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Engler K, Avallone F, Cadri A, Lebouché B. Patient-reported outcome measures in adult HIV care: A rapid scoping review of targeted outcomes and instruments used. HIV Med 2024; 25:633-674. [PMID: 38282323 DOI: 10.1111/hiv.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVE There is international interest in the integration of patient-reported outcome measures (PROMs) into routine HIV care, but little work has synthesized the content of published initiatives. We conducted a rapid scoping review primarily to identify their selected patient-reported outcomes and respective instruments. METHODS Four databases were searched on 4 May 2022 (Medline, Embase, CINAHL and PsychINFO) for relevant English language documents published from 2005 onwards. Dual review of at least 20% of records, full texts and data extraction was performed. Outcomes and instruments were classified with an adapted 14-domain taxonomy. Instruments with evidence of validation were described. RESULTS Of 13 062 records generated for review, we retained a final sample of 94 documents, referring to 60 distinct initiatives led mostly in the USA (n = 29; 48% of initiatives), Europe (n = 16; 27%) and Africa (n = 9; 15%). The measured patient-reported outcome domains were: mental health (n = 42; 70%), substance use (n = 23; 38%), self-management (n = 16; 27%), symptoms (n = 12; 20%), sexual/reproductive health (n = 12; 20%), physical health (n = 9; 15%), treatment (n= 8; 13%), cognition (n = 7; 12%), quality of life (n = 7; 12%), violence/abuse (n = 6; 10%), stigma (n = 6; 10%), socioeconomic issues (n = 5; 8%), social support (n = 3; 5%) and body/facial appearance (n = 1; 2%). Initiatives measured 2.6 outcome domains, on average (range = 1-11). In total, 62 distinct validated PROMs were identified, with 53 initiatives (88%) employing at least one (M = 2.2). Overwhelmingly, the most used instrument was any version of the Patient Health Questionnaire to measure symptoms of depression, employed by over a third (26; 43%) of initiatives. CONCLUSION Published PROM initiatives in HIV care have spanned 19 countries and disproportionately target mental health and substance use.
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Affiliation(s)
- Kim Engler
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Francesco Avallone
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Abdul Cadri
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
- Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Golin CE, Rosen EP, Ferguson EG, Perry NR, Poliseno AJ, Munson AJ, Davis A, Hill LM, Keys J, White NR, Farel CE, Kashuba A. Feasibility, Acceptability and Appropriateness of MedViewer: A Novel Hair-Based Antiretroviral Real-Time Clinical Monitoring Tool Providing Adherence Feedback to Patients and Their Providers. AIDS Behav 2023; 27:3886-3904. [PMID: 37493932 DOI: 10.1007/s10461-023-04104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/27/2023]
Abstract
Antiretroviral therapy (ART) adherence is key to achieving viral load suppression and ending the HIV epidemic but monitoring and supporting adherence using current interventions is challenging. We assessed the feasibility, acceptability and appropriateness of MedViewer (MV), a novel intervention that provides real-time adherence feedback for patients and providers using infra-red matrix-assisted laser desorption electrospray ionization (IR-MALDESI) for mass spectrometry imaging of daily ART concentrations in patients' hair. We used mixed methods to feasibility test MV at a busy Infectious Diseases (ID) clinic, enrolling 16 providers and 36 patients. Providers underwent standardized training; patients and providers watched an 8-min informational video about MV. We collected patient and provider data at baseline and within 24 h of clinic visits and, with patients, approximately 1 month after clinic visits. MedViewer was feasible, liked by patients and providers, and perceived to help facilitate adherence conversations and motivate patients to improve adherence. Trial Registration: NCT04232540.
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Affiliation(s)
- Carol E Golin
- Division of General Internal Medicine and Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, CB#7110, Chapel Hill, NC, 27599, USA.
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Elias P Rosen
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ella Gillespie Ferguson
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nzi Rose Perry
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Alexandra J Munson
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexandra Davis
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren M Hill
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessica Keys
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nicole R White
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Claire E Farel
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela Kashuba
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Fuentes A, Coulehan K, Byrd D, Arentoft A, Miranda C, Arce Rentería M, Monzones J, Rosario A, Rivera Mindt M. Neurocognitive, Sociocultural, and Psychological Factors Impacting Medication Beliefs Among HIV-Seropositive Latinx Adults. AIDS Patient Care STDS 2023; 37:616-625. [PMID: 38096115 PMCID: PMC10732168 DOI: 10.1089/apc.2023.0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Among Latinx people living with HIV (PLWH), neurocognitive (NC) function, culture, and mental health impact medication adherence. Similarly, health beliefs and attitudes play a role in health care barriers and health behaviors. Research has not examined the effect that compromised neurocognition, sociocultural factors, and mental health have on health beliefs and attitudes. This is especially relevant for Latinx PLWH who are disproportionately impacted by HIV, given that sociocultural factors may uniquely impact HIV-related NC and psychological sequelae. This study investigated the associations between neurocognition, sociocultural factors, mental health, health beliefs, and health attitudes among Latinx HIV-seropositive adults. Within a sample of 100 Latinx PLWH, better verbal learning and executive functioning abilities were associated with more positive attitudes about the benefits of medications and memory for medications. In terms of sociocultural factors, higher English language competence was related to better self-reported memory for medications, and overall, higher US acculturation was associated with more positive attitudes toward health professionals. Depressive symptomatology was negatively associated with attitudes toward medications and health professionals, as well as with self-reported memory for medications. These findings highlight the important interplay between NC, sociocultural, psychological factors, and health beliefs among Latinx PLWH. Adherence intervention strategies and suggestions for dispensing medical information are presented for clinicians and health care practitioners.
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Affiliation(s)
- Armando Fuentes
- Department of Psychology, Fordham University, New York, New York, USA
| | - Kelly Coulehan
- Department of Neurology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Desiree Byrd
- Department of Psychology, Queens College, Flushing, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alyssa Arentoft
- Department of Psychology, California State University, Northridge, California, USA
| | - Caitlin Miranda
- Department of Neurology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Miguel Arce Rentería
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Jennifer Monzones
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Ana Rosario
- Department of Psychology, Fordham University, New York, New York, USA
| | - Monica Rivera Mindt
- Department of Psychology, Fordham University, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Latin American and Latino Studies Institute, and Department of African and African American Studies, Fordham University, Bronx, New York, USA
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Chan AHY, Foot H, Pearce CJ, Horne R, Foster JM, Harrison J. Effect of electronic adherence monitoring on adherence and outcomes in chronic conditions: A systematic review and meta-analysis. PLoS One 2022; 17:e0265715. [PMID: 35312704 PMCID: PMC8936478 DOI: 10.1371/journal.pone.0265715] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/07/2022] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Electronic adherence monitoring (EAM) is increasingly used to improve adherence. However, there is limited evidence on the effect of EAM in across chronic conditions and on patient acceptability. We aimed to assess the effect of EAM on adherence and clinical outcomes, across all ages and all chronic conditions, and examine acceptability in this systematic review and meta-analysis. METHODS A systematic search of Ovid MEDLINE, EMBASE, Social Work Abstracts, PsycINFO, International Pharmaceutical Abstracts and CINAHL databases was performed from database inception to December 31, 2020. Randomised controlled trials (RCTs) that evaluated the effect of EAM on medication adherence as part of an adherence intervention in chronic conditions were included. Study characteristics, differences in adherence and clinical outcomes between intervention and control were extracted from each study. Estimates were pooled using random-effects meta-analysis, and presented as mean differences, standardised mean differences (SMD) or risk ratios depending on the data. Differences by study-level characteristics were estimated using subgroup meta-analysis to identify intervention characteristics associated with improved adherence. Effects on adherence and clinical outcomes which could not be meta-analysed, and patient acceptability, were synthesised narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed, and Risk of bias (RoB) assessed using the Cochrane Collaboration's RoB tool for RCTs. The review is registered with PROSPERO CRD42017084231. FINDINGS Our search identified 365 studies, of which 47 studies involving 6194 patients were included. Data from 27 studies (n = 2584) were extracted for the adherence outcome. The intervention group (n = 1267) had significantly better adherence compared to control (n = 1317), (SMD = 0.93, CI:0.69 to 1.17, p<0.0001) with high heterogeneity across studies (I2 = 86%). There was a significant difference in effect according to intervention complexity (p = 0.01); EAM only improved adherence when used with a reminder and/or health provider support. Clinical outcomes were measured in 38/47 (81%) of studies; of these data from 14 studies were included in a meta-analysis of clinical outcomes for HIV, hypertension and asthma. In total, 13/47 (28%) studies assessed acceptability; patient perceptions were mixed. INTERPRETATION Patients receiving an EAM intervention had significantly better adherence than those who did not, but improved adherence did not consistently translate into clinical benefits. Acceptability data were mixed. Further research measuring effects on clinical outcomes and patient acceptability are needed.
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Affiliation(s)
- Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Centre of Behavioural Medicine, School of Pharmacy, University College London, London, United Kingdom
| | - Holly Foot
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Christina Joanne Pearce
- Centre of Behavioural Medicine, School of Pharmacy, University College London, London, United Kingdom
| | - Rob Horne
- Centre of Behavioural Medicine, School of Pharmacy, University College London, London, United Kingdom
| | | | - Jeff Harrison
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Engler K, Vicente S, Ma Y, Hijal T, Cox J, Ahmed S, Klein M, Achiche S, Pant Pai N, de Pokomandy A, Lacombe K, Lebouché B. Implementation of an electronic patient-reported measure of barriers to antiretroviral therapy adherence with the Opal patient portal: Protocol for a mixed method type 3 hybrid pilot study at a large Montreal HIV clinic. PLoS One 2021; 16:e0261006. [PMID: 34969046 PMCID: PMC8717992 DOI: 10.1371/journal.pone.0261006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/12/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) remains problematic. Regular monitoring of its barriers is clinically recommended, however, patient-provider communication around adherence is often inadequate. Our team thus decided to develop a new electronically administered patient-reported outcome measure (PROM) of barriers to ART adherence (the I-Score) to systematically capture this data for physician consideration in routine HIV care. To prepare for a controlled definitive trial to test the I-Score intervention, a pilot study was designed. Its primary objectives are to evaluate patient and physician perceptions of the I-Score intervention and its implementation strategy. METHODS This one-arm, 6-month study will adopt a mixed method type 3 implementation-effectiveness hybrid design and be conducted at the Chronic Viral Illness Service of the McGill University Health Centre (Montreal, Canada). Four HIV physicians and 32 of their HIV patients with known or suspected adherence problems will participate. The intervention will involve having patients complete the I-Score through a smartphone application (Opal), before meeting with their physician. Both patients and physicians will have access to the I-Score results, for consideration during the clinic visits at Times 1, 2 (3 months), and 3 (6 months). The implementation strategy will focus on stakeholder involvement, education, and training; promoting the intervention's adaptability; and hiring an Application Manager to facilitate implementation. Implementation, patient, and service outcomes will be collected (Times 1-2-3). The primary outcome is the intervention's acceptability to patients and physicians. Qualitative data obtained, in part, through physician focus groups (Times 2-3) and patient interviews (Times 2-3) will help evaluate the implementation strategy and inform any methodological adaptations. DISCUSSION This study will help plan a definitive trial to test the efficacy of the I-Score intervention. It will generate needed data on electronic PROM interventions in routine HIV care that will help improve understanding of conditions for their successful implementation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04702412; https://clinicaltrials.gov/.
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Affiliation(s)
- Kim Engler
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Serge Vicente
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Yuanchao Ma
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Tarek Hijal
- Department of Radiation Oncology, Cedars Cancer Center, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joseph Cox
- Division of Infectious Disease, Department of Medicine, Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sara Ahmed
- School of Physical & Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Marina Klein
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Disease, Department of Medicine, Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sofiane Achiche
- Department of Mechanical Engineering, École Polytechnique de Montréal, Montreal, Quebec, Canada
| | - Nitika Pant Pai
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Alexandra de Pokomandy
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Disease, Department of Medicine, Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Karine Lacombe
- Sorbonne Université, Inserm IPLESP, Hôpital St Antoine, Assistance Publique -Hôpitaux de Paris, Paris, France
| | - Bertrand Lebouché
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Disease, Department of Medicine, Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Behavioral and social science research to support accelerated and equitable implementation of long-acting preexposure prophylaxis. Curr Opin HIV AIDS 2021; 15:66-72. [PMID: 31644482 DOI: 10.1097/coh.0000000000000596] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The sociobehavioral research agenda for HIV prevention urgently needs to progress beyond research on end user preferences to examine how to best support patient access, engagement, and choice in the rollout of long-acting modalities. We outline critical challenges for an era of choice in biomedical prevention that could benefit from the rigorous application of sociobehavioral research methods. RECENT FINDINGS Research in three areas could accelerate implementation of long-acting antiretrovirals for prevention: integrating dual process models into research on patient decision-making and behavior; identifying strategies that mitigate against unconscious and implicit biases in provider decision-making and behavior; and developing tools to support patient-centered communication that incorporate research in both of the first two areas. SUMMARY We encourage the development of dual process models and measures to better understand patient behavior, including behavior related to initiating biomedical prevention, choice of prevention strategy, switching among strategies, and discontinuation. Second, there is the need to develop intervention research that targets provider behavior. Finally, we call for research to inform patient-centered communication tools that integrate an understanding of affective drivers of preexposure prophylaxis (PrEP) decision-making and protect against implicit bias in provider recommendations related to PrEP.
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Puttkammer N, Simoni JM, Sandifer T, Chéry JM, Dervis W, Balan JG, Dubé JG, Calixte G, Robin E, François K, Casey C, Wilson I, Honoré JG. An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART. AIDS Behav 2020; 24:3320-3336. [PMID: 32715409 DOI: 10.1007/s10461-020-02945-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of ≥ 90% for "proportion of days covered" (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI 0.92-1.45, p = 0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC ≥ 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC ≥ 90% with the intervention was 4.00 (95% CI 1.91-8.38, p < 0.001), representing a highly favorable association between the intervention and the trajectory of PDC outcomes. Qualitative data affirmed acceptability of the intervention, although providers reported some challenges consistently implementing it. Future research is needed to demonstrate efficacy and explore optimal implementation strategies.
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Using Real-Time Adherence Feedback to Enhance Communication About Adherence to Antiretroviral Therapy: Patient and Clinician Perspectives. J Assoc Nurses AIDS Care 2020; 31:25-34. [PMID: 31033629 PMCID: PMC6815236 DOI: 10.1097/jnc.0000000000000089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
New technologies for real-time adherence monitoring hold the potential to enhance antiretroviral therapy adherence interventions by providing objective information about daily medication-taking behavior. To realize this potential, we need to understand how to integrate real-time adherence feedback into existing best practices to promote antiretroviral therapy adherence at the point of care. Using in-depth interviews with 30 HIV-infected patients and 29 HIV care clinicians, our primary aims were to understand patients' and clinicians' perceptions of anticipated benefits and preferred uses of objective feedback to enhance conversations about adherence and to identify concerns about the impact of objective monitoring on patient-clinician relationships and communication. Both patients and clinicians suggested that identifying patterns of nonadherence with real-time feedback could (a) facilitate collaborative adherence problem-solving, (b) motivate patient adherence, and (c) reinforce the importance of optimal adherence. Some clinicians worried that delivery of real-time feedback could imply mistrust of patient-reported adherence and suggested careful framing of monitoring results. A few patients and clinicians were concerned that negative reactions to monitoring could discourage retention in care and reduce adherence motivation. These results indicate the potential of real-time feedback to enhance existing evidence-based adherence interventions targeting the key adherence precursors of adherence information, motivation, and behavioral skills. Guidance for the delivery of real-time adherence feedback should focus on both optimizing adherence and mitigating negative perceptions of adherence monitoring.
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Laws MB, Lee Y, Rogers WS, Taubin T, Wilson IB. An instrument to assess HIV-related knowledge and adjustment to HIV+ status, and their association with anti-retroviral adherence. PLoS One 2020; 15:e0227722. [PMID: 32569272 PMCID: PMC7307754 DOI: 10.1371/journal.pone.0227722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 06/02/2020] [Indexed: 12/02/2022] Open
Abstract
Background Findings on the association between health literacy and anti-retroviral (ARV) adherence are inconsistent. Health literacy is usually operationalized with simple tests of basic literacy, but more complex conceptions of health literacy include content knowledge. People living with chronic illness also conceptualize and experience illness in ways other than biomedical or mechanistic models of disease. Objective There are no instruments that comprehensively assess knowledge of people living with HIV concerning HIV disease and treatment; or psychological adjustment to being HIV+. Little is known about the relationship between factual knowledge, or positive identification as HIV+, and anti-retroviral (ARV) adherence. Methods Formative work with in-depth semi-structured interviews, and cognitive testing, to develop a structured instrument assessing HIV-related knowledge, and personal meanings of living with HIV. Pilot administration of the instrument to a convenience sample of 101 respondents. Key results Respondents varied considerably in their expressed need for in-depth knowledge, the accuracy of their understanding of relevant scientific concepts and facts about ARV treatment, and psychological adjustment and acceptance of HIV+ status. Most knowledge domains were not significantly related to self-reported ARV adherence, but accurate knowledge specifically about ARV treatment was (r = 0.25, p = .02), as was an adapted version of the Need for Cognition scale (r = .256, p = .012). Negative feelings about living with HIV (r = .33, p = .0012), and medication taking (r = .276, p = .008) were significantly associated with non-adherence. Conclusion The instrument may be useful in diagnosing addressable reasons for non-adherence, as a component of psychoeducational interventions, and for evaluation of such interventions.
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Affiliation(s)
- M. Barton Laws
- Dept., of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States of America
- * E-mail:
| | - Yoojin Lee
- Dept., of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States of America
| | - William S. Rogers
- Institute for Clinical Research and Health Policy Studies, Tufts University, Boston, MA, United States of America
| | - Tatiana Taubin
- Dept., of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States of America
| | - Ira B. Wilson
- Dept., of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States of America
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McConnell M, Rogers W, Simeonova E, Wilson IB. Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians. Health Serv Res 2019; 55:136-145. [PMID: 31835278 PMCID: PMC6981078 DOI: 10.1111/1475-6773.13243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures. DATA SOURCES AND STUDY SETTING The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness. STUDY DESIGN In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist. DATA COLLECTION Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims. PRINCIPAL FINDINGS We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default. CONCLUSIONS Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.
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Affiliation(s)
- Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - William Rogers
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | | | - Ira B Wilson
- Brown University School of Public Health, Providence, Rhode Island
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11
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Lessard D, Toupin I, Engler K, Lènàrt A, Lebouché B. HIV-Positive Patients' Perceptions of Antiretroviral Therapy Adherence in Relation to Subjective Time: Imprinting, Domino Effects, and Future Shadowing. J Int Assoc Provid AIDS Care 2019; 17:2325958218759208. [PMID: 29473484 PMCID: PMC6748544 DOI: 10.1177/2325958218759208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Antiretroviral treatment adherence barriers are major concerns in HIV care. They are multiple and change over time. Considering temporality in patients' perceptions of adherence barriers could improve adherence management. We explored how temporality manifests itself in patients' perceptions of adherence barriers. We conducted 2 semi-structured focus groups on adherence barriers with 12 adults with HIV which were analyzed with grounded theory. A third focus group served to validate the results obtained. Three temporal categories were manifest in HIV-positive patients' perceptions of barriers: (1) imprinting (events with lasting impacts on patients), (2) domino effects (chain of life events), and (3) future shadowing (apprehension about long-term adherence). An overarching theme, weathering (gradual erosion of abilities to adhere), traversed these categories. These temporalities explain how similar barriers may be perceived differently by patients. They could be useful to providers for adapting their interventions and improving understanding of patients' subjective experience of adherence.
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Affiliation(s)
- David Lessard
- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Isabelle Toupin
- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kim Engler
- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Andràs Lènàrt
- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- 1 Department of Family Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Sued O, Cassetti I, Cecchini D, Cahn P, de Murillo LB, Weiss SM, Mandell LN, Soni M, Jones DL. Physician-delivered motivational interviewing to improve adherence and retention in care among challenging HIV-infected patients in Argentina (COPA2): study protocol for a cluster randomized controlled trial. Trials 2018; 19:396. [PMID: 30041703 PMCID: PMC6056946 DOI: 10.1186/s13063-018-2758-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 06/25/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND "Challenging" HIV-infected patients, those not retained in treatment, represent a critical focus for positive prevention, as linkage to care, early initiation of antiretroviral therapy, adherence and retention in treatment facilitate viral suppression, thus optimizing health and reducing HIV transmission. Argentina was one of the first Latin American countries to guarantee HIV prevention, diagnosis and comprehensive care services, including antiretroviral medication, which removed cost and access as barriers. Yet, dropout occurs at every stage of the HIV continuum. An estimated 110,000 individuals are HIV-infected in Argentina; of these, 70% have been diagnosed and 54% were linked to care. However, only 36% have achieved viral suppression and 31% of those diagnosed delayed entry to care. To achieve meaningful reductions in HIV infection at the community level, innovative strategies must be developed to re-engage patients. Motivational Interviewing (MI) is a patient-centered approach and has been used by therapists in Central and South America to enhance motivation and commitment in substance use and risk reduction. Our pilot feasibility study utilized culturally tailored MI in physicians to target patients not retained in treatment in public and private clinics in Buenos Aires, Argentina. Results demonstrated that a physician-based MI intervention was feasible and effective in enhanced and sustained patient adherence, viral suppression, and patient-physician communication and attitudes about treatment among these patients at 6 and 9 months post baseline. METHODS/DESIGN This clinical trial seeks to extend these findings in public and private clinics in four urban population centers in Argentina, in which clinics (n = 6 clinics, six MDs per clinic site) are randomized to experimental (physician MI Intervention) (n = 3) or control (physician Standard of Care) (n = 3) conditions in a 3:3 ratio. Using a cluster randomized clinical trial design, the study will test the effectiveness of a physician-based MI intervention to improve and sustain retention, adherence, persistence, and viral suppression among "challenging" patients (n = 420) over 24 months. DISCUSSION Results are anticipated to have significant public health implications for the implementation of MI to re-engage and retain patients in HIV treatment and care and improve viral suppression through high levels of medication adherence. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02846350 . Registered on 1 July 2016.
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Affiliation(s)
- Omar Sued
- Fundación Huésped, Pasaje Angel Peluffo 3932, C1202ABB Buenos Aires, Argentina
| | | | | | - Pedro Cahn
- Fundación Huésped, Pasaje Angel Peluffo 3932, C1202ABB Buenos Aires, Argentina
| | - Lina Bofill de Murillo
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL USA
| | - Stephen M. Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL USA
| | - Lissa N. Mandell
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL USA
| | - Manasi Soni
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL USA
| | - Deborah L. Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1400 NW 10th Ave, Miami, FL USA
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Engler K, Lènàrt A, Lessard D, Toupin I, Lebouché B. Barriers to antiretroviral therapy adherence in developed countries: a qualitative synthesis to develop a conceptual framework for a new patient-reported outcome measure. AIDS Care 2018; 30:17-28. [PMID: 29719990 DOI: 10.1080/09540121.2018.1469725] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Suboptimal adherence to antiretroviral therapy (ART) remains common. Patient-centered tools are needed to comprehensively assess adherence barriers in HIV clinical practice. Thus, we conducted a research synthesis to produce a conceptual framework for a new patient-reported outcome measure (PRO) for use in routine HIV care in Canada and France. A PRO's conceptual framework graphically represents the concepts to be measured and the potential relationships between them. Towards ensuring the framework's relevance to the target populations' concerns, qualitative studies with HIV-positive adults on barriers to ART adherence in developed countries were synthesized with thematic analysis, attending to the cross-study prevalence and interrelationships of barrier themes. In March 2016, searches within Medline, PsychINFO, and Embase produced 5,284 records. Two reviewers determined the final sample (n = 41). Analysis generated three levels of ART adherence barrier themes. Twenty Level 2 themes and their component subthemes (Level 3) were organized into 6 higher-order themes (Level 1): Cognitive and emotional aspects (100% of studies contributing content -prevalence), Lifestyle factors (95%), Social and material context (95%), Characteristics of ART (90%), Health experience and state (73%), and Healthcare services and system (66%). As to interrelationships, study authors articulated relationships between all higher-order themes (Level 3). Linkages between Level 2 barrier themes showed great variability, from 21% to 95%. Overall, this synthesis contributes an exceptionally detailed conceptual framework and report of ART adherence barriers, applicable to a wide range of PLHIV. It suggests that a key to understanding many barriers is through their interconnections. It also identifies gaps in barrier research. Concerning the new PRO's development, comprehensiveness will need to be weighed against other concerns (e.g., respondent burden) and the provision of barrier-specific guidance for clinically addressing its scores seems essential.
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Affiliation(s)
- Kim Engler
- a Department of Family Medicine , McGill University , Montreal , QC , Canada.,b Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials , Montreal , QC , Canada.,c Center for Outcomes Research & Evaluation , Research Institute, McGill University Health Centre (MUHC) , Montreal , QC , Canada
| | - Andras Lènàrt
- a Department of Family Medicine , McGill University , Montreal , QC , Canada.,b Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials , Montreal , QC , Canada.,c Center for Outcomes Research & Evaluation , Research Institute, McGill University Health Centre (MUHC) , Montreal , QC , Canada
| | - David Lessard
- a Department of Family Medicine , McGill University , Montreal , QC , Canada.,b Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials , Montreal , QC , Canada.,c Center for Outcomes Research & Evaluation , Research Institute, McGill University Health Centre (MUHC) , Montreal , QC , Canada
| | - Isabelle Toupin
- a Department of Family Medicine , McGill University , Montreal , QC , Canada.,b Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials , Montreal , QC , Canada.,c Center for Outcomes Research & Evaluation , Research Institute, McGill University Health Centre (MUHC) , Montreal , QC , Canada
| | - Bertrand Lebouché
- a Department of Family Medicine , McGill University , Montreal , QC , Canada.,b Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials , Montreal , QC , Canada.,c Center for Outcomes Research & Evaluation , Research Institute, McGill University Health Centre (MUHC) , Montreal , QC , Canada.,d Chronic Viral Illness Service , Royal Victoria Hospital, MUHC , Montreal , QC , Canada
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14
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de Kok BC, Widdicombe S, Pilnick A, Laurier E. Doing patient-centredness versus achieving public health targets: A critical review of interactional dilemmas in ART adherence support. Soc Sci Med 2018; 205:17-25. [PMID: 29631198 DOI: 10.1016/j.socscimed.2018.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 03/16/2018] [Accepted: 03/21/2018] [Indexed: 12/19/2022]
Abstract
Anti-retroviral Therapy (ART) transformed HIV into a chronic disease but its individual and public health benefits depend on high levels of adherence. The large and rising number of people on ART, now also used as prevention, puts considerable strain on health systems and providers in low and middle as well as high-income countries, which are our focus here. Delivering effective adherence support is thus crucial but challenging, especially given the promotion of patient-centredness and shared decision making in HIV care. To illuminate the complexities of ART adherence support delivered in and through clinical encounters, we conducted a multi-disciplinary interpretative literature review. We reviewed and synthesized 82 papers published post 1997 (when ART was introduced) belonging to three bodies of literature: public health and psychological studies of ART communication; anthropological and sociological studies of ART; and conversation analytic studies of patient-centredness and shared decision-making. We propose three inter-related tensions which make patient-centredness particularly complex in this infectious disease context: achieving trust versus probing about adherence; patient-centredness versus reaching public health targets; and empowerment versus responsibilisation as 'therapeutic citizens'. However, there is a dearth of evidence concerning how precisely ART providers implement patient-centredness, shared-decision making in practice, and enact trust and therapeutic citizenship. We show how conversation analysis could lead to new, actionable insights in this respect.
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Affiliation(s)
- B C de Kok
- Department of Anthropology, University of Amsterdam, Nieuwe Achtergracht 166, PO Box 15508, 1001 NA, Amsterdam, The Netherlands.
| | - S Widdicombe
- Psychology, 7 George Square, Edinburgh, EH8 9JZ, UK.
| | - A Pilnick
- Language, Medicine and Society, School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK.
| | - E Laurier
- Geography, Drummond Street, Edinburgh, EH8 9XP, UK.
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Stirratt MJ, Curtis JR, Danila MI, Hansen R, Miller MJ, Gakumo CA. Advancing the Science and Practice of Medication Adherence. J Gen Intern Med 2018; 33:216-222. [PMID: 29204969 PMCID: PMC5789101 DOI: 10.1007/s11606-017-4198-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Medication adherence remains a significant unmet challenge for optimizing patient outcomes. Recent advances in the conceptualization, measurement, and support of medication adherence offer fresh opportunities to make a meaningful impact on adherence-related behavior and outcomes. These advances emphasize the multifaceted and dynamic nature of medication adherence, provide novel methods for monitoring medication adherence in clinical care, and articulate a set of multilevel strategies to more effectively improve and sustain medication adherence. Here, we offer recommendations for how clinicians can better engage with, and benefit from, these innovations to improve patient medication adherence and associated treatment outcomes.
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Affiliation(s)
- Michael J Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA.
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard Hansen
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Michael J Miller
- Department of Pharmaceutical Sciences, Texas A&M University Irma Lerma Rangel College of Pharmacy, College Station, TX, USA
| | - C Ann Gakumo
- Department of Acute, Chronic & Continuing Care, University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
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Zaugg V, Korb‐Savoldelli V, Durieux P, Sabatier B. Providing physicians with feedback on medication adherence for people with chronic diseases taking long-term medication. Cochrane Database Syst Rev 2018; 1:CD012042. [PMID: 29320600 PMCID: PMC6491069 DOI: 10.1002/14651858.cd012042.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Poor medication adherence decreases treatment efficacy and worsens clinical outcomes, but average rates of adherence to long-term pharmacological treatments for chronic illnesses are only about 50%. Interventions for improving medication adherence largely focus on patients rather than on physicians; however, the strategies shown to be effective are complex and difficult to implement in clinical practice. There is a need for new care models addressing the problem of medication adherence, integrating this problem into the patient care process. Physicians tend to overestimate how well patients take their medication as prescribed. This can lead to missed opportunities to change medications, solve adverse effects, or propose the use of reminders in order to improve patients' adherence. Thus, providing physicians with feedback on medication adherence has the potential to prompt changes that improve their patients' adherence to prescribed medications. OBJECTIVES To assess the effects of providing physicians with feedback about their patients' medication adherence for improving adherence. We also assessed the effects of the intervention on patient outcomes, health resource use, and processes of care. SEARCH METHODS We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase, all from database inception to December 2016 and without any language restriction. We also searched ISI Web of Science, two trials registers, and grey literature. SELECTION CRITERIA We included randomised trials, controlled before-after studies, and interrupted time series studies that compared the effects of providing feedback to physicians about their patients' adherence to prescribed long-term medications for chronic diseases versus usual care. We included published or unpublished studies in any language. Participants included any physician and any patient prescribed with long-term medication for chronic disease. We included interventions providing the prescribing physician with information about patient adherence to medication. Only studies in which feedback to the physician was the sole intervention or the essential component of a multifaceted intervention were eligible. In the comparison groups, the physicians should not have had access to information about their patients' adherence to medication. We considered the following outcomes: medication adherence, patient outcomes, health resource use, processes of care, and adverse events. DATA COLLECTION AND ANALYSIS Two independent review authors extracted and analysed all data using standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. Due to heterogeneity in study methodology, comparison groups, intervention settings, and measurements of outcomes, we did not carry out meta-analysis. We describe the impact of interventions on outcomes in tabular form and make a qualitative assessment of the effects of studies. MAIN RESULTS We included nine studies (23,255 patient participants): eight randomised trials and one interrupted time series analysis. The studies took place in primary care and other outpatient settings in the USA and Canada. Seven interventions involved the systematic provision of feedback to physicians concerning all their patients' adherence to medication, and two interventions involved issuing an alert for non-adherent patients only. Seven studies used pharmacy refill data to assess medication adherence, and two used an electronic device or self-reporting. The definition of adherence differed across studies, making comparisons difficult. Eight studies were at high risk of bias, and one study was at unclear risk of bias. The most frequent source of bias was lack of protection against contamination.Providing physicians with feedback may lead to little or no difference in medication adherence (seven studies, 22,924 patients), patient outcomes (two studies, 1292 patients), or health resource use (two studies, 4181 patients). Providing physicians with feedback on medication adherence may improve processes of care (e.g. more medication changes, dialogue with patient, management of uncontrolled hypertension) compared to usual care (four studies, 2780 patients). None of the studies reported an adverse event due to the intervention. The certainty of evidence was low for all outcomes, mainly due to high risk of bias, high heterogeneity across studies, and indirectness of evidence. AUTHORS' CONCLUSIONS Across nine studies, we observed little or no evidence that provision of feedback to physicians regarding their patients adherence to prescribed medication improved medication adherence, patient outcomes, or health resource use. Feedback about medication adherence may improve processes of care, but due to the small number of studies assessing this outcome and high risk of bias, we cannot draw firm conclusions on the effect of feedback on this outcome. Future research should use a clear, standardised definition of medication adherence and cluster-randomisation to avoid the risk of contamination.
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Affiliation(s)
- Vincent Zaugg
- Georges Pompidou European Hospital, AP‐HPClinical Pharmacy Department20 rue LeblancParisFrance75015
| | - Virginie Korb‐Savoldelli
- Georges Pompidou European Hospital, AP‐HPClinical Pharmacy Department20 rue LeblancParisFrance75015
- Paris Sud UniversityFaculty of PharmacyChatenay‐MalabryFrance
| | - Pierre Durieux
- Georges Pompidou European HospitalDepartment of Public Health and Medical Informatics20 rue LeblancParisFrance75015
- Paris Descartes UniversityParisFrance
| | - Brigitte Sabatier
- Georges Pompidou European Hospital, AP‐HPClinical Pharmacy Department20 rue LeblancParisFrance75015
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Wachira J, Genberg B, Kafu C, Braitstein P, Laws MB, Wilson IB. Experiences and expectations of patients living with HIV on their engagement with care in Western Kenya. Patient Prefer Adherence 2018; 12:1393-1400. [PMID: 30122904 PMCID: PMC6078080 DOI: 10.2147/ppa.s168664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In resource-limited HIV care settings, effective and innovative interventions that respond to the existing challenges along the HIV care continuum are urgently needed to realize the benefits of antiretroviral therapy (ART). Initiating effective ART adherence dialog in an environment that promotes patient engagement in care is key. It is therefore critical to enhance our understanding about how patients living with HIV in these regions conceptualize and experience patient engagement. This study explores HIV patients' perceptions, experiences and expectations of their engagement in care. MATERIALS AND METHODS We sampled 86 patients from three Academic Model for Providing Access to Healthcare (AMPATHplus) sites, one urban and two rural. We conducted 24 in-depth interviews and eight focus group discussions in either Swahili or English. Audio recordings of the interviews were transcribed, and then translated into English. We performed content analysis after thematic coding. RESULTS Patients living with HIV in Kenya desire active engagement with care. However, their engagement was inconsistent and varied depending on the provider. Patients had a sense of how provider's interpersonal behaviors influenced their level of engagement. These included various aspects of provider-patient communication and relationship dynamics. Patients also highlighted relational boundaries that influenced the level and kind of information they shared with their providers. Aspects of their psychological, social or economic wellbeing were often viewed as personal and not discussed with their clinicians. Patients identified factors that would promote or impede their engagement with care including those related to patients themselves, providers, and the healthcare system. CONCLUSION Patients living with HIV desired more active engagement in their care. In addition, they desired clinicians to engage in more social behaviors to promote patient engagement. To address existing patient engagement barriers, HIV care systems in the region should apply contextualized patient-centered interventions.
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Affiliation(s)
- Juddy Wachira
- Department of Behavioral Sciences, School of Medicine, Moi University, Eldoret, Kenya,
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Becky Genberg
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Catherine Kafu
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Michael Barton Laws
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
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A Review of HIV-Specific Patient-Reported Outcome Measures. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 10:187-202. [PMID: 27637488 DOI: 10.1007/s40271-016-0195-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The use of patient-reported outcome (PRO) measures to provide added feedback to health providers is receiving interest as a means of improving clinical care and patient outcomes, and contributing to more patient-centered care. In human immunodeficiency virus (HIV), while PROs are used in research, their application in clinical practice has been limited despite their potential utility. PRO selection is an important consideration when contemplating their use. As past reviews of PROs in HIV have focused on particular areas (e.g. disability, satisfaction with care), a more comprehensive review could better inform on the available instruments and their scope. This article reviews HIV-specific PROs to produce an inventory and to identify the central concepts targeted over time. Seven databases were searched (HAPI, MEDLINE, PsychINFO, PubMed, EMBASE, CINAHL, Google Scholar), generating 14,794 records for evaluation. From these records, 117 HIV-specific PROs were identified and categorized based on a content analysis of their targeted concept: Health-Related Quality of Life (23; 20 %), ART and Adherence-Related Views and Experiences (19; 16 %), Healthcare-Related Views and Experiences (15; 13 %), Psychological Challenges (12; 10 %), Symptoms (12; 10 %), Psychological Resources (10; 9 %), HIV Self-Management and Self-Care (8; 7 %), HIV-Related Stigma (8; 7 %), Body and Facial Appearance (4; 3 %), Social Support (3; 3 %), Sexual and Reproductive Health (2; 2 %), and Disability (1; 1 %). This review highlights the variety and evolution of HIV-specific PROs, with the arrival of seven categories of PROs only after the advent of highly-active antiretroviral therapy. Our inventory also offers a useful resource. However, the interest of further HIV-specific PRO development should be explored in sexual health, which received little independent attention.
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Crane HM, Crane PK, Tufano JT, Ralston JD, Wilson IB, Brown TD, Davis TE, Smith LF, Lober WB, McReynolds J, Dhanireddy S, Harrington RD, Rodriguez CV, Nance RM, Delaney JAC, Safren SA, Kitahata MM, Fredericksen RJ. HIV Provider Documentation and Actions Following Patient Reports of At-risk Behaviors and Conditions When Identified by a Web-Based Point-of-Care Assessment. AIDS Behav 2017; 21:3111-3121. [PMID: 28205041 DOI: 10.1007/s10461-017-1718-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We compared same-day provider medical record documentation and interventions addressing depression and risk behaviors before and after delivering point-of-care patient-reported outcomes (PROs) feedback for patients who self-reported clinically relevant levels of depression or risk behaviors. During the study period (1 January 2006-15 October 2010), 2289 PRO assessments were completed by HIV-infected patients. Comparing the 8 months before versus after feedback implementation, providers were more likely to document depression (74% before vs. 87% after feedback, p = 0.02) in patients with moderate-to-severe depression (n = 317 assessments), at-risk alcohol use (41 vs. 64%, p = 0.04, n = 155) and substance use (60 vs. 80%, p = 0.004, n = 212). Providers were less likely to incorrectly document good adherence among patients with inadequate adherence after feedback (42 vs. 24%, p = 0.02, n = 205). While PRO feedback of depression and adherence were followed by increased provider intervention, other domains were not. Further investigation of factors associated with the gap between awareness and intervention are needed in order to bridge this divide.
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Toupin I, Engler K, Lessard D, Wong L, Lènàrt A, Raffi F, Spire B, Lebouché B. Patient profiles as organizing HIV clinicians' ART adherence management: a qualitative analysis. AIDS Care 2017; 30:207-210. [PMID: 28764563 DOI: 10.1080/09540121.2017.1360995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The effectiveness of antiretroviral therapy (ART) depends on optimal clinical management and patient adherence. Little is known about patient characteristics that clinicians consider in the management of ART adherence. Exploring this issue, five focus groups were conducted with 31 HIV-clinicians from across France. A qualitative typological analysis suggests that clinician management of patient adherence is based on characteristics that coalesce into seven patient profiles. For the "passive" patient, described as taking ART exactly as prescribed without questioning their doctor's expertise, a directive and simple management style was preferred. The "misleading" patient is characterized as concerned with social desirability and as reporting no adherence difficulties for fear of displeasing their doctor. If clinical outcomes are suboptimal, the clinicians' strategy is to remind them of the importance of open patient-clinician communication. The "stoic" patient is described as requesting and adequately taking the most potent ART available. Here, clinicians emphasize assessment of side effects, which the patient may minimize. The "hedonistic" patient's festive lifestyle and sexual risk-taking are seen as compromising adherence; with them, clinicians stress the patient's responsibility for their own health and that of their sexual partners. The "obsessive" patient is portrayed as having an irrational fear of ART failure and an inability to distinguish illusory from genuine adherence barriers. With this patient, clinicians seek to identify the latter. The "overburdened" patient is recognized as coping with life priorities that interfere with adherence and, with them, a forgiving ART is favored. The "underprivileged" patient is presented as having limited education, income and housing. In this case, clinicians seek to improve the patient's living conditions and access to care. These results shed light on HIV clinicians' ART adherence management. The value of these profiles for HIV care and patients should be investigated.
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Affiliation(s)
- Isabelle Toupin
- a Department of Family Medicine , McGill University , Montreal , Canada.,b Research Institute , McGill University Health Centre , Montreal , Canada.,c Royal Victoria Hospital, Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada.,d Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials (Canadian Institutes of Health Research) , Montreal , Canada
| | - Kim Engler
- a Department of Family Medicine , McGill University , Montreal , Canada.,b Research Institute , McGill University Health Centre , Montreal , Canada.,c Royal Victoria Hospital, Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada.,d Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials (Canadian Institutes of Health Research) , Montreal , Canada
| | - David Lessard
- a Department of Family Medicine , McGill University , Montreal , Canada.,b Research Institute , McGill University Health Centre , Montreal , Canada.,c Royal Victoria Hospital, Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada.,d Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials (Canadian Institutes of Health Research) , Montreal , Canada
| | - Leo Wong
- b Research Institute , McGill University Health Centre , Montreal , Canada.,c Royal Victoria Hospital, Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada
| | - Andràs Lènàrt
- a Department of Family Medicine , McGill University , Montreal , Canada
| | - Francois Raffi
- e Department of Infectious Diseases , CHU de Nantes and CIC 1413, INSERM , Nantes , France
| | - Bruno Spire
- f SESSTIM , Université Aix-Marseille , Marseille , France
| | - Bertrand Lebouché
- a Department of Family Medicine , McGill University , Montreal , Canada.,b Research Institute , McGill University Health Centre , Montreal , Canada.,c Royal Victoria Hospital, Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada.,d Strategy for Patient-Oriented Research (SPOR) Mentorship Chair in Innovative Clinical Trials (Canadian Institutes of Health Research) , Montreal , Canada
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Risher KA, Kapoor S, Daramola AM, Paz-Bailey G, Skarbinski J, Doyle K, Shearer K, Dowdy D, Rosenberg E, Sullivan P, Shah M. Challenges in the Evaluation of Interventions to Improve Engagement Along the HIV Care Continuum in the United States: A Systematic Review. AIDS Behav 2017; 21:2101-2123. [PMID: 28120257 PMCID: PMC5843766 DOI: 10.1007/s10461-017-1687-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. 'Linkage' studies utilized 11 different outcome definitions, while 'retention' studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework.
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Affiliation(s)
- Kathryn A Risher
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615N. Wolfe St, W6604, Baltimore, MD, 20205, USA.
| | - Sunaina Kapoor
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alice Moji Daramola
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Gabriela Paz-Bailey
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kate Doyle
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kate Shearer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615N. Wolfe St, W6604, Baltimore, MD, 20205, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615N. Wolfe St, W6604, Baltimore, MD, 20205, USA
| | - Eli Rosenberg
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Patrick Sullivan
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Engler K, Lessard D, Toupin I, Lènàrt A, Lebouché B. Engaging stakeholders into an electronic patient-reported outcome development study: On making an HIV-specific e-PRO patient-centered. HEALTH POLICY AND TECHNOLOGY 2017. [DOI: 10.1016/j.hlpt.2016.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kahler CW, Caswell AJ, Laws MB, Walthers J, Magill M, Mastroleo NR, Howe CJ, Souza T, Wilson I, Bryant K, Monti PM. Using topic coding to understand the nature of change language in a motivational intervention to reduce alcohol and sex risk behaviors in emergency department patients. PATIENT EDUCATION AND COUNSELING 2016; 99:1595-602. [PMID: 27161165 PMCID: PMC5028244 DOI: 10.1016/j.pec.2016.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 04/22/2016] [Accepted: 05/01/2016] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To elucidate patient language that supports changing a health behavior (change talk) or sustaining the behavior (sustain talk). METHODS We developed a novel coding system to characterize topics of patient speech in a motivational intervention targeting alcohol and HIV/sexual risk in 90 Emergency Department patients. We further coded patient language as change or sustain talk. RESULTS For both alcohol and sex, discussions focusing on benefits of behavior change or change planning were most likely to involve change talk, and these topics comprised a large portion of all change talk. Greater discussion of barriers and facilitators of change also was associated with more change talk. For alcohol use, benefits of drinking behavior was the most common topic of sustain talk. For sex risk, benefits of sexual behavior were rarely discussed, and sustain talk centered more on patterns and contexts, negations of drawbacks, and drawbacks of sexual risk behavior change. CONCLUSIONS Topic coding provided unique insights into the content of patient change and sustain talk. PRACTICE IMPLICATIONS Patients are most likely to voice change talk when conversation focuses on behavior change rather than ongoing behavior. Interventions addressing multiple health behaviors should address the unique motivations for maintaining specific risky behaviors.
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Affiliation(s)
- Christopher W Kahler
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA.
| | - Amy J Caswell
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - M Barton Laws
- Department of Health Services, Policy, & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Justin Walthers
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nadine R Mastroleo
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Chanelle J Howe
- Center for Population Health and Clinical Epidemiology, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Timothy Souza
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Ira Wilson
- Department of Health Services, Policy, & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Lane, Bethesda, MD, USA
| | - Peter M Monti
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
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Jones DL, Sued O, Cecchini D, Bofill L, Cook R, Lucas M, Bordato A, Cassetti I, Cahn P, Weiss SM. Improving Adherence to Care Among "Hard to Reach" HIV-Infected Patients in Argentina. AIDS Behav 2016; 20:987-97. [PMID: 26152608 DOI: 10.1007/s10461-015-1133-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many HIV-infected patients fail to achieve undetectable viral load and are not retained in care. This pilot study examined patients lost to care in public and private clinics in Buenos Aires, Argentina. The impact of patient and provider interventions was compared separately and collectively. In Phase 1, participants prescribed antiretrovirals and non-adherent to treatment in the prior 3-6 months (n = 60) were randomized to patient intervention or standard of care (SOC) and assessed over 12 months. In Phase 2, providers were trained in interviewing techniques and 60 additional patients were randomized to patient intervention or SOC condition. Averaged across patient intervention status, Phase 2 provider intervention patients reported the most improved adherence and viral suppression at 6 and 12 months. Adherence in "patient intervention only" improved at midpoint and returned to baseline at 12 months. Results suggest provider training sustained patient adherence and viral suppression among "hard to reach" patients.
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Affiliation(s)
- Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard M. Miller School of Medicine, 1400 NW 10th Ave., Miami, FL, 33136, USA.
| | - Omar Sued
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | | | - Lina Bofill
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard M. Miller School of Medicine, 1400 NW 10th Ave., Miami, FL, 33136, USA
| | - Ryan Cook
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard M. Miller School of Medicine, 1400 NW 10th Ave., Miami, FL, 33136, USA
| | - Mar Lucas
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | | | | | - Pedro Cahn
- Clinical Research Department, Fundación Huésped, Buenos Aires, Argentina
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Leonard M. Miller School of Medicine, 1400 NW 10th Ave., Miami, FL, 33136, USA
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Jones DL, Lucas M, Arístegui I, Bordato A, Fernandez-Cabanillas G, Zalazar V, Sued O, Cecchini D, Cassetti I, Cahn P, Bofill L, Weiss SM. Implementation and uptake of the Conexiones y Opciones en la Argentina intervention: feasibility and acceptability. AIDS Care 2016; 28:1287-95. [PMID: 27120502 DOI: 10.1080/09540121.2016.1178697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Challenging HIV-infected patients, those neither adherent nor actively engaged in care, represent an important opportunity for intervention if the HIV epidemic is to be contained. This pilot study assessed the feasibility and acceptability of an adapted patient adherence intervention and a motivational interview-based provider intervention in urban Buenos Aires, Argentina, in order to optimize health benefits in challenging HIV-infected patients. To maximize implementation and uptake of both strategies, interventions were adapted to the local setting. Qualitative data and a short quantitative assessment from patients, staff, fellows, residents and physicians (n = 84) were examined to establish the feasibility and acceptability of offering patient and provider evidence-based interventions in both public and private health-care settings. Results identified key themes on provision of information, use of specialized communication techniques and group support in the utilization of the interventions. Both providers (n = 12) and patients (n = 120) endorsed the acceptability and value of the interventions, and the feasibility of their delivery. Findings support the use of both intervention modalities with challenging patients in diverse urban health-care settings.
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Affiliation(s)
- Deborah L Jones
- a Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , FL , USA
| | | | | | | | | | | | | | | | | | | | - Lina Bofill
- a Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Stephen M Weiss
- a Department of Psychiatry & Behavioral Sciences , University of Miami Miller School of Medicine , Miami , FL , USA
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Dodson S, Klassen KM, McDonald K, Millard T, Osborne RH, Battersby MW, Fairley CK, Simpson JA, Lorgelly P, Tonkin A, Roney J, Slavin S, Sterjovski J, Brereton M, Lewin SR, Crooks L, Watson J, Kidd MR, Williams I, Elliott JH. HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV. BMC Infect Dis 2016; 16:114. [PMID: 26945746 PMCID: PMC4779564 DOI: 10.1186/s12879-016-1422-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 02/09/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV. METHODS/DESIGN The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ). DISCUSSION The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access. TRIAL REGISTRATION Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014.
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Affiliation(s)
- Sarity Dodson
- School of Health and Social Development, Deakin University, Geelong, Australia. .,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Karen M Klassen
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Karalyn McDonald
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Tanya Millard
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Richard H Osborne
- School of Health and Social Development, Deakin University, Geelong, Australia.
| | - Malcolm W Battersby
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia.
| | - Christopher K Fairley
- Melbourne Sexual Health Centre and Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia.
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Paula Lorgelly
- Centre for Health Economics, Monash University, Melbourne, Australia.
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Janine Roney
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Sean Slavin
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
| | - Jasminka Sterjovski
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
| | - Margot Brereton
- Science and Engineering Faculty, Queensland University of Technology, Brisbane, Australia.
| | - Sharon R Lewin
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
| | - Levinia Crooks
- Australasian Society for HIV Medicine, Sydney, Australia. .,Department of Public Health and Human Biosciences, La Trobe University, Melbourne, Australia.
| | - Jo Watson
- National Association of People with HIV Australia, Sydney, Australia.
| | - Michael R Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia.
| | - Irith Williams
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
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Beach MC, Roter DL, Saha S, Korthuis PT, Eggly S, Cohn J, Sharp V, Moore RD, Wilson IB. Impact of a brief patient and provider intervention to improve the quality of communication about medication adherence among HIV patients. PATIENT EDUCATION AND COUNSELING 2015; 98:1078-83. [PMID: 26021185 PMCID: PMC4546873 DOI: 10.1016/j.pec.2015.05.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/13/2015] [Accepted: 05/14/2015] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. METHODS We randomized 26 providers at three HIV care sites to receive or not receive a one-hour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the roter interaction analysis system (RIAS). RESULTS There was more dialogue about therapeutic regimen in visits with intervention patients and providers (167 vs 128, respectively, p=.004), with the majority of statements coming from providers. These visits also included more brainstorming solutions to nonadherence (41% vs. 22%, p=0.026). Intervention compared with control visit providers engaged in more positive talk (44 vs. 38 statements, p=0.039), emotional talk (26 vs. 18 statements, p<0.001), and probing of patient opinion (3 vs. 2 statements, p=0.009). CONCLUSION A brief provider training combined with patient coaching sessions, improved provider communication behaviors and increased dialogue regarding medication adherence.
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Affiliation(s)
- Mary Catherine Beach
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, USA; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Welch Center for Prevention, Epidemiology and Clinical Research, USA.
| | - Debra L Roter
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Somnath Saha
- Portland VA Medical Center, Portland, USA; Department of Medicine, Oregon Health Sciences University, Portland, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, USA
| | - Susan Eggly
- Department of Medicine, Wayne State University, Detroit, USA
| | - Jonathan Cohn
- Department of Medicine, Wayne State University, Detroit, USA
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, USA
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Laws MB, Rose GS, Beach MC, Lee Y, Rogers WS, Velasco AB, Wilson IB. Patient-provider concordance with behavioral change goals drives measures of motivational interviewing consistency. PATIENT EDUCATION AND COUNSELING 2015; 98:728-733. [PMID: 25791372 PMCID: PMC4417001 DOI: 10.1016/j.pec.2015.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 02/10/2015] [Accepted: 02/14/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Motivational Interviewing (MI) consistent talk by a counselor is thought to produce "change talk" in clients. However, it is possible that client resistance to behavior change can produce MI inconsistent counselor behavior. METHODS We applied a coding scheme which identifies all of the behavioral counseling about a given issue during a visit ("episodes"), assesses patient concordance with the behavioral goal, and labels providers' counseling style as facilitative or directive, to a corpus of routine outpatient visits by people with HIV. Using a different data set of comparable encounters, we applied the concepts of episode and concordance, and coded using the Motivational Interviewing Treatment Integrity system. RESULTS Patient concordance/discordance was not observed to change during any episode. Provider directiveness was strongly associated with patient discordance in the first study, and MI inconsistency was strongly associated with discordance in the second. CONCLUSION Observations that MI-consistent behavior by medical providers is associated with patient change talk or outcomes should be evaluated cautiously, as patient resistance may provoke MI-inconsistency. PRACTICE IMPLICATIONS Counseling episodes in routine medical visits are typically too brief for client talk to evolve toward change. Providers with limited training may have particular difficulty maintaining MI consistency with resistant clients.
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Affiliation(s)
- Michael Barton Laws
- Dept of Health Services, Policy and Practice, Brown University School of Public Health, Providence, USA.
| | - Gary S Rose
- Massachusetts School of Professional Psychology, Boston, USA
| | - Mary Catherine Beach
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yoojin Lee
- Dept of Health Services, Policy and Practice, Brown University School of Public Health, Providence, USA
| | - William S Rogers
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA
| | - Alyssa Bianca Velasco
- Dept of Health Services, Policy and Practice, Brown University School of Public Health, Providence, USA
| | - Ira B Wilson
- Dept of Health Services, Policy and Practice, Brown University School of Public Health, Providence, USA
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Langebeek N, Nieuwkerk P. Electronic medication monitoring-informed counseling to improve adherence to combination anti-retroviral therapy and virologic treatment outcomes: a meta-analysis. Front Public Health 2015; 3:139. [PMID: 26042212 PMCID: PMC4436806 DOI: 10.3389/fpubh.2015.00139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/30/2015] [Indexed: 11/26/2022] Open
Abstract
Background Adherence to combination anti-retroviral therapy for HIV infection is a primary determinant of treatment success, but is often suboptimal. Previous studies have suggested that electronic medication monitoring-informed counseling is among the most effective adherence intervention components. Our objective was to review available evidence about the effectiveness of monitoring-informed counseling and to aggregate findings into quantitative estimates of the effect of such intervention on medication adherence and virologic treatment outcomes. Methods We searched PubMed for papers reporting on randomized controlled trials comparing intervention groups receiving monitoring-informed counseling as one of the intervention components versus control groups not receiving such counseling for their effect on medication adherence and viral load concentrations. The standardized mean difference (SMD) in adherence and the odds ratio (OR) of undetectable HIV RNA in intervention versus control groups were the common effect sizes. Random-effect models with inverse variance weights were used to aggregate findings into pooled effect estimates with 95% confidence limits (CI). Results A total of 13 studies were included. Adherence was significantly higher in intervention groups than in control groups (SMD 0.51, 95% CI 0.31–0.71). Patients in intervention groups were significantly more likely to have undetectable HIV RNA concentrations than patients in control groups (OR 1.35, 95% CI 1.12–1.63). However, in studies in which monitoring-informed counseling was the only intervention component, the difference in adherence and virologic response between intervention and control groups was not statistically significant. Conclusion Electronic monitoring-informed counseling improved adherence and virologic response compared with control groups not receiving such counseling in studies in which it was one out of multiple intervention components, but not in studies where it was the only intervention component.
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Affiliation(s)
- Nienke Langebeek
- Department of Internal Medicine, Rijnstate Hospital , Arnhem , Netherlands ; Department of Medical Psychology, Academic Medical Center , Amsterdam , Netherlands
| | - Pythia Nieuwkerk
- Department of Medical Psychology, Academic Medical Center , Amsterdam , Netherlands
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Genberg BL, Lee Y, Rogers WH, Wilson IB. Four types of barriers to adherence of antiretroviral therapy are associated with decreased adherence over time. AIDS Behav 2015; 19:85-92. [PMID: 24748240 DOI: 10.1007/s10461-014-0775-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objectives of this study were to understand how different types of barriers to adherence to antiretroviral therapy (ART) were related and their differential impact on objectively measured adherence over time. Data from 151 patients taking ART were used to describe four sub-types of self-reported adherence barriers: medication and health concerns (MHC), stigma (S), family responsibilities (FR), and problems with schedule and routine (PSR). Generalized linear models with generalized estimating equations (GEE) were used to examine the impact of barriers on adherence over time. The sample was 23 % female, mean age 42 years, with 26 % African-American and 20 % Hispanic. The overall average adherence was 73 %. Patients reported at least one PSR barrier in 66 % of study visits, MHC in 40 %, S in 17 %, and FR in 6 %. In 40 % of visits, patients reported two or more barrier sub-types. There were statistically significant (p ≤ 0.05) decreases of 3.9, 2.5, and 2.4 in percent adherence, for MHC, PSR, and S, respectively, per unit increase in barrier score. Interventions to address different types of patient-identified barriers to ART adherence using targeted approaches are needed.
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Affiliation(s)
- Becky L Genberg
- Program in Public Health, Department of Health Services, Policy & Practice, Brown University, Box G-121-6, 121 South Main Street, Providence, RI, 02912, USA,
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Laws MB, Lee Y, Rogers WH, Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Moore R, Wilson IB. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. AIDS Behav 2014; 18:1279-87. [PMID: 24464408 PMCID: PMC4047172 DOI: 10.1007/s10461-014-0697-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.
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Affiliation(s)
- M Barton Laws
- Department of Health Services, Policy and Practice, Brown University, G-S121-7, Providence, RI, 02912, USA,
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Wallace BC, Laws MB, Small K, Wilson IB, Trikalinos TA. Automatically annotating topics in transcripts of patient-provider interactions via machine learning. Med Decis Making 2014; 34:503-12. [PMID: 24285151 PMCID: PMC3991772 DOI: 10.1177/0272989x13514777] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Annotated patient-provider encounters can provide important insights into clinical communication, ultimately suggesting how it might be improved to effect better health outcomes. But annotating outpatient transcripts with Roter or General Medical Interaction Analysis System (GMIAS) codes is expensive, limiting the scope of such analyses. We propose automatically annotating transcripts of patient-provider interactions with topic codes via machine learning. METHODS We use a conditional random field (CRF) to model utterance topic probabilities. The model accounts for the sequential structure of conversations and the words comprising utterances. We assess predictive performance via 10-fold cross-validation over GMIAS-annotated transcripts of 360 outpatient visits (>230,000 utterances). We then use automated in place of manual annotations to reproduce an analysis of 116 additional visits from a randomized trial that used GMIAS to assess the efficacy of an intervention aimed at improving communication around antiretroviral (ARV) adherence. RESULTS With respect to 6 topic codes, the CRF achieved a mean pairwise kappa compared with human annotators of 0.49 (range: 0.47-0.53) and a mean overall accuracy of 0.64 (range: 0.62-0.66). With respect to the RCT reanalysis, results using automated annotations agreed with those obtained using manual ones. According to the manual annotations, the median number of ARV-related utterances without and with the intervention was 49.5 versus 76, respectively (paired sign test P = 0.07). When automated annotations were used, the respective numbers were 39 versus 55 (P = 0.04). While moderately accurate, the predicted annotations are far from perfect. Conversational topics are intermediate outcomes, and their utility is still being researched. CONCLUSIONS This foray into automated topic inference suggests that machine learning methods can classify utterances comprising patient-provider interactions into clinically relevant topics with reasonable accuracy.
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Affiliation(s)
- Byron C. Wallace
- Dept of Health Services, Policy and Practice,121 South Main Street, Providence, RI, 02903, USA
| | - M. Barton Laws
- Dept of Health Services, Policy and Practice,121 South Main Street, Providence, RI, 02903, USA
| | - Kevin Small
- National Institutes of Health, 2 Center Drive, Bethesda, MD 20892, USA
| | - Ira B. Wilson
- Dept of Health Services, Policy and Practice,121 South Main Street, Providence, RI, 02903, USA
| | - Thomas A. Trikalinos
- Dept of Health Services, Policy and Practice,121 South Main Street, Providence, RI, 02903, USA
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Lehmann HP. From Text Tagging to Decision Support. Med Decis Making 2014; 34:414-6. [DOI: 10.1177/0272989x14529847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis. Drugs 2014; 73:545-62. [PMID: 23588595 PMCID: PMC3647098 DOI: 10.1007/s40265-013-0041-3] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Non-adherence to medications is prevalent across all medical conditions that include ambulatory pharmacotherapy and is thus a major barrier to achieving the benefits of otherwise effective medicines. Objective The objective of this systematic review was to identify and to compare the efficacy of strategies and components thereof that improve implementation of the prescribed drug dosing regimen and maintain long-term persistence, based on quantitative evaluation of effect sizes across the aggregated trials. Data sources MEDLINE, EMBASE, CINAHL, the Cochrane Library, and PsycINFO were systematically searched for randomized controlled trials that tested the efficacy of adherence-enhancing strategies with self-administered medications. The searches were limited to papers in the English language and were included from database inception to 31 December 2011. Study selection Our review included randomized controlled trials in which adherence was assessed by electronically compiled drug dosing histories. Five thousand four hundred studies were screened. Eligibility assessment was performed independently by two reviewers. A structured data collection sheet was developed to extract data from each study. Study appraisal and synthesis methods The adherence-enhancing components were classified in eight categories. Quality of the papers was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions guidelines to assess potential bias. A combined adherence outcome was derived from the different adherence variables available in the studies by extracting from each paper the available adherence summary variables in a pre-defined order (correct dosing, taking adherence, timing adherence, percentage of adherent patients). To study the association between the adherence-enhancing components and their effect on adherence, a linear meta-regression model, based on mean adherence point estimates, and a meta-analysis were conducted. Results Seventy-nine clinical trials published between 1995 and December 2011 were included in the review. Patients randomized to an intervention group had an average combined adherence outcome of 74.3 %, which was 14.1 % higher than in patients randomized to the control group (60.2 %). The linear meta-regression analysis with stepwise variable selection estimated an 8.8 % increase in adherence when the intervention included feedback to the patients of their recent dosing history (EM-feedback) (p < 0.01) and a 5.0 % increase in adherence when the intervention included a cognitive-educational component (p = 0.02). In addition, the effect of interventions on adherence decreased by 1.1 % each month. Sensitivity analysis by selecting only high-quality papers confirmed the robustness of the model. The random effects model in the meta-analysis, conducted on 48 studies, confirmed the above findings and showed that the improvement in adherence was 19.8 % (95 % CI 10.7–28.9 %) among patients receiving EM-feedback, almost double the improvement in adherence for studies that did not include this type of feedback [10.3 % (95 % CI 7.5–13.1 %)] (p < 0.01). The improvement in adherence was 16.1 % (95 % CI 10.7–21.6 %) in studies that tested cognitive-educational components versus 10.1 % (95 % CI 6.6–13.6 %) in studies that did not include this type of intervention (p = 0.04). Among 57 studies measuring clinical outcomes, only 8 reported a significant improvement in clinical outcome. Limitations Despite a common measurement, the meta-analysis was limited by the heterogeneity of the pooled data and the different measures of medication adherence. The funnel plot showed a possible publication bias in studies with high variability of the intervention effect. Conclusions Notwithstanding the statistical heterogeneity among the studies identified, and potential publication bias, the evidence from our meta-analysis suggests that EM-feedback and cognitive-educational interventions are potentially effective approaches to enhance patient adherence to medications. The limitations of this research highlight the urgent need to define guidelines and study characteristics for research protocols that can guide researchers in designing studies to assess the effects of adherence-enhancing interventions. Electronic supplementary material The online version of this article (doi:10.1007/s40265-013-0041-3) contains supplementary material, which is available to authorized users.
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Genberg BL, Lee Y, Rogers WH, Willey C, Wilson IB. Stages of change for adherence to antiretroviral medications. AIDS Patient Care STDS 2013; 27:567-72. [PMID: 24093810 DOI: 10.1089/apc.2013.0126] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Providers do not predict reliably which of their HIV-positive patients are having difficulty adhering to antiretroviral therapy (ART). The transtheoretical, or stages of change model, may be a useful tool to help providers identify patients who are having difficulty with ART adherence. The objective of the current study was to determine the relationship between stages of change and ART adherence among patients who were actively taking ART. Data from a randomized trial of a provider-focused intervention were used to examine the relationship between the stages of change and adherence, measured using electronic monitoring devices in the 30 days following the stages of change assessment. Individuals were eligible for inclusion if they were taking ART and had detectable plasma viral load (HIV-RNA). Repeated measures analysis of covariance was used to determine the impact of stages of change on adherence after controlling for potential confounders. The sample of 137 participants was 22% female, 48% white, 28% African-American, with a mean age of 42 years. Fifty-eight percent reported sex with a man as an HIV risk factor, while 13% reported sex with a woman, 14% reported injecting drugs and 15% reported other risk factors. In adjusted models, those in earlier stages of change (i.e., contemplation and preparation) had significantly lower adherence (-9.8%, p=0.04) compared to those in the action and maintenance phases. No demographic characteristics predicted adherence. The stages of change model may function as a screening tool for clinicians to discover patients at-risk of lower adherence.
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Affiliation(s)
- Becky L Genberg
- 1 Department of Health Services, Policy and Practice; Program in Public Health; Brown University , Providence, Rhode Island
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Marcellin F, Spire B, Carrieri MP, Roux P. Assessing adherence to antiretroviral therapy in randomized HIV clinical trials: a review of currently used methods. Expert Rev Anti Infect Ther 2013; 11:239-50. [PMID: 23458765 DOI: 10.1586/eri.13.8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antiretroviral therapy for the treatment of HIV infection requires high levels of adherence to both maintain plasma HIV RNA at undetectable levels and prevent the emergence of drug resistance. As adherence to treatment is a major criterion for the evaluation of therapeutic outcomes, randomized clinical trials (RCTs) conducted among HIV-infected patients commonly include an assessment of adherence. However, there is still no gold-standard tool for assessing adherence behaviors in HIV RCTs. The methods currently used to collect and analyze adherence data are varied, which makes the comparison of results between studies difficult. The scope of this article is to review and discuss the range of adherence measures currently used in RCTs conducted among HIV-infected adults.
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Laws MB, Taubin T, Bezreh T, Lee Y, Beach MC, Wilson IB. Problems and processes in medical encounters: the cases method of dialogue analysis. PATIENT EDUCATION AND COUNSELING 2013; 91:192-9. [PMID: 23391684 PMCID: PMC3622168 DOI: 10.1016/j.pec.2012.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 12/21/2012] [Accepted: 12/28/2012] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To develop methods to reliably capture structural and dynamic temporal features of clinical interactions. METHODS Observational study of 50 audio-recorded routine outpatient visits to HIV specialty clinics, using innovative analytic methods. The comprehensive analysis of the structure of encounters system (CASES) uses transcripts coded for speech acts, then imposes larger-scale structural elements: threads--the problems or issues addressed; and processes within threads--basic tasks of clinical care labeled presentation, information, resolution (decision making) and Engagement (interpersonal exchange). Threads are also coded for the nature of resolution. RESULTS 61% of utterances are in presentation processes. Provider verbal dominance is greatest in information and resolution processes, which also contain a high proportion of provider directives. About half of threads result in no action or decision. Information flows predominantly from patient to provider in presentation processes, and from provider to patient in information processes. Engagement is rare. CONCLUSIONS In this data, resolution is provider centered; more time for patient participation in resolution, or interpersonal engagement, would have to come from presentation. PRACTICE IMPLICATIONS Awareness of the use of time in clinical encounters, and the interaction processes associated with various tasks, may help make clinical communication more efficient and effective.
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Affiliation(s)
- M Barton Laws
- Brown University, Department of Health Services, Policy & Practice, USA.
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Dang BN, Westbrook RA, Black WC, Rodriguez-Barradas MC, Giordano TP. Examining the link between patient satisfaction and adherence to HIV care: a structural equation model. PLoS One 2013; 8:e54729. [PMID: 23382948 PMCID: PMC3559888 DOI: 10.1371/journal.pone.0054729] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/14/2012] [Indexed: 11/18/2022] Open
Abstract
Introduction Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative, patient-centered focus for increasing retention in HIV care and adherence to HAART, and ultimately HIV suppression. Objective To test, through structural equation modeling (SEM), a model of HIV suppression in which patient satisfaction influences HIV suppression indirectly through retention in HIV care and adherence to HAART. Methods We conducted a cross-sectional study of adults receiving HIV care at two clinics in Texas. Patient satisfaction was based on two validated items, one adapted from the Consumer Assessment of Healthcare Providers and Systems survey (“Would you recommend this clinic to other patients with HIV?) and one adapted from the Delighted-Terrible Scale, (“Overall, how do you feel about the care you got at this clinic in the last 12 months?”). A validated, single-item question measured adherence to HAART over the past 4 weeks. Retention in HIV care was based on visit constancy in the year prior to the survey. HIV suppression was defined as plasma HIV RNA <48 copies/mL at the time of the survey. We used SEM to test hypothesized relationships. Results The analyses included 489 patients (94% of eligible patients). The patient satisfaction score had a mean of 8.5 (median 9.2) on a 0- to 10- point scale. A total of 46% reported “excellent” adherence, 76% had adequate retention, and 70% had HIV suppression. In SEM analyses, patient satisfaction with care influences retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression (all p<.0001). Conclusions Patient satisfaction may have direct effects on retention in HIV care and adherence to HAART. Interventions to improve the care experience, without necessarily targeting objective clinical performance measures, could serve as an innovative method for optimizing HIV outcomes.
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Affiliation(s)
- Bich N Dang
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Houston, Texas, USA.
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Laws MB, Beach MC, Lee Y, Rogers WH, Saha S, Korthuis PT, Sharp V, Wilson IB. Provider-patient adherence dialogue in HIV care: results of a multisite study. AIDS Behav 2013; 17:148-59. [PMID: 22290609 DOI: 10.1007/s10461-012-0143-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Few studies have analyzed physician-patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician-patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African-American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients' understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.
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Affiliation(s)
- M Barton Laws
- Department of Health Services Policy and Practice, Brown University, G-S121-7, Providence, RI 02912, USA.
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Dewing S, Mathews C, Schaay N, Cloete A, Louw J, Simbayi L. "It's important to take your medication everyday okay?" An evaluation of counselling by lay counsellors for ARV adherence support in the Western Cape, South Africa. AIDS Behav 2013; 17:203-12. [PMID: 22610373 DOI: 10.1007/s10461-012-0211-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
There is growing interest in standard care programmes for antiretroviral (ARV) adherence support. In South Africa, individual counselling following ARV initiation is a main strategy for supporting adherence in the public sector. Egan's client-centred "Skilled Helper" counselling model is the predominant model used in HIV counselling in this context. This study evaluated counselling delivered by lay ARV adherence counsellors in Cape Town in terms of adherence to Egan's model. Thirty-eight transcripts of counselling sessions with non-adherent patients were analysed based on the methods of content analysis. These sessions were conducted by 30 counsellors. Generally counsellors' practice adhered neither to Egan's model nor a client-centred approach. Inconsistent with evidence-based approaches to counselling for ARV adherence support, counsellors mainly used information-giving and advice as strategies for addressing clients' non-adherence. Recommendations for improving practice are made. The question as to how appropriate strategies from developed countries are for this setting is also raised.
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McInnes DK, Hardy H, Goetz MB, Skolnik PR, Brewster AL, Hofmann RH, Gifford AL. Development and field testing of an HIV medication touch screen computer patient adherence tool with telephone-based, targeted adherence counseling. J Int Assoc Provid AIDS Care 2012; 12:397-406. [PMID: 22968353 DOI: 10.1177/1545109712454333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence. OBJECTIVE To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients. METHODS The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter. RESULTS 72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent. CONCLUSIONS This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.
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Affiliation(s)
- D Keith McInnes
- VA QUERI Program and Center for Health Quality, Outcomes and Economic Research, VA New England Healthcare System, Bedford, MA, USA
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Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, Orrell C, Altice FL, Bangsberg DR, Bartlett JG, Beckwith CG, Dowshen N, Gordon CM, Horn T, Kumar P, Scott JD, Stirratt MJ, Remien RH, Simoni JM, Nachega JB. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med 2012; 156:817-33, W-284, W-285, W-286, W-287, W-288, W-289, W-290, W-291, W-292, W-293, W-294. [PMID: 22393036 PMCID: PMC4044043 DOI: 10.7326/0003-4819-156-11-201206050-00419] [Citation(s) in RCA: 481] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
DESCRIPTION After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.
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Jones D, Sharma A, Kumar M, Waldrop-Valverde D, Nehra R, Vamos S, Cook R, Weiss SM. Enhancing HIV medication adherence in India. J Int Assoc Provid AIDS Care 2012; 12:343-8. [PMID: 22628369 DOI: 10.1177/1545109712446177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy. METHODS Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report. RESULTS At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; χ(2) = 5.67, P = .02). CONCLUSIONS Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.
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Affiliation(s)
- Deborah Jones
- Miller School of Medicine, University of Miami, Miami, FL, USA
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Cocohoba JM, Althoff KN, Cohen M, Hu H, Cunningham CO, Sharma A, Greenblatt RM. Pharmacist counseling in a cohort of women with HIV and women at risk for HIV. Patient Prefer Adherence 2012; 6:457-63. [PMID: 22791983 PMCID: PMC3393123 DOI: 10.2147/ppa.s30797] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND METHODS Achieving high adherence to antiretroviral therapy for human immunodeficiency virus (HIV) is challenging due to various system-related, medication-related, and patient-related factors. Community pharmacists can help patients resolve many medication-related issues that lead to poor adherence. The purpose of this cross-sectional survey nested within the Women's Interagency HIV Study was to describe characteristics of women who had received pharmacist medication counseling within the previous 6 months. The secondary objective was to determine whether HIV-positive women who received pharmacist counseling had better treatment outcomes, including self-reported adherence, CD4(+) cell counts, and HIV-1 viral loads. RESULTS Of the 783 eligible participants in the Women's Interagency HIV Study who completed the survey, only 30% of participants reported receiving pharmacist counseling within the last 6 months. Factors independently associated with counseling included increased age (odds ratio [OR] 1.28; 95% confidence interval [CI] 1.07-1.55), depression (OR 1.75; 95% CI 1.25-2.45), and use of multiple pharmacies (OR 1.65; 95% CI 1.15-2.37). Patients with higher educational attainment were less likely to report pharmacist counseling (OR 0.68; 95% CI 0.48-0.98), while HIV status did not play a statistically significant role. HIV-positive participants who received pharmacist counseling were more likely to have optimal adherence (OR 1.23; 95% CI 0.70-2.18) and increased CD4(+) cell counts (+43 cells/mm(3), 95% CI 17.7-104.3) compared with those who had not received counseling, though these estimates did not achieve statistical significance. CONCLUSION Pharmacist medication counseling rates are suboptimal in HIV-positive and at-risk women. Pharmacist counseling is an underutilized resource which may contribute to improved adherence and CD4(+) counts, though prospective studies should be conducted to explore this effect further.
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Affiliation(s)
- Jennifer M Cocohoba
- University of California, San Francisco School of Pharmacy, San Francisco, CA
- Correspondence: Jennifer M Cocohoba, Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, 521 Parnassus Avenue, C-152, Box 0622, San Francisco, CA 94143-0622, USA, Tel +1 415 514 0892, Fax +1 415 476 6632, Email
| | - Keri N Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mardge Cohen
- Department of Medicine, Stroger Hospital and Rush Medical College, Chicago, IL
| | - Haihong Hu
- Department of Medicine, Georgetown University, Washington, DC
| | | | | | - Ruth M Greenblatt
- University of California, San Francisco School of Pharmacy, San Francisco, CA
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
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Laws MB, Rose GS, Bezreh T, Beach MC, Taubin T, Kogelman L, Gethers M, Wilson IB. Treatment acceptance and adherence in HIV disease: patient identity and the perceived impact of physician-patient communication. Patient Prefer Adherence 2012; 6:893-903. [PMID: 23271898 PMCID: PMC3526886 DOI: 10.2147/ppa.s36912] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Studies have found that physician-patient relationships and communication quality are related to medication adherence and outcomes in HIV care. Few qualitative studies exist of how people living with HIV experience clinical communication about their self-care behavior. Eight focus groups with people living with HIV in two US cities were conducted. Participants responded to a detailed discussion guide and to reenactments of actual physician-patient dialogue about antiretroviral adherence. The 82 participants were diverse in age, sex, and ethnicity. Most had been living with HIV for many years and had stable relationships with providers. They appreciated providers who knew and cared about their personal lives, who were clear and direct about instructions, and who were accessible. Most had struggled to overcome addiction, emotional turmoil, and/or denial before gaining control over their lives and becoming adherent to medications. They made little or no causal attribution for their transformation to any outside agency, including their providers. They generally saw medication adherence as a function of autonomous motivation. Successful coping with HIV with its prevalent behavioral comorbidities, stigma, and other challenges requires a transformation of identity and internalization of motivation to maintain health. Effective methods for clinicians to support such development are needed.
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Affiliation(s)
- M Barton Laws
- Department of Health Services Policy and Practice, Brown University, Providence, RI, USA
- Correspondence: M Barton, Laws Department of Health Services Policy and Practice, Brown University, G-S121-7, 121 South Main Street, Providence, RI 02912, USA, Tel +1 401 863 6977, Email
| | - Gary S Rose
- Massachusetts School of Professional Psychology, Boston, MA, USA
| | - Tanya Bezreh
- Department of Health Services Policy and Practice, Brown University, Providence, RI, USA
| | | | - Tatiana Taubin
- Department of Health Services Policy and Practice, Brown University, Providence, RI, USA
| | | | - Marcia Gethers
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ira B Wilson
- Department of Health Services Policy and Practice, Brown University, Providence, RI, USA
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Bezreh T, Laws MB, Taubin T, Rifkin DE, Wilson IB. Challenges to physician-patient communication about medication use: a window into the skeptical patient's world. Patient Prefer Adherence 2012; 6:11-8. [PMID: 22272065 PMCID: PMC3262486 DOI: 10.2147/ppa.s25971] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients frequently do not take medicines as prescribed and often do not communicate with their physicians about their medication-taking behavior. The movement for "patient-centered" care has led to relabeling of this problem from "noncompliance" to "nonadherence" and later to a rhetoric of "concordance" and "shared decision making" in which physicians and patients are viewed as partners who ideally come to agreement about appropriate treatment. We conducted a qualitative content analysis of online comments to a New York Times article on low rates of medication adherence. The online discussion provides data about how a highly selected, educated sample of patients thinks about medication use and the doctor-patient relationship. Our analysis revealed patient empowerment and self-reliance, considerable mistrust of medications and medical practice, and frequent noncommunication about medication adherence issues. We discuss how these observations can potentially be understood with reference to Habermas's theory of communicative action, and conclude that physicians can benefit from better understanding the negative ways in which some patients perceive physicians' prescribing practices.
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Affiliation(s)
- Tanya Bezreh
- Health Services Policy and Practice, Brown University, Providence, RI, USA
| | - M Barton Laws
- Health Services Policy and Practice, Brown University, Providence, RI, USA
- Correspondence: M Barton Laws, Department of Health Services Policy and Practice, Brown University, 121 South Main Street, G-S121-7, Providence, RI 02912, USA, Tel +1 401 863 6977, Fax +1 401 863 3713, Email
| | - Tatiana Taubin
- Health Services Policy and Practice, Brown University, Providence, RI, USA
| | - Dena E Rifkin
- Divisions of Nephrology and of Preventive Medicine, University of California, San Diego, CA, USA
| | - Ira B Wilson
- Health Services Policy and Practice, Brown University, Providence, RI, USA
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Laws MB, Epstein L, Lee Y, Rogers W, Beach MC, Wilson IB. The association of visit length and measures of patient-centered communication in HIV care: a mixed methods study. PATIENT EDUCATION AND COUNSELING 2011; 85:e183-e188. [PMID: 21592716 PMCID: PMC3158953 DOI: 10.1016/j.pec.2011.04.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 03/08/2011] [Accepted: 04/08/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Patient centered clinical communication may be associated with longer encounters. METHODS We used the General Medical Interaction Analysis System (GMIAS) to code transcripts of routine outpatient visits in HIV care, and create 5 measures of patient-centeredness. We defined visit length as number of utterances. To better understand properties of encounters reflected in these measures, we conducted a qualitative analysis of the 15 longest and 15 shortest visits. RESULTS All 5 measures were significantly associated with visit length (p<0.05, rank order correlations 0.21-0.44). In multivariate regressions, association of patient centeredness with visit length was attenuated for 4 measures, and increased for 1; two were no longer statistically significant (p>0.05). Black and Hispanic race were associated with shorter visits compared with White race. Some of the longest visits featured content that could be considered extraneous to appropriate care. CONCLUSION Patient centeredness is weakly related to visit length, but may reflect inefficient use of time in long encounters. PRACTICE IMPLICATIONS Efforts to make visits more patient centered should focus on improving dialogue quality and efficient use of time, not on making visits longer. Shorter visits for Black and Hispanic patients could contribute to health disparities related to race and ethnicity.
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Laws MB, Bradshaw YS, Safren SA, Beach MC, Lee Y, Rogers W, Wilson IB. Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study. AIDS Behav 2011; 15:812-22. [PMID: 20981480 DOI: 10.1007/s10461-010-9844-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction; two others included substantial discussion which was not evidently directed at the patient's changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.
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Affiliation(s)
- M Barton Laws
- Public Health Program, Warren Alpert School of Medicine, Brown University, G-S121-7, Providence, RI 02912, USA.
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