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Kadam E, Javaid M, Sen P, Saha S, Ziade N, Day J, Wincup C, Andreoli L, Parodis I, Tan AL, Shinjo SK, Dey D, Cavagna L, Chatterjee T, Knitza J, Wang G, Dalbeth N, Velikova T, Battista S, Cheng K, Boyd P, Kobert L, Gracia-Ramos AE, Mittal S, Makol A, Gutiérrez CET, Uribe CVC, Kuwana M, Burmester GR, Guillemin F, Nikiphorou E, Chinoy H, Aggarwal V, Gupta L. Collating the voice of people with autoimmune diseases: Methodology for the Third Phase of the COVAD Studies. Rheumatol Int 2024; 44:1233-1244. [PMID: 38609655 PMCID: PMC11178609 DOI: 10.1007/s00296-024-05562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/21/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION The growing recognition of holistic patient care highlights the various factors shaping the quality of life of individuals with autoimmune and rheumatic diseases (AIRDs). Beyond the traditional disease measures, there is an emerging acknowledgment of the less-explored aspects, including subjective well-being, social determinants of health, comorbidities, mental health, and medication adherence. Moreover, digital health services have empowered patients to engage actively in decision-making alongside clinicians. To explore these domains within the context of AIRDs, the "Collating the Voice of People with Autoimmune Diseases" COVAD survey was conceived, a successor of the previous two COVAD surveys. In this document, we present the study protocol in comprehensive detail. METHODS The COVAD-3 survey is a cross-sectional patient self-reported e-survey incorporating multiple widely accepted scales/scores to assess various aspects of patients' lifestyles objectively. To ensure the survey's accuracy and usability across diverse regions, it will be translated into multiple languages and subjected to rigorous vetting and pilot testing. It will be distributed by collaborators via online platforms and data will be collected from patients with AIRDs, and healthy individuals over eight months. Data analysis will focus on outcome measures related to various social, demographic, economic, and psychological factors. CONCLUSION With the increasing awareness to adopt a holistic treatment approach encompassing all avenues of life, the COVAD-3 survey aims to gain valuable insights into the impact of social, demographic, economic, and psychological determinants of health on the subjective well-being in patients with AIRDs, which will contribute to a better understanding of their overall health and well-being.
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Affiliation(s)
- Esha Kadam
- Seth Gordhandhas Sunderdas Medical College and King Edwards Memorial Hospital, Mumbai, Maharashtra, India
| | | | - Parikshit Sen
- Maulana Azad Medical College, 2-Bahadurshah Zafar Marg, New Delhi, Delhi, 110002, India
| | - Sreoshy Saha
- Mymensingh Medical College, Mymensingh, Bangladesh
| | - Nelly Ziade
- Rheumatology Department, Saint-Joseph University, Beirut, Lebanon
- Rheumatology Department, Hotel-Dieu de France Hospital, Beirut, Lebanon
| | - Jessica Day
- Department of Rheumatology, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
- Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili and University of Brescia, 25123, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, 25123, Brescia, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ai Lyn Tan
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Samuel Katsuyuki Shinjo
- Division of Rheumatology, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Dzifa Dey
- Department of Medicine and Therapeutics, School of Medicine and Dentistry, University of Ghana, College of Health Sciences, Korle-Bu, Accra, Ghana
| | - Lorenzo Cavagna
- Rheumatology Unit, Dipartimento di Medicine Interna e Terapia Medica, Università degli Studi di Pavia, Pavia, Lombardy, Italy
| | - Tulika Chatterjee
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Johannes Knitza
- Medizinische Klinik 3, Rheumatologie Und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland
| | - Guochun Wang
- Department of Rheumatology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, Beijing, 100029, China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Tsvetelina Velikova
- Medical Faculty, Sofia University, St. Kliment Ohridski, 1 Kozyak Str., 1407, Sofia, Bulgaria
| | - Simone Battista
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Campus of Savona, University of Genova, Savona, Italy
| | - Karen Cheng
- Patient Research Partner/Volunteer, Myositis Support and Understanding, Lincoln, USA
| | - Peter Boyd
- Services Support Officer, Arthritis Ireland, Dublin, Ireland
- Chair, EULAR PARE Committee, Kilchberg, Switzerland
| | - Linda Kobert
- Research and Communications Specialist, The Myositis Association, Lincoln, USA
| | - Abraham Edgar Gracia-Ramos
- Department of Internal Medicine, National Medical Center "La Raza", Instituto Mexicano del Seguro Social, General Hospital, Av. Jacaranda S/N, Col. La Raza, Del. Azcapotzalco, C.P. 02990, Mexico City, Mexico
| | - Srijan Mittal
- Maulana Azad Medical College, 2-Bahadurshah Zafar Marg, New Delhi, Delhi, 110002, India
| | - Ashima Makol
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Carlos Enrique Toro Gutiérrez
- Reference Center for Osteoporosis, Rheumatology and Dermatology, Pontificia Universidad Javeriana Cali, Columbia, USA
| | | | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8602, Japan
| | - Gerd-Rüdiger Burmester
- Department of Rheumatology and Clinical Immunology, Charité, University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Francis Guillemin
- EA 4360 Apemac, Université de Lorraine, Nancy, France
- Inserm, CHRU Nancy, CIC-1433 Epidémiologie Clinique, Université de Lorraine, Nancy, France
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College Hospital, London, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, The University of Manchester, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Vikas Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Latika Gupta
- Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK.
- Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.
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van Mierlo T, Rondina R, Fournier R. Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial. JMIR Form Res 2024; 8:e52558. [PMID: 38592752 DOI: 10.2196/52558] [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: 09/07/2023] [Revised: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health. OBJECTIVE This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research. METHODS Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022. RESULTS Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001). CONCLUSIONS Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/37231.
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Affiliation(s)
| | - Renante Rondina
- Rotman School of Managment, University of Toronto, Toronto, ON, Canada
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Godny L, Reshef L, Sharar Fischler T, Elial-Fatal S, Pfeffer-Gik T, Raykhel B, Rabinowitz K, Levi-Barda A, Perets TT, Barkan R, Goren I, Ollech JE, Yanai H, Gophna U, Dotan I. Increasing adherence to the Mediterranean diet and lifestyle is associated with reduced fecal calprotectin and intra-individual changes in microbial composition of healthy subjects. Gut Microbes 2022; 14:2120749. [PMID: 36226673 PMCID: PMC9578447 DOI: 10.1080/19490976.2022.2120749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The Mediterranean diet (MED) is associated with the modification of gut microbial composition. In this pilot study, we investigate the feasibility of a microbiota-targeted MED-based lifestyle intervention in healthy subjects. MED intervention integrating dietary counseling, a supporting mobile application, and daily physical activity measurement using step trackers was prospectively applied for 4 weeks. Blood and fecal samples were collected at baseline, after the 4-week intervention, and at 6 and 12 months. Blood counts, inflammatory markers, microbial and eukaryotic composition were analyzed. Dietary adherence was assessed using daily questionnaires. All 20 healthy participants (females 65%, median age 37), completed the 4-week intervention. Adherence to MED increased from 15.6 ± 4.1 (baseline) to 23.2 ± 3.6 points (4 weeks), p < .01, reflected by increased dietary fiber and decreased saturated fat intake (both p < .05). MED intervention modestly reduced fecal calprotectin, white blood cell, neutrophil, and lymphocyte counts, within the normal ranges (P < .05). Levels of butyrate producers including Faecalibacterium and Lachnospira were positively correlated with adherence to MED and the number of daily steps. Bacterial composition was associated with plant-based food intake, while fungal composition with animal-based food as well as olive oil and sweets. Increasing adherence to MED correlated with increased absolute abundances of multiple beneficial gut symbionts. Therefore, increasing adherence to MED is associated with reduction of fecal calprotectin and beneficial microbial alterations in healthy subjects. Microbiota targeted lifestyle interventions may be used to modify the intestinal ecosystem with potential implications for microbiome-mediated diseases.
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Affiliation(s)
- L. Godny
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L. Reshef
- The Shmunis School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - T. Sharar Fischler
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S. Elial-Fatal
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T. Pfeffer-Gik
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B. Raykhel
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K. Rabinowitz
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A. Levi-Barda
- Biobank, Department of Pathology, Rabin Medical Center, Petah Tikva, Israel
| | - TT. Perets
- Gastroenterology Laboratory, Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel,Adelson School of Medicine, Ariel University, Ariel, Israel
| | - R. Barkan
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - I. Goren
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Department of inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Ohio, USA
| | - JE. Ollech
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H. Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - U. Gophna
- The Shmunis School of Biomedicine and Cancer Research, Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - I. Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,CONTACT I. Dotan Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zeng L, Deng Y, Yang K, Chen J, He Q, Chen H. Safety and efficacy of fecal microbiota transplantation for autoimmune diseases and autoinflammatory diseases: A systematic review and meta-analysis. Front Immunol 2022; 13:944387. [PMID: 36248877 PMCID: PMC9562921 DOI: 10.3389/fimmu.2022.944387] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo evaluate the safety and efficacy of fecal microbiota transplantation for autoimmune diseases and autoinflammatory diseases.MethodsRelevant literature was retrieved from the PubMed database, Embase database, Cochrane Library database, etc. The search period is from the establishment of the database to January 2022. The outcomes include clinical symptoms, improvement in biochemistry, improvement in intestinal microbiota, improvement in the immune system, and adverse events. Literature screening and data extraction were independently carried out by two researchers according to the inclusion and exclusion criteria, and RevMan 5.3 software was used for statistics and analysis.ResultsOverall, a total of 14 randomized controlled trials (RCTs) involving six types of autoimmune diseases were included. The results showed the following. 1) Type 1 diabetes mellitus (T1DM): compared with the autologous fecal microbiota transplantation (FMT) group (control group), the fasting plasma C peptide in the allogenic FMT group at 12 months was lower. 2) Systemic sclerosis: at week 4, compared with one of two placebo controls, three patients in the experimental group reported a major improvement in fecal incontinence. 3) Ulcerative colitis, pediatric ulcerative colitis, and Crohn’s disease: FMT may increase clinical remission, clinical response, and endoscopic remission for patients with ulcerative colitis and increase clinical remission for patients with Crohn’s disease. 4) Psoriatic arthritis: there was no difference in the ratio of ACR20 between the two groups.ConclusionBased on current evidence, the application of FMT in the treatment of autoimmune diseases is effective and relatively safe, and it is expected to be used as a method to induce remission of active autoimmune diseases.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021235055, identifier CRD42021235055.
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Affiliation(s)
- Liuting Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Liuting Zeng, ; Kailin Yang, ; Ying Deng, ; Hua Chen, ; Junpeng Chen,
| | - Ying Deng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Liuting Zeng, ; Kailin Yang, ; Ying Deng, ; Hua Chen, ; Junpeng Chen,
| | - Kailin Yang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
- *Correspondence: Liuting Zeng, ; Kailin Yang, ; Ying Deng, ; Hua Chen, ; Junpeng Chen,
| | - Junpeng Chen
- School of Mechanical Engineering, Hunan University of Science and Technology, Xiangtan, China
- *Correspondence: Liuting Zeng, ; Kailin Yang, ; Ying Deng, ; Hua Chen, ; Junpeng Chen,
| | - Qi He
- People's Hospital of Ningxiang City, Ningxiang City, China
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Liuting Zeng, ; Kailin Yang, ; Ying Deng, ; Hua Chen, ; Junpeng Chen,
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Pouls BP, Bekker CL, van Dulmen S, Vriezekolk JE, van den Bemt BJ. A Serious Puzzle Game to Enhance Adherence to Antirheumatic Drugs in Patients With Rheumatoid Arthritis: Systematic Development Using Intervention Mapping. JMIR Serious Games 2022; 10:e31570. [PMID: 35179510 PMCID: PMC8900908 DOI: 10.2196/31570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/08/2021] [Accepted: 11/06/2021] [Indexed: 12/14/2022] Open
Abstract
Background Patients’ implicit attitudes toward medication need and concerns may influence their adherence. Targeting these implicit attitudes by combining game-entertainment with medication-related triggers might improve medication adherence in patients with rheumatoid arthritis (RA). Objective The aim of this study was to describe the systematic development of a serious game to enhance adherence to antirheumatic drugs by using intervention mapping. Methods A serious game was developed using the intervention mapping framework guided by a multidisciplinary expert group, which proceeded along 6 steps: (1) exploring the problem by assessing the relationship between medication adherence and implicit attitudes, (2) defining change objectives, (3) selecting evidence-based behavior change techniques that focused on adjusting implicit attitudes, (4) designing the intervention, (5) guaranteeing implementation by focusing on intrinsic motivation, and (6) planning a scientific evaluation. Results Based on the problem assessment and guided by the Dual-Attitude Model, implicit negative and illness-related attitudes of patients with RA were defined as the main target for the intervention. Consequently, the change objective was “after the intervention, participants have a more positive attitude toward antirheumatic drugs.” Attention bias modification, evaluative conditioning, and goal priming were the techniques chosen to implicitly target medication needs. These techniques were redesigned into medication-related triggers and built in the serious puzzle game. Thirty-seven patients with RA tested the game at several stages. Intrinsic motivation was led by the self-determination theory and addressed the 3 needs, that is, competence, autonomy, and relatedness. The intervention will be evaluated in a randomized clinical trial that assesses the effect of playing the serious game on antirheumatic drug adherence. Conclusions We systematically developed a serious game app to enhance adherence to antirheumatic drugs among patients with RA by using the intervention mapping framework. This paper could serve as a guideline for other health care providers when developing similar interventions.
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Affiliation(s)
- Bart Ph Pouls
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Charlotte L Bekker
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands.,Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Johanna E Vriezekolk
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands
| | - Bart Jf van den Bemt
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
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Rondina R, van Mierlo T, Fournier R. Testing Behavioral Nudges and Prompts in Digital Courses for Self-Guided Treatment of Depression and Anxiety, Protocol for 3-Arm Randomized Controlled Trial (Preprint). JMIR Res Protoc 2022; 11:e37231. [PMID: 35969446 PMCID: PMC9425166 DOI: 10.2196/37231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/26/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite showing strong evidence of positive outcomes, a common problem in the field of digital health is poor engagement and adherence. Non–health care, for-profit digital ventures, such as Facebook, LinkedIn, and Twitter, conduct behavioral experiments to increase user engagement. To our knowledge, digital health organizations have not published similar types of experiments in ad libitum environments, and there are limited published data indicating whether nudges and prompts can be leveraged to increase engagement with digital health interventions. Objective The main objective of our 3-arm randomized controlled trial is to test whether registered members in two well-established digital health courses for anxiety and depression will engage with four different types of nudges and prompts, and whether engaging with nudges and prompts increases engagement within the courses. Methods New members who register for the self-guided anxiety and depression courses on the Evolution Health platform will be randomized into 1 of 3 arms. The first control arm will feature a member home page without any behavioral nudges or prompts. The second arm will feature a member home page with a Tip-of-the-Day section containing directive content. Arm 3 will feature a member home page with a Tip-of-the-Day section containing social proof and present bias content. The third arm will also feature a to-do item checklist. Results The experiment was designed in August 2021 and was launched in November 2021. Initially, we will measure engagement with the tips and the to-do checklist by calculating the frequency of use by age and gender. If members do engage, we will then, according to age and gender, examine whether nudges and prompts result in higher course completion rates and whether specific types of prompts and nudges are more popular than others. Conclusions Our 3-arm randomized controlled trial will be the first to compare four distinct types of behavioral prompts and nudges in two self-guided digital health courses that were designed to treat mental health issues. We expect the results to generate insights into which types of behavioral prompts and nudges work best in the population. If they are shown to increase engagement, the insights will then be used to apply prompts and nudges to the platform’s addiction-focused courses. Based on the results of the experiment, the insights will be applied to using artificial intelligence to train the platform to recognize different usage patterns and provide specific engagement recommendations to stratified users. International Registered Report Identifier (IRRID) DERR1-10.2196/37231
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Affiliation(s)
- Renante Rondina
- Rotman School of Mangement, University of Toronto, Toronto, ON, Canada
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Forma F, Chiu K, Shafrin J, Boskovic DH, Veeranki SP. Are caregivers ready for digital? Caregiver preferences for health technology tools to monitor medication adherence among patients with serious mental illness. Digit Health 2022; 8:20552076221084472. [PMID: 35295765 PMCID: PMC8918958 DOI: 10.1177/20552076221084472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/14/2022] [Indexed: 01/23/2023] Open
Abstract
Background Adherence to antipsychotic medication is critical for bipolar disorder (BPD), major depression (MDD) and schizophrenia (SCZ) patients. Digital tools have emerged to monitor medication adherence along with tracking general health. Evidence on physician or patient preferences for such tools exists but is limited among caregivers. The study objective was to assess preferences and willingness-to-pay (WTP) for medication adherence monitoring tools among caregivers of SMI patients. Methods A web-based survey was administered to caregivers of adult SMI patients. Twelve discrete choice questions comparing adherence monitoring tools that varied across two attribute bundles: (1) tool attributes including source of medication adherence information, frequency of information updates, access to adherence information, and physical activity, mood, and rest tracking, and (2) caregiver monthly out-of-pocket cost attribute were administered to caregiver respondents. Attributes were parameterized for both digital and non-digital tools. Random utility models were used to estimate caregivers’ preferences and WTP. Results Among 184 study-eligible caregivers, 57, 61 and 66 participants cared for BPD, MDD, and SCZ patients, respectively. Caregivers highly preferred (odds ratio (OR): 7.34, 95% confidence interval (CI): 5.00–10.79) a tool that tracked medication ingestion using a pill embedded with an ingestible event market (IEM) sensor and tracked patients’ physical activity, mood, and rest than a non-digital pill organizer. Additionally, caregivers were willing to pay $255 per month (95% CI: $123–$387) more for this tool compared to a pill organizer. Conclusion Caregivers of SMI patients highly preferred and were willing to pay more for digital tools that not only measures medication ingestion but also tracks general health.
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Yerrapragada G, Siadimas A, Babaeian A, Sharma V, O'Neill TJ. Machine Learning to Predict Tamoxifen Nonadherence Among US Commercially Insured Patients With Metastatic Breast Cancer. JCO Clin Cancer Inform 2021; 5:814-825. [PMID: 34383580 DOI: 10.1200/cci.20.00102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Adherence to tamoxifen citrate among women diagnosed with metastatic breast cancer can improve survival and minimize recurrence. This study aimed to use real-world data and machine learning (ML) methods to classify tamoxifen nonadherence. METHODS A cohort of women diagnosed with metastatic breast cancer from 2012 to 2017 were identified from IBM MarketScan Commercial Claims and Encounters and Medicare claims databases. Patients with < 80% proportion of days coverage in the year following treatment initiation were classified as nonadherent. Training and internal validation cohorts were randomly generated (4:1 ratio). Clinical procedures, comorbidity, treatment, and health care encounter features in the year before tamoxifen initiation were used to train logistic regression, boosted logistic regression, random forest, and feedforward neural network models and were internally validated on the basis of area under receiver operating characteristic curve. The most predictive ML approach was evaluated to assess feature importance. RESULTS A total of 3,022 patients were included with 40% classified as nonadherent. All models had moderate predictive accuracy. Logistic regression (area under receiver operating characteristic 0.64) was interpreted with 94% sensitivity (95% CI, 89 to 92) and 0.31 specificity (95% CI, 29 to 33). The model accurately classified adherence (negative predictive value 89%) but was nondiscriminate for nonadherence (positive predictive value 48%). Variable importance identified top predictive factors, including age ≥ 55 years and pretreatment procedures (lymphatic nuclear medicine, radiation oncology, and arterial surgery). CONCLUSION ML using baseline administrative data predicts tamoxifen nonadherence. Screening at treatment initiation may support personalized care, improve health outcomes, and minimize cost. Baseline claims may not be sufficient to discriminate adherence. Further validation with enriched longitudinal data may improve model performance.
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Affiliation(s)
- Gayathri Yerrapragada
- School of Computing, Clemson University, Clemson, SC.,Data Science & Services, Diagnostics Information Solutions, Roche Diagnostics, Belmont, CA
| | - Athanasios Siadimas
- Data Science & Services, Diagnostics Information Solutions, Roche Diagnostics, Belmont, CA
| | - Amir Babaeian
- Data Science & Services, Diagnostics Information Solutions, Roche Diagnostics, Belmont, CA
| | - Vishakha Sharma
- Data Science & Services, Diagnostics Information Solutions, Roche Diagnostics, Belmont, CA
| | - Tyler J O'Neill
- Data Science & Services, Diagnostics Information Solutions, Roche Diagnostics, Belmont, CA
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9
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Liu Y, Wang R, Huang R, Cao Y, Wang J, Feng D. Influencing factors and their relationships of risk perception and decision-making behaviour of polypharmacy in patients with chronic diseases: a qualitative descriptive study. BMJ Open 2021; 11:e043557. [PMID: 33906839 PMCID: PMC8088251 DOI: 10.1136/bmjopen-2020-043557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES In order to understand the influencing factors of the medication-taking behaviour in patients with chronic diseases, reveal the deep-seated causes underlying the phenomenon of polypharmacy, explore the formation rules of the risk perception of polypharmacy and how risk perception affect the medication decision-making behaviour of patients with chronic diseases. DESIGN A qualitative descriptive design was used. Study data were collected through semi-structured interviews with patients and physicians. We used the grounded theory approach to refine influencing factors, followed by interpretative structural modelling that analysed the interaction between these factors. SETTING Patients from two hospitals, two nursing homes and two communities. Physicians from two community hospitals in Wuhan, China. PARTICIPANTS Patients with chronic diseases with high willingness to cooperate and good communication ability. Physicians with rich experience in the treatment of chronic diseases. RESULTS Twenty-nine interviews were conducted (20 patients and 9 physicians). A total of 35 influencing factors of the medication-taking behaviours in patients with chronic diseases were extracted from the interview data, further integrated into 10 integrated influencing factors and ultimately clustered into three aspects: 'medication benefit', 'medication risk' and 'medication strategy'. Medication risk can be divided into four specific dimensions: economic risk, physical risk, psychosocial risk and time risk. 10 integrated influencing factors constituted the interpretative structural model of the medication decision-making behaviours in patients with chronic diseases. CONCLUSIONS The causes underlying the medication decision-making behaviour of patients with chronic diseases are complex, involving a series of influencing factors such as their risk perception of the medication-taking behaviour. In order to alleviate the adverse effects of polypharmacy on patients' health and medical costs, further safety measures should be proposed to improve the medication-taking behaviour in patients with chronic diseases based on the relationship and internal mechanism of the influencing factors of the medication decision-making behaviour.
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Affiliation(s)
- Yuxin Liu
- Tongji Medical College, School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
| | - Ruoxi Wang
- Tongji Medical College, School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Huang
- Tongji Medical College, School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Cao
- Tongji Medical College, School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wang
- Tongji Medical College, School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
| | - Da Feng
- Tongji Medical College, School of Pharmacy, Huazhong University of Science and Technology, Wuhan, China
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10
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Mendoza-Pinto C, García-Carrasco M, Campos-Rivera S, Munguía-Realpozo P, Etchegaray-Morales I, Ayón-Aguilar J, Alonso-García NE, Méndez-Martínez S. Medication adherence is influenced by resilience in patients with systemic lupus erythematosus. Lupus 2021; 30:1051-1057. [PMID: 33794703 DOI: 10.1177/09612033211004722] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evidence on the relationship between resilience and medication adherence in systemic lupus erythematosus (SLE) patients is lacking. We aimed to examine the impact of resilience on medication adherence in SLE patients. METHOD In a cross-sectional analysis SLE outpatients were assessed for resilience (Connor-Davison Resilience Scale, CD-RISC), depressive symptoms (CES-D) and medication adherence (Compliance Questionnaire for Rheumatology [CQR]). The disease activity index (mexSLEDAI) and damage (SLICC Damage Index) were administered. Factors independently associated with adherence were identified using multivariate logistic regression. RESULTS Of the 157 patients, 152 (96.8%) were female with a median age of 45.9 (IQR: 39.0-55.5) years and disease duration of 14 (IQR: 10.0-19.0) years. Medication adherence (CQR ≥80%) and depressive symptoms were found in 74.5% and 43.9% of patients, respectively. Adherent patients had a lower CES-D score and a higher CD-RISC score. In the multivariate analysis adjusting for demographic and clinical confounders, resilience and older age protected against non-adherence (OR 0.96, [95% CI 0.94-0.99] and OR 0.96 [95% CI 0.93-0.98], respectively). CONCLUSION In SLE patients, resilience and older age, which possibly associated with better medication adherence, may protect against non-adherence.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, México.,Department of Rheumatology and Immunology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Mario García-Carrasco
- Systemic Autoimmune Diseases Research Unit, High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, México.,Department of Rheumatology and Immunology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Sandra Campos-Rivera
- Department of Rheumatology and Immunology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, High-Specialty Medical Unit-CIBIOR, Mexican Social Security Institute, Puebla, México.,Department of Rheumatology and Immunology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Department of Rheumatology and Immunology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Jorge Ayón-Aguilar
- Research Coordination, Puebla Delegation, Mexican Social Security Institute, Puebla, México
| | - Norma Edith Alonso-García
- Department of Psychology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
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11
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Udongwo NE, Odak M, AlBayati A, Zheng M, Tang X. Unusual Subacute Interphalangeal Tophaceous Gouty Arthritis. Cureus 2021; 13:e13732. [PMID: 33842110 PMCID: PMC8021002 DOI: 10.7759/cureus.13732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Gout is an arthritic syndrome that causes extensive joint damage and discomfort. It is due to an elevated uric acid level in the blood which deposits in the joints. This causes an inflammatory response and joint damage. Gout typically presents as an acute monoarticular attack, resulting in hot, erythematous, swollen, and exquisitely tender joint. Tophaceous gout, which is commonly a later complication of long-standing gout, can rarely be the presenting manifestation of gout. Tophaceous gout is considered a late complication of chronic gout. As early recognition of gout can lead to prompt initiation of treatment and improvement in clinical status, a patient with an alcohol use history who presents with polyarticular swelling and tenderness should raise the suspicion of a tophaceous gout exacerbation even if the patient does not have a documented history of gout.
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Affiliation(s)
| | - Mihir Odak
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Asseel AlBayati
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Min Zheng
- Pathology and Laboratory Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Xiaoyin Tang
- Rheumatology, Jersey Shore University Medical Center, Neptune, USA
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12
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Ritschl V, Stamm TA, Aletaha D, Bijlsma JWJ, Böhm P, Dragoi R, Dures E, Estévez-López F, Gossec L, Iagnocco A, Negrón JB, Nudel M, Marques A, Moholt E, Skrubbeltrang C, Van den Bemt B, Viktil K, Voshaar M, Carmona L, de Thurah A. Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider. RMD Open 2020; 6:e001432. [PMID: 33161377 PMCID: PMC7856118 DOI: 10.1136/rmdopen-2020-001432] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs). METHODS An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews. RESULTS After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise. CONCLUSIONS The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.
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Affiliation(s)
- Valentin Ritschl
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | - Peter Böhm
- Deutsche Rheuma-Liga Bundesverband e.V., Bonn, Germany
| | - Razvan Dragoi
- University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Emma Dures
- University of the West of England Bristol, Bristol, UK
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | | | - Laure Gossec
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
- APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - José B Negrón
- Instituto de Investigación Social y Sanitaria, Puerto Rico
| | | | - Andréa Marques
- Centro Hospitalar e Universitário de Coimbra, Health Sciences Research Unit: Nursing, UICISA-E, Coimbra, Portugal
| | - Ellen Moholt
- Diakonhjemmet Hospital, Division of Rheumatology and Research, Oslo, Norway
| | | | - Bart Van den Bemt
- Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands
- Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kirsten Viktil
- University of Oslo, Oslo, Norway
- Diakonhjemmet Hospital Pharmacy, Oslo, Norway
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (Inmusc), Madrid, Spain
| | - Annette de Thurah
- Rheumatology, Aarhus University Hospital, Århus N, Denmark
- Clinical Medicine, Aarhus University, Aarhus, Denmark
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13
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Yokose C, Jorge A, D'Silva K, Serling-Boyd N, Matza M, Nasrallah M, Keller S, Oza A, Choi H, Bolster MB, Collier D. Using electronic visits (E-visits) to achieve goal serum urate levels in patients with gout in a rheumatology practice: A pilot study. Semin Arthritis Rheum 2020; 50:1382-1386. [PMID: 32359694 DOI: 10.1016/j.semarthrit.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/24/2020] [Accepted: 03/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Achieving goal serum urate levels in patients with gout remains difficult in primary care and rheumatology practices. This study measured the ability of an asynchronous electronic visit (E-visit) program to facilitate achieving a goal serum urate (SU) of less than 6.0 mg/dL. METHODS We performed a retrospective cohort study in a large academic medical center rheumatology practice between April 1, 2017 and May 31, 2018. Patients with gout and SU levels over 6.0 mg/dL were enrolled in an E-visit program and were compared with historical controls who received usual care, matched 1:1 for age and sex. The primary outcome of interest was the proportion of patients achieving SU target of less than 6.0 mg/dL at six months. RESULTS Sixty-two patients were enrolled by their rheumatologist in the gout asynchronous E-visit program and were compared to 62 historical controls who were seen within one year prior to E-visit program initiation. Baseline characteristics including age, sex, body mass index, renal function, and initial SU were similar among patients enrolled in the E-visit program and controls. At six months, a significantly higher proportion of patients in the E-visit program achieved goal SU of less than 6.0 mg/dL compared to controls (63.8% vs 33.9%, respectively, p < 0.01), and the E-visit patients had a lower mean SU level than historical controls (5.5 mg/dL versus 6.7 mg/dL, respectively, p < 0.01). CONCLUSION A physician-initiated E-visit program led to a substantial improvement in the rate of achieving goal SU among patients with gout within an academic rheumatology practice.
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Affiliation(s)
- Chio Yokose
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - April Jorge
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kristin D'Silva
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Naomi Serling-Boyd
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mark Matza
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mazen Nasrallah
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sarah Keller
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Amar Oza
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Hyon Choi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcy B Bolster
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Deborah Collier
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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14
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Dantas LO, Weber S, Osani MC, Bannuru RR, McAlindon TE, Kasturi S. Mobile health technologies for the management of systemic lupus erythematosus: a systematic review. Lupus 2020; 29:144-156. [PMID: 31924145 DOI: 10.1177/0961203319897139] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE We aimed to perform a standardized review of available mobile health (mHealth) applications (apps) for systemic lupus erythematosus (SLE) and to conduct a systematic review of the literature on mHealth technologies in SLE. METHODS Google Play and AppStore in the United States of America were queried and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Web of Science, EMBASE, Medline, and Cochrane databases were systematically searched from inception through June 2019. RESULTS Of 324 mHealth apps found, 20 were eligible for inclusion; 10 focused on education, 7 offered tools to track patient-reported symptoms, 5 included interactive online communities, and 1 enabled emoji sharing. The reviewed apps scored poorly on the MARS quality scale with a mean score 2.3 (0.6) out of 5. Of 1147 studies identified in the literature review, 21 were eligible for inclusion; 11 studies (52.4%) focused on the development and use of mHealth for providing patient information, while only 2 (9.5%) were randomized trials of mHealth interventions. CONCLUSIONS Although there is growing interest in the development of mHealth technologies to support SLE patients, currently available tools are of poor quality and limited functionality, and the literature examining this area is sparse.
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Affiliation(s)
- L O Dantas
- Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
- Physical Therapy Department, Federal University of São Carlos, São Carlos, Brazil
| | - S Weber
- Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
| | - M C Osani
- Center for Treatment Comparison and Integrative Analysis, Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
| | - R R Bannuru
- Center for Treatment Comparison and Integrative Analysis, Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
| | - T E McAlindon
- Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
| | - S Kasturi
- Division of Rheumatology, Allergy and Immunology, Tufts Medical Center, Boston, Massachusetts, USA
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15
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Kasperkiewicz M, Lai O, Recke A, Betlachin A, Ji L, Groshen S, Woodley D. Clinical outcomes of patients with pemphigus treated by the same physicians in a public safety net healthcare system vs. a private healthcare system. Br J Dermatol 2019; 181:850-852. [DOI: 10.1111/bjd.17983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- M. Kasperkiewicz
- Department of Dermatology The Keck School of Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
- Department of Dermatology University of Lübeck Lübeck Germany
| | - O. Lai
- Department of Dermatology The Keck School of Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
| | - A. Recke
- Department of Dermatology University of Lübeck Lübeck Germany
| | - A. Betlachin
- Department of Dermatology The Keck School of Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
| | - L. Ji
- Department of Preventive Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
| | - S. Groshen
- Department of Preventive Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
| | - D. Woodley
- Department of Dermatology The Keck School of Medicine University of Southern California, USC/Norris Cancer Center Los Angeles CA U.S.A
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16
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Limmroth V, Hechenbichler K, Müller C, Schürks M. Assessment of Medication Adherence Using a Medical App Among Patients With Multiple Sclerosis Treated With Interferon Beta-1b: Pilot Digital Observational Study (PROmyBETAapp). J Med Internet Res 2019; 21:e14373. [PMID: 31359863 PMCID: PMC6690164 DOI: 10.2196/14373] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/04/2019] [Accepted: 06/15/2019] [Indexed: 12/18/2022] Open
Abstract
Background Accurate measurement of medication adherence using classical observational studies typically depends on patient self-reporting and is often costly and slow. In contrast, digital observational studies that collect data directly from the patient may pose minimal burden to patients while facilitating accurate, timely, and cost-efficient collection of real-world data. In Germany, ~80% of patients with multiple sclerosis (MS) treated with interferon beta 1b (Betaferon) use an electronic autoinjector (BETACONNECT), which automatically records every injection. Patients may also choose to use a medical app (myBETAapp) to document injection data and their well-being (using a “wellness tracker” feature). Objective The goal of this pilot study was to establish a digital study process that allows the collection of medication usage data and to assess medication usage among patients with MS treated with interferon beta-1b who use myBETAapp. Methods The PROmyBETAapp digital observational study was a mixed prospective and retrospective, noninterventional, cohort study conducted among users of myBETAapp in Germany (as of December 2017: registered accounts N=1334; actively used accounts N=522). Between September and December 2017, users received two invitations on their app asking them to participate. Interested patients were provided detailed information and completed an electronic consent process. Data from consenting patients’ devices were collected retrospectively starting from the first day of usage if historical data were available in the database and collected prospectively following consent attainment. In total, 6 months of data on medication usage behavior were collected along with 3 months of wellness tracker data. Descriptive statistics were used to analyze persistence, compliance, and adherence to therapy. Results Of the 1334 registered accounts, 96 patients (7.2%) provided informed consent to participate in the study. Of these, one patient withdrew consent later. For another patient, injection data could not be recorded during the study period. Follow-up of the remaining 94 patients ended in May 2018. The mean age of participants was 46.6 years, and 50 (53%) were female. Over the 6-month study period, persistence with myBETAapp usage was 96% (90/94), mean compliance was 94% of injections completed, and adherence (persistence and ≥80% compliance) was 89% (84/94). There was no apparent difference between male and female participants and no trend across age groups. The wellness tracker was used by 21% of participants (20/94), with a mean of 3.1 entries per user. Conclusions This study provides important information on medication usage among patients with MS treated with interferon beta-1b and on consenting behavior of patients in digital studies. In future studies, this approach may allow patients’ feedback to be rapidly implemented in existing digital solutions. Trial Registration ClinicalTrials.gov NCT03134573; https://clinicaltrials.gov/ct2/show/NCT03134573
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Affiliation(s)
- Volker Limmroth
- Clinic for Neurology and Palliative Medicine, Municipal Hospital Köln-Merheim, Cologne, Germany
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17
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Willis E. Applying the Health Belief Model to Medication Adherence: The Role of Online Health Communities and Peer Reviews. JOURNAL OF HEALTH COMMUNICATION 2018; 23:743-750. [PMID: 30280998 DOI: 10.1080/10810730.2018.1523260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Millions of Americans are living with at least one chronic disease, and while the majority has been prescribed medication to control symptoms-medication adherence is a widespread problem. Medication nonadherence varies by chronic disease, patient characteristics, and insurance coverage, and previous research has identified non-financial barriers including disease-related knowledge, health literacy and polypharmacy. However, given the increasing popularity of online health communities, little research examines the influence of user-generated content on health behaviors. Many patients use the internet to seek and share information related to prescription medications. The current study examines patients' attitudes and behavioral intentions formed (in part) by the user-generated content exchanged within online health communities. Specifically, the Health Belief Model's perceived barriers and perceived benefits are explored here. Twenty members from online health communities related to arthritis are interviewed to understand how peer-to-peer communication is used in regards to medication adherence. Three themes emerged from the data, including striving for pain relief, negotiating potential side effects, and finding the new normal. Theoretical and practical implications are discussed.
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Affiliation(s)
- Erin Willis
- a Advertising, Public Relations & Media Design , University of Colorado Boulder , Boulder , CO , USA
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18
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Maniadakis N, Toth E, Schiff M, Wang X, Nassim M, Szegvari B, Mountian I, Curtis JR. A Targeted Literature Review Examining Biologic Therapy Compliance and Persistence in Chronic Inflammatory Diseases to Identify the Associated Unmet Needs, Driving Factors, and Consequences. Adv Ther 2018; 35:1333-1355. [PMID: 30078176 PMCID: PMC6133150 DOI: 10.1007/s12325-018-0759-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Indexed: 12/19/2022]
Abstract
Abstract Chronic inflammatory diseases (CIDs) represent a substantial clinical and economic burden to patients, providers, payers and society overall. Biologics, such as tumor necrosis factor inhibitors (TNFi), have emerged as effective treatment options for patients with CIDs. However, the therapeutic potential of biologics is not always achieved in clinical practice, with results from studies examining the use of biologics in real-world settings suggesting lower levels of treatment effectiveness compared with clinical trial results. Using a targeted approach, this literature review demonstrates that compliance and persistence with biologic therapy is suboptimal and that this has implications for both clinical outcomes and treatment costs. The review identified a variety of predictors of treatment compliance and persistence, including increased age, female gender, presence of comorbidities, increased disease activity, longer disease duration, smoking, increased body mass index, higher biologic treatment dose, higher treatment cost and lower health-related quality-of-life scores. Patients often cited factors associated with medication delivery as a reason for non-compliance and non-persistence, and device-related improvements to treatment delivery were associated with higher rates of compliance and persistence. The articles identified in this review provide insights that have the potential to help guide the development of new solutions to improve disease management and optimize treatment regimens. This has the potential to benefit patients’ health by improving clinical outcomes and to reduce the burden to society by limiting the economic impact of patients’ disease. Funding UCB Pharma. Electronic supplementary material The online version of this article (10.1007/s12325-018-0759-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nikos Maniadakis
- Department of Health Services Organization and Management, National School of Public Health, Athens, Greece.
| | | | - Michael Schiff
- University of Colorado School of Medicine, Denver, CO, USA
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19
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Martin LR, Feig C, Maksoudian CR, Wysong K, Faasse K. A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence. Patient Prefer Adherence 2018; 12:1527-1535. [PMID: 30197504 PMCID: PMC6112807 DOI: 10.2147/ppa.s155971] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.
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Affiliation(s)
- Leslie R Martin
- Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, USA,
| | - Cheyenne Feig
- Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, USA,
| | - Chloe R Maksoudian
- Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, USA,
| | - Kenrick Wysong
- Department of Psychology and Neuroscience, La Sierra University, Riverside, CA, USA,
| | - Kate Faasse
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
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20
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Chehab G, Sauer GM, Richter JG, Brinks R, Willers R, Fischer-Betz R, Winkler-Rohlfing B, Schneider M. Medical adherence in patients with systemic lupus erythematosus in Germany: predictors and reasons for non-adherence – a cross-sectional analysis of the LuLa-cohort. Lupus 2018; 27:1652-1660. [DOI: 10.1177/0961203318785245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective Adherence to medication has a major impact on treatment control and success especially in chronic diseases but often remains unrecognized. Besides clinical, socioeconomic, disease-related and treatment-related parameters, general and personal health beliefs, as well as perception of health, can affect adherence. Our aim was to investigate the adherence to lupus-specific medications in German lupus patients and to assess influencing factors including detrimental or beneficial effects of health perceptions and beliefs. Methods The Lupus Erythematosus (LE) Long-Term Study (LuLa-study) is a nationwide longitudinal study among German Caucasian patients with systemic lupus erythematosus who have been assessed annually using a self-reported questionnaire since 2001. In 2013, we included questions concerning medical adherence (Morisky Medication Adherence Scale; MMAS-4), beliefs about medication prescribed (BMQ), illness perception and about the patients’ health locus of control (HLC). We present a cross-sectional analysis to assess predictors of adherence using a multivariable stepwise logistic regression. Results Five hundred and seventy-nine patients participated, 81 of whom did not take any lupus-specific medication and 40 of whom did not complete the MMAS-4 and were therefore omitted. Only 62.7% reported high adherence. Unintentional behaviour for low medical adherence exceeded the intentional behaviour by far. The use of azathioprine (OR: 1.85; 95% CI: 1.02–3.34), prednisone <7.5 mg (OR: 1.56; 95% CI: 0.97–2.49), a higher age (OR: 1.06; 95% CI: 1.03–1.08) and higher external HLC (OR: 1.15; 95% CI: 1.01–1.30) proved conducive for high adherence in our multivariable model. On the contrary, the general perception of medication being harmful or addictive (OR: 0.89; 95% CI: 0.82–0.97) was detrimental. Conclusion A low belief that one's own health is determined by healthcare providers (external HLC) and the belief of the harmfulness of medication were independent predictors of low adherence besides age and the choice of the medical agent. The recognition of these potential obstacles in physician–patient relationships is essential to ameliorate adherence. Provision of sufficient information and education might help to reach the best possible outcome.
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Affiliation(s)
- G Chehab
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - G M Sauer
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - J G Richter
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - R Brinks
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - R Willers
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - R Fischer-Betz
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - M Schneider
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
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Abstract
PURPOSE OF REVIEW Gout management is currently suboptimal despite excellent available therapy. Gout patient education has been shown to enhance medication adherence and self-management, but needs improvement. We explored the literature on gout patient education including gaps in gout patient knowledge; use of written materials; in-person individual and group sessions; education via nurses, pharmacists, or multi-disciplinary groups; and use of phone, web-based, mobile health app, and text messaging educational efforts. RECENT FINDINGS Nurse-led interventions have shown significant improvement in reaching urate goals. Pharmacist-led programs have likewise succeeded, but to a lesser degree. A multi-disciplinary approach has shown feasibility. Needs-assessments, patient questionnaires, and psychosocial evaluations can enhance targeted education. An interactive and patient-centered approach can enhance gout educational interventions. Optimal programs will assess for and address educational needs related to knowledge gaps, health literacy, race, gender, socio-economic status, and level of social support.
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Affiliation(s)
- Theodore R Fields
- Division of Rheumatology, Hospital for Special Surgery, 535 East 70th St., Suite 848-West, New York, NY, 10021, USA.
- Weill Cornell College of Medicine, New York, NY, USA.
| | - Adena Batterman
- Department of Social Work Programs, Hospital for Special Surgery, New York, NY, USA
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22
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Marshall JK, Bessette L, Thorne C, Shear NH, Lebovic G, Gerega SK, Millson B, Oraichi D, Gaetano T, Gazel S, Latour MG, Laliberté MC. Impact of the Adalimumab Patient Support Program's Care Coach Calls on Persistence and Adherence in Canada: An Observational Retrospective Cohort Study. Clin Ther 2018. [PMID: 29519714 DOI: 10.1016/j.clinthera.2018.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Adalimumab (ADA) is a tumor necrosis factor-α inhibitor indicated for use in various immune-mediated inflammatory diseases. Patients receiving ADA in Canada are eligible to enroll in the AbbVie Care's Patient Support Program (PSP), which provides personalized services, including tailored interventions in the form of nurse-provided care coach calls (CCCs), with the goal of improving patients' experiences and outcomes. The primary objective of this study was to evaluate the impact of PSP services, including CCCs and patient characteristics, on persistence with and adherence to ADA for those patients enrolled in the PSP. A secondary objective was to estimate the effect of initial CCCs on treatment-initiation abandonment (ie, failure to initiate therapy after enrollment in the PSP). METHODS An observational retrospective cohort study was conducted. A patient linkage algorithm based on probabilistic matching was developed to link the AbbVie Care PSP database to the QuintilesIMS longitudinal pharmacy transaction database. Patients who started ADA therapy between July 2010 and August 2014 were selected, and their prescriptions were evaluated for 12 months after the date of ADA start to calculate days until drug discontinuation, that is, the end of persistence, defined as >90 days without therapy. Cox proportional hazards modeling was used for estimating hazard ratios for the association between persistence and patient characteristics and each PSP service. Adherence, measured by medication possession ratio, was calculated, and multivariate logistic regression provided adjusted odds ratios for the relationship between being adherent (medication possession ratio ≥80%) and patient characteristics and each PSP service. Treatment-initiation abandonment among patients who received an initial CCC compared with those who did not was analyzed using the χ2 test. FINDINGS Analysis of 10,857 linked patients yielded statistically significant differences in the hazard ratio of discontinuation and the likelihood of being adherent across multiple variables between patients who received CCCs in comparison to patients who did not. Patients receiving CCCs were found to have a 72% decreased risk for therapy discontinuation (hazard ratio = 0.282; P < 0.0001), and a greater likelihood of being adherent (odds ratio = 1.483; P < 0.0001), when compared with those patients who did not receive CCCs. The rate of treatment-initiation abandonment was significantly higher in patients who did not receive initial CCCs (P < 0.0001). IMPLICATIONS Ongoing CCCs, provided by AbbVie Care PSP, were associated with greater patient persistence and adherence over the first 12 months of treatment, while initial CCCs were associated with a lower rate of treatment-initiation abandonment. Results may inform the planning of interventions aimed at improving treatment adherence and patient outcomes.
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Affiliation(s)
- John K Marshall
- Department of Medicine, Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Louis Bessette
- Department of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Carter Thorne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Neil H Shear
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Prados-Moreno S, Sabio JM, Pérez-Mármol JM, Navarrete-Navarrete N, Peralta-Ramírez MI. Adherencia al tratamiento en pacientes con lupus eritematoso sistémico. Med Clin (Barc) 2018; 150:8-15. [DOI: 10.1016/j.medcli.2017.05.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 01/30/2023]
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Anghel LA, Farcaş AM, Oprean RN. Medication adherence and persistence in patients with autoimmune rheumatic diseases: a narrative review. Patient Prefer Adherence 2018; 12:1151-1166. [PMID: 30013327 PMCID: PMC6037147 DOI: 10.2147/ppa.s165101] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Several drugs are available for the treatment of autoimmune rheumatic diseases; however, their effectiveness may be negatively influenced by inappropriate adherence. Low adherence and persistence rates have a significant impact on patient quality of life and are associated with health-related expenses. PURPOSE To provide an up-to-date narrative review on treatment adherence and persistence rates, and discuss the factors that influence them, in patients with autoimmune rheumatic diseases. MATERIALS AND METHODS We searched the PubMed database for studies among patients with a diagnosis of rheumatoid arthritis (RA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), or psoriatic arthritis (PsA), published from January 2015 to February 2017. Only studies with a well-defined measurement of adherence/persistence and those that carried out an evaluation of the influencing factors were included. RESULTS Fifteen relevant studies that evaluated adherence and/or persistence were included. Adherence rates varied between 9.3% and 94%, and persistence rates between 23% and 80%. Most of the studies used one method to evaluate adherence or persistence (different questionnaire scores, proportion of days covered, and mean treatment duration). A high concordance was found between the adherence measurements of the Medication Event Monitoring System and Visual Analog Scale. Factors of economic, demographic, and clinical nature were only moderately linked to treatment adherence or persistence. However, patient-related factors - such as positive and increased beliefs in medication necessity, strong views of the chronic nature of the diseases, and increased knowledge of the disease - were related to better treatment adherence. CONCLUSION Owing to the heterogeneity of the study results, we consider that the use of more than one method to assess adherence/persistence should yield more comprehensive and accurate data about patient adherence behavior. Patient-related factors should be included and analyzed more often in adherence studies as the former may be modified to improve patient adherence.
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Affiliation(s)
- Laura-Alexandra Anghel
- Department of Analytical Chemistry and Instrumental Analysis, Faculty of Pharmacy, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania,
| | - Andreea Maria Farcaş
- Drug Information Research Centre, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania
| | - Radu Nicolae Oprean
- Department of Analytical Chemistry and Instrumental Analysis, Faculty of Pharmacy, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania,
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25
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The rate of adherence to urate-lowering therapy and associated factors in Chinese gout patients: a cross-sectional study. Rheumatol Int 2017; 37:1187-1194. [DOI: 10.1007/s00296-017-3746-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/17/2017] [Indexed: 12/27/2022]
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26
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Georgopoulou S, Efraimidou S, MacLennan SJ, Ibrahim F, Cox T. The relationship between social support and health-related quality of life in patients with antiphospholipid (hughes) syndrome. Mod Rheumatol 2017; 28:147-155. [DOI: 10.1080/14397595.2017.1317319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sofia Georgopoulou
- Academic Department of Rheumatology, King’s College London, School of Medicine, London, United Kingdom
| | - Sofia Efraimidou
- Centre for Sustainable Working Life, Birkbeck University of London, United Kingdom
| | | | - Fowzia Ibrahim
- Academic Department of Rheumatology, King’s College London, School of Medicine, London, United Kingdom
| | - Thomas Cox
- Centre for Sustainable Working Life, Birkbeck University of London, United Kingdom
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27
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Lenti MV, Selinger CP. Medication non-adherence in adult patients affected by inflammatory bowel disease: a critical review and update of the determining factors, consequences and possible interventions. Expert Rev Gastroenterol Hepatol 2017; 11:215-226. [PMID: 28099821 DOI: 10.1080/17474124.2017.1284587] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Achieving adherence to medications can be a serious challenge for patients affected by inflammatory bowel disease (IBD). Medical treatment is fundamental for inducing and maintaining remission, preventing flares and reducing the risk of colorectal cancer. Non-adherence may affect patients' quality of life resulting in unfavourable treatment outcomes, more hospitalizations and higher healthcare-related costs. Recognising and improving adherence is therefore a primary aim for the treatment of IBD. Areas covered: We critically discuss the current knowledge on medication non-adherence in adult patients affected by IBD, also mentioning a few issues concerning the paediatric and adolescent populations. In particular, we reviewed the literature focusing on the definition and detection of non-adherence, on its extent and on the possible non-modifiable and modifiable factors involved (patient-centred, therapy-related, disease-related and physician-related). Furthermore, we analysed the interventional studies performed so far. The literature review was conducted through PubMed addressing medication non-adherence in IBD, using the keywords 'adherence' and related terms and 'IBD, ulcerative colitis or Crohn's disease'. Expert commentary: Adherence to therapy for IBD is a complex yet fundamental issue that cannot be solved by addressing a single aspect only. Future studies should focus on patient-tailored and multidimensional interventions.
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Affiliation(s)
- Marco Vincenzo Lenti
- a First Department of Internal Medicine , San Matteo Hospital Foundation; University of Pavia , Pavia , Italy.,b Department of Gastroenterology , Leeds Teaching Hospitals NHS Trust, University of Leeds , Leeds , UK
| | - Christian P Selinger
- b Department of Gastroenterology , Leeds Teaching Hospitals NHS Trust, University of Leeds , Leeds , UK
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28
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van Mierlo T, Li X, Hyatt D, Ching AT. Demographic and Indication-Specific Characteristics Have Limited Association With Social Network Engagement: Evidence From 24,954 Members of Four Health Care Support Groups. J Med Internet Res 2017; 19:e40. [PMID: 28213340 PMCID: PMC5336601 DOI: 10.2196/jmir.6330] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 12/31/2016] [Accepted: 01/13/2017] [Indexed: 01/10/2023] Open
Abstract
Background Digital health social networks (DHSNs) are widespread, and the consensus is that they contribute to wellness by offering social support and knowledge sharing. The success of a DHSN is based on the number of participants and their consistent creation of externalities through the generation of new content. To promote network growth, it would be helpful to identify characteristics of superusers or actors who create value by generating positive network externalities. Objective The aim of the study was to investigate the feasibility of developing predictive models that identify potential superusers in real time. This study examined associations between posting behavior, 4 demographic variables, and 20 indication-specific variables. Methods Data were extracted from the custom structured query language (SQL) databases of 4 digital health behavior change interventions with DHSNs. Of these, 2 were designed to assist in the treatment of addictions (problem drinking and smoking cessation), and 2 for mental health (depressive disorder, panic disorder). To analyze posting behavior, 10 models were developed, and negative binomial regressions were conducted to examine associations between number of posts, and demographic and indication-specific variables. Results The DHSNs varied in number of days active (3658-5210), number of registrants (5049-52,396), number of actors (1085-8452), and number of posts (16,231-521,997). In the sample, all 10 models had low R2 values (.013-.086) with limited statistically significant demographic and indication-specific variables. Conclusions Very few variables were associated with social network engagement. Although some variables were statistically significant, they did not appear to be practically significant. Based on the large number of study participants, variation in DHSN theme, and extensive time-period, we did not find strong evidence that demographic characteristics or indication severity sufficiently explain the variability in number of posts per actor. Researchers should investigate alternative models that identify superusers or other individuals who create social network externalities.
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Affiliation(s)
- Trevor van Mierlo
- Research Associate, Henley Business School, University of Reading, Henley-on-Thames, United Kingdom.,Evolution Health Systems Inc, Toronto, ON, Canada
| | - Xinlong Li
- Rotman School of Managment, University of Toronto, Toronto, ON, Canada
| | - Douglas Hyatt
- Rotman School of Managment, University of Toronto, Toronto, ON, Canada
| | - Andrew T Ching
- Rotman School of Managment, University of Toronto, Toronto, ON, Canada
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Bragazzi NL, Watad A, Brigo F, Adawi M, Amital H, Shoenfeld Y. Public health awareness of autoimmune diseases after the death of a celebrity. Clin Rheumatol 2016; 36:1911-1917. [PMID: 28000011 DOI: 10.1007/s10067-016-3513-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 12/10/2016] [Indexed: 01/23/2023]
Abstract
Autoimmune disorders impose a high burden, in terms of morbidity and mortality worldwide. Vasculitis is an autoimmune disorder that causes inflammation and destruction of blood vessels. Harold Allen Ramis, a famous American actor, director, writer, and comedian, died on the February 24, 2014, of complications of an autoimmune inflammatory vasculitis. To investigate the relation between interests and awareness of an autoimmune disease after a relevant event such as the death of a celebrity, we systematically mined Google Trends, Wikitrends, Google News, YouTube, and Twitter, in any language, from their inception until October 31, 2016. Twenty-eight thousand eight hundred fifty-two tweets; 4,133,615 accesses to Wikipedia; 6780 news; and 11,400 YouTube videos were retrieved, processed, and analyzed. The Harold Ramis death of vasculitis resulted into an increase in vasculitis-related Google searches, Wikipedia page accesses, and tweet production, documenting a peak in February 2014. No trend could be detected concerning uploading YouTube videos. The usage of Big Data is promising in the fields of immunology and rheumatology. Clinical practitioners should be aware of this emerging phenomenon.
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Affiliation(s)
- Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Abdulla Watad
- Department of Medicine B, Tel-Hashomer, Tel-Aviv, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.,Department of Neurological, Biomedical, and Movement Sciences, University of Verona, Verona, Italy
| | - Mohammad Adawi
- Padeh and Ziv Hospitals, Faculty of Medicine, Bar-Ilan University, Zefat, Israel
| | - Howard Amital
- Department of Medicine B, Tel-Hashomer, Tel-Aviv, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Michetti P, Weinman J, Mrowietz U, Smolen J, Peyrin-Biroulet L, Louis E, Schremmer D, Tundia N, Nurwakagari P, Selenko-Gebauer N. Impact of Treatment-Related Beliefs on Medication Adherence in Immune-Mediated Inflammatory Diseases: Results of the Global ALIGN Study. Adv Ther 2016. [PMID: 27854054 DOI: 10.1007/s12325-016-0441-3 10.1007/s12325-017-0602-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Medication adherence is critical in chronic immune-mediated inflammatory diseases (IMIDs) and could be affected by patients' treatment-related beliefs. The objective of this study was to determine beliefs about systemic medications in patients with IMIDs and to explore the association of those beliefs and other factors with adherence. METHODS This was a multi-country, cross-sectional, self-administered survey study. Included were adults diagnosed with one of six IMIDs receiving conventional systemic medications and/or tumor necrosis factor inhibitors (TNFi). Patients' necessity beliefs/concerns towards and adherence to treatments were assessed by the Beliefs about Medicines Questionnaire and four-item Morisky Medication Adherence Scale. Correlation of patients' beliefs about treatment and other factors with adherence were evaluated by multivariable regression analyses. RESULTS Among studied patients (N = 7197), 32.0% received TNFi monotherapy, 27.7% received TNFi-conventional combination therapy, and 40.3% received conventional medications. Across IMIDs, high adherence to systemic treatment was more prevalent in TNFi groups (61.3-80.7%) versus corresponding conventional treatment groups (28.4-64.7%). In at least four IMIDs, greater perception of the illness continuing forever (P < 0.001), of the treatment helping (P < 0.001), and more concerns about the illness (P < 0.01), but not clinical parameters, were associated with higher treatment necessity beliefs. Higher treatment necessity beliefs, older age, Caucasian race, and TNFi therapy were associated with high medication adherence in at least four IMIDs. CONCLUSIONS Treatment necessity beliefs were higher than concerns about current medication in patients with IMID. Illness perceptions had a greater impact on treatment necessity beliefs than clinical parameters. Older age, greater treatment necessity beliefs, and TNFi therapy were associated with high self-reported medication adherence in at least four IMIDs. TRIAL REGISTRATION ACTRN12612000977875. FUNDING AbbVie.
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Affiliation(s)
- Pierre Michetti
- Crohn and Colitis Centre, Gastro-entérologie La Source-Beaulieu and Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois, 1004, Lausanne, Switzerland.
| | - John Weinman
- Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Ulrich Mrowietz
- Psoriasis-Center at the Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Josef Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.,2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | | | | | - Pascal Nurwakagari
- Medical Department, AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
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31
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Michetti P, Weinman J, Mrowietz U, Smolen J, Peyrin-Biroulet L, Louis E, Schremmer D, Tundia N, Nurwakagari P, Selenko-Gebauer N. Impact of Treatment-Related Beliefs on Medication Adherence in Immune-Mediated Inflammatory Diseases: Results of the Global ALIGN Study. Adv Ther 2016; 34:91-108. [PMID: 27854054 PMCID: PMC5216107 DOI: 10.1007/s12325-016-0441-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Indexed: 11/30/2022]
Abstract
Introduction Medication adherence is critical in chronic immune-mediated inflammatory diseases (IMIDs) and could be affected by patients’ treatment-related beliefs. The objective of this study was to determine beliefs about systemic medications in patients with IMIDs and to explore the association of those beliefs and other factors with adherence. Methods This was a multi-country, cross-sectional, self-administered survey study. Included were adults diagnosed with one of six IMIDs receiving conventional systemic medications and/or tumor necrosis factor inhibitors (TNFi). Patients’ necessity beliefs/concerns towards and adherence to treatments were assessed by the Beliefs about Medicines Questionnaire and four-item Morisky Medication Adherence Scale. Correlation of patients’ beliefs about treatment and other factors with adherence were evaluated by multivariable regression analyses. Results Among studied patients (N = 7197), 32.0% received TNFi monotherapy, 27.7% received TNFi–conventional combination therapy, and 40.3% received conventional medications. Across IMIDs, high adherence to systemic treatment was more prevalent in TNFi groups (61.3–80.7%) versus corresponding conventional treatment groups (28.4–64.7%). In at least four IMIDs, greater perception of the illness continuing forever (P < 0.001), of the treatment helping (P < 0.001), and more concerns about the illness (P < 0.01), but not clinical parameters, were associated with higher treatment necessity beliefs. Higher treatment necessity beliefs, older age, Caucasian race, and TNFi therapy were associated with high medication adherence in at least four IMIDs. Conclusions Treatment necessity beliefs were higher than concerns about current medication in patients with IMID. Illness perceptions had a greater impact on treatment necessity beliefs than clinical parameters. Older age, greater treatment necessity beliefs, and TNFi therapy were associated with high self-reported medication adherence in at least four IMIDs. Trial registration ACTRN12612000977875. Funding AbbVie. Electronic supplementary material The online version of this article (doi:10.1007/s12325-016-0441-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre Michetti
- Crohn and Colitis Centre, Gastro-entérologie La Source-Beaulieu and Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois, 1004, Lausanne, Switzerland.
| | - John Weinman
- Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Ulrich Mrowietz
- Psoriasis-Center at the Department of Dermatology, Venereology and Allergology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Josef Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | | | | | - Pascal Nurwakagari
- Medical Department, AbbVie Deutschland GmbH & Co. KG, Wiesbaden, Germany
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Mueller SM, Itin P, Vogt DR, Walter M, Lang U, Griffin LL, Euler S. Assessment of “corticophobia” as an indicator of non-adherence to topical corticosteroids: A pilot study. J DERMATOL TREAT 2016; 28:104-111. [DOI: 10.1080/09546634.2016.1201189] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Lakatos P, Takács I, Marton I, Tóth E, Zoltan C, Lang Z, Psachoulia E, Intorcia M. A Retrospective Longitudinal Database Study of Persistence and Compliance with Treatment of Osteoporosis in Hungary. Calcif Tissue Int 2016; 98:215-25. [PMID: 26686694 DOI: 10.1007/s00223-015-0082-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022]
Abstract
This study assessed persistence and compliance with anti-osteoporosis therapies, and associations between compliance and clinical outcomes (fracture, fracture-related hospitalization and death), in Hungarian women with postmenopausal osteoporosis. The study used the Hungarian National Health Insurance Fund Administration database and included women with PMO aged at least 50 years, for whom a prescription for anti-osteoporosis medication had been filled between 1 January 2004 and 31 December 2013 (index event). Persistence (prescription refilled within 8 weeks of the end of the previous supply) was evaluated over 2 years; good compliance (medication possession ratio ≥ 80 %) was evaluated at 1 year. Associations between compliance and clinical outcomes (data collected for up to 6 years) were assessed with adjustment for baseline covariates. A total of 296,300 women met the inclusion criteria (524,798 index events). Persistence and compliance were higher for less frequent and parenteral therapies (1- and 2-year persistence: half-yearly [parenteral] vs. daily/weekly/monthly [oral and parenteral], 81 and 38 % vs. 21-34 and 10-18 %, respectively; parenteral vs. oral, 75 and 36 % vs. 32 and 16 %; good compliance: half-yearly vs. daily/weekly/monthly, 70 vs. 24-39 %; parenteral vs. oral 78 vs. 36 %). Good compliance significantly reduced the risks of fracture, fracture-related hospitalization and death (relative risk vs. non-compliance [95 % confidence interval]: 0.77 [0.70-0.84], 0.72 [0.62-0.85] and 0.57 [0.51-0.64], respectively; P < 0.01). Improving compliance through long-interval parenteral therapies may result in clinical benefits for patients.
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Affiliation(s)
- Péter Lakatos
- 1st Department of Medicine, Semmelweis University, Koranyi 2/A, Budapest, 1083, Hungary.
| | - István Takács
- 1st Department of Medicine, Semmelweis University, Koranyi 2/A, Budapest, 1083, Hungary
| | - István Marton
- Healthware Tanácsadó Kft., Warehouse u. 30-32, 6th floor. (RiverPark Office Building), 1093, Budapest, Hungary
| | - Emese Tóth
- Healthware Tanácsadó Kft., Warehouse u. 30-32, 6th floor. (RiverPark Office Building), 1093, Budapest, Hungary
| | - Cina Zoltan
- Healthware Tanácsadó Kft., Warehouse u. 30-32, 6th floor. (RiverPark Office Building), 1093, Budapest, Hungary
| | - Zsolt Lang
- Healthware Tanácsadó Kft., Warehouse u. 30-32, 6th floor. (RiverPark Office Building), 1093, Budapest, Hungary
| | - Emi Psachoulia
- Amgen (Europe) GmbH, 23 Dammstrasse, Zug, 6300, Switzerland
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Abstract
OBJECTIVES The aim of this study was to systematically review the rates of nonadherence to oral maintenance treatment in adolescents with inflammatory bowel disease (IBD), and to describe perceived barriers to adherence and psychosocial factors involved. METHODS The article considered studies published in MEDLINE, Embase, and PsycINFO up to March 2015. Studies that had collected data on adherence to thiopurines or aminosalicylates in a cohort of adolescents with IBD. Case reports and case series were excluded. RESULTS A total of 25 studies were included. Lack of uniformity of outcome measures made pooling of data impossible. Rates of medication nonadherence ranged from 2% to 93%. The most frequently reported barriers were "just forgot," "wasn't home," and "interferes with activity." Family dysfunction, peer victimization, poor health-related quality of life, poor child-coping strategies, anxiety, and depressive symptoms were associated with medication nonadherence. CONCLUSIONS Nonadherence to oral maintenance therapy in adolescents with IBD is a significant health care problem and can lead to unnecessary escalation in therapy. Difficulties in family and social interactions, and psychosocial dysfunction can jeopardize IBD treatment outcome and should receive attention early in the course of the disease.
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van Mierlo T, Fournier R, Fedorak R. Don't Forget the Doctor: Gastroenterologists' Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease. JMIR Mhealth Uhealth 2015; 3:e5. [PMID: 25608628 PMCID: PMC4319145 DOI: 10.2196/mhealth.3987] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 11/24/2014] [Accepted: 12/11/2014] [Indexed: 12/30/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools. Objective Our goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists. Methods Using a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted. Results Survey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them. Conclusions Gastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.
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