A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Innovative Approaches to Enhance and Measure Medication Adherence in Chronic Disease Management: A Review

Medication non-adherence is a problem that affects up to 50% of patients with chronic diseases. The result is a failure to achieve therapeutic goals and an increased burden on the healthcare system. It is, therefore, highly appropriate to develop models to assess patient adherence to prescribed therapy. To date, there are many methods for doing this. However, several tools have been developed that subjectively or objectively, directly or indirectly, assess the level of patient adherence. Electronic medication packaging devices are among the most rapidly evolving methods of measuring adherence. Other emerging technologies include the use of artificial intelligence algorithms and ingestible biosensors. The former is being used to create applications for mobile phones and laptops. The latter appears to be the least susceptible to the risk of overestimating adherence but remains very expensive. Here, we present recent developments in measuring patient adherence, and provide details of achievements in objective methods for assessing adherence, such as electronic monitoring devices, video-observed therapy, and ingestible biosensors. A dedicated section on using artificial intelligence and machine learning in adherence measurement and reviewing questionnaires and scales used in specific diseases is also included. Methods are discussed along with their advantages and potential limitations. This article aimed to review current measures and future initiatives to improve patient medication adherence.

Discrepancies between self-reported medication in adherence and indirect measurement adherence among patients undergoing antiretroviral therapy: a systematic review

BACKGROUND

Given the critical importance of medication adherence in HIV/AIDS treatment, this study aims to compare medication adherence measured by self-report (SR) and indirect measurement among antiretroviral therapy (ART) patients, exploring the differences of adherence results measured by different tools.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library to identify all relevant literature published up to November 22, 2023, without language restrictions, reporting adherence to ART measured by both SR and indirect measurement methods, while also analyzing individual and group adherence separately. Discrepancies between SR and indirect measurement results were assessed using the Mann-Whitney U test or Wilcoxon signed-rank test, with correlations evaluated using the Pearson correlation coefficient. Following one-to-one comparisons, meta-epidemiological one-step analysis was conducted, and network meta-analysis techniques were applied to compare results obtained through specific adherence assessment tools reported in the identified articles.

RESULTS

The analysis encompassed 65 original studies involving 13,667 HIV/AIDS patients, leading to 112 one-to-one comparisons between SR and indirect measurement tools. Statistically significant differences were observed between SR and indirect measurement tools regarding both individual and group adherence (P < 0.05), with Pearson correlation coefficients of 0.843 for individual adherence and 0.684 for group adherence. During meta-epidemiological one-step analysis, SR-measured adherence was determined to be 3.94% (95% CI: -4.48-13.44%) higher for individual adherence and 16.14% (95% CI: 0.81-18.84%) higher for group adherence compared to indirectly measured results. Subgroup analysis indicated that factors such as the year of reporting and geographic region appeared to influence the discrepancies between SR and indirect measurements. Furthermore, network meta-analysis revealed that for both individual and group adherence, the results obtained from most SR and indirect measurement tools were higher than those from electronic monitoring devices, with some demonstrating statistical significance (P < 0.05).

CONCLUSIONS

The findings underscored the complexity of accurately measuring medication adherence among ART patients. Significant variability was observed across studies, with self-report methods showing a significant tendency towards overestimation. Year of reporting, geographic region, and adherence measurement tools appeared to influence the differences between SR and indirect measurements. Future research should focus on developing and validating integrated adherence measurements that can combine SR data with indirect measures to achieve a more comprehensive understanding of adherence behaviors.

Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis

In response to growing recognition that nonadherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this article was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this article was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.

Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve

INTRODUCTION

Randomized controlled trials (RCTs) are important sources of evidence that strongly influence guidelines for patient management, including for elevated blood pressure in adults.

AREAS COVERED

Critical questions regarding the interpretation of hypertension trial results have recently increased, especially for concerns over methodology. In particular, investigator adherence to the protocol and patient adherence to investigational drugs are often far from optimal. These issues may be ignored or underreported because physicians' behavior during trials is often not monitored and patients' medication adherence is neither measured adequately nor reported or analyzed in the final report or in the publication. This situation may lead to misinterpretations of study results and misevaluations of the safety and efficacy profile of new drugs. In this short review, the problem of measuring, reporting, and analyzing drug adherence in RCTs is discussed and illustrated with several examples in the field of hypertension.

EXPERT OPINION

The main conclusion is that drug adherence should always be measured in clinical trials, possibly with more than one method. In addition, prespecified analyses of adherence data should be included in the statistical plan of all trials to improve their overall quality.

Using a Semiautomated Procedure (CleanADHdata.R Script) to Clean Electronic Adherence Monitoring Data: Tutorial

BACKGROUND

Patient adherence to medications can be assessed using interactive digital health technologies such as electronic monitors (EMs). Changes in treatment regimens and deviations from EM use over time must be characterized to establish the actual level of medication adherence.

OBJECTIVE

We developed the computer script CleanADHdata.R to clean raw EM adherence data, and this tutorial is a guide for users.

METHODS

In addition to raw EM data, we collected adherence start and stop monitoring dates and identified the prescribed regimens, the expected number of EM openings per day based on the prescribed regimen, EM use deviations, and patients' demographic data. The script formats the data longitudinally and calculates each day's medication implementation.

RESULTS

We provided a simulated data set for 10 patients, for which 15 EMs were used over a median period of 187 (IQR 135-342) days. The median patient implementation before and after EM raw data cleaning was 83.3% (IQR 71.5%-93.9%) and 97.3% (IQR 95.8%-97.6%), respectively (Δ+14%). This difference is substantial enough to consider EM data cleaning to be capable of avoiding data misinterpretation and providing a cleaned data set for the adherence analysis in terms of implementation and persistence.

CONCLUSIONS

The CleanADHdata.R script is a semiautomated procedure that increases standardization and reproducibility. This script has broader applicability within the realm of digital health, as it can be used to clean adherence data collected with diverse digital technologies.

Medical Measures in Hypertensives Considered Resistant

BACKGROUND

Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk.

METHODS

All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension.

RESULTS

Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled.

CONCLUSIONS

Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.

Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine

PURPOSE

Capecitabine is an oral chemotherapy used to treat many gastrointestinal cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality care.

METHODS

We conducted a pilot study of PENNY-GI, a mobile phone text messaging-based chatbot that leverages algorithmic surveys and natural language processing to promote medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. Eligibility initially included all capecitabine-containing regimens but was subsequently restricted to capecitabine monotherapy because of challenges in integrating PENNY-GI with radiation and intravenous chemotherapy schedules. We used design thinking principles and real-time data on safety, accuracy, and usefulness to make iterative refinements to PENNY-GI with the goal of minimizing the proportion of text messaging exchanges with incorrect medication or symptom management recommendations. All patients were invited to participate in structured exit interviews to provide feedback on PENNY-GI.

RESULTS

We enrolled 40 patients (median age 64.5 years, 52.5% male, 62.5% White, 55.0% with colorectal cancer, 50.0% on capecitabine monotherapy). We identified 284 of 3,895 (7.3%) medication-related and 13 of 527 (2.5%) symptom-related text messaging exchanges with incorrect recommendations. In exit interviews with 24 patients, participants reported finding the medication reminders reliable and user-friendly, but the symptom management tool was too simplistic to be helpful.

CONCLUSION

Although PENNY-GI provided accurate recommendations in >90% of text messaging exchanges, we identified multiple limitations with respect to the intervention's generalizability, usefulness, and scalability. Lessons from this pilot study should inform future efforts to develop and implement digital health interventions in oncology.

A structured oral chemotherapy teaching tool to improve adherence in adults with multiple myeloma: A pilot randomized controlled trial

INTRODUCTION

Many of the newer treatments for adults with newly-diagnosed and relapsed multiple myeloma (MM) are orally administered. Adherence is a challenge, and little is known about strategies to optimize adherence.

MATERIALS AND METHODS

Forty-seven patients initiating orally-administered anti-myeloma therapy were enrolled and randomized in a pilot study to receive either standard of care teaching or the Multinational Association of Supportive Care in Cancer Oral agent Teaching Tool (MOATT), a structured teaching tool. Adherence was measured electronically with a Medication Event Monitoring System (MEMS) cap. Optimal adherence was defined as an adherence rate of ≥90% over the six months study duration. Patients completed surveys regarding cancer therapy satisfaction and self-efficacy for medication management at one month and six months following the initiation of treatment in both arms.

RESULTS

The mean adherence of patients over six months was 86.9%; 43.9% of the cohort were classified as non-adherent using the 90% threshold of adherence. Mean adherence was similar among standard of care teaching (87.9%) versus the MOATT intervention tool (85.6%) as was cancer therapy satisfaction and self-efficacy for medication management.

DISCUSSION

In our pilot, the MOATT tool was not found to be feasible or acceptable. There were no preliminary differences noted between standard of care teaching versus the structured MOATT teaching tool with regards to overall adherence rates, cancer therapy satisfaction, or self-efficacy in medication management. Overall adherence rates were suboptimal in our study. Future research should work to identify aspects of educational interventions which are effective, and investigate different strategies which can be used to supplement patient education and potentially optimize medication adherence in patients with MM.

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial

BACKGROUND

Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial.

METHODS

Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty.

RESULTS

None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures.

CONCLUSION

These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting.

TRIAL REGISTRATION

Dutch National trial register: NTR4457 (March, 6th, 2014).

Immunosuppressant adherence in adult outpatient hematopoietic cell transplant recipients

INTRODUCTION

Medication nonadherence continues to be challenging for allogeneic hematopoietic cell transplant (HCT) recipients. The risk and severity of chronic graft-versus-host disease (GVHD) are associated with low immunosuppressant concentrations (which can be improved with model-informed precision dosing (MIPD)) and with immunosuppressant nonadherence (which can be improved with acceptable interventions).

METHODS

With the goals of improving adherence and achieving therapeutic concentrations of immunosuppressants to eliminate GVHD, we characterized the feasibility of using the Medication Event Monitoring (MEMS®) Cap in adult HCT recipients.

RESULTS

Of the 27 participants offered the MEMS® Cap at the time of hospital discharge, 7 (25.9%) used it, which is below our a priori threshold of 70%. These data suggest the MEMS® Cap is not feasible for HCT recipients. The MEMS® Cap data were available for a median of 35 days per participant per medication (range: 7-109 days). The average daily adherence per participant ranged from 0 to 100%; four participants had an average daily adherence of over 80%.

CONCLUSIONS

MIPD may be supported by MEMS® technology to provide the precise time of immunosuppressant self-administration. The MEMS® Cap was used by only a small percentage (25.9%) of HCT recipients in this pilot study. In accordance with larger studies using less accurate tools to evaluate adherence, immunosuppressant adherence varied from 0% to 100%. Future studies should establish the feasibility and clinical benefit of combining MIPD with newer technology, specifically the MEMS® Button, which can inform the oncology pharmacist of the time of immunosuppressant self-administration.

Evaluation of methods measuring medication adherence in patients with polypharmacy: a longitudinal and patient perspective

PURPOSE

To explore patients' willingness to have medication adherence measured using different methods and evaluate the feasibility and validity of their combination (i.e., pill counts, a medication diary and a questionnaire assessing adherence two months post-discharge).

METHODS

(1) A cross-sectional evaluation of the willingness of patients with polypharmacy to have their medication adherence measured post-discharge. (2) Medication adherence was monitored during two months using pill counts based on preserved medication packages and a diary in which patients registered their adherence-related problems. During a home visit, the Probabilistic Medication Adherence Scale (ProMAS) and a questionnaire on feasibility were administered.

RESULTS

A total of 144 participants completed the questionnaire at discharge. The majority was willing to communicate truthfully about their adherence (97%) and to share adherence-related information with healthcare providers (99%). More participants were willing to preserve medication packages (76%) than to complete a medication diary (67%) during two months. Most participants reported that preserving medication packages (91%), completing the diary (99%) and the ProMAS (99%) were no effort to them. According to the majority of participants (60%), pill counts most accurately reflected medication adherence, followed by the diary (39%) and ProMAS (1%). Medication adherence measured by pill counts correlated significantly with ProMAS scores, but not with the number of diary-reported problems. However, adherence measured by the medication diary and ProMAS correlated significantly.

CONCLUSION

Combining tools for measuring adherence seems feasible and can provide insight into the accordance of patients' actual medication use with their prescribed regimen, but also into problems contributing to non-adherence.

Monitoring compliance to topical therapy in children and young people with uveitis

BACKGROUND/OBJECTIVES

Uveitis in children and young people (CYP) is a rare but potentially debilitating condition. Steroid eye drops are the first step in treatment and poor compliance may result in vision-threatening complications. This study aims to measure compliance with prescribed eye drops prospectively in a child-specific manner.

SUBJECTS/METHODS

Patients aged 0-18 years attending a tertiary paediatric uveitis clinic using steroid drops were recruited. Both the CYP, and person with parental responsibility (PPR) completed questionnaires about compliance. A subgroup had bottles of Prednisolone 1% drops dispensed and weighed at the first appointment and reweighed at follow-up. The weight reduction was compared with expected weight change over the interval.

RESULTS

The study was completed by 42 patients of the 50 patients recruited. Thirty-one CYP and their respective PPR completed both questionnaires, 11 completed only one questionnaire (9 CYP, 2 PPR). Drop errors for all eye drops were reported more than "once a week" by 13/39 CYP (33.3%, 95% CI: 19.1%-50.2% of respondents), and 3/31 PPR (9.7%, CI: 19.1%-50.2% of respondents). Many PPR could not recall prescribed drop frequency (n = 13/31, 40.6%, CI: 23.7%-59.4% of respondents). Twelve patients had bottles weighed and returned. Insufficient weight reduction was found in 9 (75%, CI: 42.8%-94.5%). Within the eye drop weighing subgroup three participants (25%, CI: 5.5%-57.2%) used <50% the expected weight of drops.

CONCLUSIONS

This study demonstrated poor eye drop compliance in CYP with uveitis. Self-reported compliance was unreliable in this population. Worryingly, some patients miss more than 50% of drops and may suffer sub-optimal disease control.

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

Interventions to improve oral endocrine therapy adherence in breast cancer patients

PURPOSE

Oral endocrine therapy (OET) is recommended in prevention and treatment of hormone receptor-positive breast cancer (HR+ BC). Despite the reduced incidence, recurrence, and mortality, OET adherence is poor in this patient population. The aim of this study was to review the latest literature to identify effective interventions to improve medication adherence in patients taking OET for prevention or treatment of HR+ BC.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework was used to perform this review. We utilized PubMed, SCOPUS, EMBASE, Cochrane, and Web of Science to acquire articles using search terms including breast cancer, adherence, persistence, and acceptability. Inclusion criteria included publication in peer-reviewed journal, primary data source, longitudinal, patients on OET such as aromatase inhibitors (AIs) or selective estrogen receptor modulators (SERMs), measuring adherence, persistence, or acceptability.

RESULTS

Out of 895 articles identified, 10 articles were included. Majority of patients had early-stage HR+ BC. Two out of two studies incorporating technological intervention, two out of three studies with text communication-based intervention, and three out of five studies with verbal communication-based intervention reported significant improvement in OET adherence and/or persistence.

CONCLUSIONS

While the interventions tested so far have shown to improve OET adherence in HR+ BC patients in some studies, there is a need to design combination interventions addressing multiple barriers in this population.

IMPLICATIONS FOR CANCER SURVIVORS

This study showcases effectiveness of novel interventions to improve OET adherence and the need to further develop patient-centered strategies to benefit all patients with HR+ BC.

Factors affecting adherence to psychotropics in trauma-affected refugees: data from a randomized controlled trial

Non-adherence to psychotropic drugs may reduce treatment effectiveness and may cause exacerbation of illness. Among migrant populations, studies have identified low adherence to psychotropic drugs. This study aimed to identify factors that were associated with the three basic components of adherence: non-initiation, non-implementation (blood sample), and discontinuation in a clinical sample of trauma-affected refugees diagnosed with posttraumatic stress disorder. The data for this study is derived from a randomized controlled trial (n = 108). Based on existing literature, individual sociodemographic and clinical candidate predictor variables that may affect the initiation, continuation, and implementation to psychotropics were selected as exposure variables. Logistic regression was used to assess the risk relation between non-initiation, non-implementation, discontinuation, and the individual sociodemographic and clinical factors. Three factors - level of education, turn-up rate for medical doctor sessions, and discomfort in relation to the psychotropics - were associated with non-initiation, non-implementation, or discontinuation. The relatively small sample size poses a limitation. Furthermore, factors not examined in the current study may have affected non-initiation, non-implementation, and discontinuation. The study identified level of education, turn-up rate for medical doctor sessions, and discomfort in relation to medicine as important factors in relation to treatment with psychotropics in trauma-affected refugees. Factors contributing to a low turn-up rate, and factors that are consequences of a low turn-up rate, as well as communication and trust in the patient-provider interaction need further research attention. Furthermore, there is a need for research on interventions addressing adherence for refugees with mental illness.

Controversies in Hypertension V: Resistant and Refractory Hypertension

Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.

Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population

INTRODUCTION

Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC.

METHODS

Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy.

RESULTS

A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC.

CONCLUSION

Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.

Medication adherence reporting in pivotal clinical trials: overview of oral oncological drugs

OBJECTIVES

To assess how and to what extent adherence to medication is reported in pivotal clinical trials of oral cancer drugs.

METHODS

All drugs authorised by the European Medicines Agency from 1 January 2014 to 31 December 2019 were considered for analysis. For each pivotal trial we extracted the journal of publication, phase of the study, posology, mention of adherence within the main text of the published article or additional material and the terms in which the adherence was reported.

RESULTS

Thirty drugs were included in the analysis from 56 clinical trials. Eleven articles (19.6%) contained a mention of medication adherence in the main document, 26 (46.4%) in the supplementary material and 19 (33.9%) did not contain any reference to adherence. Seven studies reported medication adherence between the results, expressed as number of patients discontinuing treatment for non-compliance and mean or median percentage.

CONCLUSIONS

Medication adherence in pivotal clinical trials of oral oncological drugs is poorly represented. There should be a greater level of reporting in the results and it should be included among the minimum set of recommendations in reporting health research.

Cranberry Supplements for Urinary Tract Infection Prophylaxis in Pregnant Women: A Systematic Review of Clinical Trials and Observational Studies on Efficacy, Acceptability, Outcomes Measurement Methods, and Studies' Feasibility

Cranberry supplements are commonly used to prevent urinary tract infections (UTIs). However, their usefulness is uncertain in pregnant women. We aimed to comprehensively summarize the current knowledge on cranberry supplements' efficacy and acceptability during pregnancy in addition to the outcomes measurement methods and studies' feasibility. To achieve it, we searched PubMed, PMC, and Europe PMC databases plus screened citations followed by critical appraisal of included eligible English-written primary studies that (1) focused on pregnant women supplemented with any cranberry supplements; (2) provided data on cranberry supplements' efficacy, acceptability, outcomes measurement methods, and studies' feasibility; (3) included human subjects; and (4) published worldwide. Two randomized clinical trials (RCTs) and one nested cohort study, including 1156 pregnant women in total, contributed to our analysis. A tendency toward UTI reduction was demonstrated, although the results' validity was impacted by significant juice-induced gastrointestinal intolerance (23%; 44 of 188 subjects). Changing the form of supplementation from cranberry juice to capsules reduced the issue, causing side effects in one of 49 subjects (2%). Nevertheless, both RCTs still experienced significant recruitment and retention problems, which were at 33% and 59% on average, respectively. Newly acquired safety data on 919 more subjects suggests no increased risks of all malformations, vaginal bleeding, and neonatal complications. Investigating cranberry capsules' efficacy as a non-antibacterial option for UTI prevention in pregnant women has become a feasible and important direction with the current advancement in understanding cranberry supplements' actions, recommended doses plus regimens, and their safety in the population. We reviewed the challenges and discovered knowledge gaps and the implementation strategies for future studies.

Exploration of smart adherence-monitoring methods in vitamin D-deficient patients: A pilot feasibility clinical study

Treatment adherence is an underestimated determinant of treatment success. Poor treatment adherence can also affect the efficacy of clinical trials. A combination of multiple adherence-monitoring methods is required to ensure robustness. We investigated whether multiple adherence-monitoring methods, including a novel smartwatch-based monitoring method, would yield reliable and concordant results. In this open, randomized, decentralized clinical trial, vitamin D-deficient individuals were randomized to an App - only group (an electronic medication diary) or an App + Watch group (i.e., App and smartwatch-based monitoring) groups after a week run-in period. The participants received vitamin D supplements (1000 IU) for 12 weeks (two consecutive periods of 6 weeks) with two pill counts (at the sixth week) and biweekly blood samplings for serum 25(OH) vitamin D concentration. Adherence was assessed and compared between the methods. Sixteen participants were enrolled, of which 13 completed the study. Serum 25(OH) vitamin D levels comparably increased in both groups until the first 7 weeks but trended higher in the App + Watch group in the second period. The number of doses recorded by the pill count and App did not differ significantly between the run-in and Period 1 (p = 0.5534) but became significantly discrepant in Period 2 (p = 0.0225). In contrast, the concordance for smartwatch-based monitoring was consistent in either period (p = 0.5898 and p = 0.5839, respectively). We explored multiple adherence-monitoring methods in this pilot feasibility clinical study. Smartwatch-based adherence monitoring may be an objective and sensitive method for measuring treatment adherence.

Osteoporosis medication adherence tools: a systematic review

Poor adherence reduces the effectiveness of osteoporosis treatment, resulting in lower bone mineral density and subsequently higher fracture rates. Reliable and practical tools are needed to measure medication adherence. The aim of this systematic review was to find osteoporosis medication adherence measurement tools and assess their applicability. Osteoporosis adherence measurement tools and all their related keywords in PubMed, Embase, Web of Science, and Scopus databases were searched on 4 December, 2022. After excluding duplicates in the Endnote software, two researchers independently investigated the remaining articles and included all those that used a method for measuring adherence to osteoporosis pharmacotherapy. Articles that did not specify the medications evaluated or if the primary focus was not adherence excluded. Two common measures of adherence, i.e., compliance and persistence were included. Four separate tables were designed, one for direct methods, one for formulas, one for questionnaires, and one for electronic methods of measuring adherence to treatment. Quality assessment was performed for selected articles by the Newcastle-Ottawa Quality Assessment Scale (NOS). A total of 3821 articles were found, of which 178 articles met the inclusion and exclusion criteria. In general, five types of methods were observed to measure medication adherence of osteoporosis, including direct methods (n = 4), pharmacy records (n = 17), questionnaires (n = 13), electronic methods (n = 1), and tablet counting (n = 1). The most commonly used adherence measurement tool, based on pharmacy records, was medication possession ratio (MPR). Among questionnaires, Morisky Medication Adherence Scale was mostly used. Our findings show what tools have been used to measure medication adherence in osteoporosis patients. Among these tools, direct methods and electronic methods are the most accurate methods. However, due to their high cost, they are practically not used in measuring osteoporosis medication adherence. Questionnaires are the most popular among them and are mostly used in osteoporosis.

A Questionnaire Survey of Prescription Preferences and Leftover Medication Conversations: Comparisons Among Kidney Disease Patients and Healthcare Professionals

BACKGROUND

Patients with chronic kidney disease (CKD) and patients with kidney failure receiving hemodialysis (HD) receive various types of medications. However, little is known about the differences in medication preference and how to deal with leftover medication among CKD patients and HD patients. The purpose of this study was to investigate the differences in medication preference and ways of dealing with leftover medication between CKD patients, HD patients, physicians, and pharmacists via a questionnaire survey.

METHODS

The ethics committee of Oita University, Oita, Japan, approved this survey. Outpatients undergoing treatment by a nephrologist in four facilities in Oita prefecture, Japan, were asked to answer a questionnaire on their preference for medication and how to deal with leftover medication. Respondents gave their informed written consent. The same questionnaire was administered to nephrologists and pharmacists online.

RESULTS

In this survey, 383 patients (260 patients with CKD and 123 patients with HD), 22 nephrologists, and 28 pharmacists responded. The response rate of valid responses was more than 90% for each of the groups. In particular, 41% of patients with CKD and 56% of patients with HD never inform their doctor about leftover medication or only inform them when there is a lot of leftover medication. On the other hand, 23% of physicians have never asked their patients about them. Ordinary logistic regression analysis indicated that there is no significant relationship between how often patients talk about leftover medication, patients' preferences, or patient states.

CONCLUSIONS

Despite the age and state of the patients, it is important to discuss the perception of medication with each other and confirm the condition of the remaining medication to improve concordance and obtain the desired treatment effect.

Effect of Pain Coping Skills Training on Pain and Pain Medication Use for Women With Breast Cancer

CONTEXT

Pain is distressing for women with breast cancer. Pain medication may not provide full relief and can have negative side-effects. Cognitive-behavioral pain intervention protocols reduce pain severity and improve self-efficacy for pain management. These interventions' impact on pain medication use is less clear. Intervention length and coping skills use might play a role in pain outcomes.

OBJECTIVES

Secondary analysis to examine differences in pain severity, pain medication use, pain self-efficacy, and coping skill use after five- and one-session cognitive-behavioral pain intervention protocols. Pain self-efficacy and coping skills use were assessed as mediators of intervention effects on pain and pain medication use.

METHODS

Women (N = 327) with stage I-III breast cancer were enrolled in a randomized trial comparing individually-delivered, five- and one-session pain coping skills training (PCST). Pain severity, pain medication use, pain self-efficacy, and coping skills use were assessed preintervention and five to eight weeks later (postintervention).

RESULTS

Pain and pain medication use significantly decreased, while pain self-efficacy increased pre-post for women randomized to both conditions (P's <.05). Five-session PCST participants demonstrated less pain (P =.03) and pain medication use (P =.04), and more pain self-efficacy (P =.02) and coping skills use (P =.04) at postintervention compared to one-session PCST participants. Pain self-efficacy mediated the relationship of intervention condition with pain and pain medication use.

CONCLUSION

Both conditions led to improvements in pain, pain medication use, pain self-efficacy, and coping skills use, and 5-session PCST showed the greatest benefits. Brief cognitive-behavioral pain intervention improve pain outcomes, and pain self-efficacy may play a role in these effects.

Using a medication event monitoring system to evaluate self-report and pill count for determining treatment completion with self-administered, once-weekly isoniazid and rifapentine

BACKGROUND

Treatment completion is essential for the effectiveness of any latent tuberculosis infection (LTBI) regimen. The Tuberculosis Trials Consortium (TBTC) Study 33 (iAdhere) combined self-report and pill counts - standard of care (SOC) with a medication event monitoring system (MEMS) to determine treatment completion for 12-dose once-weekly isoniazid and rifapentine (3HP). Understanding the performance of SOC relative to MEMS can inform providers and suggest when interventions may be applied to optimize LTBI treatment completion.

METHOD

iAdhere randomized participants to directly observed therapy (DOT), SAT, or SAT with text reminders in Hong Kong, South Africa, Spain and the United States (U.S.). This post-hoc secondary analysis evaluated treatment completion in both SAT arms, and compared completion based on SOC with MEMS to completion based on SOC only. Treatment completion proportions were compared. Characteristics associated with discordance between SOC and SOC with MEMS were identified.

RESULTS

Overall 80.8% of 665 participants completed treatment per SOC, compared to 74.7% per SOC with MEMS, a difference of 6.1% (95%CI: 4.2%, 7.8%). Among U.S. participants only, this difference was 3.3% (95% CI: 1.8%, 4.9%). Differences in completion was 3.1% (95% CI: -1.1%, 7.3%) in Spain, and 36.8% (95% CI: 24.3%, 49.4%) in South Africa. There was no difference in Hong Kong.

CONCLUSION

When used for monitoring 3HP, SOC significantly overestimated treatment completion in U.S. and South Africa. However, SOC still provides a reasonable estimate of treatment completion of the 3HP regimen, in U.S., Spain, and Hong Kong.

Medication Adherence in Tobacco Cessation Clinical Trials

Adherence is a critical mediator of treatment outcome across health conditions and low rates of adherence undermine success in smoking cessation treatment. This narrative review provides an overview of different techniques that can be used to measure adherence to smoking cessation treatments and outlines strategies to address treatment adherence. Techniques to measure adherence include conducting pill counts, collecting self-reports of adherence, directly observed therapy, biochemical verification methods, and electronic data collection via medication events monitoring systems. Techniques examined for increasing tobacco cessation treatment adherence include counseling, automated adherence calls, feedback from electronic monitors, contingency management and directly observed therapy. Adherence monitoring and optimization should be a standard component of smoking cessation treatment research.

Motivational Interviewing Counseling to Increase Endocrine Therapy Adherence in Diverse Patients

Background: Oral endocrine therapy (ET) is an inexpensive and effective therapy for hormone receptor-positive (HR+) breast cancer that prevents recurrence but relies upon long-term adherence for up to ten years. More than 80% of breast cancer patients have an HR+ phenotype and are candidates for ET, but approximately half discontinue or become non-adherent by five years. ET underuse is more prevalent in Black and young (<50 yrs) women, which may contribute to outcome disparities in these groups. The objective of this study was to evaluate the feasibility, acceptability, and utility of a patient-centered counseling intervention to enhance ET adherence, with a focus on the needs of Black and younger women. Methods: We conducted a single-arm pilot study of a twelve-month motivational interviewing (MI) intervention consisting of five MI counseling sessions, an interactive workbook, a resource guide, and an educational video developed and revised with iterative patient and clinician input. The eligible participants were >18 years old, English speaking, and with stage I–III HR+ breast cancer. Participants were recruited across a large academic medical center and four community sites. Feasibility and acceptability were assessed by measures of participant recruitment, retention, session participation, and patient-reported satisfaction. ET adherence at 12 months was assessed by self-report and medication event monitoring system (MEMS) caps using a continuous measure of the proportion of days covered (PDC) as well as a dichotomous measure of the optimal adherence, defined as >80% PDC. Results: Forty-two women initiated the intervention, of whom thirty-five participants (83%) completed outcome assessments at 12 months, including thirteen Black and twenty-two non-Black participants. The average participant age was 54.8 years (range: 25–73). Overall, 97% completed at least three MI sessions and 83% completed at least four sessions. Participant retention and satisfaction were high, particularly among Black women. Self-reported adherence at 12 months was 88% overall (100% in Black women and 81% in non-Black women). The majority of women also achieved 80% of days adherent using MEMS caps, with a greater adherence in Black women. Conclusions: This study demonstrates the feasibility, acceptability, and early promise of the effectiveness of an MI counseling-based intervention to promote ET adherence and prevent breast cancer recurrence in diverse populations.

In the eyes of the beholders: Subjective experiences of positive symptoms among patients with symptoms of psychosis seeking psychotherapy

BACKGROUND

Reduction of positive symptoms is often the focus of psychiatric treatment for patients with psychosis; however, it is becoming increasingly clear that some patients experience ambivalence towards positive symptoms or may even experience them as pleasant. The present study extends upon work from online studies of patients without verified diagnoses. The first aim was to examine the frequency with which patients report negative, neutral or even positive appraisals of positive symptoms. A second aim was to identify whether these appraisals were associated with medication adherence.

METHODS

One-hundred twelve treatment-seeking patients with current symptoms of psychosis completed the Subjective Perception of Positive Symptoms-Revised (SUPPOSY-R), a scale assessing appraisals of positive symptoms (e.g., gain from illness, impact on daily life), as well as questions regarding medication adherence.

RESULTS

Although most patients reported experiencing positive symptoms as predominantly unpleasant, appraisals differed between symptom clusters and up to 54.4 % reported that they would miss at least some aspects of positive symptoms should they disappear. Patients particularly welcomed the disappearance of auditory hallucinations (71.2 %). Symptom appraisal was not significantly associated with medication compliance (p > .17); however, more patients with low medication adherence reported they would feel at least some regret if their symptoms were to completely disappear (48.9 %, n = 23) versus patients with high adherence (41.7 %, n = 20).

DISCUSSION

Ambivalent or positive appraisals of positive symptoms are lower among treatment-seeking patients compared to patients recruited for online studies, who may not be actively seeking treatment. Auditory hallucinations may cause most distress among treatment-seeking patients. A collaborative approach including assessment of possible positive appraisals of symptoms is important when identifying treatment goals.

Withdrawal of antihypertensive medication in young to middle-aged adults: a prospective, single-group, intervention study

BACKGROUND

Although antihypertensive drug therapy is commonly believed to be a life-long therapy, several recent guidelines have suggested that antihypertensive medications can be gradually reduced or discontinued for some patients whose blood pressure (BP) is well-controlled for an extended period. Thus, this pilot study aimed to describe the success rate of antihypertensive drug discontinuation over 6 months among young and middle-aged patients with hypertension.

METHODS

This was a prospective, single-group, intervention study. Patients were eligible for inclusion if their cardiologist judged them to be appropriate candidates for this study, their BP had been controlled both in the office (< 140/90 mmHg) and 24-h ambulatory BP monitoring (< 135/85 mmHg) for at least 6 months with a single tablet dose of antihypertensive medication. A total of 16 patients withdrew their antihypertensive medications at baseline after they received the education, and were followed up over 6 months. After the follow-ups, six patients participated in the in-depth interview.

RESULTS

The likelihood of remaining normotensive at 30, 90, 180, and 195 days was 1.00, 0.85, 0.51, and 0.28, respectively. There were also no significant differences in baseline characteristics and self-care activities over time between normotensive (n = 8) and hypertensive groups (n = 8). In the interview, most patients expressed ambivalent feelings toward stopping medications. Psychological distress (e.g., anxiety) was the primary reason for withdrawal from this study although the patients' BP was under control.

CONCLUSIONS

We found that only a limited portion of antihypertensive patients could stop their medication successively over 6 months. Although we could not identify factors associated with success in maintaining BP over 6 months, we believe that careful selection of eligible patients may increase success in stopping antihypertensive medications. Also, continuous emotional support might be essential in maintaining patients' off-medication.

Revisiting agency and medical health technology: actor network theory and breast cancer survivors’ perspectives on an adherence tool

Purpose

Optimal treatment adherence is critical in the management of breast cancer patients/survivors taking hormonal therapy. However, lack of adherence is common. Many technologies have been developed to encourage medication intake, such as reminders on phones or digital pills, with varying degrees of success.

Methods

To explore the role of technology in medical adherence requires a framework that considers all complexities of technology, from software to the end user’s beliefs. Actor Network Theory (ANT) defines technology based on its technical, social, and abstract components. We conducted three focus groups, which we analyzed using a thematic analysis to determine topics in breast cancer survivors’ discussions of these technologies. We also conducted a deductive content analysis using ANT concepts as codes.

Results

In discussing the use of technology to improve medical adherence, participants had an empowering view of technology (48.8%) a neutral one (41.5%) or a disempowering view (9.8%). When it comes to their medication adherence, breast cancer survivors taking hormonal therapy perceived technology as something on which they could assert agency while their own agency dictated their adherence behaviors.

Conclusions

In line with a non-technologically deterministic view of medical technologies, this finding shows that technology can be both constraining and enabling, depending on the specific context of human use. This networked understanding of technology in terms of social dynamics has relevant implications in designing interventions that use technology to improve adherence.

The gastrointestinal and microbiome impact of a resistant starch blend from potato, banana, and apple fibers: A randomized clinical trial using smart caps

The gastrointestinal (GI) impact of fibers including resistant starch (RS) consumption depends on various types and amounts of fibers, the initial microbiome states, and accurate intake measurements. A randomized clinical trial evaluated the GI impact of varying doses of a novel resistant starch blend (RSB) with smart cap monitoring. RSB contained at least 50% RS and was a proprietary mixture of a potato starch, green banana flour, and apple fiber powder (a source of apple pectin, not resistant starch). The study design randomized participants to one of four arms: 10 g/day of potato starch (0 RSB), 10 g/day of RSB, 10 to 20 to 20 g/day of RSB or 10 to 20 to 30 g/day RSB for two-week intervals over 6 weeks. Results confirmed that while resistant starch of approximately 5 g per day improves GI symptoms at 2, 4, and 6 weeks, it did not demonstrate a detectable effect on short chain fatty acids. Increasing doses of the blend (RSB) led to a decrease in the diarrhea score. Using an estimate of total consumption of RSB based on smart cap recordings of container openings and protocol-specified doses of RSB, a reduction in the sleep disturbance score was associated with higher RSB dose. The exploratory microbiome evaluation demonstrated that among the 16S rRNA gene sequences most associated with the consumption of the novel blend RSB, two belong to taxa of notable interest to human health: Faecalibacterium and Akkermansia.

Accountability in reminder-based adherence interventions: A review

OBJECTIVE

Interventions to elicit accountability capitalize on social behaviors to improve adherence but are distinct from reminders. However, little is known about the impact of accountability in reminder-based adherence interventions. Through a literature review, we aim to identify the frequency and effectiveness of accountability in reminder-based intervention studies.

METHODS

PubMed and PsycArticles were searched for reminder-based adherence studies. Articles were categorized as reminder-only or reminder with accountability studies. Studies were characterized by outcome measures, and differences between control and intervention groups were compared for studies that used electronic monitoring devices.

RESULTS

165 studies met the inclusion criteria; 154 used reminders without accountability (93%). 79 of the 154 reminder-only studies (51%) improved adherence in intervention groups compared to controls. Eleven of the 165 studies (6.6%) included an accountability aspect. The intervention group had better adherence than controls in 10 out of the 11 reminder with accountability studies (91%).

CONCLUSIONS

Although distinct from reminders, accountability can be incorporated in reminder-based interventions. However, it is not commonly included in reminder-based interventions.

PRACTICE IMPLICATIONS

It is important to consider accountability's effects on encouraging patient medication adherence. The addition of accountability interventions may further boost adherence, but few studies currently incorporate these types of interventions.

Electronically monitored medication adherence in idiopathic pulmonary fibrosis: prevalence, predictors and outcomes

Medication adherence studies in idiopathic pulmonary fibrosis (IPF) are limited, use cross-sectional designs and report discontinuation rates.

We prospectively investigated adherence to pirfenidone in IPF patients using electronic monitoring, which provides insights on whether and when the medication was taken on a day-by-day basis. We investigated the impact of nonadherence on lung function and selected predictors for nonadherence based on the COM-B behavioural model. The longitudinal statistical analyses included generalised estimation equations and linear mixed effects models.

55 patients initiating pirfenidone were followed-up for 2 years after diagnosis (76.4% men, mean age 71.1 years (range 50–87 years), mean forced vital capacity (FVC) 88% predicted (sd 18.3), mean diffusing capacity of the lung for carbon monoxide (D_LCO) 58.1% predicted (sd 14.7)). Our data showed an association (p=0.03) between the proportion of days with three pirfenidone intakes (i.e. dosing adherence) and FVC % predicted, whereby a high dosing adherence seemed necessary to maintain stable or improving FVC % predicted values. 58.2% of the participants were able to implement at least 90% correct dosing days, yet adherence significantly decreased over time. Too short dosing intervals had negative effects on lung function outcomes. Knowledge on IPF and self-reported adherence were significantly associated with electronically measured adherence.

In conclusion, nonadherence is prevalent and might negatively affect lung function. Further research is needed on the impact of nonadherence on outcomes and its predictors, so that tailored interventions can be developed. Meanwhile, a self-report questionnaire could be used to identify adherence issues and teams should equip patients with knowledge about their treatment and how to take it.

This study used electronic monitoring systems for the first time in IPF patients to assess taking and timing of pirfenidone. Medication nonadherence is a prevalent issue that increases over time and is associated with patients’ lung function outcomes.https://bit.ly/3wEFUlq

Memory complaints moderate the concordance between self-report and electronically monitored adherence in adults with type 2 diabetes

AIMS

We examined the impact of memory complaints on the concordance between self-report (SR) and electronically monitored (EM) medication adherence, independent of depression symptoms, among adults with type 2 diabetes (T2D).

METHODS

Adults (N = 104, age = 56.6 ± 9.2; 64% female) completed a prospective and retrospective memory questionnaire (PRMQ) and a depression symptom interview at baseline. EM was tracked over 3 months and participants rated adherence using SR. Multiple linear regression evaluated PRMQ as a moderator of the relationship between EM and SR, adjusting for depression and other covariates.

RESULTS

PRMQ was correlated with lower SR (r = -0.31, p = 0.001), but not with EM. PRMQ moderated the relationship between SR and EM, independent of depression symptoms. At low levels of PRMQ, SR and EM were closely related (β = 0.76, p < 0.001); at high levels of PRMQ the relationship was weaker (β = 0.28, p = 0.02). Participants who under-reported their adherence (SR < EM) had higher PRMQ scores than more concordant reporters (p = 0.016).

CONCLUSIONS

SR and EM measures were less concordant among adults with T2D who endorsed higher PRMQ scores. Memory complaints may contribute to under-reporting of medication adherence in adults with T2D.

Behavioural and psychological patterns of patients with idiopathic pulmonary fibrosis: a prospective study

Background

Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive lung condition. Currently, care models predominantly focus on acute medical and pharmacological needs. As a step towards holistic care, the aim of this prospective study was to investigate the psychological and behavioural needs of IPF patients treated with pirfenidone from diagnosis until two years of follow-up.

Methods

The following variables were selected from the literature on patients’ needs and the COM-B model, a theoretical model explaining behaviour: medication adherence, barriers to adherence, importance and intentions of medication adherence, anxiety, depression, health literacy, knowledge, reported side effects, adherence to sun protection recommendations, alcohol use, physical activity, quality of life and health status. Linear and generalised linear models for longitudinal data were used to evaluate the evolution since treatment initiation.

Results

We included 66 outpatients: 72.7% men, mean age of 70.3 years (range 50–87), predicted mean forced vital capacity of 85.8% (SD 17.4) and predicted mean diffusing capacity for monoxide of 56.9% (SD 15.7). The participants placed considerable importance on following the treatment recommendations. We noticed difficulties regarding health literacy, alcohol use, pirfenidone adherence (decline over time) and adherence to sun protection recommendations (early in follow-up care). There were low levels of physical activity (no effect of time), high body mass indices (decline over time) and moderate levels of depression and anxiety.

Conclusion

When providing care to IPF patients, behavioural issues, health literacy and psychological well-being should be taken into consideration. There is a need to further explore interventions and care models to tackle these difficulties.

Trial registration This study was registered in the ClinicalTrials.gov database (identifier NCT03567785) on May 9th, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02041-6.

The value of adherence information during clinical pharmaceutical trials

BACKGROUND/AIMS

The quality of the evidence used to evaluate a drug's safety and efficacy depends, in part, on how well participants adhere to the prescribed drug-taking regime. There are multiple approaches to measure adherence in clinical trials, varying in their cost and accuracy. We demonstrate a method for evaluating the cost-effectiveness of common adherence monitoring methods, considering the costs and data quality for drugs that differ in how forgiving they are of nonadherence.

METHODS

We propose a simulation approach to estimate the value of evidence about adherence, considering both costs of collection and potential errors in interpreting clinical trial results. We demonstrate the approach with a simulated clinical trial of nitrendipine, a common calcium channel blocker. We consider two trial designs, one using pretrial adherence to "enrich" the trial sample and one without an enrichment strategy. We use scenarios combining high and low values of two key properties of a clinical trial: participant adherence and drug forgiveness.

RESULTS

Under the conditions of these simulations, the most cost-effective adherence monitoring approach depends on both trial participant adherence and drug forgiveness. For example, the enrichment strategy is not cost-effective for the base scenario (high forgiveness and high adherence), but is for other scenarios. We also estimate the effects of evaluable patient analysis, a controversial procedure that excludes nonadherent participants from the analyses, after a trial is completed.

CONCLUSIONS

Our proposed approach can guide drug regulators and developers in designing efficient clinical trials and assessing the impact of nonadherence on trial results. It can identify cost-effective adherence-monitoring methods, given available knowledge about the methods, drug, and patients' expected adherence.

Methods to Assess Adult and Adolescent Patients' Adherence to Antimalarial Treatment: A Systematic Review

Malaria is a curable disease for which early diagnosis and treatment, together with the elimination of vectors, are the principal control tools. Non-adherence to antimalarial treatment may contribute to therapeutic failure, development of antimalarial resistance, introduction or resurgence of malaria in non-endemic areas, and increased healthcare costs. The literature describes several methods to directly or indirectly assess adherence to treatment, but no gold standard exists. The main purpose of this review is to systematize the methods used to assess patient adherence to antimalarial treatment. A systematic review was performed, in accordance with the PRISMA statement, of the following databases: LILACS, EMBASE, PUBMED, COCHRANE, GOOGLE SCHOLAR, WEB OF SCIENCE, SCOPUS, and OPENGREY, through 14 December 2021. A snowball search was also performed by screening the references of the included studies as well as those cited in relevant reviews. Inclusion criteria were reporting assessment of the patient's adherence to antimalarials in individuals with laboratory diagnosis of malaria, the description of antimalarials prescribed, and adherence estimates. Exclusion criteria were studies exclusively about directly observed therapy, studies of populations ≤12 yo and guidelines, commentaries, reviews, letters, or editorials. Study quality was assessed using MINORS and the Cochrane Risk of Bias Tool. Proportions were calculated to measure frequencies considering the number of articles as the denominator. Twenty-one studies were included in this review. Most of them (76.5%) assessed adherence to falciparum malaria treatment. Seventeen studies (80.9%) used a combination of methods. The methods described were pill counts, self-reports, biological assays, use of electronic pillboxes, and clinical cure. It was possible to identify different adherence classifications for all the methods used. Our review found that indirect methods like pill counts and self-reports are the most commonly used. Combining an method that gives solid proof of the ingestion of medication and a method that completes the research with information regarding factors, beliefs or barrier of adherence seems to be the best approach. Future studies of antimalarial treatment should standardize adherence classifications, and collect data on the types and causes of nonadherence, which can contribute to the development of tools to promote medication adherence. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020148054, identifier CRD42020148054.

How to handle a delayed or missed dose of edoxaban in patients with non-valvular atrial fibrillation? A model-informed remedial strategy

AIM

Edoxaban is a non-vitamin K antagonist oral anticoagulant (NOAC) widely used for the long-term prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Adherence to NOAC therapy has been unsatisfactory and decreases over time. Remedial strategies are currently used to address the non-adherence events. Current recommendations, however, are generic and not well supported by evidence. The aim of this study was to explore appropriate remedial dosing regimens for non-adherent edoxaban-treated NVAF patients through the Monte Carlo simulation.

METHODS

Six regimens were compared with the current recommendations of the European Heart Rhythm Association (EHRA) guide based on total deviation time. Both edoxaban plasma concentration and intrinsic Factor Xa activity were considered. Monte Carlo simulations were performed using RxODE based on a published population pharmacokinetics/pharmacodynamics (PK/PD) model.

RESULTS

The proposed remedial strategies were different than the EHRA recommendations and were related to the delay time. However, it was found that the missed dose can be administered immediately if the delay time is within 11 h. When the delay is between 12 and 19 h, a half dose followed by a regular dosing schedule is recommended. When the delay time exceeds 19 h, a full dose followed by a half dose is preferred.

CONCLUSION

PK/PD modelling and simulation are effective in developing and evaluating the remedial strategies of edoxaban, which can help maximise its therapeutic effect.

"I'd feel like someone was watchin' me… watching for a good reason": perceptions of data privacy, access, and sharing in the context of real-time PrEP adherence monitoring among HIV-negative MSM with substance use

Once-daily oral tenofovir/emtricitabine is highly effective as pre-exposure prophylaxis (PrEP) against HIV but is dependent on adherence, which may be challenging for men who have sex with men (MSM) and use substances. Digital pill systems (DPS) permit the direct, real-time measurement of adherence, though user perceptions of data privacy in this context are unknown. Thirty prospective DPS users - HIV-negative MSM with non-alcohol substance use - completed in-depth qualitative interviews exploring preferences around privacy, access, and sharing of DPS adherence data. Participants discussed some concerns about the impact of DPS use on personal privacy, and emphasized the need for robust data protections in the technology. Participants were interested in having on-demand access to their adherence data, and were most willing to share data with primary care providers and long-term relationship partners. Future investigations exploring bioethical frameworks around DPS use are warranted, and user preferences should inform best practices for protecting DPS data.

Depression, Quantified Medication Adherence, and Quality of Life in Renal Transplant Candidates and Recipients

Like patients with many chronic illnesses, ESRD patients experience psychological challenges with greater incidence of depression and reduced quality of life (QoL). A series of 139 transplant candidates' depression and QoL, and a subset of 82 candidates' medication adherence were monitored, revealing heterogenous patterns of depression and adherence and reduced QoL. Twenty-eight patients who received kidney transplants were re-evaluated 6 months post-transplant revealing mixed patterns. Mean depression and quantitated adherence decreased and QoL increased. Some patients improved whereas others declined in depression and adherence. Pre-transplant depression was negatively correlated with post-transplant adherence but positively correlated with post-transplant depression. Nevertheless, the ability to predict individuals' post-transplant adherence and depression, principal objectives of pre-transplant psychological evaluations, is limited. Consequently, it is important to provide periodic screening of ESRD patients for depression and adherence pre- and post-transplant as they reflect changing states, rather than static traits, with variable patterns across patients.

Barriers and facilitators of adherence to antiretroviral treatment at a public health facility in Ghana: a mixed method study

BACKGROUND

HIV/AIDS is a disease of global public health concern with high morbidity and mortality rates. Poor adherence to antiretroviral therapy (ART) increases the risk of viral drug resistance and reduces treatment effectiveness towards viral suppression leading to disease progression, greater risk of death and increased risk of viral transmission. The study sought to assess current adherence levels to ART among patients in Ghana, exploring barriers and enablers of adherence to it, to provide future guidance to all key stakeholder groups.

METHOD

A mixed method approach was used comprising of a cross-sectional survey of patients followed by a focused group discussion with patients and an in-depth interview of four key health professionals working in the ART clinic of Atua Government Hospital, a primary care health facility in the Eastern Region of Ghana. A structured questionnaire was used to assess current adherence levels and their determinants among 231 randomly selected patients attending the clinic between July to September, 2019. Quantitative data were analysed using bivariate and multivariate methods while qualitative data were analysed using thematic framework approach.

RESULTS

Adherence levels was found to be 42.9% among our study population. Lower adherence to ART was associated with patients' belief in herbal medicine (aOR =0.34 CI: 0.19-0.61). Other barriers identified from the qualitative analysis included low motivation arising from pill fatigue, forgetfulness, frequent stock out of medicines, long waiting times and worrying side-effects; while enablers, on the other hand, included measures that ensure improved assessment of adherence and health facility-related activities that improve patient satisfaction with ART services. Conclusion: Adherence to ART among patients living with HIV was sub-optimal in our study population. Understanding of the barriers and factors that enable adherence to ART is a key step to developing evidence-based adherence improvement strategies to enhance clinical outcomes.

PrEP Use, Sexual Behaviour, and PrEP Adherence Among Men who have Sex with Men Living in Wales Prior to and During the COVID-19 Pandemic

We examined PrEP use, condomless anal sex (CAS), and PrEP adherence among men who have sex with men (MSM) attending sexual health clinics in Wales, UK. In addition, we explored the association between the introduction of measures to control transmission of SARS-CoV-2 on these outcomes. We conducted an ecological momentary assessment study of individuals in receipt of PrEP in Wales. Participants used an electronic medication cap to record PrEP use and completed weekly sexual behaviour surveys. We defined adherence to daily PrEP as the percentage of CAS episodes covered by daily PrEP (preceded by ≥ 3 days of PrEP and followed by ≥ 2 days). Sixty participants were recruited between September 2019 and January 2020. PrEP use data prior to the introduction of control measures were available over 5785 person-days (88%) and following their introduction 7537 person-days (80%). Data on CAS episodes were available for 5559 (85%) and 7354 (78%) person-days prior to and following control measures respectively. Prior to the introduction of control measures, PrEP was taken on 3791/5785 (66%) days, there were CAS episodes on 506/5559 (9%) days, and 207/406 (51%) of CAS episodes were covered by an adequate amount of daily PrEP. The introduction of pandemic-related control measures was associated with a reduction in PrEP use (OR 0.44, 95%CI 0.20–0.95), CAS (OR 0.35, 95%CI 0.17–0.69), and PrEP adherence (RR = 0.55, 95%CI 0.34–0.89) and this may have implications for the health and wellbeing of PrEP users and, in addition to disruption across sexual health services, may contribute to wider threats across the HIV prevention cascade.

Prevalence and Correlates of Viral Load Suppression and Human Immunodeficiency Virus (HIV) Drug Resistance Among Children and Adolescents in South Rift Valley and Kisumu, Kenya

BACKGROUND

Children and adolescents living with HIV (CALHIV) face unique challenges, including poorer treatment outcomes, risk for drug-resistance mutations (HIVDRMs), and limited drug formulations. We estimated viral suppression (VS) prevalence and evaluated predictors of VS and HIVDRMs in Kenya.

METHODS

From 2018-2020, CALHIV 1-19 years on antiretroviral therapy (ART) >6 months were enrolled in this cross-sectional study. Participants underwent viral load (VL) testing; those with VL ≥1000 copies/mL had HIVDRM testing. Sociodemographic questionnaires and medical record abstraction were completed. VS prevalence (VL <1000 copies/mL) was estimated; robust Poisson regression models were used to estimate prevalence ratios (PRs) and 95% CIs for associations between potential predictors of VS.

RESULTS

Nine hundred and sixty-nine participants were enrolled. VS prevalence was .80 (95% CI: .78-.83). Being on ART >24 months (adjusted PR [aPR]: 1.22; 95% CI: 1.06-1.41), an integrase strand transfer inhibitor-containing regimen (1.13; 1.02-1.26), and attending a level 3 health facility (1.23; 1.11-1.36) were associated with VS. Missing ≥3 doses of ART in the past month (aPR: .73; 95% CI: .58-.92), having a viremic mother with HIV (.72; .53-.98), and having 3-7 (.90; .83-.97), 8-13 (.89; .82-.97), or ≥14 (.84; .77-.92) compared with <2 adherence counseling referrals were inversely associated with VS. A high proportion (n = 119, 81.5%) of unsuppressed participants had evidence of any major HIVDRM.

CONCLUSIONS

HIV treatment programs should target interventions for pediatric patients at risk for treatment failure-namely, those with a caregiver with failed VS and those struggling with adherence.

Adherence to Analgesics Among Outpatients Seriously Ill With Cancer

BACKGROUND

Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort.

OBJECTIVE

The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics.

METHODS

This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index.

RESULTS

The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001).

CONCLUSION

Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed.

IMPLICATION FOR PRACTICE

Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.

Imagine to Remember: An Episodic Future Thinking Intervention to Improve Medication Adherence in Patients with Type 2 Diabetes

PURPOSE

Medication nonadherence is prevalent in diabetic populations, with "forgetting" a commonly cited reason. This issue of forgetfulness is due, in part, to a failure of prospective memory (PM). Episodic future thinking (EFT) has been shown to improve PM but has not been used to improve medication adherence.

PATIENTS AND METHODS

The current study used a multiple baseline design (N = 4) to test the effects of EFT on medication non-adherence for four patients with a diagnosis of type 2 diabetes or prediabetes, with comorbid high blood pressure or high cholesterol. Medication adherence was objectively measured over 15 weeks using medication event monitoring systems.

RESULTS

Results of visual analysis showed medication adherence was reliably improved, confirmed by mixed model analysis of variance (p < 0.001), with significant differences from baseline to treatment (Tau <0.05) for 3 of 4 participants. Improvements in two measures of PM (effect size (ES) = 0.73, 0.80) and delay discounting (ES = 1.20) were observed.

CONCLUSION

This study provides a feasible way to improve medication adherence in patients with prediabetes or type 2 diabetes.

The Role of Depression on Treatment Adherence in Patients with Heart Failure-a Systematic Review of the Literature

INTRODUCTION

Although poor medication adherence is considered an impacting risk factor for worsening heart failure (HF) outcomes, adherence rates in HF patients continue to be considerably low. To improve this condition, several studies investigated the impact of many determinants on medication adherence; however, few authors explored the role of depression on it.

PURPOSE OF REVIEW

The purpose of this systematic review was to explore the association between depressive symptoms and medication adherence in HF patients. In particular, the research question was is depression a barrier to medication adherence in HF patients?

METHODS

A systematic review of quantitative analysis studies was undertaken. Six electronic databases were searched between the end of October and March 2022. Thirty-one trials were included, all of them assessed depression, adherence to medication, and their possible relationship.

RESULTS

As was intended, findings showed that the impact of a mild to moderate level of depression was significant on adherence to treatment in HF patients. However, many other risk factors emerged, like family support and health practices (es. low sodium diet).

CONCLUSION

The detection of depression in the setting of HF should be crucial to HF patients' physical health and quality of life. Future research should take depression into account, exploring this area through self-report and qualitative interview as well.

Exploring Stem Cell Transplanted Patients' Perspectives on Medication Self-Management and Electronic Monitoring Devices Measuring Medication Adherence: A Qualitative Sub-Study of the Swiss SMILe Implementation Science Project

PURPOSE

Little is known about allogeneic stem cell transplant (alloSCT) patients' medication adherence strategies. Acceptability and preferences regarding electronic monitoring (EM) systems to assess all three phases of medication adherence (ie, initiation, implementation, persistence) are crucial to allow their successful implementation in clinical or research settings but have not yet been evaluated. We therefore aimed to explore: 1) alloSCT patients' medication adherence and self-management strategies; and 2) their acceptability and preferences of three different EM systems (MEMS Cap, Helping Hand, Button) as part of the Swiss SMILe study.

PATIENTS AND METHODS

Respecting anti-pandemic measures, we used a purposive sample of six adult alloSCT patients from the University Hospital Basel, Switzerland (USB)-6 weeks to 2 years post-alloSCT-to conduct three focus group sessions with two patients each. Using a semi-structured outline, we explored 1) patients' medication adherence strategies and medication self-management; and 2) their acceptance and preferences regarding EM use. The three tested EM systems were available for testing during each session. Discussions were audio-recorded, visualized using mind-mapping and analyzed using Mayring's qualitative content analysis.

RESULTS

Patients (33% females; mean age 54.6±16.3 years; 10.4±8.4 months post-alloSCT) used medication adherence enhancing strategies (eg, preparing pillbox, linking intake to a habit). Still, they indicated that post-alloSCT medication management was challenging (eg, frequent schedule changes). All participants preferred the MEMS Button. Participants said its small size and the possibility to combine it with existing pillboxes (eg, putting it into/next to them) made them more confident about implementing it in their daily lives.

CONCLUSION

Regarding EM systems for medication adherence, end-user preferences and acceptability influence adoption and fidelity. Of the three systems tested, our sample found the MEMS Button most acceptable and most preferable. Therefore, we will use it for our USB SMILe study.

Association between adherence to oral therapies in cancer patients and clinical outcome: A systematic review of the literature

AIMS

Adherence to therapy is a key factor in successful treatment. The aim of this systematic review is to assess the extent to which patients with better adherence to oral therapy have better clinical outcomes among cancer patients.

METHODS

All studies published in PubMed up to 20 October 2020, which considered the use of oral anticancer drugs for cancer patients and which correlated treatment adherence with a clinical outcome, were considered.

RESULTS

From the 42 studies considered in the systematic review, 14 were for oncological indications and 28 for haematological indications. There was considerable variance in calculation methods, outcomes considered, and in the definitions of adherence. However, it emerged that most studies reported a significant correlation between adherence to therapy and clinical outcome.

CONCLUSION

As adherence to therapy is a key factor in achieving a better clinical outcome, future studies with large samples, robust endpoints and the use of at least two methods of assessing adherence would be desirable in order to produce more robust evidence.

Barriers for Antiretroviral Therapy Adherence and Viral Suppression in Members of the Key Population in Mumbai, India: Implications for Interventions

Background:

Poor adherence to antiretroviral therapy (ART) is associated with poor virologic control and drug resistance in people living with HIV/AIDS. Some barriers to ART adherence are cost, lack of information, stigma, or dissatisfaction with health services.

Aims and Objectives:

To study the association between barriers for ART adherence and viral suppression, and explore the role of "missing ART dose" as a potential mediator in high-risk groups.

Materials and Methods:

Demographic, clinical, and behavioral data from 50 "virally suppressed" (viral load [VL] <1000 copies/ml) and 48 "not suppressed" (VL > 1000 copies/ml) individuals belonging to the key population in Mumbai were collected. Sociodemographic, behavioral, and other characteristics were compared, and mediation analysis was used to identify the mediator in the pathway to viral suppression.

Results:

Those who had missed their ART at least once in the past three months (37% versus 60%, P = 0.03) and stayed alone were less likely to be virally suppressed (31% versus 69%, P = 0.002). Individuals who had negative perception about ART (adjusted odds ratio [aOR]: 0.11, 95% confidence interval [CI]: 0.02, 0.47; P = 0.002), poor ART-related knowledge/behaviors (aOR: 0.14, 95% CI: 0.03, 0.60; P = 0.007), and poor pill taking practices (aOR: 0.10, 95% CI: 0.02, 0.61; P = 0.01) were significantly less likely to be virally suppressed. The mediation pathway "adherence theme > missed ART in the past three months > viral suppression" was significant in these themes.

Conclusions:

The factors associated with low viral suppression were knowledge/behaviors, perceptions about ART, and poor pill taking practices. Thus, it is important to provide correct information about ART, its effects, side effects, and potential limitations to marginalized population. Involving brothel keepers and Gurus (head of male-to-female transgendered people/Hijras clans), and technology enabled customized counseling sessions will be helpful.