Outcome Measures in Rheumatology - Interventions for medication Adherence (OMERACT-Adherence) Core Domain Set for Trials of Interventions for Medication Adherence in Rheumatology: 5 Phase Study Protocol

Strategies to promote implementation of core outcomes for medication adherence trials in rheumatology: A report from the OMERACT-Adherence Group

OBJECTIVES

To identify barriers, facilitators, and strategies for future implementation of the OMERACT-Adherence Core Outcome Set (COS) in medication adherence trials for rheumatic conditions.

METHODS

Preliminary Delphi survey findings were discussed at OMERACT 2023, utilising the Consolidated Framework for Implementation Research 2 to identify implementation barriers, facilitators, and solutions.

RESULTS

Implementation strategies included simplifying the COS definitions, making it adaptabile for clinical practice and drug trials, adherence trial training workshops, and collaborating with key stakeholders such as payers and other COS developers.

CONCLUSION

Ongoing collaboration with individuals and organisations within and beyond rheumatology ensures broader applicability of OMERACT-Adherence COS.

Interventions to enhance medication adherence in pregnancy- a systematic review

BACKGROUND

Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes.

METHODS

Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity.

RESULTS

Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect  of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist.

CONCLUSIONS

There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.

Relationship between hyperuricemia with deposition and sexual dysfunction in males and females

PURPOSE

The association between gout, the most common crystal arthropathy, and sexual dysfunctions has often been investigated by studies in the last decades. Despite the presence of shared risk factors and comorbidities and the possible effects on sexual health of long-term gout complications, awareness of this association is severely lacking and the pathogenetic mechanisms have only partially been identified. In the present review, we aimed to investigate the current evidence regarding the potential mechanisms linking sexual dysfunctions and gout.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the association between gout and sexual dysfunctions.

RESULTS

Gout and sexual dysfunctions share several risk factors, including diabesity, chronic kidney disease, hypertension, metabolic syndrome, and peripheral vascular disease. Gout flares triggered by intense inflammatory responses feature severe pain and disability, resulting in worse sexual function, and some, but not all, treatments can also impair sexual health. Long-term gout complications can result in persistent pain and disability due to joint deformity, fractures, or nerve compression, with negative bearing on sexual function. The presence of low-grade inflammation impairs both sex steroids synthesis and endothelial function, further advancing sexual dysfunctions. The psychological burden of gout is another issue negatively affecting sexual health.

CONCLUSIONS

According to currently available evidence, several biological and psychological mechanisms link sexual dysfunctions and gout. Addressing risk factors and providing adequate treatment could potentially have beneficial effects on both conditions. Appropriate clinical evaluation and multidisciplinary approach are recommended to improve patient care.

The use of medication adherence guidelines in medication taking behaviour research

Medication nonadherence continues to be a serious issue in a range of long-term medical conditions and has been studied extensively over the past few decades. However, despite the plethora of research studies on medication adherence, poor methodological rigour in many studies has contributed to limited generalisability of the positive findings, limited impact on patients' medication adherence, and inability to compare between studies. This paper focuses on current guidelines designed specifically for research on medication adherence. It discusses key elements to consider during study design, selection of adherence measurements, and reporting on medication adherence research, to ensure a higher quality of research in medication adherence. Overall, there appears to be variations in adherence terminology reported in the literature despite improvements in defining medication taking behaviour and the availability of taxonomies. In addition, limited guidance exists on how best to measure adherence. Recommendations are provided on appropriate adherence measures for the adherence behaviour being investigated, including careful consideration of adherence concepts, validity of adherence instruments, appropriate instrument selection, definition of nonadherence threshold, and how to report medication adherence. Improving adherence research requires greater clarity and standardisation of descriptions of nonadherence behaviour, increased methodological rigour in study designs, better selection of adherence measurements, and comprehensive reporting.

Researchers' perspectives on methodological challenges and outcomes selection in interventional studies targeting medication adherence in rheumatic diseases: an OMERACT-adherence study

Background

Research on adherence interventions in rheumatology is limited by methodological issues, particularly heterogeneous outcomes. We aimed to describe researchers’ experiences with conducting interventional studies targeting medication adherence in rheumatology and their perspectives on establishing core outcomes.

Methods

Semi-structured interviews using audio conference were conducted with researchers who had conducted an adherence study of any design in the past 10 years. Data collection and thematic analysis were performed iteratively, until saturation.

Results

We interviewed 13 researchers, most of whom worked in academia and specialized in epidemiology and/or health services research. We identified three themes: 1) improving measurement of adherence (considering all phases of adherence, using appropriate and relevant measures, and establishing clinically meaningful thresholds); 2) challenges in designing and appraising adherence intervention studies (considering the confusion over a plethora of outcomes, difficulties with powering studies to demonstrate meaningful changes, and suboptimal descriptions of adherence interventions in published studies); and 3) advancing outcome assessment in adherence intervention studies (capturing rationale for developing a core domain set as well as recommendations and anticipated challenges by participants).

Conclusions

Uniquely gathering perspectives from international adherence researchers, our findings led to researcher-informed recommendations for improving adherence research including specifying the targeted adherence phase in designing interventions and studies and providing a glossary of terms to promote consistency in reporting. We also identified recommendations for developing a core domain set for interventional studies targeting medication adherence including involvement of patients, clinicians, and other stakeholders and methodological and practical considerations to establish rigor and support uptake.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00193-4.

A musculoskeletal ultrasound program as an intervention to improve disease modifying anti-rheumatic drugs adherence in rheumatoid arthritis: a randomized controlled trial

Objectives: To evaluate the effect of a musculoskeletal ultrasound programme (MUSP) applying real-time ultrasonography with reinforcement of findings by a rheumatologist on improving disease-modifying anti-rheumatic drugs (DMARDs) adherence in rheumatoid arthritis (RA).Method: Eligible RA patients with low adherence score (< 6) on the 8-item Morisky Medication Adherence Scale (MMAS-8) were randomized to either an intervention group (receiving MUSP at baseline) or a control group (no MUSP), and followed up for 6 months. Adherence measures (patient-reported and pharmacy dispensing records) and clinical efficacy data were collected. The MUSP's feasibility and acceptability were assessed.Results: Among 132 recruited RA patients, six without baseline visits were excluded; therefore, 126 patients were analysed (62 intervention and 64 control). The primary outcome (proportion of patients with 1 month MMAS-8 score < 6) was significantly smaller (p = 0.019) in the intervention (35.48%) than the control group (56.25%). However, 3 and 6 month adherence and clinical efficacy outcomes were not significantly different between the two groups (all p > 0.05). All 62 patients completed the MUSP (mean time taken, 9.2 min), with the majority reporting moderately/very much improved understanding of their joint condition (71%) and the importance of regularly taking their RA medication(s) (79%). Most patients (90.3%) would recommend the MUSP to another RA patient.Conclusions: The MUSP improved RA patients' DMARDs adherence in the short term and was feasible and well accepted by patients. Future studies could evaluate whether repeated feedback using MUSP could help to sustain the improvement in DMARD adherence in RA patients, and whether this may be clinically impactful and cost-effective.

Patient Perspectives on Outcome Domains of Medication Adherence Trials in Inflammatory Arthritis: An International OMERACT Focus Group Study

OBJECTIVE

To describe the perspectives of patients with inflammatory arthritis (IA) on outcome domains of trials evaluating medication adherence interventions.

METHODS

Adult patients (≥ 18 yrs) with IA taking disease-modifying antirheumatic drugs from centers across Australia, Canada, and the Netherlands participated in 6 focus groups to discuss outcome domains that they consider important when participating in medication adherence trials. We analyzed the transcripts using inductive thematic analysis.

RESULTS

Of the 38 participants, 23 (61%) had rheumatoid arthritis and 21 (55%) were female. The mean age was 57.3 ± (SD 15.0) years. Improved outcome domains that patients wanted from participating in an adherence trial were categorized into 5 types: medication adherence, adherence-related factors (supporting adherence; e.g., medication knowledge), pathophysiology (e.g., physical functioning), life impact (e.g., ability to work), and economic impact (e.g., productivity loss). Three overarching themes reflecting why these outcome domains matter to patients were identified: how taking medications could improve patients' emotional and physical fitness to maintain their social function; how improving knowledge and confidence in self-management increases patients' trust and motivation to take medications as agreed with minimal risk of harms; and how respect and reassurance, reflecting health care that values patients' opinions and is sensitive to patients' individual goals, could improve medication-taking behavior.

CONCLUSION

Patients value various outcome domains related to their overall well-being, confidence in medication use, and patient-healthcare provider relationships to be evaluated in future adherence trials.

Generating a Core Set of Outcomes for Hospital-Based Violence Intervention Programs

Hospital-based violence intervention programs (HVIPs) engage individuals who have experienced violent victimization in postmedical care programming, with the goal of reducing the incidence and impact of future injuries. Although there is some empirical support for HVIPs' impact on violence and crime-related outcomes, proper impact assessment is limited by a lack of systematized research on outcomes that relate to the proximal goals and activities of the programs themselves. To address this critical gap, we conducted a two-stage Delphi method to elicit and prioritize these outcomes using the wisdom and experience of those who are engaged in service delivery (i.e., HVIP community-based practitioners, program coordinators, and embedded researchers; N = 79). Through this process, respondents prioritized outcomes related to posttraumatic stress symptoms, beliefs about aggression, coping strategies, and emotional regulation, which have not been consistently measured using validated or standardized tools. Results suggest that, rather than limiting program outcomes to those related to repeat violent injury or criminality, hospital- and community-based violence prevention programs seek to improve and measure mental health and socioemotional outcomes as a benchmark for healing and recovery after a violent injury. Prioritization of these outcomes broadens the definition of recovery to include psychosocial health and well-being. In addition, inclusion of these outcomes in effectiveness studies will serve to bolster the relevance of findings, and provide support for continued development and refinement of HVIP practice.

Systematic review of international Delphi surveys for core outcome set development: representation of international patients

OBJECTIVES

A core outcome set (COS) describes a minimum set of outcomes to be reported by all clinical trials of one healthcare condition. Delphi surveys are frequently used to achieve consensus on core outcomes. International input is important to achieve global COS uptake. We aimed to investigate participant representation in international Delphi surveys, with reference to the inclusion of patients and participants from low and middle income countries as stakeholders (LMICs).

DESIGN

Systematic review.

DATA SOURCES

EMBASE, Medline, Web of Science, COMET database and hand-searching.

ELIGIBILITY CRITERIA

Protocols and studies describing Delphi surveys used to develop an international COS for trial reporting, published between 1 January 2017 and 6 June 2019.

DATA EXTRACTION AND SYNTHESIS

Delphi participants were grouped as patients or healthcare professionals (HCPs). Participants were considered international if their country of origin was different to that of the first or senior author. Data extraction included participant numbers, country of origin, country income group and whether Delphi surveys were translated. We analysed the impact these factors had on outcome prioritisation.

RESULTS

Of 90 included studies, 69% (n=62) were completed and 31% (n=28) were protocols. Studies recruited more HCPs than patients (median 60 (IQR 30-113) vs 30 (IQR 14-66) participants, respectively). A higher percentage of HCPs was international compared with patients (57% (IQR 37-78) vs 20% (IQR 0-68)). Only 31% (n=28) studies recruited participants from LMICs. Regarding recruitment from LMICs, patients were under-represented (16% studies; n=8) compared with HCPs (22%; n=28). Few (7%; n=6) studies translated Delphi surveys. Only 3% studies (n=3) analysed Delphi responses by geographical location; all found differences in outcome prioritisation.

CONCLUSIONS

There is a disproportionately lower inclusion of international patients, compared with HCPs, in COS-development Delphi surveys, particularly within LMICs. Future international Delphi surveys should consider exploring for geographical and income-based differences in outcome prioritisation.

PROSPERO REGISTRATION NUMBER

CRD42019138519.

A practical guide to interpreting and applying systematic reviews of qualitative studies in rheumatology

While patient-centered care is widely advocated in the management of rheumatic diseases, it can be challenging to implement, particularly for patients with complex systemic conditions. Patient-centered care involves identifying and integrating the patient's experiences, attitudes, and preferences in decision-making. Qualitative research is used to describe patient perspectives and priorities that may not always be expressed in clinical settings. Systematic reviews of qualitative studies can provide new and more comprehensive evidence of patients' beliefs and priorities across different populations and healthcare settings and are increasingly being reported across medical specialties, including rheumatology. In rheumatology, they have been used to examine topics including medication-taking and adherence, coping with systemic sclerosis and conservative management and exercise in osteoarthritis. By referencing recent examples of systematic qualitative reviews in the rheumatology literature, this article will outline the methodology and methods used, and provide an approach to guide the appraisal of reviews. We aim to give the reader a practical understanding of systematic reviews of qualitative literature and elucidate how knowledge gained from such reviews can be applied to improve the care of patients with rheumatic conditions.

Core Outcome Measures for Research in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation for Acute Respiratory or Cardiac Failure: An International, Multidisciplinary, Modified Delphi Consensus Study

OBJECTIVES

Research evaluating outcomes in critically ill patients with acute respiratory and cardiac failure supported with extracorporeal membrane oxygenation has increased significantly. The objective was to identify a core set of outcomes that are essential to include in all clinical research evaluating the use of either venoarterial or venovenous extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events.

DESIGN

A three-round modified Delphi process.

SUBJECTS

Patients, caregivers, multidisciplinary clinicians, researchers, industry partners, and research funders were included.

SETTING

Participants represented key extracorporeal membrane oxygenation organizations, including the Extracorporeal Life Support Organization, the International Extracorporeal Membrane Oxygenation Network, clinicians from high volume extracorporeal membrane oxygenation centers, and extracorporeal membrane oxygenation researchers or former extracorporeal membrane oxygenation patients from five continents.

INTERVENTIONS

We used recommended standards for the development of a core outcome set. Outcome measures identified from systematic reviews of the literature and from qualitative studies of survivors were mapped to the domains identified by the Core Outcome Measures in Effectiveness Trials initiative separately for venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

Participant response rates were 40 of 47 (85%), 35 of 37 (95%), and 64 of 69 (93%) for survey rounds 1, 2, and 3, respectively, with participants representing 10 different countries on five continents. After the third round survey, 8 outcome measures met consensus for both venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.

CONCLUSIONS

This study identified core outcomes to assess in all research evaluating the use of extracorporeal membrane oxygenation, including adverse events specific to this intervention, permitting standardization of outcome reporting for the first time. Identifying appropriate measurement instruments to evaluate these outcomes is an important next step to enable synthesis of extracorporeal membrane oxygenation research.

Universal Health Literacy Precautions Are Associated With a Significant Increase in Medication Adherence in Vulnerable Rheumatology Patients

OBJECTIVE

Our objective was to determine the impact of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, on medication adherence, patient satisfaction, and feasibility in all patients; its effect on the clinical disease activity index (CDAI) was studied in a rheumatoid arthritis (RA) subpopulation.

METHODS

Data collected during a 6-month prospective quality assurance intervention was compared with data from a prior 6-month period. Interventions included 1) encouraging questions, 2) teach-back communication, and 3) brown-bag medication review. Analysis was performed using linear regression or generalized estimating equation (GEE) regression.

RESULTS

During the intervention period, 46 physicians completed 1737 patient visits. Questions were encouraged, and teach-back communication was performed in more than 90% of visits. Brown-bag medication reviews were performed in 47% of visits overall and 69% of visits in a subgroup that received additional reminder calls. Visit duration and patient satisfaction were not significantly increased. Adherence for rheumatology-related medications that were prescribed both before and during the intervention increased by 22% (P ≤ 0.001; by GEE). Teach-back communication predicted a statistically significant improvement in medication adherence in this subpopulation (by linear regression). The mean CDAI did not improve; however, African American race and Hispanic ethnicity were associated with a decreased CDAI (by GEE).

CONCLUSION

Implementation of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, improved medication adherence in our safety-net clinic, with particularly strong effects seen with teach-back communication. In certain populations, use of the toolkit may also improve RA disease activity. This is the first study to document improved medication adherence with this intervention in a real-world setting.

Scope of Outcomes in Trials and Observational Studies of Interventions Targeting Medication Adherence in Rheumatic Conditions: A Systematic Review

OBJECTIVE

Nonadherence to medications is common in rheumatic conditions and associated with increased morbidity. Heterogeneous outcome reporting by researchers compromises the synthesis of evidence of interventions targeting adherence. We aimed to assess the scope of outcomes in interventional studies of medication adherence.

METHODS

We searched electronic databases to February 2019 for published randomized controlled trials and observational studies of interventions with the primary outcome of medication adherence including adults with any rheumatic condition, written in English. We extracted and analyzed all outcome domains and adherence measures with prespecified extraction and analysis protocols.

RESULTS

Overall, 53 studies reported 71 outcome domains classified into adherence (1 domain), health outcomes (38 domains), and adherence-related factors (e.g., medication knowledge; 32 domains). We subdivided adherence into 3 phases: initiation (n = 13 studies, 25%), implementation (n = 32, 60%), persistence (n = 27, 51%), and phase unclear (n = 20, 38%). Thirty-seven different instruments reported adherence in 115 unique ways (this includes different adherence definitions and calculations, metric, and method of aggregation). Forty-one studies (77%) reported health outcomes. The most frequently reported were medication adverse events (n = 24, 45%), disease activity (n = 11, 21%), bone turnover markers/physical function/quality of life (each n = 10, 19%). Thirty-three studies (62%) reported adherence-related factors. The most frequently reported were medication beliefs (n = 8, 15%), illness perception/medication satisfaction/satisfaction with medication information (each n = 5, 9%), condition knowledge/medication knowledge/trust in doctor (each n = 3, 6%).

CONCLUSION

The outcome domains and adherence measures in interventional studies targeting adherence are heterogeneous. Consensus on relevant outcomes will improve the comparison of different strategies to support medication adherence in rheumatology.

Addressing Challenges in Developing a Core Domain Set in Adherence Interventions in Rheumatology: A Report from the OMERACT-Adherence Group

Objective.

The OMERACT-Adherence meeting was convened to discuss the conceptual and methodological challenges in developing a core domain set (Adherence-CDS) for trials of interventions for medication adherence in rheumatology.

Methods.

Forty participants from nine countries participated.

Results.

Four ideas emerged: for adherence trials, the Adherence-CDS could include adherence and the condition-specific CDS; many factors affect adherence and are intervention targets, contextual factors, or outcome domains; adherence is a critical factor in drug trials; and standardized adherence measures are needed.

Conclusion.

Despite the challenges, the meeting clarified an approach to developing an Adherence-CDS that complements existing OMERACT work and methodology.