A patient education program to improve adherence rates with antituberculosis drug regimens

Community Nursing Practice in Hypertension Management in China: Qualitative Analysis Using a Bourdieusian Framework

OBJECTIVE

This study explores the practices of Chinese community nurses in hypertension management, using Pierre Bourdieu's theory of practice to understand how their routines are shaped by sociocultural and institutional forces, along with their professional dispositions.

DESIGN

A qualitative descriptive study was conducted in Shenzhen, China, between March and June 2024, and is reported following the COREQ guidelines.

SAMPLE

Eighteen nurses, each with at least 1 year of full-time experience in hypertension care within the local community healthcare system, were recruited from a participant pool established through prior research.

MEASUREMENTS

Face-to-face individual semistructured interviews were conducted using a structured interview protocol, and data were analyzed through thematic analysis.

RESULTS

Community nurses face tensions between traditional health beliefs and modern hypertension care, as well as institutional pressures that prioritize efficiency over personalized care. Power imbalances, particularly the authority of doctors, complicate their role. However, nurses adapt their care strategies through embodied practices, balancing clinical standards with patient needs.

CONCLUSIONS

Community nurses are not mere enforcers of guidelines but adaptive professionals who navigate complex sociocultural norms, institutional demands, and power dynamics in hypertension care. This study underscores the necessity for flexible, culturally sensitive practices to improve public health outcomes.

Improving Proton-Pump Inhibitor Adherence Intervention Between Primary Care and Community Pharmacies: A Pre-Post Intervention Study

Purpose

Proton-pump inhibitor (PPI) therapy stands as the primary treatment for upper gastrointestinal symptoms, yet poor adherence often results in treatment failure. Given that patients experiencing these symptoms frequently seek assistance at community pharmacies, the development of collaborative tools with primary care is becoming imperative. The objective was to assess the effectiveness of a pharmaceutical intervention, as demonstrated by a collaborative model between primary care and community pharmacies, in enhancing adherence to PPI among patients experiencing upper gastrointestinal symptoms.

Patients and methods

A Pre-post intervention study was carried out in Spanish community pharmacies (June-October 2022). During the baseline visit, patients' sociodemographic and clinical variables were evaluated. Patients were categorized as adherent or non-adherent using the Morisky Medication Adherence Scale (MMAS-4). In the follow-up visit (14 days later), the impact of the intervention was measured by changes in the Gastroesophageal Reflux Disease Impact Scale (GIS).

Results

Of the 351 patients with an active PPI prescription, 178 (50.7%) were non-adherent. Nearly 70% of these patients (122, 68.5%) received an intervention to improve adherence. The overall GIS score improved after the intervention (mean 25.34, SD 5.66 vs mean 27.64, SD 5.63, p < 0.001). All GIS score items showed improvement after the intervention except for the item regarding the taking of additional medication different from that prescribed by the clinician (p = 0.200).

Conclusion

The pharmaceutical intervention had a positive impact on patients' symptom relief and overall quality of life, highlighting the significance and efficacy of a collaborative model between primary care and professional pharmaceutical services.

Clinical Trials Registry

Clinical Trial Registration (NCT05162079).

Medication perceptions mediate the association between illness perceptions and adherence to oral anticancer agents among patients with gastrointestinal tract cancer: A cross-sectional study

PURPOSE

Patients with gastrointestinal tract cancer reported suboptimal adherence to oral anticancer agents, reducing the therapeutic benefit and increasing mortality risk. The Common-Sense Model of Self-Regulation highlights patients' perceptions of illness and treatment influence adherence. However, how these perceptions influence adherence remains unknown among this population. This study aimed to explore whether illness perceptions influence adherence via their effect on medication perceptions.

METHODS

A multi-center cross-sectional study design was conducted. Between July and August 2023, a questionnaire was administered to patients from four tertiary hospitals in Mainland China. Illness perceptions were assessed using the Brief Illness Perceptions Questionnaire. Medication perceptions were measured in medication belief and self-efficacy using the Belief about Medicines Questionnaire and Self-efficacy for Appropriate Medication Use Scale, respectively. Adherence was evaluated using the Morisky 4-item Medication Adherence Scale. Mediation analyses were conducted.

RESULTS

In total, 253 participants were recruited. Patients with worse negative illness perceptions reported higher concern, lower self-efficacy, and poorer adherence. Medication self-efficacy was positively associated with adherence, whereas the necessity and concern belief of taking oral anticancer agents were not. Illness perceptions, including the cognitive and emotional dimensions, had direct and indirect effects on adherence via its effects on medication self-efficacy. The indirect effect explained 26.63% of the total effect.

CONCLUSIONS

The association between illness perceptions and adherence is partially mediated by medication self-efficacy. Strategies to foster positive illness perceptions may contribute to better medication self-efficacy and adherence. Attention should be equally focused on both the emotional and cognitive dimensions of illness perceptions.

Urban-Rural Differences in the Association of eHealth Literacy With Medication Adherence Among Older People With Frailty and Prefrailty: Cross-Sectional Study

Background

With advances in science and technology and improvements in health literacy, more studies have focused on frailty prevention by promoting medication adherence, emphasizing the role of eHealth literacy. However, the association between eHealth literacy and medication adherence in frail older adults has not been well studied, and it is unknown whether urban-rural differences exist in this relationship.

Objective

This study aims to examine the relationship between eHealth literacy and medication adherence in older people with different frailty statuses, emphasizing variations between rural and urban areas.

Methods

Between November and December 2020, a total of 4218 urban and rural community members (aged ≥60 years) in China were recruited as participants using a multistage random sampling method. A face-to-face structured questionnaire survey was conducted to collect information on demographic characteristics, eHealth literacy (consisting of application, evaluation, and decision dimensions), and medication adherence. eHealth literacy was assessed using the Chinese version of the eHealth Literacy Scale developed by Norman and Skinner, and medication adherence was measured using the 4-item Morisky scale. We used a general descriptive analysis and stratified logistic regression models to examine how eHealth literacy is linked to medication adherence and urban-rural differences.

Results

There were 4218 respondents, of which 2316 (54.9%) lived in urban areas and 1902 (45.1%) in rural areas, respectively. After adjusting for potential confounders, among participants with prefrailty, eHealth literacy was associated with medication adherence in urban areas in terms of less application (adjusted odds ratio [AOR] 1.16, 95% CI 0.82-1.63), less evaluation (AOR 1.29, 95% CI 0.92-1.81), and less decision ability (AOR 1.20, 95% CI 0.86-1.68); eHealth literacy was linked with medication adherence in the rural areas in terms of less application (AOR 1.10, 95% CI 0.56-2.13), less evaluation (AOR 1.05, 95% CI 0.61-1.79), and less decision ability (AOR 1.10, 95% CI 0.64-1.90). Among frail participants, less eHealth literacy (AOR 0.85, 95% CI 0.48-1.51), along with its dimensions, including less application (AOR 0.85, 95% CI 0.47-1.54), evaluation (AOR 0.89, 95% CI 0.50-1.57), and decision ability (AOR 0.99, 95% CI 0.55-1.76), were associated with medication adherence in urban areas; less eHealth literacy (AOR 0.89, 95% CI 0.48-1.65), along with its dimensions, including less application (AOR 1.23, 95% CI 0.62-2.44), evaluation (AOR 0.98, 95% CI 0.53-1.82), and decision ability (AOR 0.90, 95% CI 0.49-1.67), were associated with medication adherence in rural areas.

Conclusions

The results of this study suggest that there is an association between eHealth literacy and medication adherence among older people with frailty and prefrailty. To promote medication adherence, eHealth literacy can be helpful in tailoring interventions.

Effects of pain, hospitalization, and medication on depressive symptom in Syrian patients with chronic diseases

Chronic diseases and pain exacerbate depressive symptom in Syria. Limited research on hospital-induced depressive symptom among Syrian patients with chronic diseases warrants further study. A cross-sectional study in four Damascus hospitals revealed high rates of pain and depressive symptom. This study aims to investigate the prevalence and severity of chronic pain and hospital-induced depressive symptom in Syrian patients, as well as the relationship between pain, depressive symptom, and medication behavior. This study analyzes the impact of pain, hospitalization, and medication on patients with chronic diseases. The four Damascus hospitals included 453 patients from various departments. Data were collected through structured interviews and internationally recognized scales such as the PSEQ, HADS, and MMAS. These findings offer insights into pain management and psychological well-being, with implications for patient care and support strategies. The study involved 453 patients with chronic diseases, with gender distribution showing 46.6% females and 53.4% males. The age range was from 7 to 87 years, with an average of 46.87 years. Chi-square tests revealed a significant connection between gender and HADS-A scores, where 48.3% of females had abnormalities (χ2 (1, N = 453) = 7.125, p = 0.028). Marital status was significantly associated with anxiety and depressive symptom levels, particularly among widowed and divorced patients. Employment status, education, and comorbidity were linked to abnormal HADS-A scores, while education level showed a positive correlation with HADS-D scores. ANOVA tests showed significant differences in MMAS scores across income groups (F (3, 449) = 3.167, p = 0.024), with a notable difference between low-income and lower-middle-income groups (mean difference = 0.389, p = 0.031. Chronic pain and HID are prevalent among Syrian patients with chronic diseases and influenced by socio-demographic factors. Personalized interventions are needed to address psychological symptoms and medication behavior.

Association of Medication Adherence and Health Status in Heart Failure With Reduced Ejection Fraction: Insights From the CHAMP-HF Registry

BACKGROUND

The foundation for managing heart failure with reduced ejection fraction (HFrEF) is adherence to guideline-directed medical therapy. Finding an association between medication adherence and patients' health status (their symptoms, function, and quality of life) can be used to underscore its importance to patients.

METHODS

The association of self-reported medication adherence in US outpatients with HFrEF enrolled in the Change the Management of Patients with Heart Failure registry from 2015 to 2017 was compared with their health status at baseline and 12 months later. A secondary analysis of changes in adherence between baseline and 6 months with 6-month health status was also performed. Medication adherence was assessed with the self-reported 4-item Morisky-Green-Levine Medication Adherence Scale, with scores ≥1 classified as nonadherent. The primary health status outcome was the disease-specific 12-item Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS; range, 0-100; higher is better). Robust linear regression models adjusted for confounders were used.

RESULTS

After excluding those who died (n=316) or did not provide 12-month KCCQ (n=1285), 3495 outpatients with HFrEF were included, of whom 1108 (31.7%) reported being nonadherent. Nonadherent participants were younger, had significantly worse baseline health status (-5.83-point difference; P<0.001), and showed less improvement at 12 months (-1.7-point difference in mean change; P=0.017) than adherent participants. Among nonadherent patients at baseline, those whose adherence improved trended toward greater 6-month health status improvements than those remaining nonadherent (fully adjusted difference of 2.52 points; P=0.054).

CONCLUSIONS

In HFrEF, medication nonadherence was associated with worse health status and less improvement over the following year. Improvements in adherence were associated with better health status than remaining nonadherent, underscoring the importance of supporting adherence with guideline-directed medical therapy in patients with HFrEF.

Adherence with oral nutritional supplements and influencing factors in postoperative patients with digestive tract tumors: a cross-sectional study

OBJECTIVE

This study aims to use structural equation modeling to explore the pathways and effect sizes of factors influencing the adherence of postoperative patients with digestive tract tumor to oral nutritional supplements, providing a theoretical basis for future nursing intervention measures.

METHODS

A total of 300 postoperative patients with digestive tract tumor within 30 days after surgery were conveniently sampled. Surveys were conducted using a General Information Questionnaire, Morisky Medication Adherence Scale, Digestive System Tumor Patient Nutrition Knowledge-Attitude-Behavior Questionnaire, Multidimensional Social Perception Scale, Beliefs about Medical Questionnaire, and General Self-Efficacy Scale. Structural equation modeling was employed to analyze the factors and pathways affecting adherence with oral nutritional supplements.

RESULTS

The adherence score of postoperative patients with digestive tract tumor to oral nutritional supplements was 1.61 ± 1.38. The structural equation model had a good fit (χ2/df = 2.685, GFI = 0.930, CFI = 0.913, AGFI = 0.887, IFI = 0.915, and RMSEA = 0.075). Nutrition knowledge, social support, medication beliefs, and self-efficacy were found to be factors influencing adherence with oral nutritional supplements in postoperative patients with digestive tract tumor, with total effects of 0.539, 0.264, 0.215, and 0.180, respectively. Nutrition knowledge indirectly affected adherence through self-efficacy and medication beliefs, while social support indirectly affected adherence through self-efficacy.

CONCLUSION

Adherence with oral nutritional supplements in postoperative patients with digestive tract tumor is at a low level. Improving social support, enhancing patients nutrition knowledge, increasing self-efficacy, and strengthening medication beliefs are effective ways to improve patient adherence.

Development and validation of a structured questionnaire for assessing risk factors of medication non-adherence among pulmonary tuberculosis patients in Indonesia

Background: Medication non-adherence is a significant concern in tuberculosis (TB) treatment, requiring a precise understanding of the associated risk factors. However, there is a lack of appropriate means to assess the risk factors among TB patients in Indonesia, leading to the development and validation of a structured questionnaire for this purpose. Method: This study unfolded in two distinct phases, namely, the first included questionnaire construction through framework development, item generation, item screening, and pretesting (in 50 patients). The second comprised questionnaire validation with 346 participants using confirmatory factor analysis (CFA) and structural equation modeling-partial least squares (SEM-PLS). Additionally, reliability testing was conducted using Cronbach's alpha and composite reliability statistical techniques. Results: In the development phase, 168 items were defined, consisting of sociodemographic characteristics (8 items) and risk factors for medication non-adherence (160 items). Expert evaluation reduced the number of items to 60, which decreased to 22 after performing a pilot study. Subsequent SEM-PLS modeling resulted in the identification of 14 valid items, representing five major risk factors, namely, socioeconomics (4 items), healthcare team (4 items), condition (3 items), therapy (2 items), and patient (1 item). Only condition-related factors were found to influence non-adherence, and all constructs showed good reliability based on Cronbach's alpha (>0.6) and composite reliability (0.7) values. Conclusion: The final 22 items that emerged from this rigorous process indicated a valid and robust questionnaire for assessing risk factors of medication non-adherence among pulmonary tuberculosis patients in Indonesia. The developed questionnaire was positioned to be a valuable tool for healthcare professionals, policymakers, and scientists in creating patient-centered strategies and interventions to address non-adherence.

Complementary Therapies and Their Association with Problems in Therapeutic Adherence to Conventional Synthetic DMARDs in Rheumatoid Arthritis: A Cross-Sectional Study

The use of complementary therapies is highly prevalent among patients with rheumatoid arthritis (RA). Nevertheless, the use of complementary medicine could involve problems in the following of scientifically accepted treatments. To date, there is limited information regarding the association of nonconventional therapies with problems regarding compliance with the treatment. Therefore, the objective of this study was to identify whether the utilization of complementary therapies is associated with a high risk of problems regarding therapeutic adherence to conventional synthetic disease-modifying anti-rheumatic drugs (cs-DMARDs) in RA patients. A survey was performed with RA patients in an outpatient rheumatology clinic in a university hospital; the use of complementary therapies, as well as their type, was identified. To assess problems with therapeutic adherence, we used the four-item Morisky-Green scale. A comprehensive assessment of clinical and therapeutic characteristics was performed. Univariable and multivariable models were performed to identify the risk of problems with therapeutic adherence in users of complementary therapies. In total, 250 RA patients were included; 92% used complementary therapies. Of them, the most frequently used were herbal medicine (65%), homeopathy (64%), and cannabis and its derivatives (51%). In the univariable logistic regression analysis, the factors associated with problems in the therapeutic adherence to cs-DMARDs were age (p = 0.019), the presence of other comorbidities (p = 0.047), and the use of complementary therapies (p = 0.042). After controlling for potential confounders, the use of complementary therapies increased the risk of problems with therapeutic adherence to cs-DMARDs (adjusted OR = 2.84, 95% CI = 1.06-7.63, p = 0.037). We concluded that the use of complementary therapies increases the risk of problems with therapeutic adherence. Therefore, for physicians and healthcare professionals, the early identification of the use of nonconventional therapies in their RA patients is required, followed by a directed discussion with their patients about the risks and benefits to which they could be exposed to complementary therapies.

A prospective, randomized, controlled, multicentre trial for secondary prevention in patients with chronic coronary syndrome using a smartphone application for digital therapy: the CHANGE study protocol

Aims

Coronary artery disease (CAD) remains the leading cause of death worldwide. 'Stable' CAD is a chronic progressive condition, which recent European guidelines recommend referring to as 'chronic coronary syndrome' (CCS). Despite therapeutic advances, morbidity and mortality among patients with CCS remain high. Optimal secondary prevention in patients with CCS includes optimization of modifiable risk factors with behavioural changes and pharmacological therapy. The CHANGE study aims to provide evidence for optimization of secondary prevention in CCS patients by using a smartphone application (app).

Methods and results

The CHANGE study is designed as a prospective, randomized, controlled trial with a 1:1 allocation ratio, which is currently performed in nine centres in Germany in a parallel group design. 210 patients with CCS will be randomly allocated either to the control group (standard-of-care) or to the intervention group, who will be provided the VantisTherapy* app in addition to standard-of-care to incorporate secondary prevention into their daily life. The study will be performed in an open design. Outcomes will be assessed using objective data from three in-person visits (0, 12, and 24 weeks). Primary outcomes will involve adherence to secondary prevention recommendations and quality of life (QoL). The recruitment process started in July 2022.

Conclusion

The CHANGE study will investigate whether a smartphone-guided secondary prevention app, combined with a monitor function compared with standard-of-care, has beneficial effects on overall adherence to secondary prevention guidelines and QoL in patients with CCS.

Trial registration

The study is listed at the German study registry (DRKS) under the registered number DRKS00028081.

A systematic review of primary care-focused, self-reported medication adherence tools

BACKGROUND

Clinician recognition of nonadherence is generally low. Tools that clinicians have used to assess medication adherence are self-reported adherence instruments that ask patients questions about their medication use experience. There is a need for more structured reviews that help clinicians comprehensively distinguish which tool might be most useful and valuable for their clinical setting and patient populations.

OBJECTIVES

This systematic review aimed to (1) identify validated, self-reported medication adherence tools that are applicable to the primary care setting and (2) summarize selected features of the tools as an assessment of clinical feasibility and applicability.

METHODS

The investigators systematically reviewed MEDLINE via Ovid, Embase via Ovid, International Pharmaceutical Abstracts, and CINAHL from inception to December 1, 2020. Investigators independently screened 3394 citations, identifying 43 articles describing validation parameters for 25 unique adherence tools. After screening each tool, 17 tools met the inclusion criteria and were qualitatively summarized.

RESULTS

Findings highlight 25 various tool characteristics (i.e., descriptions, parameters and diseases, measures and validity comparators, and other information), which clinicians might consider when selecting a self-reported adherence tool with strong measurement validity that is practical to administer to patients. There was much variability about the nature and extent of adherence measurement. Considerable variation was noted in the objective measures used to correlate to the self-reported tools' measurements. There were wide ranges of correlation between self-reported and objective measures. Several included tools had relatively low to moderate criterion validities. Many manuscripts did not describe whether tools were associated with costs, had copyrights, and were available in other languages; how much time was required for patients to complete self-report tools; and whether patient input informed tool development.

CONCLUSION

There is a critical need to ensure that adherence tool developers establish a key list of tool characteristics to report to help clinicians and researchers make practical comparisons among tools.

Patient reported quality of life and medication adherence in Fabry disease patients treated with migalastat: A prospective, multicenter study

AIMS

Chaperone therapy with migalastat is a novel therapy option in Fabry disease (FD). In contrast to biweekly intravenous enzyme-replacement-therapy in a healthcare setting, oral delivery of migalastat every other day relies on the patient self-administration. Therapy adherence to migalastat and patient reported outcomes have not yet been studied in a real-world scenario.

METHODS AND RESULTS

Prospective multicenter 'MigALastat Therapy Adherence among FABRY patients' (MALTA-FABRY) study examined therapy adherence and patient-reported outcomes including quality of life in FD-patients receiving migalastat. Outcome measurements were elicited by the 'Medication Adherence Questionnaire (MAQ)', 'SF-36' and 'Fabry Pain Questionnaire' over a follow-up period of 24 months. Therapy adherence was graded as high (MAQ score of 4), medium (score of 2-3) or low (score 0-1). Within the recruitment period between 2017 and 2021, 40 patients (19 females) from 3 German FD-centers were included in the study. Nearly all patients (n = 37, 92.5%) showed good therapy adherence (MAQ6M_mean:3.93, MAQ12M_mean:3.71 and MAQ24M_mean:3.7). Only one patient fulfilled criteria for low adherence. Patient reported outcomes with completed SF-36 questionnaires were available in 28 patients (14 females). Over 24 months, significant improvement of pain and life role limitations due to physical activity was reported (Pain: change from baseline: 8.57 points, 95%-CI: 1.32-15.82, p = 0.022; role limitations physical: change from baseline: 13.39 points, 95%-CI: 0.61-23.2, p = 0.048).

CONCLUSION

Migalastat therapy adherence in FD-patients was high and remained high over a follow-up period of 2 years. Patient reported quality of life remained mostly stable, while pain and physical limitations improved over time.

Evaluation of an Automated Reminder System for Reducing Missed MRI Appointments

Background: The high frequency of missed appointments continues to be a burden on healthcare providers, leading to decreased productivity, quality of service, and quality of outcome. The purpose of this study is to evaluate the effectiveness of Televox's automated appointment reminder service in reducing the missed appointment rate for MRI (magnetic resonance imaging). The appointment reminders were sent 72 h in advance. The total and no-show numbers were tallied to calculate missed appointment rates. Comparison of the missed appointment rate with and without Televox implementation and different payment types was performed. Temporal comparisons were also made across the corresponding time periods in order to control for seasonal fluctuations. Results: An insignificant decline in missed appointment rates was found in locations implementing Televox (P = .495) overall, although a significant decrease in missed appointments was found among Medicaid patients (P = .0381). Conclusion: Implementation of Televox appointment reminder systems did not significantly affect appointment attendance overall, but could be more useful specifically for encouraging Medicaid patients to attend MRI appointments.

Cognitive Behavioral Therapy (CBT) Telehealth Augmented With a CBT Smartphone Application to Address Type 2 Diabetes Self-Management: A Randomized Pilot Trial

Purpose:

The purpose of the study was to investigate the feasibility and acceptability of phone-delivered cognitive behavioral therapy (CBT) combined with an adjunctive smartphone application CBT MobileWork-DM© to improve self-management of type 2 diabetes mellitus (T2DM).

Methods:

Participants were 12 patients with T2DM on antihyperglycemic medication and had an A1C level of 8 or greater. A randomized controlled pilot study assessed treatment as usual (TAU) T2DM care versus a phone-delivered CBT (6, 8, or 12 weekly sessions) augmented with a CBT skills practice smartphone application. The CBT telehealth intervention addressed T2DM self-management and diabetes distress. Electronic and self-report medication taking, diabetes-related distress, and A1C were assessed at baseline and post-intervention.

Results:

After 16 weeks, a decrease in A1C and distress levels was observed in all 3 CBT phone groups and TAU group. The group with the most improvement was the 12-week CBT group, which had the greatest mean decrease in A1C (−2.33) and diabetes distress (−31.67). The TAU group exhibited a mean decrease of −2.15 and −21 for A1C and diabetes distress, respectively. The overall rate of completion for phone CBT sessions across the 3 CBT groups was 83%.

Conclusion:

This study demonstrates that telehealth CBT augmented with a smartphone application is feasible and acceptable. Patients demonstrated improvements in both T2DM management and distress.

Perceptions, preferences, and experiences of tuberculosis education and counselling among patients and providers in Kampala, Uganda: A qualitative study

Tuberculosis (TB) education seeks to increase patient knowledge about TB, while TB counselling seeks to offer tailored advice and support for medication adherence. While universally recommended, little is known about how to provide effective, efficient, patient-centred TB education and counselling (TEC) in low-income, high HIV-TB burden settings. We sought to characterise stakeholder perceptions of TEC in a public, primary care facility in Kampala, Uganda, by conducting focus group discussions with health workers and TB patients in the TB and HIV clinics. Participants valued TEC but reported that high-quality TEC is rarely provided, because of a lack of time, space, staff, planning, and prioritisation given to TEC. To improve TEC, they recommended adopting practices that have proven effective in the HIV clinic, including better specifying educational content, and employing peer educators focused on TEC. Patients and health workers suggested that TEC should not only improve TB patient knowledge and adherence, but should also empower and assist all those undergoing evaluation for TB, whether confirmed or not, to educate their households and communities about TB. Community-engaged research with patients and front-line providers identified opportunities to streamline and standardise the delivery of TEC using a patient-centred, peer-educator model.

Self-Reported Overall Adherence and Correct Inhalation Technique Discordance in Chronic Obstructive Pulmonary Disease Population

Background: Adherence to inhaled medication constitutes a major problem in patients with chronic obstructive pulmonary disease (COPD) globally. However, large studies evaluating adherence in its entirety and capturing a large variety of potentially associated factors are still lacking.

Objective: To study both elementary types of adherence to chronic inhaled COPD medication in “real-life” COPD patients and to assess relationships with a wide-ranging spectrum of clinical parameters.

Methods: Data from the Czech Multicentre Research Database (CMRD) of COPD, an observational prospective study, were used. Overall adherence (OA) was evaluated with Morisky Medication Adherence Scale (©MMAS-4) and adherence to an application technique (A-ApplT) with the Five Steps Assessment. Mann–Whitney U test, Spearman’s correlation, and logistic regression were used to explore relationships between variables.

Results: Data of 546 participants (69.6% of all patients from the CMRD) were analyzed. Two-thirds self-reported optimal OA, but only less than one-third demonstrated A-ApplT without any error. OA did not correlate with A-ApplT. Next, better OA was associated with higher education, a higher number of inhalers, a lower rate of exacerbations, poorer lung function, higher degree of upper respiratory tract symptoms (SNOT-22), absence of depressive symptoms, ex-smoking status, regular mouthwash after inhaled corticosteroids (ICS), and flu vaccination. By contrast, better A-ApplT was associated with a lower number of inhalers, better lung function, and regular mouthwash after ICS. Independent predictors of nonoptimal OA included lower degree of education, absence of flu vaccination, anemia, depression, and peptic ulcer history, whereas independent predictors of lower A-ApplT were lower education, absence of regular mouthwash after ICS, and higher COPD Assessment Test score.

Conclusions: Parameters associated with OA and A-ApplT differ, and those associated with both adherence domains are sometimes associated inversely. Based on this finding, we understand these as two separate constructs with an overlap.

The Persian version of the 8-item Morisky Medication Adherence Scale (MMAS-8): can we trust it?

Background

Diabetes mellitus (DM) is a common serious health problem. Medication adherence is a crucial determinant of therapeutic success in patients with diabetes mellitus. This study aims to examine the 8-item Morisky Medication Adherence Scale (MMAS-8) psychometric properties among diabetic patients.

Methods

This study was carried out at the Internal Medicine clinic of Firooz Abadi Hospital in Tehran, Iran, from 2018 to 2020. The English version of the MMAS-8 was translated into Persian and administered to patients with diabetes mellitus. A total of 150 patients who had diabetes were included. Cronbach's alpha was calculated to assess the reliability.

Results

According to the recommended scoring method, the Mean ± SD of MMAS-8 scores was 4.97 ± 1.92. Good internal consistency was found in our study (Cronbach's α = 0.70). Not any significant relationship between MMAS-8 categories and occurrence of complications was found.

Conclusions

The findings of this validation study indicate that the Persian version of the MMAS-8 is a reliable measure of medication adherence, but it has not acceptable validity. Further studies are needed to reach a good validity.

[Severe adult asthma and treatment adherence: Results of the FASE-CPHG study]

INTRODUCTION

Data on severe asthma in France are scarce. The aim of this study was to evaluate adherence to asthma treatments and its determinants in a population of severe asthmatics.

METHODS

From May 2016 to June 2017, the French Collège des Pneumologues des Hôpitaux Généraux organized a large-scale prospective, cross-sectional, multicenter study on this topic; 1502 patients with severe asthma were included.

RESULTS

The average number of substantive treatments was 2.5±1.1. Assessed by self-questionnaire in 1289 patients, overall adherence was 64.8%, in good agreement with the findings of the pneumologist in charge (p<0.0001). Control of asthma according to the GINA criteria was more successful in compliant patients (p<0.01). In univariate analysis, the most compliant participants were frequent exacerbator patients (p=0.02), those with nasal polyposis (p=0.01) and those receiving an anticholinergic agent (p<0.01), anti-IgE biotherapy (p<0.0001) or oral corticosteroids (p<0.01). The least compliant participants were younger (p<0.0001), active smokers (p<0.001), with shorter average disease duration (24.2±15.7 vs 29.1±18.7 years, p<0.0001) and a lower number of substantive asthma treatments (2.2±1 vs 2.6±1, p<0.0001). In multivariate analysis, age, length of disease and anti-IgE treatment were the only factors affecting therapeutic compliance.

CONCLUSION

In this large-scale study of severe asthmatic patients, 64.8% were compliant according to the MMAS-4© self-administered questionnaire and appeared to be better monitored according to the criteria defined in our study. Overall, adherence was more satisfactory among older patients and those whose disease had been evolving over a long period of time or were receiving anti-IgE biotherapy.

Improved Patient-Reported Medication Adherence, Patient Satisfaction, and Glycemic Control in a Collaborative Care Pharmacist-Led Diabetes "Tune-Up" Clinic

Diabetes complications remain a leading cause of death, which may be due to poor glycemic control resulting from medication nonadherence. The relationship between adherence status and HbA1c (glycemic control) has not been well-studied for clinical pharmacist interventions. This study evaluated medication adherence, patient satisfaction, and HbA1c, in a collaborative pharmacist-endocrinologist diabetes clinic over 6 months. Of 127 referred, 83 patients met the inclusion criteria. Mean medication adherence scores, considered "good" at baseline, 1.4 ± 1.2, improved by 0.05 points (p = 0.018), and there was a 26% increase in patients with good adherence. A significant improvement of 0.40 percentage points (95% CI: -0.47, -0.34) was observed in mean HbA1c across the three time points (p < 0.001). Mean total satisfaction scores were high and increased, with mean 91.3 ± 12.2 at baseline, 94.7 ± 9.6 at 3 months, and 95.7 ± 10.8 at 6 months (p = 0.009). A multimodal personalized treatment approach from a pharmacist provider significantly and positively impacted glycemic control regardless of self-reported medication adherence, and patient satisfaction remained high despite changing to a clinical pharmacist provider and increased care intensity.

Cyclothymic Temperament is Associated with Poor Medication Adherence and Disordered Eating in Type 2 Diabetes Patients: A Case-Control Study

INTRODUCTION

Poor medication adherence and disordered eating are major self-care problems in patients with type 2 diabetes that worsen glycemic control and increase the risk of developing severe diabetes complications. Affective temperament, which remains mostly unchanged throughout life, is speculated to predict poor treatment response and high comorbidity. The aim of this study was to explore the link between affective temperament and poor glycemic control due to insufficient self-care.

METHODS

This single-center case-control study involved 77 outpatients divided into the 'poor glycemic control' group (n = 52) and the 'better glycemic control' group (n = 25) based on their mean glycated hemoglobin (HbA1c) levels over the past 12 months. All participants underwent one-on-one interviews during which they completed the following psychometric questionnaires: (1) the Mini-International Neuropsychiatric Interview 5.0.0; (2) the Temperament Evaluation of Memphis, Pisa, and San Diego Auto-questionnaire; (3) a researcher-designed single question for assessing subclinical stress-induced overeating; and (4) the Morisky Medication Adherence Scale. The difference between two continuous independent variables was determined using Student's t test. Discrete variables were compared using the Chi-square (χ2) or Fisher's exact test. Multiple testing corrections were performed using the false discovery rate.

RESULTS

Those outpatients in the poor glycemic control group exhibited significantly more stress-induced overeating (χ2 = 1.14, q statistic = 0.040) and poor medication adherence (t = 3.70, q = 0.034) than those in the better glycemic control group. However, there were no significant differences between the two groups in terms of affective temperaments, clinical eating disorders, or diabetes-specific distress. Patients with stress-induced overeating (t = - 2.99, p = 0.004) and poor medication adherence (t = - 4.34, p = 0.000) exhibited significantly higher scores for cyclothymic temperament than their counterparts.

CONCLUSION

Cyclothymic temperament is significantly associated with disordered eating and/or poor medication adherence in patients with type 2 diabetes and is possibly linked to poor glycemic control.

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study

OBJECTIVES

To identify root causes of preventable adverse drug events (pADEs) contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community.

METHODS

Cross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported.

RESULTS

Most common pADE-related medical conditions: chronic obstructive pulmonary disease/asthma (13.3%), bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%) and pneumonia (5%). Most common root causes were: providers not confirming that the patient/family understands information given (29.2%), can identify how a medication helps them/have their concerns addressed (16.7%), can identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%); absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented.

CONCLUSIONS

To prevent pADEs, providers need to confirm that patients/families understand information given, how a medication helps them, how to recognise and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient's/families' medication use and monitoring competency.

Impact of a Multicomponent Digital Therapeutic Mobile App on Medication Adherence in Patients with Chronic Conditions: Retrospective Analysis

BACKGROUND

Strategies to improve medication adherence are widespread in the literature; however, their impact is limited in real practice. Few patients persistently engage long-term to improve health outcomes, even when they are aware of the consequences of poor adherence. Despite the potential of mobile phone apps as a tool to manage medication adherence, there is still limited evidence of the impact of these innovative interventions. Real-world evidence can assist in minimizing this evidence gap.

OBJECTIVE

The objective of this study was to analyze the impact over time of a previously implemented digital therapeutic mobile app on medication adherence rates in adults with any chronic condition.

METHODS

A retrospective observational study was performed to assess the adherence rates of patients with any chronic condition using Perx Health, a digital therapeutic that uses multiple components within a mobile health app to improve medication adherence. These components include gamification, dosage reminders, incentives, educational components, and social community components. Adherence was measured through mobile direct observation of therapy (MDOT) over 3-month and 6-month time periods. Implementation adherence, defined as the percentage of doses in which the correct dose of a medication was taken, was assessed across the study periods, in addition to timing adherence or percentage of doses taken at the appropriate time (±1 hour). The Friedman test was used to compare differences in adherence rates over time.

RESULTS

We analyzed 243 and 130 patients who used the app for 3 months and 6 months, respectively. The average age of the 243 patients was 43.8 years (SD 15.5), and 156 (64.2%) were female. The most common medications prescribed were varenicline, rosuvastatin, and cholecalciferol. The median implementation adherence was 96.6% (IQR 82.1%-100%) over 3 months and 96.8% (IQR 87.1%-100%) over 6 months. Nonsignificant differences in adherence rates over time were observed in the 6-month analysis (Fr(2)=4.314, P=.505) and 3-month analysis (Fr(2)=0.635, P=.728). Similarly, the timing adherence analysis revealed stable trends with no significant changes over time.

CONCLUSIONS

Retrospective analysis of users of a medication adherence management mobile app revealed a positive trend in maintaining optimal medication adherence over time. Mobile technology utilizing gamification, dosage reminders, incentives, education, and social community interventions appears to be a promising strategy to manage medication adherence in real practice.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

People-centred care versus clinic-based DOT for continuation phase TB treatment in Armenia: a cluster randomized trial

Background

WHO’s directly observed therapy (DOT) strategy for tuberculosis (TB) treatment depends upon a well–organized healthcare system. This study sought to evaluate the effectiveness of self-administered drug intake supported by a family member versus in-clinic DOT.

Methods

This open–label, nationally-representative stratified cluster randomized controlled non–inferiority trial with two parallel equal arms involved drug–susceptible pulmonary TB patients in the continuation treatment phase. We randomly assigned outpatient–TB–centres (52 clusters) to intervention and control arms. The intervention included an educational/counseling session to enhance treatment adherence; weekly visits to outpatient–TB–centres to receive medication, and daily SMS medication reminders and phone calls to track adherence and record side effects. Controls followed clinical DOT at Outpatient–TB–centres. Both groups participated in baseline and 4–5 months follow–up surveys. The trial’s non–inferiority comparisons include: treatment success as the clinical (primary) outcome and medication adherence (self–reported), knowledge, depressive symptoms, stigma, quality of life, and social support as non–clinical (secondary) outcomes.

Results

Per–protocol analysis showed that the intervention (n = 187) and control (n = 198) arms achieved successful treatment outcome of 92.0 and 92.9%, respectively, indicating that the treatment success in the intervention group was non–inferior to DOT. Knowledge, depression, stigma, quality of life, and social support also showed non–inferiority, demonstrating substantial improvement over time for knowledge (change in the intervention = 1.05: 95%CL (0.49, 1.60); change in the control = 1.09: 95%CL (0.56, 1.64)), depression score (change in the intervention = − 3.56: 95%CL (− 4.99, − 2.13); change in the control = − 1.88: 95% CL (− 3.26, − 0.49)) and quality of life (change in the intervention = 5.01: 95%CL (− 0.64, 10.66); change in the control = 7.29: 95%CL (1.77, 12.81)). The intervention resulted in improved treatment adherence.

Conclusions

This socially empowering alternative strategy might be a preferable alternative to DOT available to patients in Armenia and in other countries. Further research evaluating cost effectiveness of the intervention and generalizability of the results is warranted.

Trial registration

Clinicaltrials.gov: NCT02082340, March 10, 2014.

Adherence to Subcutaneous Anti-TNF Treatment in Chronic Inflammatory Rheumatism and Therapeutic Patient Education

OBJECTIVE

Poor patient adherence to anti-TNF treatment has proven to be a major roadblock to effective management. Therapeutic patient education (TPE) is now recognized as a crucial tool in managing conditions like chronic inflammatory rheumatism and in improving treatment adherence. This study aimed to assess whether different TPE programs might improve adherence to subcutaneous anti-tumor necrosis factor (anti-TNF) treatment in patients with rheumatoid arthritis (RA), ankylosing spondyloarthritis (AS), and psoriatic arthritis (PsA).

METHODS

This was a retrospective, observational, monocentric study of current care practices. We included 193 patients (124 women; mean age 53.3 ± 14.8 years). All patients received subcutaneous anti-TNF treatment and one of three TPE models, delivered by a nurse, from 2009 to 2013. The cohort was grouped according to different educational models: M1: information (N=92); M2: individual TPE (N=80); and M3: individual and group TPE sessions (N=21). Adherence was assessed with the Morisky Medication Adherence Scale (MMAS-4™). Scores were rated as follows: good adherence (MMAS-4 = 4), moderate adherence (MMAS-4 = 2-3), and poor adherence (MMAS-4 = 0-1).

RESULTS

The mean disease duration was 10 years [95% CI: 5 to 18]. The cohort comprised 113 patients with RA, 73 with AS, and seven with PsA. Overall, 146 (75.7%) patients displayed good adherence, 34 (17.6%) displayed moderate adherence, and 13 (6.7%) displayed poor adherence. The M3 group displayed less adherence than the M1 and M2 groups. Old age was the only factor correlated with good adherence (p=0.005). The level of knowledge had no significant impact on adherence.

CONCLUSION

This study demonstrated good adherence to anti-TNF treatment in patients that received TPE, particularly when it was delivered in individual sessions.

The Effect of a Tailored Patient Activation Intervention in Inflammatory Bowel Disease Patients

Purpose A pre-test, post-test, control group design was employed to investigate the impact of a tailored patient activation intervention (PAI) among inflammatory bowel disease (IBD) patients. Methods Patients who met the inclusion criteria were selected from medical records via convenience sampling, were consented, and completed a baseline survey. Based on responses to the baseline 13-item patient activation measure (PAM-13), they were categorized into one of four patient activation stages. During office visits, intervention patients (N=23) were given a tailored PAI based on their baseline stage, which consisted of an information booklet and focused discussion with the gastroenterologist, while the control group (N=27) received usual care. Baseline and 1-month post-intervention scores were compared between the intervention (N=20) and control (N=21) groups for changes in patient activation score, medication adherence, and satisfaction with care. Results Most participants were Caucasian (88%), female (64%), college graduates (56%), and had Crohn's disease (59.2%). Overall, females had a significantly higher (p=0.04) mean activation score (mean=70.9±15.4) than males (mean=60.9±10.7) at baseline. This trend was the same post-intervention (75.6 females vs 64.4 males; p=0.03). The difference in mean activation scores pre- vs post-intervention was not statistically significant between the intervention and control groups (mean=4.9±12.3, p=0.21). However, this difference could be considered to be clinically significant based on results from previous studies. There were no significant differences in medication adherence or satisfaction scores pre- vs post-intervention for either group. Conclusion Tailored PAIs have the potential to increase activation level of patients with inflammatory bowel disease. This customized medical interaction increased patient involvement in disease management and could potentially lead to improved health outcomes.

A systematic review of non-pharmacological interventions to improve therapeutic adherence in tuberculosis

BACKGROUND

Reviews examining non-pharmacological interventions to improve therapeutic adherence in tuberculosis have several limitations (design, quality assessment…). Consequently, for clinical practice, it is important to generate a review containing all the information to improve patient adherence, solving the previous issues.

OBJECTIVES

To examine non-pharmacological interventions to improve therapeutic adherence in tuberculosis through clinical trials.

METHODS

A systematic review in MEDLINE/EMBASE was performed.

RESULTS

Thirty seven papers were analysed. The disease treatment interventions were disparate, grouped into: education, psychological interventions, new technologies, directly observed treatment, incentives and improved access to health services. In the treatment of latent infection, the majority of studies were conducted in the marginal population (drug addicts, homeless individuals and prisoners) and were based mainly on the provision of incentives. Study quality was generally low.

CONCLUSIONS

Great variability exists in the studies comparing strategies for identifying interventions, objectives and effects. The designs carried out generally have methodological deficits.

Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies

BACKGROUND

Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes.

METHODS AND FINDINGS

We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions.

CONCLUSION

TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.

Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial

BACKGROUND

Poor adherence to long-term antipsychotic injectable (LAI) medication in patients with psychotic disorders is associated with a range of negative outcomes. No psychosocial intervention has been found to be consistently effective in improving adherence.

OBJECTIVES

To test whether or not offering financial incentives is effective and cost-effective in improving adherence and to explore patient and clinician experiences with such incentives.

DESIGN

A cluster randomised controlled trial with economic and nested qualitative evaluation. The intervention period lasted for 12 months with 24 months' follow-up. The unit of randomisation was mental health teams in the community.

SETTING

Community teams in secondary mental health care.

PARTICIPANTS

Patients with a diagnosis of schizophrenia, schizoaffective psychosis or bipolar illness, receiving ≤ 75% of their prescribed LAI medication. In total, 73 teams with 141 patients (intervention n = 78 and control n = 63) were included.

INTERVENTIONS

Participants in the intervention group received £15 for each LAI medication. Patients in the control group received treatment as usual.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

adherence to LAI medication (the percentage of received out of those prescribed).

SECONDARY OUTCOMES

percentage of patients with at least 95% adherence; clinical global improvement; subjective quality of life; satisfaction with medication; hospitalisation; adverse events; and costs. Qualitative evaluation: semistructured interviews with patients in the intervention group and their clinicians.

RESULTS

PRIMARY OUTCOME

outcome data were available for 131 patients. Baseline adherence was 69% in the intervention group and 67% in the control group. During the intervention period, adherence was significantly higher in the intervention group than in the control group (85% vs. 71%) [adjusted mean difference 11.5%, 95% confidence interval (CI) 3.9% to 19.0%; p = 0.003]. Secondary outcome: patients in the intervention group showed statistically significant improvement in adherence of at least 95% (adjusted odds ratio 8.21, 95% CI 2.00 to 33.67; p = 0.003) and subjective quality of life (difference in means 0.71, 95% CI 0.26 to 1.15; p = 0.002). Follow-ups: after incentives stopped, adherence did not differ significantly between groups, neither during the first 6 months (adjusted difference in means -7.4%, 95% CI -17.0% to 2.1%; p = 0.175) nor during the period from month 7 to month 24 (difference in means -5.7%, 95% CI -13.1% to 1.7%; p = 0.130). Cost-effectiveness: the average costs of the financial incentives was £303. Overall costs per patient were somewhat higher in the intervention group, but the difference was not significant. Semistructured interviews: the majority of patients and clinicians reported positive experiences with the incentives beyond their monetary value. These included improvement in the therapeutic relationship. The majority of both patients and clinicians perceived no negative impact after the intervention was stopped after 1 year.

CONCLUSIONS

Financial incentives are effective in improving adherence to LAI medication. Health-care costs (including costs of the financial incentive) are unlikely to be increased substantially by this intervention. Once the incentives stop, the advantage is not maintained. The experiences of both patients and clinicians are largely, but not exclusively, positive. Whether or not financial incentives are effective for patients with more favourable background, those on oral mediation or for shorter or longer time periods remains unknown.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77769281.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 70. See the NIHR Journals Library website for further project information.

Predictors of effective therapeutic relationships between pharmacists and patients with type 2 diabetes: Comparison between Arabic-speaking and Caucasian English-speaking patients

BACKGROUND

The benefits of pharmacist-led interventions in achieving desired patient outcomes have been well established. Effective patient-pharmacist relationships are required to provide high-quality pharmacy care. Limited information is available about how Arabic-speaking migrants with diabetes, in Australia, perceive patient-pharmacist relationship and how these perspectives differ from the mainstream society (represented by Caucasian English-speaking people).

OBJECTIVE

To examine and compare the patient-pharmacist relationship, medication underuse and adherence levels among Arabic-speaking and Caucasian English-speaking patients with type 2 diabetes.

METHODS

A 98-item survey incorporating several previously-validated measurements was completed by Arabic-speaking migrants (ASMs) and Caucasian English-speaking patients (ESPs) with type 2 diabetes. Participants were recruited from various healthcare settings in the Melbourne metropolitan area and rural Victoria, Australia. This survey-based, cross-sectional study was designed to explore patients' perceptions of the patient-pharmacist relationship. A descriptive analysis of responses was undertaken, and binary logistic regression was used to explore patient-pharmacist relationships.

RESULTS

A total of 701 participants were recruited; 392 ASMs and 309 ESPs. Of ASMs, 88.3% were non-adherent to their prescribed medication, compared with 45.1% of ESPs. The degree of relationship with community pharmacists differed significantly between ASMs and ESPs. Compared with ASMs, significantly more ESPs reported that they have thought about consulting a pharmacist when they had health problems (P = 0.002). Compared with ESPs, significantly fewer ASMs reported always following pharmacist recommendations (32% versus 61.9% respectively).

CONCLUSIONS

Arabic-speaking migrants had less-effective relationships with community pharmacists when having their prescriptions filled. Community pharmacists' expertise appeared to be underused. These minimal relationships represent missed opportunities to improve health outcomes.

Medication adherence in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory condition with intestinal and extraintestinal manifestations. Medications are the cornerstone of treatment of IBD. However, patients often adhere to medication poorly. Adherence to medications is defined as the process by which patients take their medications as prescribed. Treatment non-adherence is a common problem among chronic diseases, averaging 50% in developed countries and is even poorer in developing countries. In this review, we will examine the adherence data in IBD which vary greatly depending on the study population, route of administration, and methods of adherence measurement used. We will also discuss the adverse clinical outcomes related to non-adherence to medical treatment including increased disease activity, flares, loss of response to anti-tumor necrosis factor therapy, and so forth. There are many methods to measure medication adherence namely direct and indirect methods, each with their advantages and drawbacks. Finally, we will explore different intervention strategies to improve adherence to medications.

Patient-reported outcomes in topical field treatment of actinic keratosis in Swedish and Danish patients

Topical treatments in dermatology can be long, complex and lead to nonadherence and nonpersistence to prescribed treatment. Clinical efficacy observed in randomized clinical trials (RCT) may therefore be reduced in real-world clinical practice. The objective of this study was to analyze patient-reported treatment adherence, treatment satisfaction and health-related quality of life (HRQoL) with topical treatments of actinic keratosis (AK) in routine clinical practice in Denmark and Sweden. Adult patients prescribed field-directed topical AK treatments with diclofenac gel, imiquimod or ingenol mebutate per routine clinical practice were eligible for the observational RAPID-ACT study. Data were collected through physician and patient questionnaires that included validated instruments to measure treatment satisfaction (TSQM-9), treatment adherence (MMAS) and HRQoL (EQ-5D-5L, EQ-VAS, AKQoL). In total, 446 patients from Denmark and Sweden were included. Ingenol mebutate patients reported a higher satisfaction with treatment effectiveness compared to patients treated with diclofenac (p = .006) while no other differences in treatment satisfaction could be determined. Treatment adherence was generally high, but higher for ingenol mebutate compared to both diclofenac (p < .001) and imiquimod (p = .007), possibly due to shorter treatment duration. No differences in improved HRQoL were found. More research is needed about the link between treatment adherence and real-world effectiveness.

Medication adherence and its associated factors among hypertensive patients attending the Debre Tabor General Hospital, northwest Ethiopia

BACKGROUND

Medication adherence is an important predictor of optimal blood pressure control; hence, it significantly reduces the risk of cardiovascular disease (CVD) and associated deaths. However, studies on medication adherence and its associated factors are scarce. Thus, this study aimed to assess adherence to antihypertensive medications and identify associated factors at Debre Tabor General Hospital, northwest Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted. Simple random sampling technique was used to select 346 participants. A structured questionnaire adapted from the World Health Organization (WHO) STEPwise approach was used to collect data. Medication adherence was measured by the four-item Morisky-Green-Levine Scale, with a score ≥3 defined as "good adherence". Data were entered using Epi Info version 7 and exported to SPSS version 20 for analysis. Descriptive and summary statistics were used. Bivariate and multivariable analyses were also carried out.

RESULTS

A total of 337 hypertensive patients participated in the study. Three-quarters (75.1%) of the participants were found to be adherent to their medication therapy. The multivariable logistic regression analysis showed that urban residence (adjusted odd ratio [AOR]=2.10, 95% confidence interval [CI]: 1.15, 3.85), taking less than two drugs per day (AOR=3.04, 95% CI: 1.53, 6.06), and having knowledge about hypertension (HTN) and its treatment (AOR=8.86, 95% CI: 4.67, 16.82) were positively and significantly associated with medication adherence, while age >60 years (AOR=0.33, 95% CI: 0.11, 0.98) was negatively and significantly associated with good medication adherence.

CONCLUSION

A significant proportion of hypertensive patients poorly adhere to antihypertensive medications. Age, residence, pill burden, and knowledge about HTN and its treatment are important predictors of medication adherence. Attention should be given to increase the knowledge of patients about their disease and its treatment, and due emphasis should also be given to older and rural patients.

Increased adolescent knowledge and behavior following a one-time educational intervention about tuberculosis

OBJECTIVE

To evaluate the impact of a tuberculosis (TB) educational intervention (EI) on change in adolescent student knowledge and participation in a TB prevention program.

METHODS

From 2/2013-5/2015, students from 2 high schools in Houston, TX participated. The 25-min EI discussed TB bacteriology, epidemiology, symptoms, and indications for TB testing/treatment. Students completed pre- and post-quizzes. Immediately after the EI, students were invited to participate in voluntary TB risk-factor screening, testing and treatment. At 6 months, focus groups were conducted.

RESULTS

895 students attended the EI. 827 students (92%) completed the EI quizzes. Knowledge improved by 12% (pre: 70%; post: 82%, p<0.001); 78% shared their TB knowledge. Following the EI, 671/827 (81%) enrolled in a TB prevention program. Focus groups indicated that the EI stimulated student learning about TB and increased their willingness to participate.

CONCLUSION

A brief, one-time, TB EI is an effective method to encourage adolescents to learn about TB and motivate their uptake of TB risk-factor screening, testing and treatment. Similar EIs should accompany TB prevention programs targeting adolescents.

PRACTICE IMPLICATIONS

The study's procedures could be considered for incorporation into school-based TB prevention programs to improve the identification, testing and treatment of adolescents at risk for TB.

Tuberculosis knowledge, attitudes, and practices among northern Ethiopian prisoners: Implications for TB control efforts

Introduction

Although awareness is an important component in tuberculosis (TB) control, we do not know how much Ethiopian prisoners know about TB. This study assessed the level of knowledge, attitudes, and practices (KAP) of prisoners about TB in eight northern Ethiopian prisons.

Methods

Data were collected cross-sectionally from 615 prisoners using a standardized questionnaire between March and May 2016. The outcome variables were defined considering the basic elements about TB.

Results

Out of 615 prisoners, only 37.7% mentioned bacteria as a cause of TB while 21.7% related TB to exposure to cold wind. Eighty-eight per cent correctly mentioned the aerial route of TB transmission and 27.3% had perceived stigma towards TB. The majority (63.7%) was not aware of the possibility of getting multi-drug-resistant strains when they would not adhere to treatment. Overall, only 24% knew the basic elements about TB, 41% had favorable attitudes, and 55% had a good practice. Prisoners who were urban residents were generally more knowledgeable than rural residents (adjusted OR = 2.16; 95% CI = 1.15–4.06). Illiterates were found to be less knowledgeable (adjusted OR = 0.17; 95% CI = 0.06–0.46), less likely to have a favorable attitude (adjusted OR = 0.31; 95% CI = 0.15–0.64), and less good practice (adjusted OR = 0.35; 95% CI = 0.18–0.69). Significant differences were also observed between the different study prisons.

Conclusions

Knowledge of prisoners regarding the cause of TB and consequences of non-adherence to TB treatment was low. Knowledge on the transmission, symptoms, and prevention was fairly high. Health education interventions, focused on the cause and the translation of the knowledge to appropriate practices, are needed in all the study prisons. Special attention should be given to less educated prisoners, and to prisons with a high number of prisoners and those in remote areas.

The impact of poor asthma control among asthma patients treated with inhaled corticosteroids plus long-acting β2-agonists in the United Kingdom: a cross-sectional analysis

There are several new treatment options for patients whose asthma remains uncontrolled on free-dose and fixed-dose combinations of inhaled corticosteroids plus long-acting β₂-agonists (ICS+LABA). In order to evaluate the likely impact of these treatments, we assessed the effect of uncontrolled asthma on healthcare and patient burden within the UK among adult patients treated with ICS+LABA. Data obtained from 2010–2011 UK National Health and Wellness Surveys identified 701 patients treated with ICS+LABA. Patients with not well-controlled asthma (Asthma Control Test™ score <20) were compared with well-controlled asthma (score ≥ 20) patients on multiple measures. Cost burden was calculated using healthcare resource utilisation models and work productivity and impairment questionnaire. Overall, 452 and 249 patients reported not well-controlled and well-controlled asthma, respectively. A greater proportion of not well-controlled patients visited the accident & emergency department (21 vs. 14%, P = 0.016), were hospitalised (13 vs. 8%, P = 0.022) and had lower mental and physical health-related quality of life (P < 0.001) and impaired work productivity and activity scores: presenteeism (23 vs. 11%, P < 0.001), work impairment (29 vs. 17%, P < 0.001) and activity impairment (46 vs. 24%, P < 0.001). Calculated direct and indirect yearly costs/person doubled among not well-controlled compared to well-controlled asthma patients (£6592 vs. £3220). Total cost to society was estimated at £6172 million/year (direct costs, £1307 million; indirect costs, £4865 million). In conclusion, not well-controlled asthma is common among UK adults treated with ICS+LABA, resulting in impairments across a number of important health outcomes and represents a significant unmet need and resource burden.

Many people who take inhaled steroids combined with long-acting β2-agonist drugs still have poorly controlled asthma. A team led by Ian Pavord from the University of Oxford, UK, identified 701 people from the 2010–2011 UK National Health and Wellness Surveys who were taking this drug combination for their asthma. The researchers found that nearly two-thirds of these individuals had poorly controlled asthma associated with more visits to the emergency room, worse quality of life (both mentally and physically), impaired productivity and other health problems. The calculated direct and indirect costs per person with poorly controlled asthma were about double that for someone whose asthma was under control. The authors conclude that better treatment and management is needed to reduce costs and address the unmet medical need for people with persistent uncontrolled asthma.

Can We Identify Minority Patients at Risk of Nonadherence to Antiplatelet Medication at the Time of Coronary Stent Placement?

BACKGROUND

Lack of medication adherence is associated with significant morbidity and mortality, particularly among minorities. We aim to identify predictors of nonadherence to antiplatelet medications at the time of percutaneous coronary intervention (PCI) with stent among African American and Hispanic patients.

METHODS

We used data collected for a randomized clinical trial that recruited 452 minority patients from a large US health insurance organization in 2010 post-PCI to compare telephone-based motivational interviewing by trained nurses with an educational video. The primary outcome was 12-month adherence to antiplatelet medications measured by the claims-based medication possession ratio (MPR). Adequate adherence was defined as an MPR of 0.80 or higher.

RESULTS

More than half of the sample (age, 69.52 ± 8.8 years) was male (57%) and Hispanic (57%). Most (78%) had a median income below $30 000 and 22% completed high school or higher. Univariate analyses revealed that symptoms of depression (<.01) and not having a spouse (P = .03) were associated with inadequate adherence. In multivariate analysis, baseline self-reported adherence (1.4; 95% confidence interval [CI], 1.05-1.89), depressive symptoms (0.49; 95% CI, 0.7-0.90), comorbidity (0.89; 95% CI, 0.80-0.98), and telephone-based motivational interviewing by trained nurses (3.5; 95% CI, 1.9-2.70) were associated with adherence.

CONCLUSIONS

Having multiple comorbidities, depression, suboptimal adherence to medications, and low English proficiency at the time of PCI increase the risk of poor 12-month adherence to antiplatelets among minorities. Identifying these risk factors can guide PCI therapy and the use of evidence-based strategies to improve long-term adherence.

Shared decision-making for biologic treatment of autoimmune disease: influence on adherence, persistence, satisfaction, and health care costs

BACKGROUND

Shared decision-making (SDM), a process whereby physicians and patients collaborate to select interventions, is not well understood for biologic treatment of autoimmune conditions.

METHODS

This was a cross-sectional survey of adults initiating treatment for Crohn's disease or ulcerative colitis (inflammatory bowel disease, IBD) or psoriatic arthritis or rheumatoid arthritis (RA/PA). Survey data were linked to administrative claims for 6 months before (baseline) and after (follow-up) therapy initiation. Measures included the Shared Decision Making Questionnaire, Patient Activation Measure (PAM), Morisky Medication Adherence Scale (MMAS), general health, and treatment satisfaction. Claims-based Quan-Charlson comorbidity scores, persistence, medication possession ratio (MPR), and health care costs were examined. Patients were compared by participation (SDM) and nonparticipation (non-SDM) in SDM.

RESULTS

Among 453 respondents, 357 were eligible, and 306 patients (204 RA/PA and 102 IBD) were included in all analyses. Overall (n=357), SDM participants (n=120) were more often females (75.0% vs 62.5%, P=0.018), had lower health status (48.0 vs 55.4, P=0.005), and higher Quan-Charlson scores (1.0 vs 0.7, P=0.035) than non-SDM (n=237) participants. Lower MMAS scores (SDM 0.17 vs non-SDM 0.41; P<0.05) indicated greater likelihood of adherence; SDM participants also reported higher satisfaction with medication and had greater activation (PAM: SDM vs non-SDM: 66.9 vs 61.6; P<0.001). Mean MPR did not differ, but persistence was longer among SDM participants (111.2 days vs 102.2 days for non-SDM; P=0.029). Costs did not differ by SDM status overall, or among patients with RA/PA. The patients with IBD, however, experienced lower (P=0.003) total costs ($9,404 for SDM vs $25,071 for non-SDM) during follow-up.

CONCLUSION

This study showed greater likelihood of adherence and satisfaction for patients who engaged in SDM and reduced health care costs among patients with IBD who engaged in SDM. This study provides a basis for defining SDM participation and detecting differences by SDM participation for biologic treatment selection for autoimmune conditions.

Medication adherence as a predictor of 30-day hospital readmissions

PURPOSE

The aim of this study was to test whether patient medication adherence, a modifiable risk factor obtainable at hospital admission, predicts readmission within 30 days.

PATIENTS AND METHODS

We used a retrospective cohort study design to test whether patient medication adherence to all chronic medications, as determined by the 4-item Morisky Medication Adherence Scale (MMAS-4) administered by a pharmacist at the time of hospital admission, predicts 30-day readmissions. We compared readmission rates among 385 inpatients who had their adherence assessed from February 1, 2013, to January 31, 2014. Multiple logistic regression was used to examine the benefit of adding medication adherence to previously published variables that have been shown to predict 30-day readmissions.

RESULTS

Patients with low and intermediate adherence (combined) had readmission rates of 20.0% compared to a readmission rate of 9.3% for patients with high adherence (P=0.005). By adding MMAS-4 data to previously published variables that have been shown to predict 30-day readmissions, we found that patients with low and intermediate medication adherence had an adjusted 2.54-fold higher odds of readmission compared to those in patients with high adherence (95% confidence interval [CI]: 1.32-4.90, P=0.005). The model's predictive power, as measured by the c-statistic, improved from 0.65 to 0.70 after adding adherence.

CONCLUSION

Because medication adherence assessed at hospital admission was independently associated with 30-day readmission risk, it offers potential for targeting interventions to improve adherence.

Lanthanum carbonate oral powder: satisfaction, preference and adherence in French and Spanish patients with end-stage renal disease

BACKGROUND

Phosphate binders, such as lanthanum carbonate, control elevated serum-phosphate levels in patients with end-stage renal disease (ESRD). Lanthanum carbonate is available in oral powder and tablet form. The aim of this survey was to investigate satisfaction with, preference for, and adherence to lanthanum carbonate oral powder in patients with ESRD.

SCOPE

Patients from France and Spain who had been taking lanthanum carbonate powder for at least 4 weeks, and who had experience of other phosphate binders of any formulation, were asked to complete an online or telephone survey. Treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication-9; preference was measured using 5-point Likert scale agreement ratings; and adherence was measured using the Morisky Medication Adherence Scale-4. Data were evaluated using bivariate analyses.

FINDINGS

Overall, 160 patients participated (80 per country). Lanthanum carbonate powder was reported to have a higher effectiveness rating (p<0.05), be more convenient (p<0.05), and provide a higher level of satisfaction (p<0.01) than previous binders. There was an overall preference for lanthanum carbonate powder over previous binders of any formulation (p<0.001). Adherence to medication was similar for all binders analysed: 66.3% of French patients adhered to lanthanum carbonate powder, and 65.0% adhered to previous binder treatment (p=not significant); 52.5% of Spanish patients adhered to lanthanum carbonate powder, and 56.3% adhered to previous binder treatment (p=not significant).

LIMITATIONS

The survey enrolled patients who had already experienced phosphate binders before the study began. Information on patient preferences for and adherence to previous phosphate binders was therefore based on the patients' memories of these experiences, which may have been subject to change over time. Although most participants completed the online survey in this study, a telephone survey was used for individuals who could not access the online version; if only one method of data recording had been used, there may have been reduced variation in responses.

CONCLUSION

Patients with ESRD report increased satisfaction with and preference for lanthanum carbonate powder over other formulations, suggesting that lanthanum carbonate powder is more convenient and easier to use than other formulations.

ENHANCE-(Electronic Hydroxyurea Adherence): A Protocol to Increase Hydroxyurea Adherence in Patients with Sickle Cell Disease

Background

Hydroxyurea (HU) is the only disease-modifying medication for patients with sickle cell disease (SCD). HU can reduce SCD-related complications but only 35% to 50% of pediatric patients adhere to HU at the rates achieved in clinical trials and this limits its clinical effectiveness. Mobile Directly Observed Therapy (Mobile DOT) is a pilot-tested, electronic, multidimensional, HU adherence intervention that targets many components of the Health Behavior Model.

Objective

The aim of this study is to evaluate the impact of Mobile DOT on HU adherence in children with SCD. The objective of our study is to inform the development of future adherence interventions and pediatric SCD protocols.

Methods

This is a single-arm crossover study of pediatric patients with SCD. Participants self-record videos of their daily HU administrations and receive text message alerts to take HU, feedback on their HU adherence, and incentives when they achieve adherence goals during the 6-month Mobile DOT phase. Participants’ HU adherence during the Mobile DOT phase is compared with their baseline HU adherence (6 months prior to study entry) and to their HU adherence 6 months after completing the Mobile DOT phase. The primary outcome of this study is HU adherence measured by medication possession ratio.

Results

The trial is ongoing. Preliminary review of participant satisfaction results suggest that most participants can complete Mobile DOT in less than 5 minutes per day and are satisfied with the intervention.

Conclusions

If effective, the Mobile DOT strategy will increase HU adherence and this could improve patients’ clinical outcomes and reduce costs of care.

Life-Style and Cardiovascular Health Among Urban Black Elderly

This study assessed life-style behaviors in a cross-sectional random sample of urban Black elderly with and without cardiovascular disease. Those with cardiac disease reported behavior modifications for salt mtake, fat intake, and smoking but more often reported being overweight and performing less exercise than did those elderly without cardiac disease. There remains substantial room for improvement in health maintenance and health promotion behaviors in this population, suggesting the need of intensive educational interventions. Additionally, Black elderly with cardiac disease had worse scores on a depression scale and a health locus-of-control question, suggesting the need for psychological assessment and intervention in this population.

Psychological and Educational Intervention to Improve Tuberculosis Treatment Adherence in Ethiopia Based on Health Belief Model: A Cluster Randomized Control Trial

BACKGROUND

Treatment non-adherence results in treatment failure, prolonged transmission of disease and emergence of drug resistance. Although the problem widely investigated, there remains an information gap on the effectiveness of different methods to improve treatment adherence and the predictors of non-adherence in resource limited countries based on theoretical models. This study aimed to evaluate the impact of psychological counseling and educational intervention on tuberculosis (TB) treatment adherence based on Health Belief Model (HBM).

METHODOLOGY

A cluster randomized control trial was conducted in Addis Ababa from May to December, 2014. Patients were enrolled into study consecutively from 30 randomly selected Health Centers (HCs) (14 HCs intervention and 16 HCs control groups). A total of 698 TB patients, who were on treatment for one month to two months were enrolled. A structured questionnaire was administered to both groups of patients at baseline and endpoint of study. Control participants received routine directly-observed anti-TB therapy and the intervention group additionally received combined psychological counseling and adherence education. Treatment non-adherence level was the main outcome of the study, and multilevel logistic regression was employed to assess the impact of intervention on treatment adherence.

RESULTS

At enrollment, the level of non-adherence among intervention (19.4%) and control (19.6%) groups was almost the same. However, after intervention, non-adherence level decreased among intervention group from 19.4 (at baseline) to 9.5% (at endpoint), while it increased among control group from 19.4% (baseline) to 25.4% (endpoint). Psychological counseling and educational interventions resulted in significant difference with regard to non-adherence level between intervention and control groups (Adjusted OR = 0.31, 95% Confidence Interval (CI) (0.18-0.53), p < 0.001)).

CONCLUSION

Psychological counseling and educational interventions, which were guided by HBM, significantly decreased treatment non-adherence level among intervention group. Provision of psychological counseling and health education to TB patients who are on regular treatment is recommended. This could be best achieved if these interventions are guided by behavioral theories and incorporated into the routine TB treatment strategy.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201506001175423.

The Effects of Psycho-Emotional and Socio-Economic Support for Tuberculosis Patients on Treatment Adherence and Treatment Outcomes - A Systematic Review and Meta-Analysis

BACKGROUND

There is uncertainty about the contribution that social support interventions (SSI) can have in mitigating the personal, social and economic costs of tuberculosis (TB) treatment on patients, and improving treatment outcomes.

OBJECTIVE

To identify psycho-emotional (PE) and socio-economic (SE) interventions provided to TB patients and to assess the effects of these interventions on treatment adherence and treatment outcomes.

SEARCH STRATEGY

We searched PubMed and Embase from 1 January 1990-15 March 2015 and abstracts of the Union World Conference on Lung Health from 2010-2014 for studies reporting TB treatment adherence and treatment outcomes following SSI.

SELECTION CRITERIA

Studies measuring the effects of PE or SE interventions on TB treatment adherence, treatment outcomes, and/or financial burden.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed titles and abstracts for inclusion of articles. One reviewer reviewed full text articles and the reference list of selected studies. A second reviewer double checked all extracted information against the articles.

MAIN RESULTS

Twenty-five studies were included in the qualitative analysis; of which eighteen were included in the meta-analysis. Effects were pooled from 11 Randomized Controlled Trials (RCTs), including 9,655 participants with active TB. Meta-analysis showed that PE support (RR 1.37; CI 1.08-1.73), SE support (RR 1.08; CI 1.03-1.13) and combined PE and SE support (RR 1.17; CI 1.12-1.22) were associated with a significant improvement of successful treatment outcomes. Also PE support, SE support and a combination of these types of support were associated with reductions in unsuccessful treatment outcomes (PE: RR 0.46; CI 0.22-0.96, SE: RR 0.78; CI 0.69-0.88 and Combined PE and SE: RR 0.42; CI 0.23-0.75). Evidence on the effect of PE and SE interventions on treatment adherence were not meta-analysed because the interventions were too heterogeneous to pool. No evidence was found to show whether SE reduced the financial burden for TB patients.

DISCUSSION AND CONCLUSIONS

Our review and meta-analysis concluded that PE and SE interventions are associated with beneficial effects on TB treatment outcomes. However, the quality of evidence is very low and future well-designed evaluation studies are needed.

Relationship Between Health Literacy and Unintentional and Intentional Medication Nonadherence in Medically Underserved Patients With Type 2 Diabetes

PURPOSE

The purpose of this study was to investigate the relationship between health literacy and overall medication nonadherence, unintentional nonadherence, and intentional nonadherence. Limited health literacy may be associated with worse diabetes outcomes, but the literature shows mixed results, and mechanisms remain unclear. Medication adherence is associated with diabetes outcomes and may be a mediating factor. Distinguishing between unintentional and intentional nonadherence may elucidate the relationship between health literacy and nonadherence in patients with type 2 diabetes.

METHODS

Cross-sectional study of 208 patients with type 2 diabetes recruited from a primary care clinic in St. Louis, Missouri. Information was obtained from written questionnaire and patient medical records. Bivariate and multivariable regression were used to examine predictors of medication nonadherence.

RESULTS

The majority of patients in the study were low income, publicly insured, and African American, with limited health literacy and a high school/GED education or less. In multivariable models, limited health literacy was significantly associated with increased unintentional nonadherence but not intentional nonadherence.

CONCLUSIONS

Results suggest differences in factors affecting intentional and unintentional nonadherence. The findings also suggest interventions are needed to decrease unintentional nonadherence among patients with type 2 diabetes and limited health literacy. Efforts to address unintentional medication nonadherence among patients with type 2 diabetes with limited health literacy may improve patient health.

The effect of temperament on the treatment adherence of bipolar disorder type I

BACKGROUND AND AIMS

Treatment adherence is one of the most important factors that may determine treatment response in patients with bipolar disorders (BD). Many factors have been described to be associated with treatment adherence in BD. Temperament that can influence the course of BD will have an impact on treatment adherence. The aim of this study is to investigate temperament effect on treatment adherence in euthymic patients with BD-I.

METHODS

Eighty patients with BD-I participated in the study. A psychiatrist used the Structured Clinical Interview for DSM-IV Axis-I Disorders to determine the diagnosis and co-morbidities. Hamilton Depression and Young Mania Rating Scale were used to detect the remission. We used the Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionnaire and the 4-item Morisky Medication Adherence Scale to evaluate temperament and treatment adherence, respectively. The study group was divided into two groups as "treatment adherent" and "treatment non-adherent".

RESULTS

The cyclothymic and anxious temperament scores of the treatment non-adherent patients with BD-I were significantly higher than those of the treatment adherent group (p < 0.001, p = 0.006, respectively). Multiple linear regression analysis determined that cyclothymic temperament predicted treatment non-adherence (p = 0.009).

CONCLUSION

It should be kept in mind that BD-I patients with cyclothymic temperament may be treatment non-adherent and future studies should explore whether temperament characteristics deteriorate BD-I course by disrupting treatment adherence.

Incentives and enablers to improve adherence in tuberculosis

BACKGROUND

Patient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence.

OBJECTIVES

To evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB.

SEARCH METHODS

We undertook a comprehensive search of the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; Science Citation Index; and reference lists of relevant publications up to 5 June 2015.

SELECTION CRITERIA

Randomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE.

MAIN RESULTS

We identified 12 eligible trials. Ten were conducted in the USA: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). The remaining two trials, in general adult populations, were conducted in Timor-Leste and South Africa. Sustained incentive programmesOnly two trials have assessed whether material incentives and enablers can improve long-term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence). In one trial, the incentive, given as a daily hot meal, was not well received by the population due to the inconvenience of attending the clinic at midday, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived.Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results (low quality evidence). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants). Single once-only incentivesHowever in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one-off clinic re-attendance for initiation or continuation of anti-TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence). Comparison of different types of incentivesSingle trials in specific sub-populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non-cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence).

AUTHORS' CONCLUSIONS

Material incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment.