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van Dommelen P, Arnaud L, Assefi AR, Crespo ML, Debicki M, Michelis F, Koledova E. The growzen™ buddy smartphone app to improve adherence in patients receiving recombinant human growth hormone therapy: a retrospective observational study in Argentina. Front Endocrinol (Lausanne) 2024; 15:1372716. [PMID: 39015178 PMCID: PMC11250275 DOI: 10.3389/fendo.2024.1372716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/20/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction This study in Argentina evaluated the impact of the growzen™ buddy smartphone app on adherence to recombinant human growth hormone (r-hGH) treatment. Methods The adherence data, invitation dates with a link to the app, app activation dates, and height measurements entered were extracted from the growzen™ digital health ecosystem. Patients with 12 months of adherence data, aged ≥2 years at treatment start, and aged <19 years were selected both before and after app implementation. Mean adherence was classified as optimal (≥85%) versus suboptimal (<85%). Adherence before and after implementation and the pre-post effect on adherence were assessed. Results Data for 830 patients were available. Prior to app implementation, the proportion of patients with optimal adherence was 68% (n = 348/515). Following the app implementation, out of 315 patients, 302 (96%) received an invitation with a link to the app, 225 (71%) activated their account, and 127 (40%) entered height data in the first year. There was a significant early increase in the proportion of patients with optimal adherence following implementation: 82% (n = 258/315), p < 0.001. After implementation, the proportion of patients with optimal adherence included 80% (n = 78/98) of those with an active account who did not enter height measurements and 89% (n = 113/127) of those who did. There was a significant and positive pre-post app effect on adherence (p < 0.01) in patients with an active account. Discussion Our results show that using the growzen™ buddy app has a rapid and positive impact on adherence to r-hGH treatment, and patients who were more engaged with the app demonstrated better adherence.
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Affiliation(s)
- Paula van Dommelen
- Department of Child Health, The Netherlands Organization for Applied Scientific Research TNO, Leiden, Netherlands
| | - Lilian Arnaud
- Global Digital Health, Global Healthcare Operations, Ares Trading SA (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Aria Reza Assefi
- Medical Department, Merck S.A. (an affiliate of Merck KGaA), Buenos Aires, Argentina
| | - Maria Lourdes Crespo
- Fertility and Endocrinology, Merck S.A. (an affiliate of Merck KGaA), Buenos Aires, Argentina
| | - Matias Debicki
- Patient Support Program, Merck S.A. (an affiliate of Merck KGaA), Buenos Aires, Argentina
| | - Fulvio Michelis
- Global Digital Health, Global Healthcare Operations, Ares Trading SA (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic and Endocrinology, Merck Healthcare KGaA, Darmstadt, Germany
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Baños RM, Peltonen LM, Martin B, Koledova E. An Augmented Reality Mobile App (Easypod AR) as a Complementary Tool in the Nurse-Led Integrated Support of Patients Receiving Recombinant Human Growth Hormone: Usability and Validation Study. JMIR Nurs 2023; 6:e44355. [PMID: 37083627 PMCID: PMC10163401 DOI: 10.2196/44355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Children with growth hormone deficiency face the prospect of long-term recombinant human growth hormone (r-hGH) treatment requiring daily injections. Adherence to treatment is important, especially at treatment initiation, to achieve positive health outcomes. Historically, telenursing services embedded in patient support programs (PSPs) have been a valid approach to support r-hGH treatment initiation and patient education and facilitate adherence by identifying and optimizing appropriate injection techniques. The development of mobile phones with augmented reality (AR) capabilities offers nurses new tools to support patient education. OBJECTIVE To investigate experiences among nurses of a new mobile phone app developed to support patient training with a phone-based PSP for r-hGH treatment. METHODS In 2020, the Easypod AR mobile app was launched to support nurse-driven telehealth education for patients initiating r-hGH therapy with the Easypod electromechanical auto-injector device. Nurses who were part of PSPs in countries where the Easypod AR app had been launched or where training was provided as part of an anticipated future launch of the app were invited to participate in an online survey based on the Mobile App Rating Scale to capture their feedback after using the app. RESULTS In total, 23 nurses completed the online questionnaire. They positively rated the quality of the app across multiple dimensions. The highest mean scores were 4.0 for engagement (ie, adaptation to the target group; SD 0.74), 4.1 (SD 0.79) for functionality (navigation) and 4.1 (SD 0.67) for aesthetics (graphics). Responses indicated the potential positive impact of such a tool on enhancing patient education, patient support, and communication between patients and PSP nurses. Some participants also suggested enhancements to the app, including gamification techniques that they felt have the potential to support the formation of positive treatment behaviors and habits. CONCLUSIONS This study highlights the potential for new digital health solutions to reinforce PSP nurse services, including patient education. Future studies could explore possible correlations between any behavioral and clinical benefits that patients may derive from the use of such apps and how they may contribute to support improved patient experiences and treatment outcomes.
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Affiliation(s)
- Rosa Maria Baños
- Department of Personality, Evaluation and Psychological Treatment, Faculty of Psychology, University of Valencia, Valencia, Spain
- Centro De Investigación Biomédica en Red of Physiopathology of Obesity and Nutrition, Carlos III Health Institute, Madrid, Spain
| | | | - Blaine Martin
- Global Digital Health, Ares Trading SA, an affiliate of Merck KGaA (Darmstadt, Germany), Eysins, Switzerland
| | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic & Endocrinology, The health care business of Merck KGaA, Darmstadt, Germany
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Interventions Designed to Improve Adherence to Growth Hormone Treatment for Pediatric Patients and Their Families: A Narrative Review. Pharmaceutics 2022; 14:pharmaceutics14112373. [DOI: 10.3390/pharmaceutics14112373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
Even though growth hormone (GH) treatment is still the only active treatment option to correct growth failure and increase stature for patients with GH deficiencies, evidence has shown that non-adherence remains high. The aim of this review was to identify and review the existing interventional strategies that have been designed to address and improve adherence to GH treatment for pediatric patients and their families. An extensive search of several electronic databases was undertaken to identify relevant interventional studies, published in English, between 1985 and 2021. Additional search strategies included hand-searching topic review articles to identify eligible studies. Articles were screened against the inclusion eligibility criteria and data on sample characteristics, intervention features, and key findings was extracted. A total of fifteen interventional studies were included in the review. The interventions identified were divided into two broad categories: novel injection devices, and patient choice of device. In conclusions, this review acknowledges that there is a lack of evidence-based, theory-driven intervention strategies, designed with the purpose of optimizing treatment adherence and improve clinical and psychosocial outcomes.
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Deeb A, Al Yaarubi S, Abbas BB, Al Jubeh J, Chaturvedi D, Al Hassani N, Mutair A, Al Masri N, Al Sanad Y, Al Shidhani A, Mahmoud NS, Alherbish A, Savage MO. Patients' Perception of the Use of the EasyPod™ Growth Hormone Injector Device and Impact on Injection Adherence: A Multi-Center Regional Study. Front Pediatr 2022; 10:839278. [PMID: 35295698 PMCID: PMC8918687 DOI: 10.3389/fped.2022.839278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/31/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE This study aimed to assess patient perceptions of the use of the EasyPod™ growth hormone delivery device and its association with compliance. METHODS This cross-sectional, multicenter study was conducted in six centers from three countries (United Arab Emirates, Oman, and Saudi Arabia,) between March 2020 and June 2020. Children and adolescents aged 3-18 years, diagnosed with growth disorders and receiving rhGH through the EasyPod™ device were enrolled. Patients and caregivers were given a pre-set questionnaire that evaluated patient satisfaction, preference for technical and personalized features, and device drawbacks. The results were analyzed using independent measures of analysis of variance to evaluate the association of higher satisfaction with device features and better compliance. RESULTS A total of 186 patients were enrolled in the study. Of these, 45.7% had GH deficiency. The mean age (±SD) of patients was 11.8 (±2.76) years; 117 (62.90%) were males. Average compliance was 87%. One hundred patients (53.76%) had injection compliance of ≥90%. Amongst these patients, 74%, 68%, and 77% top-scored (5/5) the technical features of hidden needle, skin sensor, and pre-set dosing, respectively, compared to top scores by 39%, 34%, and 51% patients in the <90% compliance group (p-value <0.05). Similarly, a statistically significant difference was observed between the groups (p-value <0.05) in the perception of the usefulness of the tracking features such as display of history of injected doses (78% vs. 47.7%), a reminder for medicine remaining (46% vs. 23.3%) and battery power indicator (48% vs. 20.9%). Personal screen messages were associated with higher compliance while the requirement to keep the device in the fridge was reported as the most inconvenient feature by 56% of patients in the higher compliance group as against 39.5% in the lower compliance group (p-value <0.05). There was no statistically significant difference in the intensity of pain reported in the two compliance groups. CONCLUSION Our study showed that there is a statistically significant association between better perception of device features and higher compliance.
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Affiliation(s)
- Asma Deeb
- Sheikh Shahbout Medical City & Khalifa University, Abu Dhabi, United Arab Emirates
| | - Saif Al Yaarubi
- College of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Bassam Bin Abbas
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Jamal Al Jubeh
- Department of Pediatrics, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Deepti Chaturvedi
- Department of Pediatrics, Burjeel Hospital, Abu Dhabi, United Arab Emirates
| | - Noura Al Hassani
- Division of Endocrine and Diabetes, Department of Pediatrics, Tawam Hospital and Faculty of Medicine and Health Science, UAE University, Al Ain, United Arab Emirates
| | - Angham Mutair
- Pediatric Endocrine Division, Department of Pediatrics, King Abdulaziz Medical City, King Abdullah Specialist Children Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Neamat Al Masri
- Sheikh Shahbout Medical City & Khalifa University, Abu Dhabi, United Arab Emirates
| | - Yazan Al Sanad
- Sheikh Shahbout Medical City & Khalifa University, Abu Dhabi, United Arab Emirates
| | - Azza Al Shidhani
- College of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Martin O Savage
- Centre for Endocrinology, Barts and the London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Tornincasa V, Dixon D, Le Masne Q, Martin B, Arnaud L, van Dommelen P, Koledova E. Integrated Digital Health Solutions in the Management of Growth Disorders in Pediatric Patients Receiving Growth Hormone Therapy: A Retrospective Analysis. Front Endocrinol (Lausanne) 2022; 13:882192. [PMID: 35846336 PMCID: PMC9281444 DOI: 10.3389/fendo.2022.882192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/06/2022] [Indexed: 01/31/2023] Open
Abstract
Digital health has seen rapid advancements over the last few years in helping patients and their healthcare professionals better manage treatment for a variety of illnesses, including growth hormone (GH) therapy for growth disorders in children and adolescents. For children and adolescents requiring such therapy, as well as for their parents, the treatment is longitudinal and often involves daily injections plus close progress monitoring; a sometimes daunting task when young children are involved. Here, we describe our experience in offering devices and digital health tools to support GH therapy across some 40 countries. We also discuss how this ecosystem of care has evolved over the years based on learnings and advances in technology. Finally, we offer a glimpse of future planned enhancements and directions for digital health to play a bigger role in better managing conditions treated with GH therapy, as well as model development for adherence prediction. The continued aim of these technologies is to improve clinical decision making and support for GH-treated patients, leading to better outcomes.
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Affiliation(s)
| | - David Dixon
- Ares Trading S.A. (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Quentin Le Masne
- Ares Trading S.A. (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Blaine Martin
- Ares Trading S.A. (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Lilian Arnaud
- Ares Trading S.A. (an affiliate of Merck KGaA), Eysins, Switzerland
| | - Paula van Dommelen
- Department of Child Health, The Netherlands Organization for Applied Scientific Research TNO, Leiden, Netherlands
| | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic & Endocrinology, Merck Healthcare KGaA, Darmstadt, Germany
- *Correspondence: Ekaterina Koledova,
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Boman N, Fernandez-Luque L, Koledova E, Kause M, Lapatto R. Connected health for growth hormone treatment research and clinical practice: learnings from different sources of real-world evidence (RWE)-large electronically collected datasets, surveillance studies and individual patients' cases. BMC Med Inform Decis Mak 2021; 21:136. [PMID: 33902570 PMCID: PMC8074467 DOI: 10.1186/s12911-021-01491-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 04/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background A range of factors can reduce the effectiveness of treatment prescribed for the long-term management of chronic health conditions, such as growth disorders. In particular, prescription medications may not achieve the positive outcomes expected because approximately half of patients adhere poorly to the prescribed treatment regimen. Methods Adherence to treatment has previously been assessed using relatively unreliable subjective methods, such as patient self-reporting during clinical follow-up, or counting prescriptions filled or vials returned by patients. Here, we report on a new approach, the use of electronically recorded objective evidence of date, time, and dose taken which was obtained through a comprehensive eHealth ecosystem, based around the easypod™ electromechanical auto-injection device and web-based connect software. The benefits of this eHealth approach are also illustrated here by two case studies, selected from the Finnish cohort of the easypod™ Connect Observational Study (ECOS), a 5-year, open-label, observational study that enrolled children from 24 countries who were being treated with growth hormone (GH) via the auto-injection device. Results Analyses of data from 9314 records from the easypod™ connect database showed that, at each time point studied, a significantly greater proportion of female patients had high adherence (≥ 85%) than male patients (2849/3867 [74%] vs 3879/5447 [71%]; P < 0.001). Furthermore, more of the younger patients (< 10 years for girls, < 12 years for boys) were in the high adherence range (P < 0.001). However, recursive partitioning of data from ECOS identified subgroups with lower adherence to GH treatment ‒ children who performed the majority of injections themselves at an early age (~ 8 years) and teenagers starting treatment aged ≥ 14 years. Conclusions The data and case studies presented herein illustrate the importance of adherence to GH therapy and how good growth outcomes can be achieved by following treatment as described. They also show how the device, software, and database ecosystem can complement normal clinical follow-up by providing HCPs with reliable information about patient adherence between visits and also providing researchers with real-world evidence of adherence and growth outcomes across a large population of patients with growth disorders treated with GH via the easypod™ device.
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Affiliation(s)
- Nea Boman
- Paediatric Endocrinology, Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Stenbackinkatu 11, PO BOX 281, 00029, Helsinki, Finland.
| | | | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic and Endocrinology, Merck KGaA, Darmstadt, Germany
| | - Marketta Kause
- Medical Department, Merck Oy Finland (an affiliate of Merck KGaA, Darmstadt, Germany), Espoo, Finland
| | - Risto Lapatto
- Paediatric Endocrinology, Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Stenbackinkatu 11, PO BOX 281, 00029, Helsinki, Finland
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Blanco-López A, Antillón-Ferreira C, Saavedra-Castillo E, Barrientos-Pérez M, Rivero-Escalante H, Flores-Caloca O, Calzada-León R, Rosas-Guerra CC, Koledova E, Chiquete E, Ayala-Estrada A. Adherence to treatment in children with growth hormone deficiency, small for gestational age and Turner syndrome in Mexico: results of the Easypod™ connect observational study (ECOS). J Endocrinol Invest 2020; 43:1447-1452. [PMID: 32239476 PMCID: PMC7481146 DOI: 10.1007/s40618-020-01218-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Assessing adherence to growth hormone (GH) is challenging. The Easypod™ connect device delivers pre-set doses of recombinant human GH (r-hGH) and stores a digital record of adherence that can be shared with healthcare provider. We assessed adherence to r-hGH delivered with Easypod™ according to the approved pediatric indications for r-hGH: growth hormone deficiency (GHD), born small for gestational age (SGA) who failed to show catch-up growth and Turner syndrome (TS). METHODS ECOS (NCT01555528) was a multicenter (24 countries), 5-year, longitudinal, observational study, which aimed to evaluate country-specific adherence to r-hGH therapy prescribed via the Easypod™ electronic injection device. The primary endpoint was yearly adherence. Secondary endpoints were height velocity, height velocity standard deviation scores (SDS), height, height SDS and IGF-1 concentrations. Clinical and auxological data were obtained from medical records and adherence from Easypod™ logs. RESULTS This study included 147 Easypod™-naïve Mexican children assessed during 3 years (mean age: 9.96 ± 3.41 years, 56.8% boys, mean height SDS at baseline: - 2.17 ± 0.97): 118 with GHD, 24 SGA and 5 with TS. A total of 105 (71.4%) patients were GH naïve. Overall median adherence was > 90% over the first year of treatment and > 80% at 3 years. Adherence was not different by r-hGH indication or between GH-naïve or experienced patients. At 1-year follow-up, mean change in height SDS was 0.57 ± 0.34, whereas mean height velocity SDS was 2.85 ± 2.51. In all, 84.7% patients had normal IGF-1 concentrations at 1-year follow-up. Adherence was associated with change in height SDS (r = 0.239, p = 0.005) and height velocity SDS (r = 0.194, p = 0.027). CONCLUSION Adherence rates with the Easypod™ device are high and maintained over time in GHD, SGA and TS Easypod™-naïve Mexican patients. High adherence is associated with better outcomes. Easypod™ assists physicians in monitoring adherence to r-hGH.
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Affiliation(s)
- A Blanco-López
- Hospital Ángeles Interlomas and Hospital Español, Mexico City, Mexico
| | | | | | | | | | | | - R Calzada-León
- Servicio de Endocrinología, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - C C Rosas-Guerra
- Merck Biopharma Distribution S.A. de C.V, Naucalpan de Juárez, Mexico
| | - E Koledova
- Merck Healthcare KGaA, Darmstadt, Germany
| | - E Chiquete
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Delegacion Tlalpan, C.P. 14080, Ciudad de Mexico, México.
| | - A Ayala-Estrada
- Servicio de Pediatría, Hospital ISSEMyM, Toluca, Estado de México, México.
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Charmandari E, Vlachopapadopoulou E, Kyritsi EM, Sakellariou D, Koledova E, Nespithal K, Michalacos S. Adherence and long-term outcomes of therapy in paediatric patients in Greece using the easypod™ electromechanical device for growth hormone treatment: The phase IV multicentre easypod™ connect observational study (ECOS). Growth Horm IGF Res 2020; 53-54:101336. [PMID: 32739654 DOI: 10.1016/j.ghir.2020.101336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The easypod™ injection device allows automatic recording and transmission of adherence data from patients receiving recombinant human growth hormone (rhGH [Saizen®]) to treat growth disorders. This analysis aimed to evaluate the adherence of Saizen® administered via easypod™ in a cohort of Greek patients from the easypod™ connect observational study (ECOS). METHODS The phase IV, open-label, multicentre, observational, and longitudinal ECOS study (EMR200104-520, NCT01363674) enrolled patients treated for a minimum of 6 months and up to 3 years. The primary endpoint was to assess the mean rate of adherence to treatment at different time points, where good adherence was defined as ≥85%. Change in height, height standard deviation score (SDS), height velocity and height velocity SDS were evaluated after 1 year of treatment as secondary endpoints, together with the impact of adherence on growth outcomes using the Spearman's product moment. RESULTS Of the 180 patients enrolled, 86 were included in the analysis. The mean adherence to Saizen®, as recorded via easypod™, was high at each individual time point, and was maintained at 95.5% after 1 year of treatment. Clinically meaningful positive changes were also noted for all of the secondary endpoints (median increase in height = 7.25 cm, height SDS = 0.32, median height velocity = 7.62 cm/year and height velocity SDS = 1.65). However, no significant correlation was noted between adherence and growth outcomes. CONCLUSIONS rhGH replacement therapy using Saizen® with easypod™ led to full compliance to the treatment in a representative Greek population from ECOS, and provided additional insights on how the easypod™ device can assist physicians in monitoring adherence and help to optimise linear growth in paediatric patients with growth disorders.
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Affiliation(s)
- E Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens, 'Aghia Sophia' Children's Hospital, Athens, Greece.
| | - E Vlachopapadopoulou
- Department of Endocrinology - Growth and Development, P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - E M Kyritsi
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens, 'Aghia Sophia' Children's Hospital, Athens, Greece
| | | | | | | | - S Michalacos
- Department of Endocrinology - Growth and Development, P. & A. Kyriakou Children's Hospital, Athens, Greece
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Centonze C, Guzzetti C, Orlando G, Loche S. Adherence to growth hormone (GH) therapy in naïve to treatment GH-deficient children: data of the Italian Cohort from the Easypod Connect Observational Study (ECOS). J Endocrinol Invest 2019; 42:1241-1244. [PMID: 30968283 PMCID: PMC6751271 DOI: 10.1007/s40618-019-01046-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the use of non-objective measurement, adherence to growth hormone (GH) therapy has been reported suboptimal in a large proportion of patients, and poor adherence has been shown to affect short-term growth response in patients receiving GH treatment. OBJECTIVE The Easypod™ electronic device allows objective measurement of adherence. In this study, we report 3-year prospective adherence data of the Italian cohort of naïve GH deficient (GHD) children extrapolated from the Easypod Connect Observational Study (ECOS) database. PATIENTS AND METHODS Seventy-three GHD children naïve to GH treatment were included in the analysis. 22 Italian centers participated in the study. RESULTS Mean adherence rate was consistently above 85% across the 3-year observation period. Particularly, mean adherence was 88.5%, 86.6%, and 85.7% after 1, 2 and 3 years, respectively. Mean (± SD) height-SDS increase after the first year was 0.41 (± 0.38). CONCLUSIONS The majority of naïve GHD children starting GH treatment with Easypod maintained an adherence rate > 85% up to 3 years. Easypod is a useful tool to follow-up patients' adherence allowing timely intervention to improve optimal treatment for these patients.
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Affiliation(s)
- C Centonze
- Medical Affairs Department, Merck Serono S.p.A., Rome, Italy
| | - C Guzzetti
- SSD di Endocrinologia Pediatrica e, Centro Screening Neonatale, Ospedale Pediatrico Miccrocitemico "A. Cao", AO Brotzu, Via Jenner, 09121, Cagliari, Italy
| | - G Orlando
- Medical Affairs Department, Merck Serono S.p.A., Rome, Italy
| | - S Loche
- SSD di Endocrinologia Pediatrica e, Centro Screening Neonatale, Ospedale Pediatrico Miccrocitemico "A. Cao", AO Brotzu, Via Jenner, 09121, Cagliari, Italy.
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Mancini A, Vergani E, Bruno C, Palladino A, Brunetti A. Relevance of Adherence Monitoring in Adult Patients With Growth Hormone Deficiency Under Replacement Therapy: Preliminary Monocentric Data With Easypod TM Connect. Front Endocrinol (Lausanne) 2019; 10:416. [PMID: 31316468 PMCID: PMC6610218 DOI: 10.3389/fendo.2019.00416] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/10/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose: Non-compliance to recombinant human growth hormone (r-hGH) therapy in adult growth hormone deficiency (aGHD) is a major concern for endocrinologist, as it affects significantly efficacy outcomes. This 12-month observational study was aimed to assess adherence in GHD patients treated with r-hGH administered via EasypodTM, an electronic, fully automated injection device designed to track the time, date and dose administered. Methods: 65 patients receiving r-hGH therapy were included in the study and 32 completed the study. The primary endpoint, adherence to treatment, was calculated as the proportion of injections correctly administered during the observational period out of the expected total number of injections. Adherence, tracked by the EasypodTM, was evaluated at months 6 (V1) and 12 (V2) after baseline (V0). As secondary end-point, serum IGF-1 levels were also determined. Results: The EasypodTM data showed a median adherence of 80% throughout the period V0-V2. Females are more compliant than males. Adherence levels are correlated to IGF-1 ones. Conclusions: Adherence is connected with therapy efficacy in aGHD. The injection-recording system and other characteristics of EasypodTM could enhance the ability of physicians to monitor adherence to r-hGH treatment, identifying non-compliant patients, thus enabling physicians to modify their management to maximize the benefits of the treatment.
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Effect of adherence to growth hormone treatment on 0-2 year catch-up growth in children with growth hormone deficiency. PLoS One 2018; 13:e0206009. [PMID: 30356273 PMCID: PMC6200242 DOI: 10.1371/journal.pone.0206009] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/04/2018] [Indexed: 11/19/2022] Open
Abstract
Background Quantifying the association between adherence and the growth response to growth hormone (GH) treatment is hampered by suboptimal methods of measuring adherence, confounders associated with the growth response, and restriction of the outcome parameters to yearly growth velocities. Aim To investigate the effect of adherence on the two-year growth response to GH treatment in prepubertal children with idiopathic isolated growth hormone deficiency (GHD) participating in the easypod connect observational study (ECOS), a 5-year, Phase IV open-label study to continuously assess real-world adherence via the easypod electronic drug-delivery device. Patients and methods Outcome measures were change in height standard deviation score (ΔHSDS), index of responsiveness (IoR), and parameters of two catch-up growth (CUG) curve functions (monomolecular growth curve and second degree polynomial) with adj-HSDS (HSDS minus Target height (TH) SDS) as dependent variable. Inclusion criteria were GHD, naïve to GH treatment, known TH, age <10y in girls and <12y in boys, ≥3 measurements, HSDS <-2 at start, complete data on growth and adherence in the first and second year. Linear regression analyses were performed to test the association between adherence (continuous and high vs. low) and the outcome measures, also adjusted for potential clinical confounders (age at start, adj-HSDS at start, birth weight SDS, gestational age (<37 weeks vs ≥37 weeks), GH dose, GH max (n = 58)). The formula of IoR already adjusts for confounders. Results In total, 95 patients complied with the inclusion criteria. The strongest associations were found between high adherence in the second year (≥91% as cut-off value) and IoR 2y (+0.62), and average adherence and high adherence (≥78%) in the first two years and ΔHSDS 0-2y (+0.11 SD per 1 injection/week, and +0.34 SD for high vs. low adherence). Conclusion Suboptimal adherence negatively affected the growth response in the first two years of GH treatment.
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Koledova E, Stoyanov G, Ovbude L, Davies PSW. Adherence and long-term growth outcomes: results from the easypod ™ connect observational study (ECOS) in paediatric patients with growth disorders. Endocr Connect 2018; 7:914-923. [PMID: 29976785 PMCID: PMC6107763 DOI: 10.1530/ec-18-0172] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/05/2018] [Indexed: 12/02/2022]
Abstract
OBJECTIVE The easypod connect observational study (ECOS) assessed treatment adherence among paediatric patients receiving growth hormone (GH) via the easypod electronic injection device. DESIGN ECOS was an open-label, observational, longitudinal study conducted in 24 countries between 2010 and 2016, enrolling children treated with GH. METHODS The primary endpoint was the rate of treatment adherence during 5 years of follow-up. Impact of adherence on growth outcomes was assessed using Spearman's product-moment correlations. RESULTS AND CONCLUSIONS Overall, 1190 patients had easypod data available for ≥3 months; most patients had GH deficiency (75%); 606 of these patients were GH naïve at baseline. Over the first year of monitoring, the median rate of adherence was 93.7% among patients overall and >93.0% in GH-naïve patients, irrespective of the treatment indication. Clinically meaningful improvements in growth rates were observed after 1 year of treatment across all GH indications. Adherence decreased with increasing treatment duration, but the overall median adherence rate remained high after 3 years of follow-up: 87.2% (n = 409), 75.5% after 4 years (n = 143) and 70.2% after 5 years (n = 43). Statistically significant correlations between adherence and 1-year change in height standard deviation score (P < 0.001 for patients overall) and height velocity (P < 0.001) were observed. CONCLUSIONS ECOS produced accurate, real-time adherence data in a large population of GH-treated children over 5 years of follow-up. Using the easypod connect system, physicians can potentially identify patients with inadequate adherence and poor response to treatment, enabling them to take appropriate action to help them maximise the benefits of GH treatment.
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Affiliation(s)
- Ekaterina Koledova
- Biopharma Global Medical AffairsGeneral Medicine and Endocrinology, Merck KGaA, Darmstadt, Germany
| | - George Stoyanov
- Biopharma Global Medical AffairsGeneral Medicine and Endocrinology, Merck KGaA, Darmstadt, Germany
| | - Leroy Ovbude
- Business & Decision Life SciencesBrussels, Woluwe-Saint-Lambert, Belgium
| | - Peter S W Davies
- Children’s Nutrition Research CentreFaculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Xiao X, Li W, Clawson C, Karvani D, Sondag P, Hahn JK. Evaluation of performance, acceptance, and compliance of an auto-injector in healthy and rheumatoid arthritic subjects measured by a motion capture system. Patient Prefer Adherence 2018; 12:515-526. [PMID: 29674844 PMCID: PMC5898887 DOI: 10.2147/ppa.s160394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE The study aimed to develop a motion capture system that can track, visualize, and analyze the entire performance of self-injection with the auto-injector. METHODS Each of nine healthy subjects and 29 rheumatoid arthritic (RA) patients with different degrees of hand disability performed two simulated injections into an injection pad while six degrees of freedom (DOF) motions of the auto-injector and the injection pad were captured. We quantitatively measured the performance of the injection by calculating needle displacement from the motion trajectories. The max, mean, and SD of needle displacement were analyzed. Assessments of device acceptance and usability were evaluated by a survey questionnaire and independent observations of compliance with the device instruction for use (IFU). RESULTS A total of 80 simulated injections were performed. Our results showed a similar level of performance among all the subjects with slightly larger, but not statistically significant, needle displacement in the RA group. In particular, no significant effects regarding previous experience in self-injection, grip method, pain in hand, and Cochin score in the RA group were found to have an impact on the mean needle displacement. Moreover, the analysis of needle displacement for different durations of injections indicated that most of the subjects reached their personal maximum displacement in 15 seconds and remained steady or exhibited a small amount of increase from 15 to 60 seconds. Device acceptance was high for most of the questions (ie, >4; >80%) based on a 0-5-point scale or percentage of acceptance. The overall compliance with the device IFU was high for the first injection (96.05%) and reached 98.02% for the second injection. CONCLUSION We demonstrated the feasibility of tracking the motions of injection to measure the performance of simulated self-injection. The comparisons of needle displacement showed that even RA patients with severe hand disability could properly perform self-injection with this auto-injector at a similar level with the healthy subjects. Finally, the observed high device acceptance and compliance with device IFU suggest that the system is convenient and easy to use.
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Affiliation(s)
- Xiao Xiao
- Department of Computer Science, The George Washington University, Washington, DC
- Correspondence: Xiao Xiao, Department of Computer Science, The George Washington University, 800 22nd Street, NW, Suite 3400, Washington, DC 20052, USA, Tel +1 202 994 5920, Fax +1 202 994 4875, Email
| | - Wei Li
- Department of Computer Science, The George Washington University, Washington, DC
| | | | | | | | - James K Hahn
- Department of Computer Science, The George Washington University, Washington, DC
- Department of Pediatrics, The George Washington University, Washington, DC, USA
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Acerini CL, Wac K, Bang P, Lehwalder D. Optimizing Patient Management and Adherence for Children Receiving Growth Hormone. Front Endocrinol (Lausanne) 2017; 8:313. [PMID: 29209274 PMCID: PMC5701910 DOI: 10.3389/fendo.2017.00313] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/30/2017] [Indexed: 01/19/2023] Open
Abstract
Poor adherence with growth hormone (GH) therapy has been associated with worse clinical outcomes, which in children relates specifically to their linear growth and loss of quality of life. The "360° GH in Europe" meeting, held in Lisbon, Portugal, in June 2016 and funded by Merck KGaA (Germany), examined many aspects of GH diseases. The three sessions, entitled "Short Stature Diagnosis and Referral," "Optimizing Patient Management," and "Managing Transition," each benefited from three guest speaker presentations, followed by an open discussion and are reported as a manuscript, authored by the speakers. Reported here is a summary of the proceedings of the second session, which reviewed the determinants of GH therapy response, factors affecting GH therapy adherence and the development of innovative technologies to improve GH treatment in children. Response to GH therapy varies widely, particularly in regard to the underlying diagnosis, although there is little consensus on the definition of a poor response. If the growth response is seen to be less than expected, the possible reasons should be discussed with patients and their parents, including compliance with the therapy regimen. Understanding and addressing the multiple factors that influence adherence, in order to optimize GH therapy, requires a multi-disciplinary approach. Because therapy continues over many years, various healthcare professionals will be involved at different periods of the patient's journey. The role of the injection device for GH therapy, frequent monitoring of response, and patient support are all important for maintaining adherence. New injection devices are incorporating electronic technologies for automated monitoring and recording of clinically relevant information on injections. Study results are indicating that such devices can at least maintain GH adherence; however, acceptance of novel devices needs to be assessed and there remains an on-going need for innovations.
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Affiliation(s)
- Carlo L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
- *Correspondence: Carlo L. Acerini,
| | - Katarzyna Wac
- Quality of Life Technologies Laboratory, University of Geneva, Geneva, Switzerland
| | - Peter Bang
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Loche S, Salerno M, Garofalo P, Cardinale GM, Licenziati MR, Citro G, Caruso Nicoletti M, Cappa M, Longobardi S, Maghnie M, Perrone R. Adherence in children with growth hormone deficiency treated with r-hGH and the easypod™ device. J Endocrinol Invest 2016; 39:1419-1424. [PMID: 27406716 PMCID: PMC5107197 DOI: 10.1007/s40618-016-0510-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/06/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Poor adherence to recombinant human growth hormone (r-hGH) therapy is associated with reduced growth velocity in children with growth hormone deficiency (GHD). This twelve-month observational study was to assess adherence in r-hGH patients treated with the easypod™, an electronic, fully automated injection device designed to track the time, date and dose administered. METHODS Ninety-seven prepubertal patients receiving r-hGH therapy were included in the study from ten Italian clinical sites and 88 completed the study. To avoid possible confounding effects, only GHD patients (79/88; 89.7 % of the overall study population) were considered in the final analysis. The primary endpoint-adherence to treatment-was calculated as the proportion of injections correctly administered during the observational period out of the expected total number of injections. The relevant information, tracked by the easypod™, was collected at months 6 (V1) and 12 (V2) after baseline (V0). At study termination, adherence data were partially available from 16 patients and fully available from 53 patients. As secondary endpoints, serum IGF-1 levels, fasting serum glucose and insulin levels and key anthropometric characteristics (height, waist circumference and BMI) were also determined. RESULTS The easypod™ data showed that 56.7 % of the patients were considered to be fully (≥92 %) adherent to their treatment throughout the period V0-V2. Treatment improved stature, significantly increased IGF-1 and produced a non-significant increase in blood glucose and insulin levels. CONCLUSIONS The injection-recording system and other characteristics of easypod™ could enhance the ability of physicians to monitor adherence to r-hGH treatment.
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Affiliation(s)
- S Loche
- SSD of Pediatric Endocrinology, Pediatric Hospital Microcitemico Antonio Cao AOB Cagliari, Via Edward Jenner, 09121, Cagliari, Italy.
| | - M Salerno
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - P Garofalo
- Endocrinology Unit, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - G M Cardinale
- Paediatric Division, Hospital F Ferrari, Casarano, Italy
| | - M R Licenziati
- Department of Pediatrics, AORN Santobono-Pausilipon, Naples, Italy
| | - G Citro
- Endocrinology Unit, Mother Theresa of Calcutta Territorial Specialist Centre, Potenza, Italy
| | - M Caruso Nicoletti
- Paediatric Endocrinology Service, University Hospital of Catania, Catania, Italy
| | - M Cappa
- University-Hospital Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - M Maghnie
- Department of Paediatrics, IRCCS Giannina Gaslini Institute, University of Genova, Genoa, Italy
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Rohrer TR, Horikawa R, Kappelgaard AM. Growth hormone delivery devices: current features and potential for enhanced treatment adherence. Expert Opin Drug Deliv 2016; 14:1253-1264. [DOI: 10.1080/17425247.2017.1243526] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tilman R. Rohrer
- Department of Pediatrics and Adolescent Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Anne-Marie Kappelgaard
- Clinical, Medical and Regulatory, Novo Nordisk International Operations A/G, Zurich, Switzerland
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Lass N, Reinehr T. Low Treatment Adherence in Pubertal Children Treated with Thyroxin or Growth Hormone. Horm Res Paediatr 2016; 84:240-7. [PMID: 26279278 DOI: 10.1159/000437305] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Treatment outcome depends largely on treatment adherence (TA). However, studies analyzing TA in chronic endocrine diseases are scarce and controversial in childhood. PATIENTS AND METHODS We studied TA in 103 children treated subcutaneously with growth hormone (GH) and 97 children treated orally with thyroxin. TA was calculated based on the prescription refill rates. The number of GH injections was recorded by an autoinjector device in 23 children treated with GH. RESULTS The correlation between recorded TA and calculated TA based on prescription refill rates was very good (p < 0.001, r = 0.83). TA was lower (p < 0.01) in pubertal children compared to prepubertal children and in children self-administering their medication compared to those whose drug was administered by their parents, both in GH- and thyroxin-treated children. Overall, 67% of the pubertal children treated with GH and 58% of the pubertal children treated with thyroxin missed at least 1 dose per week. TA was higher (p < 0.001) in children with thyroxin treatment compared to children treated with recombinant human GH (8 vs. 26% missed >3 doses/week). DISCUSSION Puberty and self-administration of drugs were negative predictors of TA. Therefore, in puberty, prevention and treatment efforts should be undertaken to improve TA, especially when adolescents administer their drugs themselves.
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Affiliation(s)
- Nina Lass
- Department of Pediatric Endocrinology, Diabetes and Nutrition Medicine, Vestische Hospital for Children and Adolescents Datteln, University of Witten/Herdecke, Datteln, Germany
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Tatlock S, Grant L, Spertus JA, Khan I, Arbuckle R, Manvelian G, Sanchez RJ. Development and Content Validity Testing of a Patient-Reported Treatment Acceptance Measure for Use in Patients Receiving Treatment via Subcutaneous Injection. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1000-1007. [PMID: 26686784 DOI: 10.1016/j.jval.2015.09.2937] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/07/2015] [Accepted: 09/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND New therapies in development for lowering low-density lipoprotein cholesterol, such as alirocumab, require administration by subcutaneous injections. There is a need to assess the acceptance of such treatments and their mode of administration. OBJECTIVES To develop a novel patient-reported outcome measure, the Injection-Treatment Acceptance Questionnaire (I-TAQ), and assess its content validity using qualitative methods. METHODS Concepts generated from a literature and instrument review informed the initial drafting of 17 items in the I-TAQ, with item wording adapted from three existing instruments. Three rounds of qualitative interviews were conducted with 29 US-English speaking patients at high cardiovascular risk. Concept elicitation questioning was used to explore patients' treatment experiences followed by cognitive debriefing of the I-TAQ using "think-aloud" methods. Verbatim transcripts were analyzed using thematic analysis. RESULTS Qualitative analysis of concept elicitation data identified the following relevant concepts: perceived efficacy, side effects, self-efficacy, convenience, and overall acceptance. Seven (24%) patients discussed an initial fear of needles, but described this as subsiding with no impact on adherence. Five items were added after round one interviews, three of which were retained after round two testing in which two further items were added, forming the conceptually comprehensive 22-item I-TAQ. Patients demonstrated good understanding of item wording, instructions, response scales, and recall period. CONCLUSIONS Successive rounds of in-depth interviews resulted in a treatment acceptance measure with strong content validity. Pending demonstration of its psychometric properties, the I-TAQ may prove to be a valuable measure of patients' perspectives toward being treated with low-density lipoprotein cholesterol-lowering therapies requiring subcutaneous injections.
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Affiliation(s)
- Sophi Tatlock
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK.
| | - Laura Grant
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK
| | - John A Spertus
- Mid America Heart Institute of Saint Luke's Hospital and the University of Missouri - Kansas City, Kansas City, MO, USA
| | | | - Rob Arbuckle
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK
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Cai Y, Xu M, Yuan M, Liu Z, Yuan W. Developments in human growth hormone preparations: sustained-release, prolonged half-life, novel injection devices, and alternative delivery routes. Int J Nanomedicine 2014; 9:3527-38. [PMID: 25114523 PMCID: PMC4122423 DOI: 10.2147/ijn.s63507] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Since the availability of recombinant human growth hormone (rhGH) enabled the application of human growth hormone both in clinical and research use in the 1980s, millions of patients were prescribed a daily injection of rhGH, but noncompliance rates were high. To address the problem of noncompliance, numerous studies have been carried out, involving: sustained-release preparations, prolonged half-life derivatives, new injectors that cause less pain, and other noninvasive delivery methods such as intranasal, pulmonary and transdermal deliveries. Some accomplishments have been made and launched already, such as the Nutropin Depot® microsphere and injectors (Zomajet®, Serojet®, and NordiFlex®). Here, we provide a review of the different technologies and illustrate the key points of these studies to achieve an improved rhGH product.
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Affiliation(s)
- Yunpeng Cai
- Department of Neurology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China ; School of Pharmacy, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Mingxin Xu
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Minglu Yuan
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Weien Yuan
- School of Pharmacy, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Hartmann K, Ittner J, Müller-Rossberg E, Schönau E, Stephan R, Ullrich KP, Hoppe B, Ramseger R, Brämswig J. Growth hormone treatment adherence in prepubertal and pubertal children with different growth disorders. Horm Res Paediatr 2014; 80:1-5. [PMID: 23860437 DOI: 10.1159/000351800] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 05/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Treatment of children with growth disorders with recombinant human growth hormone is necessary for improved outcomes, including final height. METHODS Adherence data from the Observational Study Saizen®-online, recorded with the easypod™ device collected between October 2009 and May 2011, were analyzed in pediatric patients receiving recombinant human growth hormone treatment for a variety of growth disorders. RESULTS Data from 75 children (46 boys, 29 girls) with different growth disorders were analyzed over a period of 343 ± 201 (SD) days. Boys and girls showed similar mean ± SD adherence rates of 90.5 ± 3.1% and 92.2 ± 10.7%, respectively. Pubertal children (n = 41) had a significantly lower adherence rate (89.1 ± 13.7%) than prepubertal children (n = 29) (96.5 ± 3.9%; p < 0.005). There were nonsignificant differences in adherence rates according to diagnosis: growth hormone deficiency (n = 48) 91.4 ± 11.0%, small for gestational age (n = 18) 91.1 ± 15.3%, Turner syndrome (n = 6) 86.0 ± 14.5%, and chronic renal failure (n = 3) 99.3 ± 1.0%, although the latter two groups were small. CONCLUSION Our data indicate that only a small number of pediatric patients using the easypod device had poor adherence to treatment. Further reliable adherence data are required to identify factors affecting long-term adherence in this population.
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Affiliation(s)
- Klaus Hartmann
- Medical Centre of Childhood and Adolescence, Frankfurt, Germany.
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Dahlgren J. Easypod™ a new electronic injection device for growth hormone. Expert Rev Med Devices 2014; 5:297-304. [DOI: 10.1586/17434440.5.3.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kappelgaard AM, Hansen NÅ. Comparison of injection dose force, accuracy and precision among three growth hormone injection devices. Expert Rev Med Devices 2014; 10:321-7. [DOI: 10.1586/erd.13.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Schwarzenbach F, Dao Trong M, Grange L, Laurent PE, Abry H, Cotten J, Granger C. Results of a human factors experiment of the usability and patient acceptance of a new autoinjector in patients with rheumatoid arthritis. Patient Prefer Adherence 2014; 8:199-209. [PMID: 24627625 PMCID: PMC3931638 DOI: 10.2147/ppa.s50583] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This study evaluated the human factors affecting the ease of use of a disposable autoinjector developed for subcutaneous self-injections performed by patients with chronic diseases. MATERIALS AND METHODS This was a randomized, single-center study conducted with 65 patients with rheumatoid arthritis. Patients performed six simulated injections. Assessments of patient device acceptance and device usability were made by patient reports and independent observations of compliance with the device instruction for use (IFU) following single injections and repeated injections. RESULTS A total of 390 simulated injections were performed. Patient device acceptance was high; more than 90% of patients found each of the tested criteria to be acceptable (>80% was required for statistical significance; P<0.016). Perceived ease of use and simplicity of the three-step process resulted in high acceptance scores: mean scores (± standard deviation) were 8.71 (±1.18) and 8.05 (±0.37), respectively, on a 0-10-point scale. Patients also expressed their acceptance with the ease and usefulness of the detection of the remaining drug in the autoinjector. In addition, 80% of patients declared that they would recommend the device to someone else. Globally, the human factors tested (age, sex, hand disability [Cochin score], extent of previous experience with self-injection [ie, expert or naïve]) had no impact on IFU device compliance. In particular, the lack of a Cochin score interaction indicated that the degree of hand disability is not a predictive factor of poor self-injection capability with this autoinjector. CONCLUSION This study demonstrated a high level of patient acceptance for self-injection with this autoinjector among patients with rheumatoid arthritis. In particular, patients with severe hand disability were able to successfully comply with device IFU.
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Affiliation(s)
- Florence Schwarzenbach
- Medical Affairs, Becton Dickinson Medical Pharmaceutical Systems, Le-Pont-de-Claix, France
- Correspondence: Florence Schwarzenbach, Medical Affairs, Becton Dickinson Medical Pharmaceutical Systems, 11 rue A Berges, F-38801 Le-Pont-de-Claix Cedex, France, Tel +33 476 689 407, Fax +33 476 689 669, Email
| | - Michèle Dao Trong
- Medical Affairs, Becton Dickinson Medical Pharmaceutical Systems, Le-Pont-de-Claix, France
| | - Laurent Grange
- Rheumatology Clinic, South University Hospital, Echirolles, France
| | | | - Herve Abry
- Commercial Development Self Administration/Injectable Systems, Becton Dickinson Medical Pharmaceutical Systems, Le-Pont-de-Claix, France
| | - Joël Cotten
- Marketing, Becton Dickinson Medical Pharmaceutical Systems, Le-Pont-de-Claix, France
| | - Corinne Granger
- Medical Affairs, Becton Dickinson Medical Pharmaceutical Systems, Le-Pont-de-Claix, France
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Hall RL, Willgoss T, Humphrey LJ, Kongsø JH. The effect of medical device dose-memory functions on patients' adherence to treatment, confidence, and disease self-management. Patient Prefer Adherence 2014; 8:775-88. [PMID: 24920889 PMCID: PMC4043803 DOI: 10.2147/ppa.s61248] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Adherence to treatment is an important issue in chronic disease management and an indicator of patients' ability to self-manage their condition and treatment. Some drug-dispensing and drug-delivery devices have been designed to support patients' medication-taking behavior by including dose-memory and combined dose-memory and dose-reminder functions, which electronically store, and visually display dose-history information, enabling the patient to review, monitor, and/or be actively reminded about their medication doses. PURPOSE This literature review explored the role and impact of these devices on patients' treatment adherence, confidence with, and self-management of their condition and treatment. MATERIALS AND METHODS A search of MEDLINE, Embase, and PsycINFO was performed to identify articles published in English from 2003-2013 that studied the effect of devices with dose-memory and combined dose-memory and dose-reminder functions on treatment adherence and users' (patients, health care professionals [HCPs], and caregivers) confidence, self-management behavior, and attitudes. RESULTS The database searches yielded 940 abstracts from which 13 articles met the inclusion criteria and were retained. Devices with dose-memory and combined dose-memory and dose-reminder functions were found to improve self-reported and electronically monitored treatment adherence in chronic conditions such as asthma, diabetes, and HIV. The ability of the devices to provide dose-history information and active medication reminders was considered valuable in disease management by patients, caregivers, and HCPs. The devices were found to enhance patients' confidence in, and motivation to manage their medication and condition, and help reduce forgotten or incorrect medication dosing. CONCLUSION The incorporation of dose-memory and combined dose-memory and dose-reminder functions in drug-delivery devices can improve patients' adherence, confidence, and self-management behavior. They can target non-intentional barriers to adherence and can provide a means of improving disease control and clinical outcomes, thereby offering clinical and economic value. This review highlights the importance of conducting further qualitative and quantitative research to further understand the value and impact of these types of devices on patients' long-term adherence to, and self-management of treatment.
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Affiliation(s)
- Rebecca L Hall
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK
- Correspondence: Rebecca L Hall, Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK, Tel +44 1625 576 815, Fax +44 1625 577 328, Email
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Meinhardt U, Eiholzer U, Seitz L, Bøgelund M, Kappelgaard AM. Parent preference in Switzerland for easy-to-use attributes of growth hormone injection devices quantified by willingness to pay. Expert Rev Med Devices 2013; 11:31-8. [DOI: 10.1586/17434440.2014.856754] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kremidas D, Wisniewski T, Divino VM, Bala K, Olsen M, Germak J, Aagren M, Holot N, Lee WC. Administration burden associated with recombinant human growth hormone treatment: perspectives of patients and caregivers. J Pediatr Nurs 2013; 28:55-63. [PMID: 22300524 DOI: 10.1016/j.pedn.2011.12.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 12/12/2011] [Accepted: 12/31/2011] [Indexed: 11/25/2022]
Abstract
Patients treated with recombinant human growth hormone (rhGH) for growth hormone disorders follow a challenging treatment schedule. This study assessed patient and caregiver experiences with rhGH therapy treatment regimens. Patients 13 years or older with growth hormone deficiency and caregivers completed Web-based surveys. A total of 61 patients and 239 caregivers participated. Storage of rhGH was considered burdensome by more than a third. More than 51% considered storage "somewhat more" to "much more of a burden" relative to the burden while not traveling. "Away from home or traveling" was the most frequently endorsed reason for missing a dose. rhGH treatment while traveling is challenging because of rhGH storage burden.
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Pleil AM, Kimel M, McCormack J, Rajicic N, Hey-Hadavi J. Psychometric assessment of the Injection Pen Assessment Questionnaire (IPAQ): measuring ease of use and preference with injection pens for human growth hormone. Health Qual Life Outcomes 2012; 10:126. [PMID: 23046797 PMCID: PMC3519573 DOI: 10.1186/1477-7525-10-126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 08/28/2012] [Indexed: 11/10/2022] Open
Abstract
Purpose To examine the psychometric properties of the Injection Pen Assessment Questionnaire (IPAQ) including the following: 1) item and scale characteristics (e.g., frequencies, item distributions, and factor structure), 2) reliability, and 3) validity. Methods Focus groups and one-on-one dyad interviews guided the development of the IPAQ. The IPAQ was subsequently tested in 136 parent–child dyads in a Phase 3, 2-month, open-label, multicenter trial for a new Genotropin® disposable pen. Factor analysis was performed to inform the development of a scoring algorithm, and reliability and validity of the IPAQ were evaluated using the data from this two months study. Psychometric analyses were conducted separately for each injection pen. Results Confirmatory factor analysis provides evidence supporting a second order factor solution for four subscales and a total IPAQ score. These factor analysis results support the conceptual framework developed from previous qualitative research in patient dyads using the reusable pen. However, the IPAQ subscales did not consistently meet acceptable internal consistency reliability for some group level comparisons. Cronbach’s alphas for the total IPAQ score for both pens were 0.85, exceeding acceptable levels of reliability for group comparisons. Conclusions The total IPAQ score is a useful measure for evaluating ease of use and preference for injection pens in clinical trials among patient dyads receiving hGH. The psychometric properties of the individual subscales, mainly the lower internal consistency reliability of some of the subscales and the predictive validity findings, do not support the use of subscale scores alone as a primary endpoint.
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Affiliation(s)
- Andreas M Pleil
- Pfizer, Inc, 10555 Science Center Dr, San Diego, CA 92121, USA.
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Rubin RR, Peyrot M, Metzinger CP, Xu Y, Lippe B, McCormack L, Davis DA. An observational study to validate the Satisfaction Measure of the Injection of Growth Hormone Therapy (SMIGHTy) questionnaire. Curr Med Res Opin 2011; 27:2009-17. [PMID: 21919819 DOI: 10.1185/03007995.2011.613922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this study was to psychometrically evaluate a tool to measure adult caregivers' level of satisfaction with the delivery device used to administer injections of recombinant human growth hormone (rhGH) to a child - the Satisfaction Measure of the Injection of Growth Hormone Therapy (SMIGHTy*) questionnaire. RESEARCH DESIGN AND METHODS One hundred caregivers who administer rhGH to a child using an injection device completed the SMIGHTy questionnaire at baseline and 7-14 days later, and also completed other measures of treatment adherence and treatment satisfaction at baseline. MAIN OUTCOME MEASURES SMIGHTy reliability (inter-item and test-retest) and external validity (association with other study measures) were assessed. RESULTS Analyses revealed good inter-item agreement and test-retest reliability for the SMIGHTy questionnaire. External validity, measured by associations with adherence and other measures of treatment satisfaction, was high. STUDY LIMITATIONS This study assessed only adult caregivers; the instrument was not validated for use by young or adult patients. CONCLUSIONS The SMIGHTy instrument is more comprehensive than existing instruments for assessing the growth hormone treatment experience. It is multidimensional, assesses both positive and negative aspects of the treatment experience (Device Satisfaction, Negative Events, Benefits), and has separate measures of overall satisfaction and preference.
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Affiliation(s)
- Richard R Rubin
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Affiliation(s)
- Shin Hye Kim
- Department of Pediatrics, Sanggye Paik Hospital, Inje University, Seoul, Korea
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Bozzola M, Colle M, Halldin-Stenlid M, Larroque S, Zignani M. Treatment adherence with the easypod™ growth hormone electronic auto-injector and patient acceptance: survey results from 824 children and their parents. BMC Endocr Disord 2011; 11:4. [PMID: 21294891 PMCID: PMC3045978 DOI: 10.1186/1472-6823-11-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 02/04/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Accurately monitoring adherence to treatment with recombinant human growth hormone (r-hGH) enables appropriate intervention in cases of poor adherence. The electronic r-hGH auto-injector, easypod™, automatically records the patient's adherence to treatment. This study evaluated adherence to treatment of children who started using the auto-injector and assessed opinions about the device. METHODS A multicentre, multinational, observational 3-month survey in which children received r-hGH as part of their normal care. Physicians reviewed the recorded dose history and children (with or without parental assistance) completed a questionnaire-based survey. Children missing ≤2 injections per month (92% of injections given) were considered adherent to treatment. Adherence was compared between GH treatment-naïve and treatment-experienced children. RESULTS Of 834 recruited participants, 824 were evaluated. The median (range) age was 11 (1-18) years. From the recorded dose history, 87.5% of children were adherent to treatment over the 3-month period. Recorded adherence was higher in treatment-naïve (89.7%, n = 445/496) than in treatment-experienced children (81.7%, n = 152/186) [Fisher's exact test FI(X) = 7.577; p = 0.0062]. According to self-reported data, 90.2% (607/673) of children were adherent over 3 months; 51.5% (421/817) missed ≥1 injection over this period (mainly due to forgetfulness). Concordance between reported and recorded adherence was 84.3%, with a trend towards self-reported adherence being higher than recorded adherence. Most children liked the auto-injector: over 80% gave the top two responses from five options for ease of use (720/779), speed (684/805) and comfort (716/804). Although 38.5% (300/780) of children reported pain on injection, over half of children (210/363) considered the pain to be less or much less than expected. Given the choice, 91.8% (732/797) of children/parents would continue using the device. CONCLUSIONS easypod™ provides an accurate method of monitoring adherence to treatment with r-hGH. In children who received treatment with r-hGH using easypod™, short-term adherence is good, and significantly higher in treatment-naïve children compared with experienced children. Children/parents rate the device highly. The high level of acceptability of the device is reflected by a desire to continue using it by over 90% of the children in the survey.
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Affiliation(s)
- Mauro Bozzola
- Paediatric Department, University of Pavia, IRCCS San Matteo Foundation, Pavia, Italy
| | | | | | - Sylvain Larroque
- Merck Serono S.A. - Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Monia Zignani
- Merck Serono S.A. - Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany
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Abstract
BACKGROUND Poor adherence to medical treatment is one of the main reasons why patients do not achieve the full benefits of their therapy. It also has a substantial financial weight in terms of money wasted for unused medication and increased healthcare costs including hospitalization due to clinical complications. OBJECTIVE To provide an overview and examples of the financial and economic consequences of poor adherence to treatment, techniques and devices for monitoring adherence and interventions for improvement of treatment adherence. RESULTS New electronic devices with monitoring features may help to objectively monitor patients' adherence to a treatment regimen that can help a healthcare professional determine how to intervene to improve adherence and subsequent clinical outcome. Interventions that aim to enhance adherence may confer cost-effectiveness benefits in some indications and settings. The nature of the intervention(s) used depends on a range of factors, including patient preference, therapy area and cost of the intervention. However, there is a pressing need for rigorous trials, as current studies often have major flaws in the economic methodology, especially in terms of incremental analysis and sensitivity analysis. LIMITATIONS This review has focused on a limited number of therapeutic areas as coverage of a more extensive range of diseases may be beyond the scope of such a summary. Nevertheless, the examples are representative of the challenges encountered in many other diseases. CONCLUSIONS The clinical and economic consequences of non-adherence and interventions to improve compliance reflect the nature and severity of non-adherence, as well as the pathophysiology and severity of the disease. Interventions that aim to enhance adherence may confer cost-effectiveness benefits in some indications and settings, and good adherence can help payers and providers contain costs by extracting maximum value from their investment in therapies.
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Affiliation(s)
- Alain Golay
- Division of Therapeutic Education for Chronic Diseases, University Hospital Geneva, Switzerland.
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Haverkamp F, Gasteyger C. A review of biopsychosocial strategies to prevent and overcome early-recognized poor adherence in growth hormone therapy of children. J Med Econ 2011; 14:448-57. [PMID: 21651428 DOI: 10.3111/13696998.2011.590829] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adherence to growth hormone (GH) therapy among children is variable and remains a problem, possibly affecting growth outcomes and future health, and having economic consequences. OBJECTIVE To provide a review of the issues related to poor adherence to GH therapy in children and describe integrative strategies that may improve adherence. RESULTS Poor adherence may be caused by various factors, affecting both the children and their families. The key reasons for adherence difficulties are psychological/emotional problems, social/everyday problems and technical handling issues of the drug delivery device. Correspondingly a broad range of strategies to address adherence to GH therapy often revolve around counseling and education, not just for the patient but also for the family giving care. LIMITATIONS This review is intended as a general survey of strategies which could help, in clinical practice, to overcome poor adherence to growth hormone therapy in children; it summarizes the representative literature but it does not aim to be a rigorous database literature search in every aspect. CONCLUSIONS If poor adherence is recognized early on during treatment, appropriate steps may be taken to identify barriers that are amenable to change for encouraging the child to adhere to the treatment regimen. A preventative approach may also be considered; for example, doctors could address adherence issues early and train families of children treated with GH to recognize the resources as well as the barriers to adherence. The broad range of different causes for poor adherence demands a great variety of interventions, making it important to individualize optimal treatment behavior. Additionally, economic studies are required to quantify the cost of poor adherence to GH therapy and to show the financial benefits of good adherence.
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Affiliation(s)
- Fritz Haverkamp
- University of Applied ScienceBochum, Immanuel-Kant-Strasse 18–20, Bochum, Germany.
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Bhosle M, Klingman D, Aagren M, Wisniewski T, Lee WC. Human growth hormone treatment: synthesis of literature on product delivery systems and administration practices. J SPEC PEDIATR NURS 2011; 16:50-63. [PMID: 21294835 DOI: 10.1111/j.1744-6155.2010.00267.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To synthesize current literature on recombinant human growth hormone (rhGH) use and to identify areas of research that have received little to no attention in light of administration practice and patient perception/behavior. DESIGN AND METHODS Relevant articles for a systematic review were identified through PubMed. RESULTS A total of 43 articles were identified: 9 (15.9%) studies on product administration practices and 34 (84.1%) on patient behavior patterns. Patients primarily preferred simple, convenient, and easy-to-use delivery devices. However, literature addressing the effect of convenient product administration practices on treatment outcomes using real-world patient/caregiver data is lacking. PRACTICE IMPLICATIONS Better understanding of real-world product administration practices will help nurses identify areas of improvement in patient education and training.
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Affiliation(s)
- Monali Bhosle
- I.M.S. Health, Health Economics and Outcomes Research, Falls Church, Virginia, USA
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User trial of Easypod™, an electronic autoinjector for growth hormone. ANNALES D'ENDOCRINOLOGIE 2008; 69:511-6. [DOI: 10.1016/j.ando.2008.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 04/23/2008] [Accepted: 04/30/2008] [Indexed: 11/21/2022]
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Bibliography. Current world literature. Diabetes and the endocrine pancreas II. Curr Opin Endocrinol Diabetes Obes 2008; 15:383-93. [PMID: 18594281 DOI: 10.1097/med.0b013e32830c6b8e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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