Self-report adherence measures in chronic illness: retest reliability and predictive validity

Psychometric evaluation of the 5-item Medication Adherence Report Scale questionnaire in persons with multiple sclerosis

The 5-item Medication Adherence Report Scale (MARS-5) is a reliable and valid questionnaire for evaluating adherence in patients with asthma, hypertension, and diabetes. Validity has not been determined in multiple sclerosis (MS). We aimed to establish criterion validity and reliability of the MARS-5 in persons with MS (PwMS). Our prospective study included PwMS on dimethyl fumarate (DMF). PwMS self-completed the MARS-5 on the same day before baseline and follow-up brain magnetic resonance imaging (MRI) 3 and 9 months after treatment initiation and were graded as highly and medium adherent upon the 24-cut-off score, established by receiver operator curve analysis. Health outcomes were represented by relapse occurrence from the 1st DMF dispense till follow-up brain MRI and radiological progression (new T2 MRI lesions and quantitative analysis) between baseline and follow-up MRI. Criterion validity was established by association with the Proportion of Days Covered (PDC), new T2 MRI lesions, and Beliefs in Medicines questionnaire (BMQ). The reliability evaluation included internal consistency and the test-retest method. We included 40 PwMS (age 37.6 ± 9.9 years, 75% women), 34 were treatment-naive. No relapses were seen during the follow-up period but quantitative MRI analysis showed new T2 lesions in 6 PwMS. The mean (SD) MARS-5 score was 23.1 (2.5), with 24 PwMS graded as highly adherent. The higher MARS-5 score was associated with higher PDC (b = 0.027, P<0.001, 95% CI: (0.0134-0.0403)) and lower medication concerns (b = -1.25, P<0.001, 95% CI: (-1.93-(-0,579)). Lower adherence was associated with increased number (P = 0.00148) and total volume of new T2 MRI lesions (P = 0.00149). The questionnaire showed acceptable internal consistency (Cronbach α = 0.72) and moderate test-retest reliability (r = 0.62, P < 0.0001, 95% CI: 0.33-0.79). The MARS-5 was found to be valid and reliable for estimating medication adherence and predicting medication concerns in persons with MS.

Effect of Attending Rheumatologists' Big 5 Personality Traits on Patient Trust in Patients With Systemic Lupus Erythematosus: The TRUMP2-SLE Project

OBJECTIVE

Differences in communication styles based on physicians' personality traits have been identified, particularly in primary care, and these physician-related factors can be important in building patient-physician trust. This study examined the effects of rheumatologists' personality traits on patients' trust in their attending rheumatologists.

METHODS

This cross-sectional study included adult Japanese patients with systemic lupus erythematosus (SLE) at 5 academic medical centers between June 2020 and August 2021. The exposures were the Big 5 personality traits (ie, extraversion, agreeableness, openness, conscientiousness, and emotional stability) of attending rheumatologists using the Japanese version of the 10-Item Personality Inventory scale (1-7 points each). The outcome was the patients' trust in their attending rheumatologist using the Japanese version of the 5-item Wake Forest Physician Trust Scale (0-100 points). A general linear model was fitted.

RESULTS

The study included 505 patients with a mean age of 46.8 years; 88.1% were women. Forty-three attending rheumatologists (mean age: 39.6 years; 23.3% female) were identified. After multivariable adjustment, higher extraversion and agreeableness were associated with higher trust (per 1-point increase, 3.76 points [95% CI 1.07-6.45] and 4.49 points [95% CI 1.74-7.24], respectively), and higher conscientiousness was associated with lower trust (per 1-point increase, -2.17 points [95% CI -3.31 to -1.03]).

CONCLUSION

Whereas higher extraversion and agreeableness of attending rheumatologists led to higher patient trust in their rheumatologist, overly high conscientiousness may lead to lower trust resulting from the physicians' demand of responsibility and adherence to instructions from patients with SLE.

Quality of measurement properties of medication adherence instruments in cardiovascular diseases and type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Medication adherence has a major impact on reducing mortality and healthcare costs related to the treatment of cardiovascular diseases and diabetes mellitus. Selecting the best patient-reported outcome measure (PROM) among the many available for this kind of patient is extremely important. This study aims to critically assess, compare and synthesize the quality of the measurement properties of patient-reported outcome measures to assess medication adherence among patients with cardiovascular diseases and/or type 2 diabetes mellitus.

METHODS

This review followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines and was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The searches were performed in Web of Science, SCOPUS, PubMed, CINAHL, EMBASE, LILACS, PsycINFO, and ProQuest (gray literature).

RESULTS

A total of 110 records encompassing 27 different PROMs were included in the review. The included records were published between 1986 and 2023, most of which reported studies conducted in the United States and were published in English. None of the PROMs were classified in the category "a", thus being recommended for use due to the quality of its measurement properties. The PROMs that should not be recommended for use (category "c") are the MTA, GMAS, DMAS-7, MALMAS, ARMS-D, and 5-item questionnaire. The remaining PROMs, e.g., MMAS-8, SMAQ, MEDS, MNPS, ARMS-12, MGT, MTA-OA, MTA-Insulin, LMAS-14, MARS-5, A-14, ARMS-10, IADMAS, MAQ, MMAS-5, ProMAS, ARMS-7, 3-item questionnaire, AS, 12-item questionnaire, and Mascard were considered as having the potential to be recommended for use (category "b").

CONCLUSION

None of the included PROMs met the criteria for being classified as trusted and recommended for use for patients with cardiovascular diseases and/or type 2 diabetes mellitus. However, 21 PROMs have the potential to be recommended for use, but further studies are needed to ensure their quality based on the COSMIN guideline for systematic reviews of PROMs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019129109.

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Trial registration

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

Funding

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

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention

INTRODUCTION

The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial.

METHODS

We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation.

RESULTS

Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries.

CONCLUSIONS

This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums.

TRIAL REGISTRATION

ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

Adherence in transplantation

PURPOSE OF REVIEW

Adequately managing a complex medical regimen is paramount to the success of organ transplants. When patients stray from their prescribed medical regimen posttransplant, graft rejection, and death can occur. Predictors of adherence have been studied for many years, and various factors have been identified as contributing to adequate or poor adherence. Both demographic and personal characteristics have been associated with adherence behavior. However, recent developments, such as the COVID-19 pandemic, increased use of mobile health interventions, and use of medical biomarkers have affected the way adherence is measured and applied.

RECENT FINDINGS

The COVID-19 pandemic affected patients' comfort with accessing outpatient care and created a wider use of telehealth services. Measurement of adherence through serum lab levels continues to be reviewed as a potential objective assessment of adherence. Psychosocial factors continue to be identified as major contributors to nonadherence.

SUMMARY

Adherence to antirejection medication, lab work, appointments, and exercise and dietary instructions remains critical to the health of the transplant patient. It is critical that providers involved in the selection process and posttransplant treatment of these patients remain well informed of potential new factors affecting adherence.

The Association Between Patient-Centered Communication and Primary Care Quality in Urban China: Evidence From a Standardized Patient Study

Background

Effective patient-physician communication has been considered a central clinical function and core value of health system. Currently, there are no studies directly evaluating the association between patient-centered communication (PCC) and primary care quality in urban China. This study aims to investigate the association between PCC and primary care quality.

Methods

The standardized patients were used to measure PCC and the quality of health care. We recruited 12 standardized patients from local communities presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. PCC was scored on three dismissions: (1) exploring disease and illness experience, (2) understanding the whole person, and (3) finding common ground. We measured the quality of the primary care by (1) accuracy of diagnosis, (2) consultation time, (3) appropriateness of treatment, (4) unnecessary exams; (5) unnecessary drugs, and (6) medical expenditure. Ordinary least-squares regression models with fixed effects were used for the continuous variables and logistic regression models with fixed effects were used for the categorical variables.

Results

The average score of PCC1, PCC2, and PCC3 was 12.24 ± 4.04 (out of 64), 0.79 ± 0.64 (out of 3), and 10.19 ± 3.60 (out of 17), respectively. The total score of PCC was 23.22 ± 6.24 (out of 84). We found 44.11% of the visits having a correct diagnosis, and 24.19% of the visits having correct treatment. The average number of unnecessary exams and drugs was 0.91 ± 1.05, and 0.45 ± 0.82, respectively. The average total cost was 35.00 ± 41.26 CNY. After controlling for the potential confounding factors and fixed effects, the PCC increased the correct diagnosis by 10 percentage points (P < 0.01), the correct treatment by 7 percentage points (P < 0.01), the consultation time by 0.17 min (P < 0.01), the number of unnecessary drugs by 0.03 items (P < 0.01), and the medical expenditure by 1.46 CNY (P < 0.01).

Conclusions

This study revealed pretty poor communication between primary care providers and patients. The PCC model has not been achieved, which could be one source of the intensified physician-patient relationship. Our findings showed the PCC model in the primary care settings has positive associations with the quality of the primary care. Interactions with a higher score of PCC were more likely to have a correct diagnosis and correct treatment, more consultation time, more unnecessary drugs, and higher medical expenditure. To improve PCC, the clinical capacity and communication skills of primary care providers need to be strengthened. Also, strategies on reforming the pay structure to better reflect the value of physicians and providing a stronger motivation for performance improvement are urgently needed.

The Psychometric Properties of General Adherence Scale in Chinese (GAS-C) in Patients with Type 2 Diabetes Using Insulin

PURPOSE

Translate General Adherence Scale (GAS) into Chinese and test its psychometric properties in middle-aged and elderly type 2 diabetes (T2D) patients using insulin in the Han people of urban China.

SUBJECTS AND METHODS

We translated the GAS into Chinese and established General Adherence Scale in Chinese (GAS-C). 136 T2D subjects were selected for testing GAS-C's reliability and validity, of which 100 study subjects were retested with GAS-C two weeks later. The other 200 T2D subjects were selected for performing Confirmatory Factor Analysis(CFA). The ceiling effect and floor effect of GAS-C data were checked.

RESULTS

No data was lost in our research. In exploratory factor analysis(EFA), the Kaiser-Meyer-Olkin measure of sampling adequacy (KMO) =0.899, Bartlett's Test's χ²=611.821 (df=10 p<0.001). The communalities of the items were between 0.740 and 0.862; The values of Measure of Sampling Adequacy (MSA) were between 0.883 and 0.945. All five items entered the factor analysis process. A common factor was extracted, and it could explain 81.403% of the total variance. CFA validated the.one-factor model was good fits with the data of GAS-C (Ratio of Chi-square to Degrees of Freedom (CMIN/DF)=2.032, Goodness of Fit Index (GFI) =0.981, Comparative Fit Index (CFI) =0.996, Tucker-Lewis Index (TLI) =0.992, Root Mean Square Residual (RMR) =0.011, Root Mean Square Error of Approximation (RMSEA) =0.072). Correlation analysis was performed between GAS-C and MMAS-8 to calculate the criterion-related validity (r=0.542 p<0.001). The internal consistency reliability α=0.942, Intraclass Correlation Coefficient (ICC)= 0.941 (95% CI 0.924-0.955). The correlation coefficient r of the test-retest reliability was 0.772 (p<0.001). Spearman-Brown coefficient of split-half was 0.939. There was no floor effect and ceiling effect on the data.

CONCLUSION

GAS-C has good reliability and validity. It can be used for general adherence studies of middle-aged and elderly type 2 diabetic patients using insulin in the Han people of Chinese cities.

The Relation Between Patients' Beliefs About Pain Medication, Medication Adherence, and Treatment Outcome in Chronic Pain Patients: A Prospective Study

OBJECTIVES

Nonadherence to prescribed pain medication is common in chronic noncancer pain patients. Beliefs about pain medication have been reported to be associated with nonadherence behavior in cross-sectional studies. The aim of this study was to prospectively investigate the relationship between patients' beliefs about pain medication and their medication adherence and treatment outcome.

METHODS

Chronic noncancer pain patients completed a baseline questionnaire including the 47-item Pain Medication Attitudes Questionnaire, consisting of 7 subscales with regards to beliefs on prescribed medication. After 11 weeks, medication underuse and overuse were assessed by self-report. In addition, patient satisfaction with regards to the effect of prescribed pain medication and satisfaction as regards prescribed medication and care, and the burden of side effects were assessed.

RESULTS

A total of 133 participants completed the baseline questionnaire, and 99 patients completed the follow-up questionnaire. Concerns over side effects at baseline were positively associated with underuse and the presence of side effects after 11 weeks. The perceived need was positively associated with overuse, whereas concerns over addiction were negatively associated with overuse. Concerns over tolerance were negatively associated with patient satisfaction with medication effects after 11 weeks. Concerns over tolerance and mistrust in the prescribing doctor were negatively associated with satisfaction about medication and care.

CONCLUSION

Attitudes and concerns toward pain medication are associated with adherence patterns and outcome parameters. To improve medication adherence and therapy outcome, patient beliefs about pain medication should be taken into account by providing tailored education, adequate follow-up, or alternate therapy.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

BACKGROUND

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

OBJECTIVE

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

CONCLUSIONS

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

The impact of personality traits on attitudes toward learning communication skills

Aims: The aim of this study was to investigate the association between personality traits and attitudes toward learning communication skills in undergraduate medical students. The relation between students’ attitudes and personality trait could help us identify those who those who will need more support to develop communication skills, based on their personality traits.Methods: The data was collected data from an intentional and cross-sectional sample composed of 204 students from three Brazilian universities. The students answered questionnaires containing the Communication Skills Attitude Scale (CSAS-BR) and the Big Five Mini-Markers (BFMM) for personality. Data were analyzed using frequency calculations, principal components analysis, and the multiple linear regression model.Results: Seven among 26 items of the original Communication Skills Attitude Scale (CSAS) presented factor loads lower than |0.30| and must be excluded in the CSAS -BR that showed one domain including positive and negative attitudes. The value of Cronbach’s alpha of the 19-item scale was 0.894. The BFMM showed similar dimensional results with five domains with Cronbach’s alpha values of 0.804 for Extroversion, 0.753 for agreeableness, 0.755 for conscientiousness, 0.780 for neuroticism and 0.668 for openness. There were positive and statically significant linear associations with the CSAS-BR and agreeableness (β: 0.230, p<0.001), extraversion (β: 0.150, p=0.030), and openness to experience (β: 0.190, p=0.010). These personality factors drive social interactions and interpersonal relations, which involve the tendency to be friendly, flexible, and cooperative; to show a willing disposition; and the ability to actively engage with others. Conclusions: Based on the methods applied in this study, the results demonstrated a relation between agreeableness, extraversion and openness to experience with attitudes on communication skills in students from three Brazilian universities. Our results suggest that the evaluation of personality traits can contribute to the recognition of students for whom the establishment of special teaching strategies can improve communication skills.

Lack of effects of evidence-based, individualised counselling on medication use in insured patients with mild hypertension in China: a randomised controlled trial

OBJECTIVE

To evaluate whether evidence-based, individualised (EBI) counselling regarding hypertension and the treatment would affect medication use in insured patients with mild hypertension in China.

METHODS

We conducted a parallel-group, randomised controlled trial in two primary care centres in Shenzhen, a metropolitan city in China. Patients with mild primary hypertension, 10-year risk of cardiovascular diseases (CVDs) lower than 20% and no history of CVDs were recruited and randomly allocated to two groups. EBI plus general counselling was provided to the intervention group and general counselling alone to the control group. EBI counselling included information on the 10-year CVD risk and treatment benefit in terms of absolute risk reduction estimated for each individual and information on average side effects and costs of antihypertensive drugs. The outcomes included use of antihypertensive drugs and adherence to the treatment at 6-month follow-up, with the former being primary outcome.

RESULTS

Two hundred and ten patients were recruited, with 103 and 107 allocated to the intervention and control groups, respectively. At baseline, 62.4% of the patients were taking antihypertensive drugs that were all covered by health insurance. At the end of 6-month follow-up, there was no statistically significant difference in the rate of medication use between the intervention group and the control group (65.0% vs 57.9%; OR=1.35, 95% CI: 0.77 to 2.36). The difference in adherence rate between the two groups was not statistically significant either (43.7% vs 40.2%; OR=1.15, 95% CI 0.67 to 2.00]). The results were robust in sensitivity analyses that used different cutoffs to define the two outcomes.

CONCLUSIONS

The EBI counselling by health educators other than the caring physicians had little impact on treatment choices and drug-taking behaviours in insured patients with mild primary hypertension in this study. It remains unclear whether EBI counselling would make a difference in uninsured patients, especially when conducted by the caring physicians.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC-14004169.

Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study

Objectives: Nonadherence to medications has been documented, but the combined effect of social risk factors on medication nonadherence has not been investigated. Methods: We conducted a cross-sectional analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort. The sample (N = 1506) included subjects who at Year 20 (2005-06) were taking prescription medications and completed a 4-item Medication Adherence Scale. Social risk factors were education of high school or less, annual household income <$25,000, high financial strain, high chronic stress, low social support, and high social strain. Results: In a fully adjusted logistic regression model, income <$25,000 (OR = 2.37 [95% CI 1.12-4.98], p < .05) and high chronic stress (OR = 2.07 [95% CI 1.09-3.94], p < .05) were significantly associated with medication nonadherence. Individuals with ≥3 social risk factors had >3 times higher odds of nonadherence than counterparts with no social risk factors (OR = 3.26 [95% CI 1.72-6.19], p < .001). Conclusion: Low income and chronic stress are associated with medication nonadherence, and the odds of nonadherence increase with the accumulation of social risk factors. Findings may be used to develop risk prediction tools to identify individuals who can benefit from adherence-promoting interventions.

Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: A systematic review and meta-analysis

OBJECTIVE

In patients with asthma and chronic obstructive pulmonary disease (COPD), disease control is still suboptimal-incorrect inhalation technique and medication non-adherence are two important reasons for this outcome. Pharmacists' interventions have been shown to have a positive effect on the clinical outcomes of asthma and COPD. Quantitative assessment of the efficacy of pharmacist-led interventions, mainly on inhalation techniques and medication adherence, is needed. Evidence for different interventions is not totally conclusive, and no results of theory-based adherence promotion interventions for asthma and COPD have been published. The objective of our study is to evaluate the effect of pharmacist-led interventions on asthma and COPD management, focusing mainly on inhalation technique and medication adherence, and whether the content of interventions (categorized based on Information-Motivation-Behavioural skills (IMB) model) affects the effectiveness and whether the IMB model is worthy of clinical promotion and application in adults with asthma or COPD.

METHODS

The PubMed, EMBASE, The Cochrane Library, Web of Science and ClinicalTrials.gov databases were searched for randomized controlled trials that involved pharmacist-led interventions among patients with asthma or COPD. We used database-specific vocabulary (eg, Medical Subject Headings) and free text terms expanding from 'asthma', 'COPD' and 'pharmacist' to identify relevant articles. Two reviewers independently selected the studies, assessed the risk of bias and extracted the data. The meta-analysis was performed in Review Manager 5.3 provided by the Cochrane Collaboration. PROSPERO registration number: CRD42019144793.

RESULTS AND DISCUSSION

Thirteen studies were eligible for qualitative analysis, and 12 studies were included in the meta-analysis. Pharmacist-led interventions showed a positive effect on medication adherence (1.34 [95% CI 1.18-1.53], P < .0001) and inhalation technique (1.85 [95% CI 1.57-2.17], P < .00001) in COPD and asthma patients. In the subgroup meta-analysis, significant medication adherence improvement was found only in COPD patients (1.41 [1.24-1.61], P < .0001). The subgroup meta-analysis also noted that interventions that included all three Information-Motivation-Behavioural skills (IMB) constructs had a significant improvement in medication adherence (1.41 [1.24-1.61], P < .0001). Subgroup meta-analysis conducted between different diseases, different intervention contents, and different measure tools did not significantly change the heterogeneity.

WHAT IS NEW AND CONCLUSION

Pharmacist-led interventions can improve inhalation technique in adult asthma and COPD patients. Significant improvement in medication adherence was found only in COPD patients. The effect among asthmatic patients requires further study. Interventions based on the IMB model may be worthy of clinical promotion and application. More future research is needed to establish solid evidence base for effective interventions and uniform measurement of medication adherence.

Is Depression Associated with Unhealthy Behaviors among Middle-Aged and Older Women with Hypertension or Heart Disease?

OBJECTIVE

Depression is a common comorbidity in patients with cardiovascular conditions. This study aims to assess the association between comorbid depression and health-promoting behavior in middle-aged and older Australian women with hypertension or heart disease.

METHODS

Data are from a subset of 45 and Up Study participants with diagnosed chronic illness (n = 1,925). Health behaviors including smoking status, alcohol consumption, and physical activity were assessed. Associations of depression with health behaviors in women with hypertension or heart disease were analyzed using unadjusted and adjusted (for chronic conditions and demographic measures) logistic regression models.

RESULTS

A total of 666 women with hypertension and 220 women with heart disease were included in the analysis. In adjusted analyses, women with hypertension and comorbid depression were 2.36 (95% confidence interval, 1.02-5.46) times more likely to be risky or high-risk drinkers and 55% (adjusted odds ratio, 0.45; 95% confidence interval, 0.27-0.73) less likely to be highly physically active, compared with women without depression. Women with heart disease and comorbid depression were 65% (adjusted odds ratio, 0.35; 95% confidence interval, 0.12-0.95) less likely to be highly physically active, compared with women without depression.

CONCLUSIONS

This study provides the first data indicating that depression may be a barrier to health-promoting behavior in middle-aged and older women with hypertension or heart disease. Given that physical inactivity and risky alcohol consumption are important risk factors for aggravation of cardiologic conditions, health-promoting behaviors should be specifically targeted in the treatment of women with comorbid depression.

Adherence profiles in kidney transplant patients: Causes and consequences

OBJECTIVE

Adherence is a dynamic phenomenon and a critical determinant of transplant patients outcome. The objective of this longitudinal study was to explore adherence in kidney transplant patients followed-up for up to three years after transplantation.

METHODS

Adherence was repeatedly estimated using the Morisky-Green-Levine 4-Item Medication Adherence Scale, in two successive cohorts of 345 (EPIGREN) and 367 (EPHEGREN) kidney transplant recipients. Mixed effect modeling with latent processes and latent classes was used to describe adherence time-profiles.

RESULTS

Two latent classes were identified. The adherent class represented 85% of the patients. Patients of the poorer-adherence class displayed a lower adherence at one month (p<10^-3), which worsened over time. Good adherence was associated with age >50 years, fewer depression episodes (5% vs. 13%, p = 0.001) and a better mental health component of quality of life (MCS-SF36 47 ± 11 vs. 41 ± 13, p = 0.015). Survival without acute rejection episodes was longer in the adherent class (p = 0.004).

CONCLUSIONS

The risk of poor adherence in renal transplant patients can be detected as early as one month post-transplantation, using appropriate and easy tools adapted to routine monitoring.

PRACTICE IMPLICATIONS

An early focus on vulnerable patients should allow putting into place actions in order to reduce the risk of poor outcome related to poor adherence.

Self-reported medication nonadherence predicts cholesterol levels over time

OBJECTIVE

Self-report measures of medication nonadherence are frequently adapted to new clinical populations without evidence of validity. We evaluated the predictive validity of a medication nonadherence measure previously validated in patients with hypertension among patients taking cholesterol-reducing medications.

METHOD

This secondary analysis involves data from a randomized trial (VA HSR&D IIR 08-297) conducted at the Durham Veterans Affairs Medical Center. At baseline, 6-months, and 12-months, serum cholesterol was obtained and participants (n = 236) completed a 3-item measure of extent of nonadherence to cholesterol-reducing medications. Two cross-lagged panel models with covariates, in addition to growth curve analysis, were used to examine the predictive utility of self-reported nonadherence on concurrent and future cholesterol levels, while accounting for potential reverse-causation.

RESULTS

Extent of nonadherence items produced reliable scores across time and fit a single-factor model (CFI = 0.99). Nonadherence, and changes in nonadherence, moderately predicted future cholesterol values, and changes in cholesterol values (7 of 9 longitudinal associations were significant at p < .05; B's ranged from 0.16 to 0.35). Evidence for reverse associations was weaker (3 of 9 longitudinal associations were significant at p < .05; B's ranged from 0.16 to 0.36).

CONCLUSION

Analyses support the predictive validity of this medication nonadherence measure over the competing reverse-causation hypothesis.

How is patient-centred care addressed in women's health? A theoretical rapid review

PURPOSE

Efforts are needed to reduce gendered inequities and improve health and well-being for women. Patient-centred care (PCC), an approach that informs and engages patients in their own health, is positively associated with improved care delivery, experiences and outcomes. This study aimed to describe how PCC for women (PCCW) has been conceptualised in research.

METHODS

We conducted a theoretical rapid review of PCCW in four health conditions. We searched MEDLINE, EMBASE, CINAHL, SCOPUS, Cochrane Library and Joanna Briggs index for English-language articles published from January 2008 to February 2018 inclusive that investigated PCC and involved at least 50% women aged 18 or older. We analysed findings using a six-domain PCC framework, and reported findings with summary statistics and narrative descriptions.

RESULTS

After screening 2872 unique search results, we reviewed 51 full-text articles, and included 14 (five family planning, three preventive care, four depression, one cardiovascular disease and one rehabilitation). Studies varied in how they assessed PCC. None examined all six PCC framework domains; least evaluated domains were addressing emotions, managing uncertainty and enabling self-management. Seven studies that investigated PCC outcomes found a positive association with appropriate health service use, disease remission, health self-efficacy and satisfaction with care. Differing views about PCC between patients and physicians, physician PCC attitudes and geographic affluence influenced PCC. No studies evaluated the influence of patient characteristics or tested interventions to support PCCW.

CONCLUSION

There is a paucity of research that has explored or evaluated PCCW in the conditions of interest. We excluded many studies because they arbitrarily labelled many topics as PCC, or simply concluded that PCC was needed. More research is needed to fully conceptualise and describe PCCW across different characteristics and conditions, and to test interventions that improve PCCW. Policies and incentives may also be needed to stimulate greater awareness and delivery of PCCW.

Is a veterinary student's performance on multiple-mini interviews affected by personality preferences?

OBJECTIVES

The objectives of this study were to evaluate the association between a student's Myers-Briggs Type Indicator (MBTI) preference pairs and resulting types and his or her multiple-mini interview (MMI) scores upon admission, and to determine the proportions of types among veterinary classes over five years.

METHODS

A cross-sectional study was conducted for data collected from 706 students admitted into the University of California Davis School of Veterinary Medicine (UCDSVM) program beginning in the fall of 2013 and ending in the fall of 2018. Data consisted of a candidate's MBTI preference pairs and types which were collected during the first week of enrollment and multiple-mini interview scores from his or her admission data.

RESULTS

A total of 706 students from 5 classes completed the MBTI survey. Multivariate analysis showed no significant association between the MBTI preference pairs of extroversion and introversion (F(_{1, 697)} = 3.30, p=0.0959), sensing and intuition (F_{(1, 697)} = 0.40, p=0.4395), thinking and feeling (F_{(1, 697)} = 3.59, p=0.0591), or judging and perceiving (F_{(1, 697)} = 0.38, p = 0.5657) and MMI score. Analysis showed no trends (χ² (60, N=706) =76.51, p=0.074) in the student's MBTI types over the 5-year period.

CONCLUSIONS

The MMI score of a candidate admitted into the UCDSVM is unlikely to be affected by personality preferences. Therefore, it is unlikely that multiple-mini interview scores included in the admission process will affect the personality diversity of candidates admitted into a veterinary class.

Objective Versus Self-Reported Adherence to Airway Clearance Therapy in Cystic Fibrosis

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.

Association of Medication Beliefs, Self-efficacy, and Adherence in a Diverse Cohort of Adults with Rheumatoid Arthritis

OBJECTIVE

Rheumatoid arthritis (RA) patients' adherence to disease-modifying antirheumatic drugs (DMARD) is often suboptimal. We examined associations among medication beliefs, self-efficacy, and adherence to medications in RA.

METHODS

Data were from a longitudinal observational cohort of persons with RA. Subjects completed telephone interviews on self-reported adherence, self-efficacy, demographics, and the Beliefs about Medicines Questionnaire (BMQ), which assesses beliefs in necessity and beliefs about taking medication. Bivariate and multivariate logistic regression identified correlates of poor adherence to synthetic DMARD and prednisone as well as to biologic therapy, including medication concerns and necessity.

RESULTS

There were 362 patients who reported taking a synthetic DMARD and/or prednisone. Of these, 14% and 21% reported poor adherence to oral DMARD or prednisone, and biologics, respectively. There were 64% who reported concern about taking medicines, 81% about longterm effects, and 47% about becoming too dependent on medicines. In multivariate analyses, the BMQ necessity score was independently associated with better adherence to oral DMARD or prednisone (adjusted OR 0.61, 95% CI 0.41-0.91), while self-efficacy was associated with greater odds of poor adherence to oral medications (adjusted OR 1.23, 95% CI 1.01-1.59). Beliefs in medicines and self-efficacy were not associated with adherence to biologics.

CONCLUSION

In a diverse cohort of patients with RA, stronger beliefs in the necessity of medication were associated with better adherence to oral DMARD or prednisone, while higher self-efficacy was associated with poor adherence. Providers can play important roles in eliciting patient beliefs about medications to improve adherence and ultimately health outcomes.

Co-occurring reasons for medication nonadherence within subgroups of patients with hyperlipidemia

Medication nonadherence is a significant clinical problem among individuals taking statins. Poor adherence is often attributable to several reasons, yet most adherence interventions target a single reason. Baseline data were examined from a randomized clinical trial of 236 patients with hyperlipidemia. A latent class analysis was then performed on patients reporting any nonadherence (n = 109). A 4-class solution provided the most optimal fit and differentiation of classes. Class 1 (N = 59, 54%) included patients who reported occasionally forgetting. Class 2 (N = 16, 14%) represented patients who were concerned about side effects. Class 3 (N = 17, 16%) represented patients who reported out-of-routine life events as contributing to nonadherence. Class 4 (N = 17, 16%) represented patients who endorsed a large number reasons indiscriminately. Class membership was almost uniformly unrelated to any patient demographic factors or treatment arm. Each cluster of reasons defining these patients may be best addressed through different intervention strategies.

Crucial conversations about weight management with healthcare providers: patients' perspectives and experiences

PURPOSE

To elicit patient experiences of weight management discussions with providers and provide recommendations for future weight-related discussions.

METHODS

1000 patients who recently saw their provider for non-weight specific appointments were mailed measures of demographics, self-reported height and weight, activity level, adherence, perceptions of and recommendations for weight-related discussions, and internalized weight bias. This study was primarily descriptive and utilized a mixed method design including collection of quantitative and qualitative data.

RESULTS

242 patients responded (24 % response rate); 32.4 % overweight (N = 72), 41.9 % obese (N = 93). 47 % of overweight and 71 % of obese patients recalled that their provider discussed weight; 92 % were motivated to follow recommendations and 89 % felt confident doing so. Most patients (75 %) would like their provider to be "very direct/straightforward" when discussing weight, and 52 % would be "not at all offended" if they were diagnosed as "overweight/obese." Most patients (63 %) reported being "extremely comfortable" discussing weight with providers. Patients with higher BMI had higher levels of internalized weight bias (p < .001) and wanted their provider to "discuss weight sensitively" (p < .05).

CONCLUSION

This study suggests that patients have important preferences that providers should be mindful of when discussing weight. While these discussions can be challenging, most patients report that they would be comfortable having these conversations directly and most would have enhanced motivation and confidence following these conversations. Communicating about weight is needed and desired by patients; doing so sensitively with those at higher weight is essential.

Self-Management of Adherence to Prescribed Stimulants in College Students With ADD/ADHD

OBJECTIVE

We examined how college students manage ADHD medication and how beliefs regarding the medication and attitudes of friends and families influence adherence on weekdays and weekends during an academic semester.

METHOD

Undergraduate students ( n = 53) responded to an online survey to report their adherence, their beliefs about the effects of the medication, and their perception of important others' views of adherence.

RESULTS

Students chose to take more medication on weekdays than weekends. On weekdays, beliefs that the medications enhance academic performance and social skills influenced adherence, and on weekends, beliefs regarding negative side effects were important. The perception that medication leads to a loss of authentic self reduced adherence at both times. Generally, students believed that important others wanted them to take medication.

CONCLUSION

Students were actively weighing the costs and benefits of taking their ADHD medication and consciously adjusting adherence levels from day to day.

Exercise and cognitive function in people living with HIV: a scoping review

BACKGROUND

Since the advent of antiretrovirals, people with HIV are living longer and have improved quality of life. However, 30-60% of these individuals experience cognitive impairment. Fortunately, physical activity has emerged as a management strategy for cognitive impairment.

PURPOSE

To map the evidence on physical activity and cognition in HIV.

METHODS

We searched five databases using terms related to physical activity and HIV. Two authors independently reviewed titles and abstracts for studies that addressed physical activity/exercise and cognition in people with HIV. Authors reviewed full texts to identify articles that met our inclusion criteria. One author extracted the data, then we collated the results and summarized the characteristics of included studies.

RESULTS

Sixteen studies from high-income countries were included; eight were interventional (five randomized controlled trials and three pre-post single group observational studies) and eight were non-interventional studies. The interventional studies included aerobic, resistive, and Tai Chi exercise for 8 weeks to 12 months in duration. Two of eight interventional studies found exercise to benefit self-reported cognition. All eight non-interventional studies showed a positive relationship between physical activity and cognitive function.

CONCLUSIONS

Results of this study suggest that physical activity may preserve or improve cognition in people living with HIV. Implications for Rehabilitation Physical activity may play a role in preserving or improving cognition in the human immunodeficiency virus population. Exercise should be prescribed for people with human immunodeficiency virus based on the stage of infection. Rehabilitation professionals should follow current exercise guidelines when prescribing exercise for people living with human immunodeficiency virus.

A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma

In severe asthma, poor control could reflect issues of medication adherence or inhaler technique, or that the condition is refractory. This study aimed to determine if an intervention with (bio)feedback on the features of inhaler use would identify refractory asthma and enhance inhaler technique and adherence.Patients with severe uncontrolled asthma were subjected to a stratified-by-site random block design. The intensive education group received repeated training in inhaler use, adherence and disease management. The intervention group received the same intervention, enhanced by (bio)feedback-guided training. The primary outcome was rate of actual inhaler adherence. Secondary outcomes included a pre-defined assessment of clinical outcome. Outcome assessors were blinded to group allocation. Data were analysed on an intention-to-treat and per-protocol basis.The mean rate of adherence during the third month in the (bio)feedback group (n=111) was higher than that in the enhanced education group (intention-to-treat, n=107; 73% versus 63%; 95% CI 2.8%-17.6%; p=0.02). By the end of the study, asthma was either stable or improved in 54 patients (38%); uncontrolled, but poorly adherent in 52 (35%); and uncontrolled, but adherent in 40 (27%).Repeated feedback significantly improved inhaler adherence. After a programme of adherence and inhaler technique assessment, only 40 patients (27%) were refractory and adherent, and might therefore need add-on therapy.

Communication and patient participation influencing patient recall of treatment discussions

CONTEXT

Patient recall of treatment information is a key variable towards chronic disease (CD) management. It is unclear what communication and patient participation characteristics predict recall.

OBJECTIVES

To assess what aspects of doctor-patient communication predict patient recall of medication information. To describe lifestyle treatment recall, in CD primary care patients.

DESIGN

Observational study within a RCT.

SETTING & PARTICIPANTS

Community-based primary care (PC) practices. Family physicians (n=18): practicing >5 years, with a CD patient caseload. Patients (n=159): >40 years old, English speaking, computer literate, off-target hypertension, type II diabetes and/or dyslipidaemia.

MAIN VARIABLES

Patient characteristics: age, education, number of CDs. Information characteristics: length of encounter, medication status, medication class. Communication variables: socio-emotional utterances, physician dominance and communication control scores and PACE (ask, check and express) utterances, measured by RIAS. Number of medication themes, dialogue and initiative measured by MEDICODE.

MAIN OUTCOME MEASURES

Recall of CD, lifestyle treatment and medication information.

RESULTS

Frequency of lifestyle discussions varied by topic. Patients recalled 43% (alcohol), 52% (diet) to 70% (exercise) of discussions. Two and a half of six possible medication themes were broached per medication discussion. Less than one was recalled. Discussing more themes, greater dialogue and patient initiative were significant predictors of improved medication information recall.

DISCUSSION

Critical treatment information is infrequently exchanged. Active patient engagement and explicit conversations about medications are associated with improved treatment information recall in off-target CD patients followed in PC.

CONCLUSION

Providers cannot take for granted that long-term off-target CD patients recall information. They need to encourage patient participation to improve recall of treatment information.

Use of Low-Literacy Decision Aid to Enhance Knowledge and Reduce Decisional Conflict Among a Diverse Population of Adults With Rheumatoid Arthritis: Results of a Pilot Study

OBJECTIVE

Despite innovations in treatment of rheumatoid arthritis (RA), adherence is poor and disparities persist. Shared decision making (SDM) promotes patient engagement and enhances adherence; however, few tools support SDM in RA. Our objective was to pilot a low-literacy medication guide and decision aid to facilitate patient-clinician conversations about RA medications.

METHODS

RA patients were consecutively enrolled into 1 of 3 arms: 1) control; patients received existing medication guide prior to clinic visit, 2) adapted guide prior to visit, and 3) adapted guide prior to plus decision aid during visit. Outcomes were collected immediately postvisit, at 1-week, and at 3- and 6-month interviews. Eligible adults had to have failed at least 1 disease-modifying antirheumatic drug and fulfill 1 of the following: age >65 years, immigrant, non-English speaker, less than high school education, limited health literacy, and racial/ethnic minority. Primary outcomes were knowledge of RA medications, decisional conflict, and acceptability of interventions.

RESULTS

The majority of 166 patients were immigrants (66%), non-English speakers (54%), and had limited health literacy (71%). Adequate RA knowledge postvisit in arm 3 was higher (78%) than arm 1 (53%; adjusted odds ratio 2.7, 95% confidence interval 1.2, 6.1). Among patients with a medication change, there was lower (better) mean decisional conflict in arms 2 and 3 (P = 0.03). There were no significant differences in acceptability.

CONCLUSION

A low-literacy medication guide and decision aid was acceptable, improved knowledge, and reduced decisional conflict among vulnerable RA patients. Enhancing knowledge and patient engagement with decision support tools may lead to medication choices better aligned with RA patients' values and preferences.

The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

BACKGROUND

Despite a variety of efficient and cost-effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients.

METHODS

The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale (MMAS-8) and objective pill count rate. Secondary outcomes include: change in the MMAS-8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out.

DISCUSSION

The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence-based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03105687 . Registered on 07 March 2017.

Measuring medication adherence in asthma: Development of a novel self-report tool

OBJECTIVE

This study presents the development and validation of MIS-A (Medication Intake Survey-Asthma), a new self-report instrument measuring key adherence properties during long-term asthma treatment.

DESIGN

Within a longitudinal asthma cohort study in France and the United Kingdom, adult patients and caregivers of children responded to computer-assisted telephone interviews.

MAIN OUTCOME MEASURES

Scores for distinct adherence properties (taking adherence, correct dosing, therapeutic coverage, drug holidays, overuse) and composite measures were computed for several time intervals. We examined distributions, longitudinal variation, associations between adherence scores and concordance with adherence calculated from medication prescribing or dispensing records.

RESULTS

Nine hundred and two participants reported on adherence to 4481 medications on 4140 occasions. About 59.47 and 70.36% revealed < 100% taking adherence in the last week and month; 42.76% had a drug holiday of > 1 week in the last 4 months. Adherence varied within patients during the follow-up (intra-class correlation = . 41-.71). Correlations between adherence scores were moderate to strong (ρ = .51-.85, p ≤ .001), except medication overuse (ρ = .04-.19, p ≤.05). Four-month taking adherence was associated with dispensing adherence, but not with prescribing adherence (ρ = .33, p < .001; and .12, p = .26).

CONCLUSION

MIS-A is a promising, easy-to-use self-report tool that can capture accurately different adherence properties over a long time period.

Targeting patients with asthma for omalizumab therapy: choosing the right patient to get the best value for money

The asthma syndrome has many manifestations, termed phenotypes, that arise by specific cellular and molecular mechanisms, termed endotypes. Understanding an individual's asthma phenotype helps clinicians make rational therapeutic decisions while the understanding of endotypes has led to the development of specific precision medications. Allergic asthma is an example of an asthma phenotype and omalizumab, a monoclonal antibody that neutralizes serum immunoglobulin (Ig)E, is a specific targeted treatment which was developed as a result of an understanding of the endotype of allergic asthma. Omalizumab has been widely used in clinical practice in Europe for over a decade as an add-on therapy to treat patients who have severe refractory allergic asthma. Over this period, many centres have reported their experience with omalizumab as an add-on therapy in patients with severe asthma. These 'real world' clinical effectiveness studies have confirmed the benefits, cost-effectiveness and clinical utility of this medication. Combining the outcomes of both sources of research has yielded important insights that may benefit patients with severe asthma, clinicians who treat them, as well as the funding agencies that reimburse the cost of this medication. The purpose of this review is to describe how to identify and evaluate a patient with asthma for whom treatment with omalizumab may be of clinical and cost-effective benefit. The assessment and investigations used to confirm allergic asthma, the objective assessment of adherence to asthma therapy and the expected benefits of add-on omalizumab treatment are described.

Assessing adherence to multiple medications and in daily life among patients with multimorbidity

OBJECTIVE

Chronic conditions often require multiple medication intake. However, past research has focused on assessing overall adherence or adherence to a single index medication only. This study explored adherence measures for multiple medication intake, and in daily life, among patients with multiple chronic conditions (i.e. multimorbidity).

DESIGN

Eighty-four patients with multimorbidity and multiple-medication regimens completed three monthly panel questionnaires. A randomly assigned subsample additionally completed a 30-day daily diary.

MAIN OUTCOME MEASURE

The Non-Adherence Report; a brief self-report measure of adherence to each prescribed medication (NAR-M), and in daily life. We further assessed the Medication Adherence Report Scale (MARS), and a subsample of participants were randomised to electronic adherence monitoring.

RESULTS

The NAR-M indicated M = 94.7% adherence at Time 1 (SD = 9.3%). The NAR-M was significantly correlated with the MARS (r_t1 = .52, r_t2 = .57, and r_t3 = .65; p < .001), and in tendency with electronically assessed adherence (r_t2 = .45, r_t3 = .46, p < .10). Variance components analysis indicated that between-person differences accounted for 10.2% of the variance in NAR-M adherence rates, whereas 22.9% were attributable to medication by person interactions.

CONCLUSION

This study highlights the importance and feasibility of studying adherence to multiple medications differentially, and in daily life. Future studies may use these measures to investigate within-person and between-medication differences in adherence.

Identifying the barriers to antiepileptic drug adherence among adults with epilepsy

PURPOSE

To identify the barriers to antiepileptic drug (AED) adherence among adults with epilepsy (AWE). The impact of AED non-adherence on quality of life (QoL) was also examined.

METHOD

Systematic design (SR) study. A search strategy was undertaken with no time limits, for articles published in English, in MEDLINE, CINANL, PsycINFO, EMBASE, Cochrane databases and grey literature sources. Eligibility criteria included participants with epilepsy over 18 years, who were prescribed AEDs. Adherence had to be defined and adherence assessment measurements identified. A screening process was undertaken to select eligible studies. Eight studies met the inclusion criteria and were included in a quantitative synthesis. Quality of evidence was conducted using the EBL critical appraisal checklist and assessing risk of bias within individual studies.

RESULTS

Across the included studies a high prevalence of non-adherence was identified. AED non-adherence was associated with specific beliefs about medications, being depressed or anxious, poor medication self-administration management, uncontrolled recent seizures, frequent medication dosage times, poor physician-patient relationship and perceived social support. Additionally, AED non-adherence impacted negatively on QoL as a result of poor seizure control.

CONCLUSION

Although included studies were of good quality, risk of biases reduced the generalisability of results. Findings suggested that comprehensive adherence assessments should routinely be performed. Recommendations for future research include the use of longitudinal research designs and a follow up SR to include the 16-18-year-old population.

Medication understanding, non-adherence, and clinical outcomes among adult kidney transplant recipients

We sought to evaluate the prevalence of medication understanding and non-adherence of entire drug regimens among kidney transplantation (KT) recipients and to examine associations of these exposures with clinical outcomes. Structured, in-person interviews were conducted with 99 adult KT recipients between 2011 and 2012 at two transplant centers in Chicago, IL; and Atlanta, GA. Nearly, one-quarter (24%) of participants had limited literacy as measured by the Rapid Estimate of Adult Literacy in Medicine test; patients took a mean of 10 (SD=4) medications and 32% had a medication change within the last month. On average, patients knew what 91% of their medications were for (self-report) and demonstrated proper dosing (via observed demonstration) for 83% of medications. Overall, 35% were non-adherent based on either self-report or tacrolimus level. In multivariable analyses, fewer months since transplant and limited literacy were associated with non-adherence (all P<.05). Patients with minority race, a higher number of medications, and mild cognitive impairment had significantly lower treatment knowledge scores. Non-white race and lower income were associated with higher rates of hospitalization within a year following the interview. The identification of factors that predispose KT recipients to medication misunderstanding, non-adherence, and hospitalization could help target appropriate self-care interventions.

Evaluation of the Measurement Properties of Self-reported Medication Adherence Instruments Among People at Risk for Metabolic Syndrome: A Systematic Review

PURPOSE

The purpose of this study was to present a systematic review of available published studies that evaluated the measurement properties of self-reported instruments assessing global medication adherence in adults at risk for metabolic syndrome.

METHODS

The authors searched PubMed, EMBASE, PsycINFO, and CINAHL in January 2015 for appropriate studies. The methodological quality (based on reliability, validity, responsiveness, and interpretability) of selected studies was assessed with the COSMIN checklist (Consensus-Based Standards for the Selection of Health Measurement Instruments).

RESULTS

Of the 44 studies reviewed, 32 used classical test theory, and 14 used self-reported medication adherence instruments. More than half the studies included patients with hypertension, followed by diabetes, dyslipidemia, and increased body mass index. Among the measurement properties, internal consistency, hypothesis testing, and structural validity were frequently assessed items, whereas only 1 study evaluated responsiveness, and none evaluated measurement error. The MMAS-8 (Morisky Medication Adherence Scale-8 items) and the Hill-Bone scale were the most frequently used instruments. They were found to be well validated, with strong evidence for internal consistency and strong positive evidence for reliability, structural validity, hypothesis testing, and criterion validity.

CONCLUSIONS

The MMAS-8 and Hill-Bone scale seem to be well-validated instruments for assessing medication adherence in adults at risk for metabolic syndrome. These findings may assist clinicians with selecting the appropriate instruments for assessing medication adherence in this population. However, further studies might be needed to define concepts to better understand the dimensions of each medication adherence instrument.

Adherence to prophylaxis and bleeding outcome in haemophilia: a multicentre study

Prevention of bleeding and joint damage in severe haemophilia is dependent on adherence to prophylactic replacement therapy. The aim of this study was to assess adherence to prophylaxis, including associations with age, bleeding and clotting factor consumption (CFC). In three Dutch haemophilia centres, semi-structured interviews about adherence to prophylaxis in the previous 2 weeks were conducted with patients or parents of a child with haemophilia. Patients were classified, according to pre-specified definitions, as adherent, sub-optimally adherent or non-adherent based on missing, timing, and dose of infusions. Association of annual bleeding rates, mean CFC, person performing the infusion (parents verus patients) with adherence categories were analysed. Overall, 241 patients with haemophilia using prophylaxis were studied. Parents were more adherent (66%; n = 48/73) than patients (43%; n = 72/168). Sub-optimal adherence occurred in 29% of parents and 37% of patients and was characterized by changes in timing of infusion (mostly from morning to evening), while missing <6% of infusions. Non-adherence occurred less often: in 5% of parents and 20% of patients. Reduced adherence was associated with lower CFC, but not with joint bleeding. In conclusion, non-adherence in haemophilia was relatively rare, yet 1/3 of patients struggled to administer prophylaxis at the appropriate time of day.

Self-reported Health Care Utilization of Patients with Inflammatory Bowel Disease Correlates Perfectly with Medical Records

BACKGROUND

Studies on the costs of health care in patients with inflammatory bowel disease (IBD) are increasingly conducted through the collection of self-reported data. We aimed to assess the concordance between estimated annual costs based on self-reported health care utilization and administrative data in IBD.

METHODS

Consecutive patients with Crohn's disease or ulcerative colitis visiting the outpatient clinic were enrolled. Participants were asked to fill out a questionnaire on their IBD-specific health care utilization over the past year. Registered health care utilization over the same time period was extracted from medical records. Health care resources were multiplied by their unit prices to obtain costs. Cost estimates were compared, and correlation, sensitivity, and specificity were calculated.

RESULTS

In total, 101 patients (70 Crohn's disease, 31 ulcerative colitis) were enrolled. Mean direct health care costs were &OV0556;4758 per year according to self-reported data and &OV0556;4866 according to administrative data (r = 0.97). Hospitalizations and diagnostics were relatively underreported with a sensitivity of 75% and 88%, and a specificity of 100% and 88%, respectively. One of 7 surgical procedures was overreported, and only 1 of 25 patients did not report the use of anti-tumor necrosis factor compounds. Suffering from a flare or having a pouch predicted a decreased recall with an adjusted odds ratio of 3.5 (95% confidence interval, 1.3-9.6) and 10.7 (95% confidence interval, 1.1-107.6), respectively.

CONCLUSIONS

We report a high concordance between costs of self-reported health care utilization and administrative data over the past year in IBD. Self-reported health care utilization reliably measures the consumption of health care in IBD.

Community-Level Quality Improvement and the Patient Experience for Chronic Illness Care

OBJECTIVE

To determine whether chronically ill adults from communities participating in a community-level quality improvement effort reported greater improvement on four domains of patient experience: care coordination, patient satisfaction, provider interaction and support, and receipt of recommended care for diabetes.

STUDY SETTING

The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative provides multistakeholder alliances with funding and technical assistance to improve quality in their communities.

STUDY DESIGN

This is a quasi-experimental, pre-post study. We used a difference-in-difference approach to detect relative changes over time on 16 survey-based outcome measures representing the four patient experience domains.

DATA COLLECTION

We surveyed adults with chronic illness(es) in 14 AF4Q communities and a national comparison group. Wave 1 was completed in 2008 (8,140 respondents) and wave 2 in 2012 (9,565 respondents).

PRINCIPAL FINDINGS

Respondents from AF4Q communities reported modestly greater improvement on patient satisfaction and receipt of recommended care for diabetes.

CONCLUSIONS

Results suggest that community-level QI efforts led by multistakeholder alliances hold the potential to improve patient satisfaction and receipt of recommended care for diabetes, but the magnitude of the effect may be limited. However, there is less evidence that community-level QI can improve patient perceptions of care coordination or provider interaction and support.

Exploring physiotherapists' personality traits that may influence treatment outcome in patients with chronic diseases: a cohort study

Background

During treatment of patients with Chronic Diseases (CD) the therapist-patient interaction is often intense, and the strategies used during treatment require physiotherapists to assume a coaching role. Uncovering therapist factors that explain inter-therapist variation might provide tools to improve treatment outcome and to train future therapists. The purpose of this study was to explore the so-called ‘therapist-effect’, by looking at the influence of intrinsic therapist factors, specifically personality traits, on treatment outcome in patients with CD.

Methods

A cohort study was performed using data from the NIVEL Primary Care Database (NPCD) in 2011–2012 and an additional questionnaire. Patients with CD (n = 393) treated by Dutch physiotherapists working in outpatient practices (n = 39) were included. Patient and treatment outcome variables were extracted from NPCD. The course of complaint was measured using the Numeric Rating Scale. Therapist variables were measured using a questionnaire consisting of demographics and the Big Five traits: Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to experiences. Data were analysed using multilevel linear regression.

Results

Only Neuroticism was found to be significant (Neuroticism F = 0.71, P = 0.01; therapist gender F = 0.72, P = 0.03; life events F = −0.54, P = 0.09; patient gender F = −0.43, P = 0.10; patient age F = 0.01, P = 0.27). Subgroup analyses of 180 patients with Osteoarthritis and 30 therapists showed similar results.

Conclusions

There are indications that patients with CD who are treated by therapists who tend to be calmer, more relaxed, secure and resilient have a greater reduction in severity of complaints compared to patients treated by therapists who show less of these traits. Being a male therapist and having experienced life events influence outcome positively. However, more extensive research is needed to validate the current findings.

Predictive Validity of Self-Reported Measures of Adherence to Noninsulin Antidiabetes Medication against Control of Glycated Hemoglobin Levels

OBJECTIVE

To assess and compare the predictive validity of 4 self-reported adherence measures.

METHODS

A convenience sample of 153 patients with type 2 diabetes completed a self-report with 4 items (SR-4) and a French version of the Morisky Medication Adherence Scale with 8 items (MMAS-8), reported the proportion of pills missed, and answered a single-item scale regarding their antidiabetes drug treatments. They also provided measures of glycated hemoglobin (A1C) taken between 3 and 6 months after the adherence measurements. We examined the relationship between self-reported adherence and glycemic control using the area under the receiver operating characteristics curve (AUC) and linear regression analyses.

RESULTS

AUCs were 0.51, 0.52, 0.53 and 0.52 for the SR-4, MMAS-8, self-reported proportion of pills missed and single-item scale, respectively. AUCs stratified according to median duration of diabetes ranged from 0.55 to 0.63. Based on linear regression analyses adjusted for diabetes duration, the association measured in the total sample between adherence measures and A1C levels was not statistically significant. When regression analyses were performed among participants with A1C levels ≥7% only, SR-4, MMAS-8 and the single-item scale scores were significantly associated with A1C levels, and beta coefficients were associated with a 1-unit increase in adherence scores of -0.46, -0.20 and 0.38, respectively.

CONCLUSION

The results support the predictive validity of all measures except the self-reported proportion of missed pills.

Depression, patient characteristics, and attachment style: correlates and mediators of medication treatment adherence in a racially diverse primary care sample

Background

The depth and breadth of problems related to depressive symptomatology and optimal treatment outcomes, including medication treatment adherence, have long been documented in the literature. Missing are clear explanations as to what factors and patient characteristics may account for lack of medication treatment adherence.

Objectives

The two objectives of the current study were to examine the predictive strength of depression, patient characteristics, and patient attachment style regarding medication treatment adherence and to consider the extent to which attachment styles mediate the relation between depression and medication treatment adherence.

Method

Participants in the present study were 237 racially diverse American primary care patients with a diagnosis of hypertension who were participants in a clinical trial. Depression, patient characteristics, attachment style, and medication treatment adherence were assessed.

Results

Partly consistent with our four hypotheses, the following results were found: (a) Black American, younger, never married, and poorer patients had lower medication treatment adherence (b) depression was significantly associated with lower self-reported medication adherence; (c) insecure–dismissing attachment style was related to lower medication adherence; and (d) insecure–dismissing attachment style mediates the relation between depression and medication treatment adherence by exacerbating the negative association.

Conclusion

Physicians and other primary care providers should consider how depressive symptomatology, patient characteristics, and attachment style may inform the treatment plans they put forward and the extent to which patients may adhere to those treatment plans.

How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study

Background

Certain personalities are ascribed to physicians. This research aims to measure the extent to which physicians identify with three predetermined personalities (workaholic, Type A and control freak) and to explore links to perceptions of professional performance, and wellness outcomes.

Methods

This is a cross-sectional study using a mail-out questionnaire sent to all practicing physicians (2957 eligible, 1178 responses, 40% response rate) in a geographical health region within a western Canadian province. Survey items were used to assess the extent to which participants felt they are somewhat of a workaholic, Type A and/or control freak, and if they believed that having these personalities makes one a better doctor. Participants’ wellness outcomes were also measured. Zero-order correlations were used to determine the relationships between physicians identifying with a personality and feeling it makes one a better doctor. T-tests were used to compare measures of physician wellness for those who identified with the personality versus those who did not.

Results

53% of participants identified with the workaholic personality, 62% with the Type A, and 36% with the control freak. Identifying with any one of the personalities was correlated with feeling it makes one a better physician. There were statistically significant differences in several wellness outcomes comparing participants who identified with the personalities versus those who did not. These included higher levels of emotional exhaustion (workaholic, Type A and control freak), higher levels of anxiety (Type A and control freak) and higher levels of depression, poorer mental health and lower levels of job satisfaction (control freak). Participants who identified with the workaholic personality versus those who did not reported higher levels of job satisfaction, rewarding patient experiences and career commitment.

Conclusions

Most participants identified with at least one of the three personalities. The beliefs of some participants that these personalities enhance professional performance may reinforce the harmful behaviors associated with poor wellness outcomes. Future research should further explore links between physician personality, perceptions of performance and actual performance, and more definitively address whether the perceived benefits offered by identifying with the workaholic personality are enough to counter the potential costs to physician wellness.

Improving the adherence of type 2 diabetes mellitus patients with pharmacy care: a systematic review of randomized controlled trials

BACKGROUND

Oral medication for patients with type 2 diabetes mellitus plays an important role in diabetes care and is associated with a high level self-care behavior and self-management. However, poor adherence to diabetes treatment is common which causes severe health complications and increased mortality. Barriers to adherence may consist of complex treatment regimens often along with long-term multi-therapies, side effects due to the medication as well as insufficient, incomprehensible or confusing information or instructions provided by the health care provider. Multidisciplinary approaches can support adherence success and can enable a more effective management of diabetes care. One approach in diabetes care can be the involvement of a pharmacist. The aim was to analyze the effectiveness of adherence-enhancing pharmacist interventions for oral medication in type 2 diabetes mellitus.

METHODS

A systematic review of randomized controlled trials. The study quality was assessed with the Cochrane risk of bias tool.

RESULTS

Of 491 hits, six publications were included. Two studies mainly examining educational interventions showed a significant improvement in adherence. Moreover, the quality of the included studies was deficient.

CONCLUSION

Although pharmacist interventions might potentially improve adherence to type 2 diabetes mellitus medication, high-quality studies are needed to assess effectiveness.

Exploring the impact of elevated depressive symptoms on the ability of a tailored asthma intervention to improve medication adherence among urban adolescents with asthma

BACKGROUND

In patients with asthma, medication adherence is a voluntary behavior that can be affected by numerous factors. Depression is an important co-morbidity in adolescents with asthma that may significantly impact their controller medication adherence and other asthma-related outcomes. The modifying effect of depressive symptoms on an asthma intervention's ability to improve asthma controller medication adherence among urban adolescents with asthma has not yet been reported.

OBJECTIVE

To assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up.

METHODS

These analyses use data from a randomized controlled trial (RCT) conducted in Detroit high schools to evaluate a tailored asthma management program. The intervention included referrals to school or community resources for students reporting symptoms of depression and other issues. "Elevated depressive symptoms" was defined as a positive answer to ≥ 5 of 7 questions from a validated tool included on the baseline questionnaire. Self-reported adherence to controller medication was collected at intervention onset (session 1) and at 6-month follow up. Analyses were restricted to students with report of a controller medication at baseline. Logistic regression was used to assess elevated depressive symptoms as an effect modifier of the relationship between randomization group and 6-month adherence.

RESULTS

Of the 422 students enrolled in the RCT, a controller medication was reported at intervention onset by n = 123 adolescents (29%). Analyzing this group, we observed an interaction between elevated depressive symptoms and adherence (p = 0.073). Stratified analysis showed better adherence in treatment group adolescents meeting criteria for elevated depressive symptoms at baseline as compared to the control group (adjusted Odds Ratio [aOR] = 9.50; p = 0.024). For adolescents without elevated depressive symptoms at baseline, differences in adherence by group assignment did not reach statistical significance (aOR 1.40, p = 0.49).

CONCLUSIONS

In this sample of students reporting controller medications at baseline, report of elevated depressive symptoms at baseline and randomization to the intervention group was associated with significantly better adherence at 6-month follow up when compared to that of a control group. Larger studies are needed to evaluate the impact of depression on the relationship between adherence and asthma intervention effectiveness.

Development of a short questionnaire to identify the risk of nonadherence to antibiotic treatment

OBJECTIVE

Nonadherence to the prescribed antibiotic treatment is a widespread problem, affecting not only individual patients, but also public health. As measures to predict it are still lacking, we aimed to design an instrument to identify nonadherence risk in short-term antibiotic therapies.

METHODS

Patient adherence was assessed by pill count and an extensive set of standardized questions, newly developed according to the five-dimension adherence model proposed by the World Health Organization. It combined previously validated questionnaires and original questions adapted from our exploratory survey. The extensive set was analyzed prospectively in adult patients treated with antibiotics in outpatient settings. The number of items was reduced stepwise keeping as many of five factor subgroups as possible. The items were dichotomized as positive (indicating nonadherence risk) or negative.

RESULTS

One third (32%) of the respondents (N = 122) did not adhere to the prescribed antibiotic regimen. The extensive set of questions was reduced to a short questionnaire. It consisted of four items independently associated with nonadherence (P < 0.05) and covered three of the five analyzed factor subgroups: healthcare-related factor (consultations about medicines), therapy-related factor (complexity of treatment), and patient-related factors (forgetfulness, health behavior). The sum of 0-1 positive answers indicated an adherent patient, and 2-4 a risky patient. Such a differential approach led to relatively good sensitivity, specificity, and total predictive value (80%, 82%, and 81%, respectively) in our sample.

CONCLUSION

The short measure representing the multiple factor subgroups was developed to identify nonadherence to antibiotic treatment with acceptable levels of sensitivity, specificity, and predictive values. It could be valuable for healthcare professionals, especially in primary healthcare. Considering limitations of the study (medium sample size, justification of patient's responses, no re-test), future studies could continue investigations on the validity and elaboration of this instrument in larger samples.

Physical exercise is associated with less neurocognitive impairment among HIV-infected adults

Neurocognitive impairment (NCI) remains prevalent in HIV infection. Randomized trials have shown that physical exercise improves NCI in non-HIV-infected adults, but data on HIV-infected populations are limited. Community-dwelling HIV-infected participants (n = 335) completed a comprehensive neurocognitive battery that was utilized to define both global and domain-specific NCI. Participants were divided into "exercise" (n = 83) and "no exercise" (n = 252) groups based on whether they self-reported engaging in any activity that increased heart rate in the last 72 h or not. We also measured and evaluated a series of potential confounding factors, including demographics, HIV disease characteristics, substance use and psychiatric comorbidities, and physical functioning. Lower rates of global NCI were observed among the exercise group (15.7 %) as compared to those in the no exercise group (31.0 %; p < 0.01). A multivariable logistic regression controlling for potential confounds (i.e., education, AIDS status, current CD4+ lymphocyte count, self-reported physical function, current depression) showed that being in the exercise group remained significantly associated with lower global NCI (odds ratio = 2.63, p < 0.05). Similar models of domain-specific NCI showed that exercise was associated with reduced impairment in working memory (p < 0.05) and speed of information processing (p < 0.05). The present findings suggest that HIV-infected adults who exercise are approximately half as likely to show NCI as compared to those who do not. Future longitudinal studies might be best suited to address causality, and intervention trials in HIV-infected individuals will determine whether exercise can prevent or ameliorate NCI in this population.

Barriers to improving primary care of depression: perspectives of medical group leaders

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.