Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

Improving Pharmacist-Led Pediatric Patient Education on Oral Chemotherapy at Home

Oral chemotherapy (OC) has been increasingly used in pediatric patients diagnosed with cancer, which is primarily managed in the outpatient setting. Different from adults, pediatric patients face unique challenges in administering these hazardous medications at home. Because of the complexity of pediatric pharmaceutical care and the hazardous nature of chemotherapy agents, comprehensive patient education is imperative to mitigate the potential safety risks associated with OC administration at home. Pharmacists play a vital role in patient education and medication consultations. However, the lack of practice guidelines and limited resources supporting OC counseling are noted. Additional barriers include insufficient knowledge and training on OC, which can be improved by continuing education. In a regional children's hospital, a comprehensive OC education checklist was developed for pediatric patients and their caregivers to standardize consultations led by pharmacists. An infographic OC handout was also formulated to improve patient knowledge and awareness. Moreover, innovative approaches such as using telepharmacy, smartphone applications, and artificial intelligence have been increasingly integrated into patient care, which can help optimize OC consultations for children and adolescents. Further studies are warranted to enhance oral chemotherapy education specifically tailored for pediatric patients in outpatient settings.

Validation of a scale to assess adherence to oral chemotherapy based on the experiences of patients and healthcare professionals (EXPAD-ANEO)

Background: Lack of adherence to Oral antineoplastic agents (OAAs) treatment has important clinical, social and economic consequences.

Objective: To develop and validate a novel instrument for assessing adherence to OAAs, based on the reported experiences of people with cancer in relation to their treatment and the opinions of the healthcare professionals who care for them.

Methods: We performed a multicenter validation study of a scale designed to assess adherence to OAAs. First, a steering committee developed the items for an initial scale, based on the results of a qualitative study that evaluated patients’ and professionals’ experiences with this treatment. We then assessed the validity and reliability of the initial scale in a sample of 268 outpatients with cancer who received their OAAs from four Spanish hospitals.

Results: The mean age of the sample of 268 outpatients was 64.1 (standard deviation [SD] 12.4) years, and 47% of participants were women. With the results of this analysis, we developed the EXPAD-ANEO scale, which has 2 factors, one for beliefs and expectations and another for behavior. Both factors explain 52% of the explained common variance. Good reliability was obtained, with a McDonald’s omega of 0.7 for the first factor and 0.6 for the second factor. The fit indices were optimal (Root Mean Square Error of Approximation = 0.02, Comparative Fit Index = 0.99, Tucker Lexis Index = 0.99 and Standardized Root Mean Squared Residual = 0.03), which verifies the appropriateness of the items to the model. We measured EXPAD-ANEO criterion validity against pill count, obtaining a specificity of 80%. We measured convergent validity with the Morisky-Green test and found a significant association (p < 0.001). We measured divergent validity with questions on health literacy from the 16-item European Health Literacy Survey and found no correlation (p = 0.153).

Conclusion: EXPAD-ANEO is the first validated instrument for evaluating patients’ experiences with and adherence to OAAs, providing valuable information that can help health professionals to establish individual strategies or collective programs for improving therapeutic results and reducing healthcare costs.

Mobile Health Interventions: Examining Medication Adherence Outcomes Among Patients With Cancer

BACKGROUND

Treatment for cancer is trending toward oral therapies, which patients can self-manage from home. Proper adherence to oral therapy is vital to safe and optimal care in this setting. Mobile health interventions (i.e., text message reminders, mobile applications, and automated calls) are an evolving strategy aimed at improving medication adherence for patients on long-term oral therapies.

OBJECTIVES

This review aims to provide an overview of research outcomes for the use of mobile health interventions among patients with cancer.

METHODS

A comprehensive review of CINAHL®, MEDLINE®, and PubMed® was completed. Eleven articles were eligible for inclusion in this review.

FINDINGS

Mobile health interventions are an acceptable approach among patients with cancer and may improve adherence outcomes for those at highest risk for suboptimal adherence.

Medication Adherence Barriers: Development and Retrospective Pilot Test of an Evidence-Based Screening Instrument

BACKGROUND

Adherence to a prescribed medication regimen is often critical to successful comorbid disease management and decreased risk for adverse outcomes. The barriers that result in nonadherence are often multilayered and complex, making them difficult to address in an outpatient clinic setting.

OBJECTIVES

The primary objective of this project was to develop an evidence-based observational screening instrument and determine its potential to identify barriers to medication adherence.

METHODS

Medication adherence barriers were divided into five categories. These barriers provided the foundation for the screening instrument. To pilot test the instrument, a retrospective, quasiexperimental, observational comparison study was designed. The pilot study evaluated retrospective data of the Oncology Care Model (OCM).

FINDINGS

Of 250 OCM patient records, 184 (74%) revealed potential medication adherence barriers for patients with uncontrolled comorbid illness or events.

Medication Experience and Adherence to Oral Chemotherapy: A Qualitative Study of Patients' and Health Professionals' Perspectives

Lack of adherence constitutes one of the most important challenges in patients undergoing treatment with oral antineoplastic drugs (ANEO). Understanding cancer patients’ experiences with respect to their medication is key for optimizing adherence and therapeutic results. We aimed to assess the medication experience (ME) in patients with cancer in treatment with ANEO, to describe the barriers and facilitators related to the disease and its treatment and to compare them with the healthcare professionals’ perspectives. We carried out an exploratory qualitative study in the University Hospital of San Juan de Alicante, Spain. Three focus groups and two nominal group discussions were conducted with 23 onco-hematological patients treated with ANEO and 18 health professionals, respectively. The data were analyzed using content analyses and were eventually triangulated. The most impactful aspects in patients’ ME were the presence of adverse effects; lack of information about treatment; beliefs, needs and expectations regarding medications; social and family support; and the relationship with the health professionals. Both patients and professionals agreed on considering the negative side effects and the information about treatment as the main barriers and facilitators of adherence, respectively, although the approaches differed between both profiles. The professionals offered a more technical vision while patients prioritized the emotional burden and motivation associated with the disease and medication. This study allowed us to understand the real-life experiences of patients being treated with ANEO and explore the factors which had an impact on adherence to treatment. This understanding enables professionals to have a positive influence on patients’ behavior and provide individualized care plans. Pharmacists’ assistance is relevant to support patients’ adherence and self-management.

Impact of dosing frequency (once daily or twice daily) on patient adherence to oral targeted therapies for hematologic malignancies: a retrospective cohort study among managed care enrollees

Purpose

Existing studies evaluating patient adherence to oral targeted therapies such as tyrosine kinase inhibitors focus on small populations with single malignancies. This study evaluated patterns of use of oral agents in a larger population across multiple hematologic malignancies.

Methods

Adult patients diagnosed with a hematologic malignancy and prescribed oral targeted therapy between 2011 and 2016 (N = 18,976) were identified from the MarketScan Commercial Claims and Encounters, and Medicare Supplemental databases. Eligible patients were enrolled in monthly prescription plans 6 months before and 12 months after the index date (date of first prescription claim; n = 2442). Multivariable logistic regressions were used to determine predictors of adherence using the medication possession ratio (MPR) and persistence through prescription refill gaps.

Results

The overall median adherence was 0.9 (MPR ≥ 80%) and was comparable between once-daily (QD) and twice-daily (BID) groups. Overall, 59% of patients were persistent at 12 months. Patients on QD and BID products did not have any significant differences in adherence (fixed-interval MPR, odds ratio 0.94; 95% confidence interval (CI), 0.75–1.18) or persistence (odds ratio 0.93; 95% CI, 0.75–1.17) 12 months from index. Significant predictors of adherence and persistence included patient age, total inpatient admissions, number of adverse events, and total hospital visits.

Conclusion

Patient-specific clinical factors, rather than regimen-specific factors, were the main predictors of oral targeted therapy adherence and persistence. Adherence to oral targeted therapies appears to be similar for patients on QD and BID regimens in the real-world setting.

Barriers to treatment: describing them from a different perspective

BACKGROUND

Poor adherence is the result of many barriers. Most of the adherence research has focused on the patients' hurdles to adherence, instead of the responsibility the physician has for assuring adherence to treatment.

OBJECTIVE

The purpose of this review is to identify barriers to medication adherence and refocus how we describe those barriers in terms of physician behavior hurdles.

METHODS

PubMed was systematically searched for systematic reviews published between January 01, 2010, and December 06, 2017, that provided barriers to medication adherence. The searches were limited to reviews having adherence to medication prescribed in the outpatient setting as the main topic.

RESULTS

Thirty-one reviews were included in this review, covering 13 different disease categories. Fifty-eight different barriers to adherence to medications for chronic conditions were identified. Nineteen barriers were cited 6 or more times, and these were further categorized based on the World Health Organization's 5 dimensions of adherence and the number of times cited.

CONCLUSION

This review provides clear evidence that adherence to medication is affected by multiple barriers. To facilitate this, adherence barriers can be framed as physician/health system hurdles. With that focus in mind, we may put the responsibility where we have the most control.

Adherence and Coping Strategies in Outpatients With Chronic Myeloid Leukemia Receiving Oral Tyrosine Kinase Inhibitors

PURPOSE/OBJECTIVES

To assess adherence and coping strategies in outpatients with chronic myeloid leukemia (CML) on oral tyrosine kinase inhibitors (TKIs).
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DESIGN

Prospective, descriptive.
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SETTING

An interdisciplinary oncology outpatient clinic in Germany.
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SAMPLE

35 outpatients with CML on oral TKIs.
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METHODS

Adherence and coping strategies were assessed with questionnaires. Clinical data were extracted from medical charts.
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MAIN RESEARCH VARIABLES

Adherence rates, main coping strategies, and frequency and contents of single coping strategies.
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FINDINGS

18 patients showed adherence according to the applied screening instrument. Main coping strategies were spirituality and search for meaning. The two single items most frequently specified were adhering to medical instructions and trusting in the medical personnel involved.
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CONCLUSIONS

The low adherence rate of 51% most likely resulted from using the Basel Assessment of Adherence Scale as the questionnaire of choice. The relevance of spirituality and search for meaning as main coping strategies has not been shown previously in outpatients with CML. Most patients wish to obey medical instructions accurately and put trust in their oncologists; this introduces a resource that should gain relevance considering the increasing number of oral anticancer drugs.
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IMPLICATIONS FOR NURSING

Nurses are encouraged to routinely assess adherence and spiritual needs in outpatients with CML. Spirituality and search for meaning represent pivotal coping strategies in this group, which has an excellent prognosis. Oncology nurses may help provide tailored support, thereby ameliorating care for these patients.

Nursing Application of Oral Chemotherapy Safety Standards:An Informal Survey

As the use of oral chemotherapy continues to rise, new approaches are needed to ensure patient safety. To help address this issue, the American Society of Clinical Oncology/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards were expanded in 2013 to include additional measures addressing oral anticancer drugs (OACs). Because minimal data assessing the application of these standards exist, ONS conducted an independent survey of oncology nurses to evaluate the application of these standards in practice as they relate to several areas of OAC use: assessment, consent, patient education, drug verification, and monitoring. The data revealed that, although the standards are followed in many settings, a large number of settings do not have processes in place to support safety standards and ensure patient safety when administering OACs. Information gained in this informal survey can be used to guide additional research and educational initiatives.

Theoretical foundations of adherence behaviors: synthesis and application in adherence to oral oncology agents

BACKGROUND

The use of theory can provide structure for understanding the dynamics of adherence to oral agents for cancer (OACs) and facilitate the development of strategies for patient assessment and care planning related to oral adherence.

OBJECTIVES

The focus of this article is to identify common theories pertinent to medication-taking behavior, as well as their applications toward assessment and care planning regarding adherence to OACs. Approaches to apply these theories and their concepts in clinical practice are identified.

METHODS

Theories applied to adherence behaviors were reviewed, and their concepts were compared and synthesized. These concepts were then applied to medication adherence behavior.

FINDINGS

Various theories can help healthcare providers to better understand the influences and determinants of patients' adherence decisions and behaviors. They can then be used to structure assessment and plan related aspects of care.

Oral antineoplastic agents: how do we care about adherence?

AIMS

Oral therapies, including hormone-based or targeted therapies, have recently taken an increasing place in cancer treatment. In this context, a state of the art of the available studies dealing with the adherence of adult patients to oral anticancer treatment is warranted. The purpose of this review is to address (i) the association between assessment methods and measured adherence, (ii) the putative factors related to adherence and (iii) new ways of improving adherence to oral cancer therapies.

METHODS

We conducted a literature-based narrative review of studies obtained from Pubmed using medical subject heading terms and free-text terms combining concepts related to oral anticancer medication and adherence.

RESULTS

The analysis is based on 48 studies published since 1990, mostly assessing hormone-based therapy in breast cancer and targeted therapies in chronic myeloid leukaemia. Various methods of adherence were reported including self-report, medication measurement or combinations of methods. Adherence rates were found to vary from 14% to 100%. Beside patient related-factors, adherence rate discrepancies were found to be dependent on the method used. Furthermore, there was no consensual definition of adherence even regarding the same methods, some of them tolerating a period of interruption during the treatment period. Finally, several studies addressing persistence found a progressive decrease in adherence with time.

CONCLUSION

Adherence to novel oral therapies is a major issue and further research is warranted to standardize adherence assessment in clinical studies better and to define better the most appropriate approaches to improve long term adherence in oncology practice.

Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics

BACKGROUND

Therapeutic cancer chemotherapy is most successful when complete dosing is achieved. Because many newer therapeutic agents are oral and self-administered by the patient, adherence is a concern. The purpose of our analysis was to explore relationships between adherence, patient characteristics, and barriers to adherence.

METHODS

This secondary analysis utilized self-reported data from a randomized trial of self-care management conducted at two cancer centers in the US. Symptom distress was measured using the 15-item Symptom Distress Scale (SDS-15) and depression with the Patient Health Questionnaire-9 (PHQ-9). Adherence to oral medication was self-reported using the 8-item Morisky Medication Adherence Scale (MMAS-8). Measures were collected via Web-based, study-specific software ~8 weeks after treatment start date. Odds of low/medium adherence (score <8) were explored using univariate logistic regression. Given the number of factors and possible relationships among factors, a classification tree was built in lieu of a multivariable logistic regression model.

RESULTS

Of the eligible participants enrolled, 77 were on oral therapy and 70 had an MMAS score. Forty-nine (70%) reported a high adherence score (=8). Higher odds of low/medium adherence were associated with greater symptom distress (P=0.09), more depression (P=0.05), chemotherapy vs hormonal oral medication (P=0.03), being female (P=0.02), and being randomized to the control group in the parent trial (P=0.09). Conversely, high adherence was associated with working (P=0.08), being married/partnered (P=0.004), and being older (P=0.02). Factors identified as significantly related to low/medium adherence from the univariate logistic regression analyses were supported by the classification tree results.

CONCLUSION

Nonadherence to therapeutic oral medications in patients with cancer was associated with being unmarried/unpartnered, symptom distress, younger age, not working, and female sex. These findings may help to identify patients at risk for nonadherence and for whom supportive interventions to enhance adherence may be needed.