001). A higher number of serious adverse events during the trial was associated with lower PDI scores (P = .02). The predicted MDI scores were 13-17 points lower in "low height trajectory-high BNP trajectory" group compared with the other 3 groups (P < .001). MDI scores were also lower in subjects who required extracorporeal membrane oxygenation during the neonatal hospitalization (P = .01) or supplemental oxygen at discharge (P = .01). CONCLUSIONS Neurodevelopmental outcome at 14 months of age is impaired in infants with SV physiology. Low height trajectory and high BNP trajectory were associated with worse neurodevelopmental outcomes. Efforts to improve nutritional status alone may not improve neurodevelopmental outcomes.
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Reychler G, Coppens T, Leonard A, Palem A, Lebecque P. Mucoviscidose : les techniques instrumentales de désencombrement des voies aériennes. Rev Mal Respir 2012; 29:128-37. [DOI: 10.1016/j.rmr.2011.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 04/19/2011] [Indexed: 10/14/2022]
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Modi AC, Rausch JR, Glauser TA. Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy. JAMA 2011; 305:1669-76. [PMID: 21521848 PMCID: PMC3480079 DOI: 10.1001/jama.2011.506] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT Because of epilepsy's common occurrence, the narrow therapeutic and safety margins of antiepileptic medications, and the recognized complications of medication nonadherence in adults with epilepsy, identifying the rates, patterns, and predictors of nonadherence in children with epilepsy is imperative. The onset and evolution of antiepileptic drug nonadherence in children with newly diagnosed epilepsy remains unknown. OBJECTIVES To identify and characterize trajectories of adherence in children with newly diagnosed epilepsy over the first 6 months of therapy and to determine sociodemographic and epilepsy-specific predictors of adherence trajectories. DESIGN, SETTING, AND PATIENTS Prospective, longitudinal observational study of antiepileptic drug adherence in a consecutive cohort of 124 children (2-12 years old) with newly diagnosed epilepsy at Cincinnati Children's Hospital Medical Center. Patients were recruited from April 2006 through March 2009, and final data collection occurred in September 2009. MAIN OUTCOME MEASURE Objective adherence measured using electronic monitors. RESULTS Fifty-eight percent of children with newly diagnosed epilepsy demonstrated persistent nonadherence during the first 6 months of therapy. Group-based trajectory models identified 5 differential adherence patterns (Bayesian information criterion = -23611.8): severe early nonadherence (13%; 95% confidence interval [CI], 8%-20%), severe delayed nonadherence (7%; 95% CI, 3%-12%), moderate nonadherence (13%; 95% CI, 8%-20%), mild nonadherence (26%; 95% CI, 19%-34%), and near-perfect adherence (42%; 95% CI, 33%-50%). The adherence pattern of most patients was established by the first month of therapy. Socioeconomic status was the sole predictor of adherence trajectory group status (χ(4)(2) = 19.3 [n = 115]; P < .001; partial r(2) = 0.25), with lower socioeconomic status associated with higher nonadherence. CONCLUSION Five trajectory patterns were identified that captured the spectrum of nonadherence to antiepileptic drugs among children with newly diagnosed epilepsy; the patterns were significantly associated with socioeconomic status.
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Affiliation(s)
- Avani C Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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