Adherence and decision AIDS: a model and a narrative review

Adherence to anti-retroviral therapy, decisional conflicts, and health-related quality of life among treatment-naïve individuals living with HIV: a DEARS-J observational study

BACKGROUND

Supporting people living with HIV using anti-retroviral therapy (ART) is important due to the requirement for strict medication adherence. To date, no data from longitudinal studies evaluating adherence by treatment-naïve people living with HIV are currently available. We investigated the adherence of treatment-naïve people living with HIV over time and examined the relationships among decisional conflicts, adherence, and health-related quality of life (HRQL).

METHODS

The survey items included adherence (visual analogue scale [VAS]), decisional conflict (decisional conflict scale [DCS]), and HRQL (Medical Outcomes Study HIV Health Survey [MOS-HIV]). The DCS and MOS-HIV scores and the VAS and MOS scores were collected electronically at the ART initiation time point and at 4-, 24-, and 48-week post-treatment time points.

RESULTS

A total of 215 participants were enrolled. The mean DCS score was 27.3 (SD, 0.9); 23.3% of participants were in the high-score and 36.7% in the low-score groups. The mean adherence rates at 4, 24, and 48 weeks were 99.2% (standard error [SE], 0.2), 98.4% (SE, 0.4), and 96.0% (SE, 1.2), respectively. The least-square means of the MOS-HIV for the DCS (high vs. low scores) were 64.4 vs. 69.2 for general health perceptions and 57.7 vs. 64.0 for HRQL, respectively.

CONCLUSION

Adherence among treatment-naïve people living with HIV was maintained at a higher level, and HRQL tended to improve with ART. People with high levels of decisional conflict tended to have lower HRQL scores. Support for people living with HIV during ART initiation may be related to HRQL.

Effects of decision aids for depression treatment in adults: systematic review

AIM AND METHOD

To determine the effect on decisional-related and clinical outcomes of decision aids for depression treatment in adults in randomised clinical trials. In January 2019, a systematic search was conducted in five databases. Study selection and data extraction were performed in duplicate. Meta-analyses were performed, and standardised and weighted mean differences were calculated, with corresponding 95% confidence intervals. The certainty of the evidence was evaluated with GRADE methodology.

RESULTS

Six randomised clinical trials were included. The pooled estimates showed that decision aids for depression treatment had a beneficial effect on patients' decisional conflict, patient knowledge and information exchange between patient and health professional. However, no statistically significant effect was found for doctor facilitation, treatment adherence or depressive symptoms. The certainty of the evidence was very low for all outcomes.

CLINICAL IMPLICATIONS

Using decision aids to choose treatment in patients with depression may have a a beneficial effect on decisional-related outcomes, but it may not translate into an improvement in clinical outcomes.

Preliminary testing of a patient decision aid for patients with relapsing-remitting multiple sclerosis

Background

Multiple first-line disease modifying therapies (DMTs) are available for relapsing-remitting multiple sclerosis (RRMS), each with different characteristics. We developed an interactive patient decision aid (PtDA) to promote informed shared decision-making (SDM).

Objective

To test the preliminary effectiveness of the PtDA in participants with RRMS.

Methods

Knowledge, and decisional conflict were measured pre- and post- implementation of the PtDA, SDM after the consultation, and 6-month treatment patterns were observed. Differences in scores were analyzed using descriptive statistics and paired t-tests. Qualitative interviews with patients and neurologists were analyzed using thematic analysis.

Results

52 participants were recruited: most were female (81%), 40 years of age or younger (62%), and had experienced MS for less than 5 years (56%). After participants used the PtDA, there was a significant improvement in decisional conflict (change = 1.00; p < 0.001) and knowledge (change = 2.15, p < 0.001). Nearly all patients wanted SDM, and 25 (56%) reported this occurred in their consult. Qualitative results suggested the PtDA supported both patients and neurologists in making decisions.

Conclusion

This pilot study suggests that PtDA use helps RRMS patients and their clinician select a DMT. Future studies will assess the feasibility of implementation and the impact of the PtDA on timely DMT initiation and longer-term adherence.

Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Background

Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.

Methods

An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.

Results

Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.

Conclusion

This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

Patient decision aid based on multi-criteria decision analysis for disease-modifying drugs for multiple sclerosis: prototype development

Background

Since decision making about treatment with disease-modifying drugs (DMDs) for multiple sclerosis (MS) is preference sensitive, shared decision making between patient and healthcare professional should take place. Patient decision aids could support this shared decision making process by providing information about the disease and the treatment options, to elicit the patient’s preference and to support patients and healthcare professionals in discussing these preferences and matching them with a treatment. Therefore, a prototype of a patient decision aid for MS patients in the Netherlands—based on the principles of multi-criteria decision analysis (MCDA) —was developed, following the recommendations of the International Patient Decision Aid Standards. MCDA was chosen as it might reduce cognitive burden of considering treatment options and matching patient preferences with the treatment options.

Results

After determining the scope to include DMDs labelled for relapsing-remitting MS and clinically isolated syndrome, users’ informational needs were assessed using focus groups (N = 19 patients) and best-worst scaling surveys with patients (N = 185), neurologists and nurses (N = 60) to determine which information about DMDs should be included in the patient decision aid. Next, an online format and computer-based delivery of the patient decision aid was chosen to enable embedding of MCDA. A literature review was conducting to collect evidence on the effectiveness and burden of use of the DMDs. A prototype was developed next, and alpha testing to evaluate its comprehensibility and usability with in total thirteen patients and four healthcare professionals identified several issues regarding content and framing, methods for weighting importance of criteria in the MCDA structure, and the presentation of the conclusions of the patient decision aid ranking the treatment options according to the patient’s preferences. Adaptations were made accordingly, but verification of the rankings provided, validation of the patient decision aid, evaluation of the feasibility of implementation and assessing its value for supporting shared decision making should be addressed in further development of the patient decision aid.

Conclusion

This paper aimed to provide more transparency regarding the developmental process of an MCDA-based patient decision aid for treatment decisions for MS and the challenges faced during this process. Issues identified in the prototype were resolved as much as possible, though some issues remain. Further development is needed to overcome these issues before beta pilot testing with patients and healthcare professionals at the point of clinical decision-making can take place to ultimately enable making conclusions about the value of the MCDA-based patient decision aid for MS patients, healthcare professionals and the quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01479-w.

Prevalence and factors associated with adherence to anti-hypertensives among adults with hypertension in a developed Asian community: A cross-sectional study

Introduction:

Poor adherence to anti-hypertensive medications (AHM) results in hypertension treatment failure. Understanding and addressing the factors associated with adherence to AHM may potentially improve health outcomes. This study aimed to assess the prevalence and factors associated with patients’ adherence to AHM in a developed Asian community.

Methods:

An assistant-administered questionnaire survey was conducted on multi-ethnic Asian adults aged 31–80 years with essential hypertension based on their electronic health records (EHR) at a public primary-care clinic. Data on their demographic characteristics, clinical measurements of blood pressure and body mass index, co-morbidities and prescriptions from the EHR, along with the Medication Adherence Report Scale-5 scores were collated, audited and analysed. A MARS-5 score of <25 indicated poor adherence. Logistic regression was used to identify factors associated with adherence to AHM.

Results:

Data of 395 patients were analysed. Of these, 179 (45.3%) had poor adherence to at least one AHM. Bivariate analysis showed that poor adherence was significantly associated with lower mean age (59 years old vs. 63 years old), higher mean clinic diastolic blood pressure (76 mmHg vs. 73 mmHg) and higher mean weight (70.4 kg vs. 67.4 kg). Logistic regression showed that patients with no co-morbidities (such as diabetes mellitus, dyslipidaemia, stroke and ischaemic heart disease) had better medication adherence (MA; odds ratio=1.98; 95% confidence interval 1.14–3.45; p=0.02). There was no significant MA difference between the classes, dose frequency and number of AHM.

Conclusion:

Almost half of the patients had poor adherence to at least one AHM. Co-morbidity significantly influenced their MA. Attention should be directed to patients with co-morbidities to assess their AHM adherence.

Prevention of low bone mass to achieve high bone density in Mexico: position of the Mexican Association for Bone and Mineral Metabolism

In Mexico, osteoporosis is a public health problem. In this document, the Mexican Association for Bone and Mineral Metabolism defines its position on calcium, vitamin D supplement use, and physical activity as an effective, safe, and cost-effective initiatives to prevent low bone mass.

INTRODUCTION

In Mexico, osteoporosis is a public health problem that is expected to increase in the decades ahead. Generally, modifiable risk factors for bone health are related with lifestyles, especially nutrition and physical activity.

METHODS

In this position paper, the Mexican Association for Bone and Mineral Metabolism (AMMOM, by its acronym in Spanish), which is a multidisciplinary group of researchers, dietitians, epidemiologists, nurses, and physicians who study bone and related tissues and communicate the best strategies for diagnosis, treatment, and prevention of bone problems, aims to analyze the association between nutrition and bone health, risk behaviors for low bone mass, and the economic impact that prevention of low bone mass represents for the health care system.

RESULTS

Addressing therapeutic management with pharmacological and non-pharmacological approaches, we emphasize the important role the patient plays in the doctor-patient relationship, both in the consulting room and in daily life. Furthermore, the AMMOM defines its position on calcium and vitamin D supplement use as an effective, safe, and cost-effective initiative to prevent low bone mass.

CONCLUSIONS

In summary, most research and clinical practice related to osteoporosis have focused on diagnosis and treatment, but general measures for primary prevention based on addressing modifiable risk factors as a public health priority to delay the onset of loss of bone mass have not been considered by Mexican authorities. Consequently, the AMMOM task force also seeks to provide information on concrete actions to prevent low bone mass.

The development of a personalized patient education tool for decision making for postmenopausal women with osteoporosis

A personalized patient education tool for decision making (PET) for postmenopausal women with osteoporosis was developed by means of a systematic development approach. A prototype was constructed and refined by involving various professionals and patients. Professionals and patients expressed a positive attitude towards the use of the PET.

INTRODUCTION

The purpose was to systematically develop a paper-based personalized PET to assist postmenopausal women with osteoporosis in selecting a treatment in line with their personal values and preferences.

METHODS

The development of the PET was based on a systematic process including scope, design, development of a prototype, and alpha testing among professionals and patients by semi-structured interviews.

RESULTS

The design and development resulted in a four-page PET prototype together with a one-page fact sheet of the different drug options. The prototype PET provided the personal risk factors, the estimated individualized risk for a future major osteoporotic fracture and potential reduction with drugs, and a summary of advantages and disadvantages whether or not to start drugs. The drug fact sheet presents five attributes of seven drugs in a tabular format. The alpha testing with professionals resulted in some adaptations, e.g., inclusion of the possibility to calculate fracture risk based on various individual risk scoring methods. Important results from the alpha testing with patients were differences in the fracture risk percentage which was seen as worthwhile to start drugs, the importance of an overview of side effects, and of the timing of the PET into the patient pathway. All women indicated that the PET could be helpful for their decision to select a treatment.

CONCLUSION

Physicians and patients expressed a positive attitude towards the use of the proposed PET. Further research would be needed to test the effects of the PET on feasibility in clinical workflow and on patient outcomes.

Interventional tools to improve medication adherence: review of literature

Medication adherence and persistence is recognized as a worldwide public health problem, particularly important in the management of chronic diseases. Nonadherence to medical plans affects every level of the population, but particularly older adults due to the high number of coexisting diseases they are affected by and the consequent polypharmacy. Chronic disease management requires a continuous psychological adaptation and behavioral reorganization. In literature, many interventions to improve medication adherence have been described for different clinical conditions, however, most interventions seem to fail in their aims. Moreover, most interventions associated with adherence improvements are not associated with improvements in other outcomes. Indeed, in the last decades, the degree of nonadherence remained unchanged. In this work, we review the most frequent interventions employed to increase the degree of medication adherence, the measured outcomes, and the improvements achieved, as well as the main limitations of the available studies on adherence, with a particular focus on older persons.

Exploring the Potential Cost-Effectiveness of Patient Decision Aids for Use in Adults with Obstructive Sleep Apnea

Background. There is increasing evidence highlighting the effectiveness of patient decision aids (PtDAs), but evidence supporting their cost-effectiveness is lacking. We consider patients with obstructive sleep apnea (OSA), in whom a PtDA may decrease nonadherence to treatment by empowering patients to receive the option that is most congruent with their own values. Objective. To determine the potential costs and benefits of delivering a PtDA to patients with moderate OSA. Methods. A Markov cohort decision-analytic model was developed for patients with moderate OSA, comparing a PtDA to usual care over 5 years from a societal perspective. Data for patient preference for treatment options was taken from a recent randomized crossover trial, event data (cardiovascular, motor vehicle accidents) came from national databases and published literature. Potential improvements in adherence are unknown, so we considered a realistic range of values. Outcome measures were 5-year costs (in 2010 Canadian dollars), quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results. When adherence to treatment was unchanged, the PtDA strategy was dominated by incurring lower QALYs and higher costs. When nonadherence was decreased by 20% in the PtDA arm (corresponding to an increase in adherence from 63% to 70% for continuous positive airway pressure and from 77% to 82% for mandibular advancement splints in year 1), the ICER fell to $62,414/QALY. Costs associated with the treatment devices and delivering the PtDA had the greatest effect on cost-effectiveness. Limitations. The model relies on surrogate measures and opinions for key parameters. Conclusions: The cost-effectiveness of PtDAs will depend on contextual factors, but a framework is described for properly considering their long-term cost-effectiveness. A number of important questions around the appropriateness of benefit measurement for PtDA trials are highlighted.

The cost-effectiveness of patient decision aids: A systematic review

The Affordable Care Act includes provisions to encourage patient-centered care through the use of shared decision making (SDM) and patient decision aids (PtDA). PtDAs are tools that can help encourage SDM by providing information about competing treatment options and elucidating patients׳ values and preferences. Implementing PtDAs into routine practice may incur additional costs through training or increases in physician time. Prominent commentaries have proposed that these costs might be offset if patients choose less expensive options than their providers. However, the cost-effectiveness of PtDAs to date is unclear. The aim of this study was to review the economic evidence from PtDA trials. Our search identified 5347 articles, with 29 included following full-text review. Only one economic evaluation of a PtDA has been completed, which found a PtDA to be cost-saving in women with menorrhagia. Other studies included in the review indicated that PtDAs will likely increase up-front costs, but in some contexts may reduce short-term costs by reducing the uptake of invasive treatments, such as elective surgery. Few studies comprehensively captured long-term costs or measured benefits in a manner conducive to economic evaluation (QALYs or general health utilities). Our review suggests that policy makers currently have insufficient economic evidence to appropriately consider their investments in PtDAs.

A matter of trust: patient barriers to primary medication adherence

Primary medication adherence occurs when a patient properly fills the first prescription for a new medication. Primary adherence only occurs about three-quarters of the time for antihypertensive medications. We assessed patients' barriers to primary adherence and attributes of patient-provider discussions that might improve primary adherence for antihypertensives. In total, 26 patients with incomplete primary adherence for an antihypertensive, identified using their retail pharmacy claims, participated in four focus groups. Following a moderators' guide developed a priori, moderators led patients in a discussion of patients' attitudes and experiences with hypertension and receiving an antihypertensive medication, barriers to primary adherence, and their preferences for shared decision making and communication with providers. Three authors analysed and organized data into salient themes, including patients' anger about and suspicion of their hypertension diagnosis, the need for medication and providers' credibility. A trusting patient-provider relationship, shared decision-making support, full disclosure of side effects and cost sensitivity were attributes that might enhance primary adherence. Developing decision support interventions that strengthen the patient-provider relationship by enhancing provider credibility and patient trust prior to prescribing may provide more effective approaches for improving primary adherence.

The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial

Background

Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence.

Methods

In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid.

Results

We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants’ intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use.

Conclusions

Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.

Clinical Pathway Analytics

Recently, medical informatics researchers have focused on supporting standardized activity coordination patterns that structure complex multi-disciplinary interventions. While the designed clinical pathways are aimed to improve the provided healthcare, this paper demonstrates that the care process of individual patients can significantly deviate from the standardized path. Examining the deviations in the individual care processes might result in the further enhancement of the provided quality of care, the evaluation of adverse events or the identification of suboptimal use of resources. This paper presents an optimal combination of process analytics for extracting valuable medical and organizational information from real-world care processes. The authors elaborate an extensive case study based on these process analytics on a series of oncological care processes.

Monitoring care processes in the gynecologic oncology department

The care processes of healthcare providers are typically considered as human-centric, flexible, evolving, complex and multi-disciplinary. Consequently, acquiring an insight in the dynamics of these care processes can be an arduous task. A novel event log based approach for extracting valuable medical and organizational information on past executions of the care processes is presented in this study. Care processes are analyzed with the help of a preferential set of process mining techniques in order to discover recurring patterns, analyze and characterize process variants and identify adverse medical events.

Shared decision making and other variables as correlates of satisfaction with health care decisions in a United States national survey

OBJECTIVE

The purpose of this study was to examine the relationship between shared decision-making (SDM) and satisfaction with decision (SWD) within a larger survey of patient decision-making in health care consultations.

METHODS

A randomly selected age-proportionate national sample of adults (aged 21-70 years) stratified on race, ethnicity, and gender (N=488) was recruited from a health research volunteer registry and completed an online survey with reference to a recent health consultation. Measures included the shared decision making-9 questionnaire (SDM-Q-9), Satisfaction With Decision (SWD) scale, sociodemographic, health, and other standardized decision-making measures. Forward selection weighted multiple regression analysis was used to model correlates of SWD.

RESULTS

After controlling for sociodemographic variables, SDM-Q-9 total score was associated with SWD, adjusted R(2)=.368, p<.001. Three of nine SDM-Q-9 items accounted for significant proportions of variance in SWD.

CONCLUSION

SDM was positively associated with SWD and was strongest for three areas of SDM: patients being helped in a health care consultation with understanding information, with treatment preference elicitation, and with weighing options thoroughly.

PRACTICE IMPLICATIONS

By identifying variables such as SDM that are associated with SWD, health care interventions can better target modifiable factors to enhance satisfaction and other outcomes.

Structural equation modeling of the proximal-distal continuum of adherence drivers

OBJECTIVES

Nonadherence to prescription medications has been shown to be significantly influenced by three key medication-specific beliefs: patients' perceived need for the prescribed medication, their concerns about the prescribed medication, and perceived medication affordability. Structural equation modeling was used to test the predictors of these three proximal determinants of medication adherence using the proximal-distal continuum of adherence drivers as the organizing conceptual framework.

METHODS

In Spring 2008, survey participants were selected from the Harris Interactive Chronic Illness Panel, an internet-based panel of hundreds of thousands of adults with chronic disease. Respondents were eligible for the survey if they were aged 40 years and older, resided in the US, and reported having at least one of six chronic diseases: asthma, diabetes, hyperlipidemia, hypertension, osteoporosis, or other cardiovascular disease. A final sample size of 1072 was achieved. The proximal medication beliefs were measured by three multi-item scales: perceived need for medications, perceived medication concerns, and perceived medication affordability. The intermediate sociomedical beliefs and skills included four multi-item scales: perceived disease severity, knowledge about the prescribed medication, perceived immunity to side effects, and perceived value of nutraceuticals. Generic health beliefs and skills consisted of patient engagement in their care, health information-seeking tendencies, internal health locus of control, a single-item measure of self-rated health, and general mental health. Structural equation modeling was used to model proximal-distal continuum of adherence drivers.

RESULTS

The average age was 58 years (range = 40-90 years), and 65% were female and 89% were white. Forty-one percent had at least a four-year college education, and just under half (45%) had an annual income of $50,000 or more. Hypertension and hyperlipidemia were each reported by about a quarter of respondents (24% and 23%, respectively). A smaller percentage of respondents had osteoporosis (17%), diabetes (15%), asthma (13%), or other cardiovascular disease (8%). Three independent variables were significantly associated with the three proximal adherence drivers: perceived disease severity, knowledge about the medication, and perceived value of nutraceuticals. Both perceived immunity to side effects and patient engagement was significantly associated with perceived need for medications and perceived medication concerns.

CONCLUSION

Testing the proximal-distal continuum of adherence drivers shed light on specific areas where adherence dialogue and enhancement should focus. Our results can help to inform the design of future adherence interventions as well as the content of patient education materials and adherence reminder letters. For long-term medication adherence, patients need to autonomously and intrinsically commit to therapy and that, in turn, is more likely to occur if they are both informed (disease and medication knowledge and rationale, disease severity, consequences of nonadherence, and side effects) and motivated (engaged in their care, perceive a need for medication, and believe the benefits outweigh the risks).