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Hazkani I, Stein E, Edwards E, Maddalozzo J, Johnston D, Samis J, Josefson J, Rastatter J. Abnormal TSH Prior to Surgery in Children with Graves' Disease Predicts Abnormal TSH Following Thyroidectomy. Laryngoscope 2023; 133:2402-2406. [PMID: 36370147 DOI: 10.1002/lary.30485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To identify variables that are associated with poor compliance to thyroid hormone replacement therapy in children after total thyroidectomy. METHOD A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 1/2014 and 9/2021. Postoperative poor compliance was characterized by at least three separate measurements of high TSH levels not associated with radioactive iodine treatment. RESULTS There were 100 patients, ages 3-20 years old who met inclusion criteria; 44 patients underwent thyroidectomy for cancer diagnosis, and 56 for Graves' disease. The mean follow-up time was 36.5 months (range 3.0-95.6 months). Overall, 42 patients (42%) were found to have at least three measurements of high TSH during follow-up, and 29 patients (29%) were diagnosed with clinical hypothyroidism. Sex, race, income, insurance type, and benign versus malignant etiology for thyroidectomy were not associated with adherence to therapy. Multivariate regression analysis identified patients with Graves' disease and hyperthyroidism at the time of surgery and Hispanic ethnicity to be associated with postoperative clinical hypothyroidism (OR 9.38, 95% CI 2.16-49.2, p = 0.004 and OR 6.15, 95% CI 1.21-36.0, p = 0.033, respectively). CONCLUSIONS Preoperative hyperthyroidism in patients with Graves' disease and Hispanic ethnicity were predictors of postoperative TSH abnormalities. Preoperative counseling for patients and their families on the implications of total thyroidectomy and the need for life-long medications postoperatively is necessary. Efforts should be made to evaluate and improve adherence to therapy pre-and postoperatively in patients with Graves' disease. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2402-2406, 2023.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eli Stein
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Evan Edwards
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John Maddalozzo
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Douglas Johnston
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jill Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jami Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jeffrey Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Varnell CD, Hooper DK, Mara CA, Modi AC, Rich KL. The Barriers Assessment Tool-A Patient-Centered Measure of Adherence Barriers in Pediatric Kidney Transplantation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1435. [PMID: 37761394 PMCID: PMC10527691 DOI: 10.3390/children10091435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Assessing barriers to adherence provides helpful information to clinicians. The objective of this study was to describe the clinical utility of the Barriers Assessment Tool (BAT) using clinical data for a large, midwestern U.S. pediatric kidney transplant program. METHODS Focus group and clinical data were obtained during post-transplant medical visits. Qualitative and quantitative assessment methods were utilized to describe patient and caregiver feedback on the BAT, clinical utility, concordance between reporters, and the effect of interventions on subsequent assessment and electronically measured adherence. RESULTS Patients were willing to discuss adherence issues with their care team. There was substantial agreement between patients and caregivers at two timepoints. If a barrier was not addressed, 89.6% (43/48) of patients and 85.9% (67/78) of caregivers reported the same BAT scores from the first to second assessment. When barriers were addressed with a clinic-based intervention, 82% of caregivers reported no adherence barriers. No significant change was found for patient-reported barriers. CONCLUSIONS Standardized assessment of barriers to medication adherence provides actionable information to clinicians. Standardized assessment of adherence barriers may give clinicians opportunities to help patients and caregivers overcome these barriers which can decrease risk of rejection.
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Affiliation(s)
- Charles D. Varnell
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH 45229, USA;
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.A.M.); (A.C.M.); (K.L.R.)
| | - David K. Hooper
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH 45229, USA;
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.A.M.); (A.C.M.); (K.L.R.)
| | - Constance A. Mara
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.A.M.); (A.C.M.); (K.L.R.)
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Avani C. Modi
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.A.M.); (A.C.M.); (K.L.R.)
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kristin L. Rich
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.A.M.); (A.C.M.); (K.L.R.)
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
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Bouchard EG, Epstein LH, Patel H, Vincent PC, LaValley SA, Devonish JA, Wadium J, Wen X, Kelly KM. Behavioral parenting skills as a novel target for improving medication adherence in young children: Feasibility and acceptability of the CareMeds intervention. Pediatr Hematol Oncol 2022; 39:529-539. [PMID: 35139726 PMCID: PMC9363525 DOI: 10.1080/08880018.2022.2025964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
In pediatric cancer care, medication non-adherence is a significant driver of avoidable suffering and death. There is a lack of interventions designed for families of young children, where patient medication refusal/avoidance is a common barrier to adherence. We developed the CareMeds intervention which focuses on caregiver skills training to help young children take medicine calmly and without use of restraint techniques. The goal of this preliminary study was to assess the acceptability and feasibility of the CareMeds intervention. Caregivers of pediatric cancer patients (ages 2-10) whose children were on a home-based oral medication regimen were recruited to participate. Feasibility was examined through study enrollment and retention rates as well as reasons for refusal and drop out. Acceptability was evaluated through usability of and engagement with intervention components and an acceptability questionnaire. Feasibility: We recruited N = 9 caregivers to participate in this intervention pilot study and had a 75% enrollment rate. Reasons for declining included scheduling concerns (n = 2) and lack of interest (n = 1). The participant retention rate was 100% with 100% adherence to intervention sessions. Acceptability: Parents rated the sessions and resource materials as acceptable and reported frequent use of skills taught in the intervention. The CareMeds intervention is an acceptable and feasible strategy for caregivers of pediatric cancer patients and warrants future research to examine the efficacy of behavioral parenting skills interventions to improve medication adherence in young children.
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Affiliation(s)
- Elizabeth G. Bouchard
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center
| | | | - Hital Patel
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center
| | - Paula C. Vincent
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center
| | - Susan A. LaValley
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center
| | - Julia A. Devonish
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center
- Department of Medicine, Division of General Internal Medicine, University at Buffalo
| | | | - Xiaozhong Wen
- Division of Behavioral Medicine, University at Buffalo
| | - Kara M. Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center
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Schick-Makaroff K, Lagendyk L, Foster B, Lam NN, Braam B, Bello A, Shojai S, Wen K. Designing an App for Immunosuppression Adherence and Communication: A Qualitative Approach. Can J Kidney Health Dis 2022; 9:20543581211072330. [PMID: 35127106 PMCID: PMC8808030 DOI: 10.1177/20543581211072330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Immunosuppression nonadherence may be the most important factor limiting long-term allograft survival. Objective: Following user-centered design, we explored the essential priorities and preferences of kidney transplant recipients and healthcare providers (HCP) to inform development of a smartphone app to improve immunosuppression adherence and communication. Design: A qualitative descriptive research design was used. Setting: The University of Alberta Hospital adult kidney transplant program in Edmonton, Canada. Participants: Participants were recruited by convenience sampling and included 32 kidney transplant recipients and 11 HCPs. Methods: Seven focus groups (5 with recipients and 2 with HCPs) were conducted to inform app development. Sessions were recorded, and transcripts were coded to elucidate themes. Results: App development to improve adherence was not a priority for HCP. Recipients prioritized choice: that all features be optional. Recipients preferred support while traveling; access to laboratory results; and use by younger or newly transplanted recipients. Both recipients and HCP preferred linkage to pharmacy; and self-management and accountability. For the app to improve communication, HCPs believed the priorities to be addressed included: clarity on scope of app; legal, ethical, and professional obligations; and charting. Both recipients and HCP prioritized HCP workload, and broader medication and health concerns. Healthcare providers preferred tech support; both recipients and HCPs preferred app access for nontransplant HCP. Limitations: Limitations include underrepresentation of physicians, recipients with racial/ethnic diversity, and potential selection bias of transplant recipients who perceived themselves to be adhering to immunosuppression medications. Conclusion: Future research is needed for the app to become a comprehensive, secure platform for broader communication between recipients and HCP, pharmacies, and nontransplant clinicians while streamlining HCP workload.
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Affiliation(s)
| | | | - Bethany Foster
- Department of Pediatrics, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- The Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ngan N. Lam
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Branko Braam
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Aminu Bello
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Soroush Shojai
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kevin Wen
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
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5
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Venkatraman K, Vijayalakshmi V, Sudarsanam N, Manoharan A. Designing Dynamic Interventions to Improve Adherence in Pediatric Long-Term Treatment - The Role of Perceived Value of the Physician by Primary Caregivers. HEALTH COMMUNICATION 2021; 36:1825-1840. [PMID: 32731759 DOI: 10.1080/10410236.2020.1796284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Primary Caregivers are the fulcrum in the physician-caregiver-child triad. Existing literature discusses static multi-component interventions in detail. In long-term treatments, dynamic intervention design is needed as the environment and situations of the families are dynamic. The objectives of this study are (a) to identify the components of the primary caregiver's perception of the physician's value with reference to the effectiveness of consultation and relationships with the former and with the child; (b) to establish the role of this perception in designing dynamic interventions, and (c) to describe the perception's potential influence on adherence. A PRISMA, chronological, and morphological analysis of the literature is carried out about caregivers' adherence in the pediatric long-term treatment context. We define communication and consultation as the functional, whereas relationship as the emotional component of the caregiver's perception of the physician. We propose a theoretical model that incorporates intervention as an integral component of care. Adherence happens as a response to changing situations and hence fluctuates. Hence, a dynamic intervention design to benefit the child should be incorporated into care through the caregiver-physician bridge. Future research should explore how intervention needs change and the driving reasons for understanding the static and dynamic components of interventions.
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Affiliation(s)
| | - V Vijayalakshmi
- Department of Management Studies, Indian Institute of Technology, Madras
| | - Nandan Sudarsanam
- Department of Management Studies, Indian Institute of Technology, Madras
| | - Anand Manoharan
- Department of Clinical Research, Kanchi Kamakoti CHILDS Trust Hospital
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Fidler A, Sweenie R, Ortega A, Cushing CC, Ramsey R, Fedele D. Meta-Analysis of Adherence Promotion Interventions in Pediatric Asthma. J Pediatr Psychol 2021; 46:1195-1212. [PMID: 34343294 DOI: 10.1093/jpepsy/jsab057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Youth with asthma commonly have suboptimal adherence to inhaled corticosteroids (ICS). It is critical to systematically evaluate the effectiveness of ICS adherence promotion interventions and discern which techniques are most effective. OBJECTIVE This study aims to (1) quantify the extent to which interventions improve ICS adherence in pediatric asthma, (2) explore differences in effect size estimates based on intervention and study characteristics, and (3) characterize the risk of bias across interventions. METHODS We conducted literature searches across five databases. Included studies quantitatively measured ICS adherence as an intervention outcome among youth (<18 years old) diagnosed with asthma and were published after 1997. We analyzed aggregate effect sizes and moderator variables using random-effects models and characterized risk of bias using the Cochrane Collaboration tool. RESULTS Thirty-three unique studies met inclusion criteria. At post-intervention, the aggregate effect size for pediatric ICS adherence promotion interventions was small but significant (n = 33, g = 0.39, 95% confidence interval [CI] = 0.24-0.54); however, the aggregate effect size at follow-up was not statistically significant (n = 6, g = 0.38, 95% CI = -0.08 to 0.83). Method of adherence measurement and intervention format were significant moderators. Most interventions had a high risk of performance bias and an unclear risk of bias in one or more domains. CONCLUSIONS ICS adherence promotion interventions are effective among youth with asthma. Additional longitudinal research is needed to quantify a more precise measure of intervention effectiveness over time, and moderators of intervention effectiveness should be reassessed as the literature base expands.
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Affiliation(s)
- Andrea Fidler
- Department of Clinical & Health Psychology, University of Florida
| | - Rachel Sweenie
- Department of Clinical & Health Psychology, University of Florida
| | - Adrian Ortega
- Clinical Child Psychology Program and Schiefelbusch Institute for Life Span Studies, University of Kansas
| | - Christopher C Cushing
- Clinical Child Psychology Program and Schiefelbusch Institute for Life Span Studies, University of Kansas
| | - Rachelle Ramsey
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - David Fedele
- Department of Clinical & Health Psychology, University of Florida
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7
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Hooper DK, Varnell CD, Rich K, Carle A, Huber J, Mostajabi F, Dahale D, Pai ALH, Goebel J, Modi AC. A Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection: A Quality Improvement Study. Am J Kidney Dis 2021; 79:335-346. [PMID: 34352285 DOI: 10.1053/j.ajkd.2021.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Adolescent and young adult kidney transplant recipients have high risk of rejection related to suboptimal adherence. Multi-component interventions improve adherence in controlled trials, but clinical implementation is lacking. We describe an initiative to reduce allograft rejection using evidence-based adherence promotion clinical strategies. STUDY DESIGN Interrupted time series. SETTING AND PARTICIPANTS Kidney transplant recipients cared for at Cincinnati Children's Hospital ≥1 year post-transplant and taking ≥1 immunosuppressive medication from 2014 through 2017. QUALITY IMPROVEMENT ACTIVITIES The following interventions were implemented over 14 months: 1) adherence promotion training for clinical staff, 2) EHR-supported adherence risk screening, 3) systematic assessment of medication adherence barriers, 4) designation of specific staff to address adherence barriers, 5) shared decision-making with the patients to overcome adherence barriers, 6) follow-up to assess progress, 7) optional electronic medication monitoring. OUTCOMES Primary Outcome: Late acute rejection. Process measures: barriers assessments performed, barriers identified, number of interventions performed. Secondary outcomes/balancing measures: de novo DSA, biopsy rate, rejections per biopsy. ANALYTICAL APPROACH Time series analysis using statistical process control, evaluated patient-days between acute rejections as well as monthly rejections per 100 patient-months before and after implementation. To control for known rejection risk factors including changes in treatment and case mix, multivariable analyses were performed. RESULTS The monthly rejection rate fell from 1.61 rejections/100 patient-months in the 26-months pre-implementation to 0.88 rejections/100 patient-months in the 22-months post-implementation. In multivariable analysis, MAPS was associated with a 50% reduction in rejection incidence (IRR 0.50, 95% CI: 0.27-0.91, p=0.02). DSA and time since transplant were also associated with rejection incidence (IRR 2.27, p=0.02 and IRR 0.87, p=0.02, respectively) LIMITATIONS: A single center study. Potential confounding by unmeasured variables. CONCLUSIONS Clinical implementation of evidence-based adherence-promotion strategies was associated with a 50% reduction in acute rejection incidence over two years.
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Affiliation(s)
- David K Hooper
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229.
| | - Charles D Varnell
- Division of Nephrology (MLC-7022), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Kristin Rich
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Adam Carle
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229; Univerisity of Cincinnati, Collage of Arts and Sciences, Department of Psychology, 155 B McMicken Hall Cincinnati, OH 45221
| | - John Huber
- Department of Information Services (MLC 9009), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Farida Mostajabi
- James M Anderson Center for Health Systems Excellence, (MLC-7014), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Devesh Dahale
- Southeast Alabama Medical Center, 1108 Ross Clark Circle, Dothan, AL 36301
| | - Ahna L H Pai
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
| | - Jens Goebel
- Section of Pediatric Nephrology, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503; Department of Pediatrics and Human Development, Michigan State University, Life Sciences Bldg. 1355 Bogue St., B240, East Lansing MI 48824
| | - Avani C Modi
- University of Cincinnati, College of Medicine, CARE/Crawley Building Suite E-870, 3230 Eden Avenue, PO BOX 670555, Cincinnati, OH 45267-0555; Division of Behavioral Medicine and Clinical Psychology (MLC-3015), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. Cincinnati, OH 45229
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8
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Varnell CD, Rich KL, Zhang B, Carle AC, Pai ALH, Modi AC, Hooper DK. Predicting acute rejection in children, adolescents, and young adults with a kidney transplant by assessing barriers to taking medication. Pediatr Nephrol 2021; 36:2453-2461. [PMID: 33501558 PMCID: PMC8263481 DOI: 10.1007/s00467-021-04946-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/15/2020] [Accepted: 01/12/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nonadherence to immunosuppression is common among pediatric, adolescent, and young adult kidney transplant recipients and a leading cause of graft loss. Assessing barriers to medication adherence in clinical practice may identify patients at risk for rejection and provide therapeutic targets. METHODS Kidney transplant patients and/or their caregivers were assessed for 14 barriers to medication adherence using the barriers assessment tool. We compared rejection rates between patients with at least one reported adherence barrier to those without reported adherence barriers using a Kaplan-Meier estimator and Cox proportional hazard models to adjust for other mediators of acute rejection at 2 years following barriers assessment. RESULTS Ninety-eight patients were assessed for barriers to adherence. Over the 2-year observation period, 22 patients developed biopsy-proven acute rejection (BPAR). Kaplan-Meier estimates show that patients with an identified barrier to adherence were more likely to have BPAR (p = 0.02) than patients without an identified barrier in the 24 months following barriers assessment. The median time to rejection for patients who experienced acute rejection was 175.5 days (IQR 63-276 days) from the time of barriers assessment. An identified barrier to adherence remained the only statistically significant predictor of BPAR with Cox modeling (HR 2.6, p = 0.04), after accounting for age, sex, and race. CONCLUSIONS Pediatric and adolescent kidney transplant recipients with identified adherence barriers are at increased risk for acute rejection. Barriers to adherence provide a potentially modifiable therapeutic target that can be assessed in clinic to guide targeted interventions.
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Affiliation(s)
- Charles D Varnell
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA. .,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Kristin L Rich
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bin Zhang
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Adam C Carle
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Ahna L H Pai
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Avani C Modi
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Hooper
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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9
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Abstract
PURPOSE OF REVIEW The European Stroke Organisation published a European Stroke Action Plan (SAP-E) for the years 2018-2030. The SAP-E addresses the entire chain of care from primary prevention through to life after stroke. Within this document digital health tools are suggested for their potential to facilitate greater access to stroke care. In this review, we searched for digital health solutions for every domain of the SAP-E. RECENT FINDINGS Currently available digital health solutions for the cerebrovascular disease have been designed to support professionals and patients in healthcare settings at all stages. Telemedicine in acute settings has notably increased the access to tissue plasminogen activator and thrombectomy whereas in poststroke settings it has improved access to rehabilitation. Moreover, numerous applications aim to monitor vital signs and prescribed treatment adherence. SUMMARY SAP-E with its seven domains covers the whole continuum of stroke care, where digital health solutions have been considered to provide utility at a low cost. These technologies are progressively being used in all phases of stroke care, allowing them to overcome geographical and organizational barriers. The commercially available applications may also be used by patients and their careers in various context to facilitate accessibility to health improvement strategies.
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10
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Plevinsky JM, Gutierrez-Colina AM, Carmody JK, Hommel KA, Crosby LE, McGrady ME, Pai ALH, Ramsey RR, Modi AC. Patient-Reported Outcomes for Pediatric Adherence and Self-Management: A Systematic Review. J Pediatr Psychol 2020; 45:340-357. [PMID: 31845997 DOI: 10.1093/jpepsy/jsz096] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/23/2019] [Accepted: 11/15/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Treatment adherence is approximately 50% across pediatric conditions. Patient-reported outcomes (PROs) are the most common method of measuring adherence and self-management across research and clinical contexts. The aim of this systematic review is to evaluate adherence and self-management PROs, including measures of adherence behaviors, adherence barriers, disease management skills, and treatment responsibility. METHODS Following PRISMA guidelines for systematic reviews, literature searches were performed. Measures meeting inclusion/exclusion criteria were evaluated using Hunsley and Mash's (2018) criteria for evidence-based assessment across several domains (e.g., internal consistency, interrater reliability, test-retest reliability, content validity, construct validity, validity generalization, treatment sensitivity, and clinical utility). Rating categories were adapted for the present study to include the original categories of adequate, good, and excellent, as well as an additional category of below adequate. RESULTS After screening 172 articles, 50 PROs across a variety of pediatric conditions were reviewed and evaluated. Most measures demonstrated at least adequate content validity (n = 44), internal consistency (n = 34), and validity generalization (n = 45). Findings were mixed regarding interrater reliability, test-retest reliability, and treatment sensitivity. Less than half of the measures (n = 22) exhibited adequate, good, or excellent construct validity. CONCLUSIONS Although use of adherence and self-management PROs is widespread across several pediatric conditions, few PROs achieved good or excellent ratings based on rigorous psychometric standards. Validation and replication studies with larger, more diverse samples are needed. Future research should consider the use of emerging technologies to enhance the feasibility of broad implementation.
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Affiliation(s)
- Jill M Plevinsky
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Ana M Gutierrez-Colina
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Julia K Carmody
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Kevin A Hommel
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Lori E Crosby
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Meghan E McGrady
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Ahna L H Pai
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Rachelle R Ramsey
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Avani C Modi
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
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11
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Parrish C, Bartolini E, Song Y, Hernandez E, Green K, Ostrander R. Pediatric medical psychology. Int Rev Psychiatry 2020; 32:284-297. [PMID: 32091271 DOI: 10.1080/09540261.2019.1705258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Paediatric medical psychology is a specialised field within clinical health psychology focussed on the behavioural, developmental, and psychological needs of children, adolescents, and families in healthcare contexts. Paediatric medical psychologists address a myriad of problems by employing evidence-based evaluations and interventions in order to support the well-being of paediatric patients and their families. In this paper, we provide an overview of paediatric medical psychology including the education and training required to be a paediatric psychologist followed by common problems addressed by paediatric psychology, the settings paediatric psychologists work in, and the services they provide. Discussion concludes with future application of integrating paediatric psychology throughout the continuum of care to optimise adjustment and health of paediatric patients.
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Affiliation(s)
- Carisa Parrish
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ellen Bartolini
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Youlim Song
- Department of Psychological and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Emily Hernandez
- College of Social and Behavioral Sciences, California State University Northridge, Northridge, CA, USA
| | - Katerina Green
- The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rick Ostrander
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
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12
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Blanc JV, Mouchabac S, Nuss P, Malandain L, Lapidus N, Ferreri F. The effects of education in psychiatry on attitudes towards antidepressants in nursing students: A cross-sectional study. Nurse Educ Pract 2020; 45:102781. [PMID: 32330849 DOI: 10.1016/j.nepr.2020.102781] [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: 07/25/2018] [Revised: 10/30/2019] [Accepted: 03/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stigma associated with depression and antidepressants is strong among the general population but also among patients and health professionals. OBJECTIVES This cross-sectional study is aimed at: 1) evaluating the knowledge and attitude towards antidepressant by nursing student; 2) exploring the association between instruction in psychiatry and representation of depression and antidepressants. PARTICIPANTS 2037 undergraduate students from 10 French nursing schools were invited to participate in 2017, 1475 (73%) completed the questionnaire. METHODS The self-report questionnaire included the Drug Attitude Inventory (DAI) and questions about representation on depression and antidepressant. Four groups of students were built: 1) pre-teaching group (PT) as a reference group, 2) clinical training in psychiatry (CT), 3) receiving mental health theoretical education (TE), 4) receiving both (CT + TE). RESULTS The mean (standard deviation) DAI score was negative: -1.9 (±4.4) with only 40% of the nursing students conveying a positive attitude towards antidepressant. A combination of CT and TE was associated with a more positive attitude towards antidepressant in comparison with the PT condition. The CT + TE group was more prone to view antidepressants as effective and safe. CONCLUSION There is strong stigma against depression/antidepressants among nursing student. Education combined with clinical experiences in psychiatry improved these representations.
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Affiliation(s)
- J-V Blanc
- Sorbonne University, APHP, Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France.
| | - S Mouchabac
- Sorbonne University, APHP, Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France
| | - P Nuss
- Sorbonne University, APHP, Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France; Sorbonne University, UPMC Univ. Paris 06, École Normale Supérieure, PSL Research University, CNRS, INSERM, APHP, Laboratoire des Biomolécules (LBM), Paris, France
| | - L Malandain
- Sorbonne University, APHP, Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France
| | - N Lapidus
- Public Health Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France
| | - F Ferreri
- Sorbonne University, APHP, Psychiatry and Medical Psychology Department, Saint-Antoine Hospital, AP-HP, F-75012, Paris, France; Sorbonne University Nurse Department, Pitié Salpêtrière AP-HP, F-75013, Paris, France
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13
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Barry-Menkhaus SA, Wagner DV, Riley AR. Small Interventions for Big Change: Brief Strategies for Distress and Self-Management Amongst Youth with Type 1 Diabetes. Curr Diab Rep 2020; 20:3. [PMID: 32002682 PMCID: PMC7083649 DOI: 10.1007/s11892-020-1290-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Diabetes self-management and diabetes distress are complex processes implicated in glycemic control and other health outcomes for youth with type 1 diabetes. Growing integration of medical and behavioral care provides opportunities for brief psychosocial interventions during routine diabetes care. This review focuses on interventions for self-management and diabetes distress that can be delivered alongside usual medical care or via a single-patient encounter. RECENT FINDINGS Recent research underscores the potential of brief interventions delivered by both medical providers and integrated behavioral health professionals, but little is known regarding the comparative effectiveness of different interventions or the factors that impact dissemination and implementation. This article asserts that brevity is critical to maximizing the reach, scalability, and impact of psychosocial interventions for youth with type 1 diabetes. The authors review existing evidence for brief interventions, describe several untested clinical strategies, and make recommendations for accelerating the translational study of brief interventions.
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Affiliation(s)
- Samantha A Barry-Menkhaus
- The Madison Clinic for Pediatric Diabetes and Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - David V Wagner
- Institute on Development & Disability, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines St., Portland, OR, 97239, USA
| | - Andrew R Riley
- Institute on Development & Disability, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines St., Portland, OR, 97239, USA.
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14
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Swann JL, Griffin PM, Keskinocak P, Bieder I, Yildirim FM, Nurmagambetov T, Hsu J, Seeff L, Singleton CM. Return on investment of self-management education and home visits for children with asthma. J Asthma 2019; 58:360-369. [PMID: 31755329 DOI: 10.1080/02770903.2019.1690660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid. METHODS We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python. RESULTS Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results. CONCLUSIONS This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.
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Affiliation(s)
- Julie L Swann
- Edward P. Fitts Department of Industrial and Systems Engineering, NC State University, Raleigh, North Carolina, USA
| | - Paul M Griffin
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Ian Bieder
- Research Institute, Georgia Institute of Technology, Atlanta, Georgia, USA
| | | | - Tursynbek Nurmagambetov
- Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joy Hsu
- Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Laura Seeff
- Office of the Chief of Staff, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christa-Marie Singleton
- Office of the Associate Director for Policy and Strategy, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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15
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Almunef M, Mason J, Curtis C, Jalal Z. Young People and the Management of Chronic Illness by Primary Care Pharmacists: A Systematic Review. PHARMACY 2019; 7:pharmacy7030089. [PMID: 31373321 PMCID: PMC6789880 DOI: 10.3390/pharmacy7030089] [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] [Received: 06/21/2019] [Revised: 07/06/2019] [Accepted: 07/09/2019] [Indexed: 11/16/2022] Open
Abstract
Recent evidence has shown that the incidence of long-term illnesses in young people aged 10-24 years is increasing. It is essential to highlight the importance of long-term health conditions in this age group and understand young people's health needs to be able to improve current support for young people. Pharmacists, as medicine experts, are in a unique position to promote young people's health. The role of primary care pharmacists in the management of chronic illnesses in young people has not been widely researched. The aim of this review was to explore the current role of primary care pharmacists in the management of chronic illnesses in young people aged 10-24 years. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using Medical Subject Headings (MeSH) and Embase subject headings (Emtree) terms, covering three main themes: Pharmacists, young people and chronic illnesses. Articles were critically appraised using Critical Appraisal Skills Programme (CASP) tools. Eight articles were included in this review. Seven articles included original research studies (one observational study, two surveys, two qualitative interview studies and two interventions). The remaining article was a literature review. All of the articles made reference to community pharmacists, while there was no information about GP pharmacists. Roles that community pharmacists identified as high-priority in their practice when dealing with young people included supporting young people to develop generic healthcare skills, counselling and building trusted relationships directly with young people, helping young people to find credible health information and the provision of specialist services. Community pharmacists feel that they have a role to play in supporting young people with chronic illness and have identified many areas where they can provide services and support.
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Affiliation(s)
- Mohammed Almunef
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Julie Mason
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Chris Curtis
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Zahraa Jalal
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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16
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Favier LA, Ting TV, Modi AC. Feasibility of a musculoskeletal ultrasound intervention to improve adherence in juvenile idiopathic arthritis: a proof-of concept trial. Pediatr Rheumatol Online J 2018; 16:75. [PMID: 30466449 PMCID: PMC6251087 DOI: 10.1186/s12969-018-0292-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/12/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Non-adherence is a prevalent and modifiable issue in juvenile idiopathic arthritis (JIA) that currently lacks provider-based intervention. Education surrounding disease status is one way in which families remain engaged in their care. Musculoskeletal ultrasound is one such form of demonstrative, real-time education that may impact the way patients and caregivers self-manage their disease. The aims of this study are to 1) assess the feasibility, acceptability and perceived usefulness of musculoskeletal ultrasound as a non-adherence intervention tool and 2) to examine changes in methotrexate adherence in adolescents with JIA following the ultrasound. METHODS Eight adolescents with polyarticular or extended oligoarticular JIA and their caregivers completed this 12 week study. A within subject design was used to compare baseline and post-intervention adherence, quality of life and disease activity indices. Adherence measures included electronic measurement of methotrexate in addition to self-reported adherence questionnaires. The ultrasound intervention included a one-time, rheumatologist provided, educational examination of three or more currently or historically active joints. RESULTS The ultrasound intervention was found to be both feasible and acceptable. One hundred percent of eligible participants completed the ultrasound intervention. The ultrasound was well received by patients and caregivers, with most believing this to be a helpful tool. Baseline adherence was 75.3% among participants, with half of the participants being classified as non-adherent. Electronically measured and self-reported adherence measures did not show significant changes during the post-intervention period. Two participants improved, four participants maintained, and two participants decreased adherence. On ultrasound, 18/27 (66.7%) of the examined joints displayed abnormalities, with 63% being discrepant and additive to the rheumatologist's physical examination. CONCLUSIONS While our intervention did not show any changes in adherence, quality of life or disease activity indices in this proof-of-concept trial, the intervention does show promise in acceptability measures and merits future study in a more robust trial design. An additional study benefit was that the musculoskeletal ultrasound intervention was able to demonstrate subclinical disease, leading to clinically impactful therapeutic changes in several participants.
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Affiliation(s)
- Leslie A. Favier
- 0000 0000 9025 8099grid.239573.9Cincinnati Children’s Hospital Medical Center, Department of Pediatric Rheumatology, 3333 Burnet Ave, MLC 4010, Cincinnati, OH 45229 USA ,0000 0000 9025 8099grid.239573.9Cincinnati Children’s Hospital Medical Center, Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, 3333 Burnet Ave, MLC 7039, Cincinnati, OH 45229 USA
| | - Tracy V. Ting
- 0000 0000 9025 8099grid.239573.9Cincinnati Children’s Hospital Medical Center, Department of Pediatric Rheumatology, 3333 Burnet Ave, MLC 4010, Cincinnati, OH 45229 USA
| | - Avani C. Modi
- 0000 0000 9025 8099grid.239573.9Cincinnati Children’s Hospital Medical Center, Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, 3333 Burnet Ave, MLC 7039, Cincinnati, OH 45229 USA
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17
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Bender BG. Nonadherence to Asthma Treatment: Getting Unstuck. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 4:849-51. [PMID: 27587318 DOI: 10.1016/j.jaip.2016.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Bruce G Bender
- Division of Pediatric Behavioral Health, Department of Pediatrics, National Jewish Health, Denver, Colo.
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18
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Boutopoulou B, Koumpagioti D, Matziou V, Priftis KN, Douros K. Interventions on Adherence to Treatment in Children With Severe Asthma: A Systematic Review. Front Pediatr 2018; 6:232. [PMID: 30186824 PMCID: PMC6110874 DOI: 10.3389/fped.2018.00232] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/31/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction: Poor adherence to inhaled medication is a commonly encountered problem among children with asthma. However, there is a relatively paucity of data regarding the adherence of children with severe asthma, as well as the merit of any interventions to improve this adherence. Objectives: The aim of this systematic review was to identify the available literature on the rate of adherence and the influence of interventions in improving adherence to controller inhaled medication, in children with severe asthma. Methods: A systematic literature search was performed in MEDLINE/PubMed, Cochrane Library, and Scopus databases. Studies were included in the present review if their target population were children and/or adolescents with severe asthma and presented data on medication adherence before and after a given intervention. Results: A total of seven studies, conducted in USA, Canada, and UK, and published between 2012 and 2018, met the inclusion criteria. Adherence to controller medication was assessed via either objective or subjective measures (questionnaires), or a combination of them. Interventions included communication during pediatric visits and audio-taped medical visits, individualized care programs, electronic monitoring devices, interactive website and peak-flow prediction with feedback. Adherence rates for the baseline (before intervention) or for the control groups ranged from 28 to 67%. In general, there was a significant improvement of adherence after intervention with rates increasing to 49-81%. Conclusion: Adherence rate in children with severe asthma is not satisfactory but it can be improved after proper interventions. Nevertheless, the heterogeneity among adherence assessment tools, and the variety of interventions, in combination with the lack of studies focusing on severe asthma, highlight the need for further research in this field.
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Affiliation(s)
- Barbara Boutopoulou
- Respiratory and Allergy Unit, 3rd Pediatric Department of National and Kapodistrian University of Athens, University General Hospital “Attikon”, Athens, Greece
| | - Despoina Koumpagioti
- 2nd Pediatric Department of National and Kapodistrian University of Athens, “P & A Kiriakou” Children Hospital, Athens, Greece
| | - Vasiliki Matziou
- Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas N. Priftis
- Respiratory and Allergy Unit, 3rd Pediatric Department of National and Kapodistrian University of Athens, University General Hospital “Attikon”, Athens, Greece
| | - Konstantinos Douros
- Respiratory and Allergy Unit, 3rd Pediatric Department of National and Kapodistrian University of Athens, University General Hospital “Attikon”, Athens, Greece
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19
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Ettenger R, Albrecht R, Alloway R, Belen O, Cavaillé-Coll MW, Chisholm-Burns MA, Dew MA, Fitzsimmons WE, Nickerson P, Thompson G, Vaidya P. Meeting report: FDA public meeting on patient-focused drug development and medication adherence in solid organ transplant patients. Am J Transplant 2018; 18:564-573. [PMID: 29288623 DOI: 10.1111/ajt.14635] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/16/2017] [Accepted: 12/18/2017] [Indexed: 01/25/2023]
Abstract
The Food and Drug Administration (FDA) held a public meeting and scientific workshop in September 2016 to obtain perspectives from solid organ transplant recipients, family caregivers, and other patient representatives. The morning sessions focused on the impact of organ transplantation on patients' daily lives and the spectrum of activities undertaken to maintain grafts. Participants described the physical, emotional, and social impacts of their transplant on daily life. They also discussed their posttransplant treatment regimens, including the most burdensome side effects and their hopes for future treatment. The afternoon scientific session consisted of presentations on prevalence and risk factors for medication nonadherence after transplantation in adults and children, and interventions to manage it. As new modalities of Immunosuppressive Drug Therapy are being developed, the patient perceptions and input must play larger roles if organ transplantation is to be truly successful.
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Affiliation(s)
- Robert Ettenger
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | - Renata Albrecht
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Office of New Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA
| | - Rita Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ozlem Belen
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Office of New Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA
| | - Marc W Cavaillé-Coll
- Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products, Office of New Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA
| | - Marie A Chisholm-Burns
- Colleges of Pharmacy and Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Peter Nickerson
- Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Graham Thompson
- Office of Program and Strategic Analysis, Office of Strategic Programs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA
| | - Pujita Vaidya
- Office of Program and Strategic Analysis, Office of Strategic Programs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA
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20
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Reeves SL, Tribble A, Madden B, Freed GL, Dombkowski KJ. Antibiotic Prophylaxis for Children With Sickle Cell Anemia. Pediatrics 2018; 141:peds.2017-2182. [PMID: 29437860 PMCID: PMC7252515 DOI: 10.1542/peds.2017-2182] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with sickle cell anemia (SCA) are at increased risk for invasive pneumococcal disease; antibiotic prophylaxis significantly reduces this risk. We calculated the proportion of children with SCA who received ≥300 days of antibiotic prophylaxis and identified predictors of such receipt. METHODS Children aged 3 months to 5 years with SCA were identified by the presence of 3 or more Medicaid claims with a diagnosis of SCA within a calendar year (2005-2012) in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. Receipt of antibiotics was identified through claims for filled prescriptions. The outcome, receipt of ≥300 days of antibiotics, was assessed annually by using varying classifications of antibiotics. By using logistic regression with generalized estimating equations, we estimated the odds of receiving ≥300 days of antibiotics, with potential predictors of age, sex, year, state, and health services use. RESULTS A total of 2821 children contributed 5014 person-years. Overall, only 18% of children received ≥300 days of antibiotics. Each additional sickle cell disease-related outpatient visit (odds ratio = 1.01, 95% confidence interval: 1.01-1.02) and well-child visit (odds ratio = 1.08, 95% confidence interval: 1.02-1.13) was associated with incrementally increased odds of receiving ≥300 days of antibiotics. CONCLUSIONS Despite national recommendations and proven lifesaving benefit, antibiotic prophylaxis rates are low among children with SCA. Numerous health care encounters may offer an opportunity for intervention; in addition, such interventions likely need to include social factors that may affect the ability for a child to receive and adhere to antibiotic prophylaxis.
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Affiliation(s)
- Sarah L Reeves
- Department of Pediatrics and Communicable Diseases and .,Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan
| | - Alison Tribble
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Brian Madden
- Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases; University of Michigan, Ann Arbor, MI
| | - Gary L Freed
- Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases; University of Michigan, Ann Arbor, MI
| | - Kevin J Dombkowski
- Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases; University of Michigan, Ann Arbor, MI
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21
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Smith G, Modi AC, Johnson EK, Shegog R, Austin JK, Wagner JL. Measurement in pediatric epilepsy self-management: A critical review. Epilepsia 2018; 59:509-522. [PMID: 29322489 DOI: 10.1111/epi.13992] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 11/30/2022]
Abstract
Given the paucity of information available regarding self-management, the aims of this paper are to synthesize the literature on factors associated with and measures to assess self-management in pediatric epilepsy. INCLUSION CRITERIA youth birth to 18 years with a seizure disorder or an epilepsy diagnosis and/or their caregivers, published 1985-2014 in English, and conducted in countries with a very high human development index. The review was conducted in 6 phases: (1) identification of bibliographical search criteria and databases; (2) abstract assessment; (3) full article review; (4) organization of final citations into categories; (5) identification of predictors, potential mediators/moderators, and outcomes associated with self-management factors and categorization of factors as influences, processes, or behaviors across individual, family, community, and health care domains; and (6) critique of self-management instrument studies. Twenty-five studies that evaluated factors associated with self-management were identified. Individual and family-focused factors were the most commonly studied predictors of self-management, with psychosocial care needs and self-efficacy for seizure management identified as key factors associated with pediatric epilepsy self-management. Few studies have included mediator and moderator analyses. Measures of adherence were the most commonly used outcome. There has been a predominant focus on pediatric epilepsy influences and processes that are modifiable in nature, potentially at the expense of evidence for the role of community and health systems in pediatric epilepsy self-management. The 6 self-management instrument tools reported scientific rationale and good psychometric properties. Results highlight several key modifiable cognitive and behavioral targets for skills development: adherence, self-efficacy for seizure management, attitudes toward epilepsy, and family variables. Moving forward, a comprehensive pediatric epilepsy self-management model, well-validated measures of self-management behaviors, mediator/moderator designs to examine the complex relationships between predictors and pediatric epilepsy self-management outcomes, and studies examining the community and health care domains of self-management are necessary.
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Affiliation(s)
- Gigi Smith
- College of Nursing, Department of Pediatrics, Comprehensive Epilepsy Center, Medical University of South Carolina, Charleston, SC, USA
| | - Avani C Modi
- Center for Treatment Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Erica K Johnson
- School of Public Health, Health Promotion Research Center, University of Washington, Seattle, WA, USA
| | - Ross Shegog
- Center for Health Promotion and Prevention Research, UT Health School of Public Health, Houston, TX, USA
| | - Joan K Austin
- School of Nursing, Indiana University-Purdue University Indianapolis, Bloomington, IN, USA
| | - Janelle L Wagner
- College of Nursing, Department of Pediatrics, Comprehensive Epilepsy Center, Medical University of South Carolina, Charleston, SC, USA
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22
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Varnell CD, Rich KL, Nichols M, Dahale D, Goebel JW, Pai ALH, Hooper DK, Modi AC. Assessing barriers to adherence in routine clinical care for pediatric kidney transplant patients. Pediatr Transplant 2017; 21:10.1111/petr.13027. [PMID: 28762577 PMCID: PMC5904833 DOI: 10.1111/petr.13027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 01/04/2023]
Abstract
Patient-identified barriers to immunosuppressive medications are associated with poor adherence and negative clinical outcomes in transplant patients. Assessment of adherence barriers is not part of routine post-transplant care, and studies regarding implementing such a process in a reliable way are lacking. Using the Model for Improvement and PDSA cycles, we implemented a system to identify adherence barriers, including patient-centered design of a barriers assessment tool, identification of eligible patients, clear roles for clinic staff, and creating a culture of non-judgmental discussion around adherence. We performed time-series analysis of our process measure. Secondary analyses examined the endorsement and concordance of adherence barriers between patient-caregiver dyads. After three methods of testing, the most reliable delivery system was an EHR-integrated tablet that alerted staff of patient eligibility for assessment. Barriers were endorsed by 35% of caregivers (n=85) and 43% of patients (n=60). The most frequently patient-endorsed barriers were forgetting, poor taste, and side effects. Caregivers endorsed forgetting and side effects. Concordance between patient-caregiver dyads was fair (k=0.299). Standardized adherence barriers assessment is feasible in the clinical care of pediatric kidney transplant patients. Features necessary for success included automation, redundant systems with designated staff to identify and mitigate failures, aligned reporting structures, and reliable measurement approaches. Future studies will examine whether barriers predict clinical outcomes (eg, organ rejection, graft loss).
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Affiliation(s)
- Charles D. Varnell
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kristin L. Rich
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Melissa Nichols
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Devesh Dahale
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Jens W. Goebel
- Division of Nephrology, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ahna L. H. Pai
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,University of Cincinnati College of Medicine, Cincinnati, OH, USA,Center for Treatment Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - David K. Hooper
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,University of Cincinnati College of Medicine, Cincinnati, OH, USA,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Avani C. Modi
- Division of Behavioral and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,University of Cincinnati College of Medicine, Cincinnati, OH, USA,Center for Treatment Adherence and Self-Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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23
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Abstract
BACKGROUND Nonadherence to treatment recommendations is associated with poorer outcomes in inflammatory bowel disease and may increase the cost of care. We examined the longitudinal relationship between nonadherence and health care costs and hypothesized that at least 3 distinct trajectories of nonadherence would be observed and that increasing nonadherence would account for significantly greater health care costs after controlling for disease activity. METHODS Ninety-nine patients aged 2 to 21 years with inflammatory bowel disease were recruited into this 2-year longitudinal study. Medication possession ratios were calculated from pharmacy refill data, disease activity ratings were obtained from medical charts, and hospital and physician charges associated with an International Classification of Diseases, Ninth Revision code for ulcerative colitis or Crohn's disease were obtained from the hospital's accounting database. RESULTS An average total cost effect size of d = 0.68 was observed between the increasing severity and stable low severity groups, but the confidence intervals overlap. Conversely, patients with increasing nonadherence demonstrated significantly higher health care costs than patients with stable ≤10%, stable 11% to 20%, or decreasing nonadherence. CONCLUSIONS Medication nonadherence is related to increased health care costs after controlling for disease severity. Patients with increasing nonadherence over time demonstrate more than a 3-fold increase in costs compared with adherent patients. In addition, patients whose adherence improves over time incur approximately the same costs as those who are consistently adherent. This suggests that, in addition to leveraging prevention efforts to keep patients from becoming more nonadherent as treatment continues, efforts aimed at modifying adherence behavior may result in significant cost savings over time.
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Pascoe JE, Sawnani H, Mayer OH, McConnell K, McDonough JM, White C, Rutkowski AM, Amin RS, Modi AC. Adherence and barriers to hyperinsufflation in children with congenital muscular dystrophy. Pediatr Pulmonol 2017; 52:939-945. [PMID: 27875025 PMCID: PMC6827716 DOI: 10.1002/ppul.23645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/09/2016] [Accepted: 11/10/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Congenital muscular dystrophy (CMD) is a rare, inherited neuromuscular disease characterized by progressive muscle weakness, thoracic insufficiency, and ultimately respiratory failure. Adherence to respiratory therapies in children with neuromuscular disorders is unknown. This study examined the multimodal assessment of adherence and barriers to 15 min, twice daily hyperinsufflation in children with CMD. Adherence was hypothesized to be greater than 50% and discomfort, embarrassment, and difficulty finding time were hypothesized to be barriers. METHODS Participants included 18 children with CMD. Personalized hyperinsufflation settings were determined based on pressure-volume measurements at each study visit. Adherence was measured by a daily phone diary (DPD) and by electronic data download from the hyperinsufflation device. The DPD was conducted twice over a 48-hr period to capture a weekend and weekday, with the goal being 60 min of hyperinsufflation over the 48 hr (100% adherence). The hyperinsufflation objective electronic data reflected daily use of hyperinsufflation for the same 48-hr period. Data from DPD and the corresponding hyperinsufflation device data were used for analyses. RESULTS Adherence to hyperinsufflation was 40% via DPD and 44% for electronic data, with strong convergence between methods (r = 0.75, P < 0.001). Surprisingly, 53% of participants reported no barriers despite low adherence. Social distractions and family obligations were identified as barriers. There were no differences in adherence between those who did and did not endorse barriers to hyperinsufflation (DPD: t(13) = 0.44, P = n.s.; hyperinsufflation device: t(13) = -0.23, P = n.s.). CONCLUSION Adherence to hyperinsufflation is a significant problem in children with CMD and families have difficulty identifying adherence barriers. An important next step is to encourage open dialog around adherence barriers and promote adherence behaviors via intervention. Pediatr Pulmonol. 2017; 52:939-945. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- John E Pascoe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Behavioral Medicine and Clinical Psychology, Center for Treatment Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Oscar H Mayer
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keith McConnell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph M McDonough
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia White
- Division of Respiratory Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Raouf S Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Avani C Modi
- Division of Behavioral Medicine and Clinical Psychology, Center for Treatment Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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25
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Abstract
BACKGROUND Despite its proven efficacy in improving symptoms and reducing exacerbations, many patients with asthma are not fully adherent to their steroid inhaler. Suboptimal adherence leads to poorer clinical outcomes and increased health service utilisation, and has been identified as a contributing factor to a third of asthma deaths in the UK. Reasons for non-adherence vary, and a variety of interventions have been proposed to help people improve treatment adherence. OBJECTIVES To assess the efficacy and safety of interventions intended to improve adherence to inhaled corticosteroids among people with asthma. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 18 November 2016. SELECTION CRITERIA We included parallel and cluster randomised controlled trials of any duration conducted in any setting. We included studies reported as full-text articles, those published as abstracts only and unpublished data. We included trials of adults and children with asthma and a current prescription for an inhaled corticosteroid (ICS) (as monotherapy or in combination with a long-acting beta2-agonist (LABA)). Eligible trials compared an intervention primarily aimed at improving adherence to ICS versus usual care or an alternative intervention. DATA COLLECTION AND ANALYSIS Two review authors screened the searches, extracted study characteristics and outcome data from included studies and assessed risk of bias. Primary outcomes were adherence to ICS, exacerbations requiring at least oral corticosteroids and asthma control. We graded results and presented evidence in 'Summary of findings' tables for each comparison.We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all using a random-effects model. We described skewed data narratively. We made no a priori assumptions about how trials would be categorised but conducted meta-analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense. MAIN RESULTS We included 39 parallel randomised controlled trials (RCTs) involving adults and children with asthma, 28 of which (n = 16,303) contributed data to at least one meta-analysis. Follow-up ranged from two months to two years (median six months), and trials were conducted mainly in high-income countries. Most studies reported some measure of adherence to ICS and a variety of other outcomes such as quality of life and asthma control. Studies generally were at low or unclear risk of selection bias and at high risk of biases associated with blinding. We considered around half the studies to be at high risk for attrition bias and selective outcome reporting.We classified studies into four comparisons: adherence education versus control (20 studies); electronic trackers or reminders versus control (11 studies); simplified drug regimens versus usual drug regimens (four studies); and school-based directly observed therapy (three studies). Two studies are described separately.All pooled results for adherence education, electronic trackers or reminders and simplified regimens showed better adherence than controls. Analyses limited to studies using objective measures revealed that adherence education showed a benefit of 20 percentage points over control (95% confidence interval (CI) 7.52 to 32.74; five studies; low-quality evidence); electronic trackers or reminders led to better adherence of 19 percentage points (95% CI 14.47 to 25.26; six studies; moderate-quality evidence); and simplified regimens led to better adherence of 4 percentage points (95% CI 1.88 to 6.16; three studies; moderate-quality evidence). Our confidence in the evidence was reduced by risk of bias and inconsistency.Improvements in adherence were not consistently translated into observable benefit for clinical outcomes in our pooled analyses. None of the intervention types showed clear benefit for our primary clinical outcomes - exacerbations requiring an oral corticosteroid (OCS) (evidence of very low to low quality) and asthma control (evidence of low to moderate quality); nor for our secondary outcomes - unscheduled visits (evidence of very low to moderate quality) and quality of life (evidence of low to moderate quality). However, some individual studies reported observed benefits for OCS and use of healthcare services. Most school or work absence data were skewed and were difficult to interpret (evidence of low quality, when graded), and most studies did not specifically measure or report adverse events.Studies investigating the possible benefit of administering ICS at school did not measure adherence, exacerbations requiring OCS, asthma control or adverse events. One study showed fewer unscheduled visits, and another found no differences; data could not be combined. AUTHORS' CONCLUSIONS Pooled results suggest that a variety of interventions can improve adherence. The clinical relevance of this improvement, highlighted by uncertain and inconsistent impact on clinical outcomes such as quality of life and asthma control, is less clear. We have low to moderate confidence in these findings owing to concerns about risk of bias and inconsistency. Future studies would benefit from predefining an evidence-based 'cut-off' for acceptable adherence and using objective adherence measures and validated tools and questionnaires. When possible, covert monitoring and some form of blinding or active control may help disentangle effects of the intervention from effects of inclusion in an adherence trial.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- BMJ Knowledge CentreBritish Medical Journal Technology Assessment Group (BMJ‐TAG)BMA HouseTavistock SquareLondonUKWC1H 9JR
| | - Elizabeth Stovold
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceTootingLondonUKSW17 0RE
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26
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Labovitz DL, Shafner L, Reyes Gil M, Virmani D, Hanina A. Using Artificial Intelligence to Reduce the Risk of Nonadherence in Patients on Anticoagulation Therapy. Stroke 2017; 48:1416-1419. [PMID: 28386037 DOI: 10.1161/strokeaha.116.016281] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/07/2017] [Accepted: 02/16/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE This study evaluated the use of an artificial intelligence platform on mobile devices in measuring and increasing medication adherence in stroke patients on anticoagulation therapy. The introduction of direct oral anticoagulants, while reducing the need for monitoring, have also placed pressure on patients to self-manage. Suboptimal adherence goes undetected as routine laboratory tests are not reliable indicators of adherence, placing patients at increased risk of stroke and bleeding. METHODS A randomized, parallel-group, 12-week study was conducted in adults (n=28) with recently diagnosed ischemic stroke receiving any anticoagulation. Patients were randomized to daily monitoring by the artificial intelligence platform (intervention) or to no daily monitoring (control). The artificial intelligence application visually identified the patient, the medication, and the confirmed ingestion. Adherence was measured by pill counts and plasma sampling in both groups. RESULTS For all patients (n=28), mean (SD) age was 57 years (13.2 years) and 53.6% were women. Mean (SD) cumulative adherence based on the artificial intelligence platform was 90.5% (7.5%). Plasma drug concentration levels indicated that adherence was 100% (15 of 15) and 50% (6 of 12) in the intervention and control groups, respectively. CONCLUSIONS Patients, some with little experience using a smartphone, successfully used the technology and demonstrated a 50% improvement in adherence based on plasma drug concentration levels. For patients receiving direct oral anticoagulants, absolute improvement increased to 67%. Real-time monitoring has the potential to increase adherence and change behavior, particularly in patients on direct oral anticoagulant therapy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02599259.
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Affiliation(s)
- Daniel L Labovitz
- From the Montefiore Medical Center, Bronx, New York (D.L.L., M.R.G., D.V.); and AiCure, New York, NY (L.S., A.H.)
| | - Laura Shafner
- From the Montefiore Medical Center, Bronx, New York (D.L.L., M.R.G., D.V.); and AiCure, New York, NY (L.S., A.H.).
| | - Morayma Reyes Gil
- From the Montefiore Medical Center, Bronx, New York (D.L.L., M.R.G., D.V.); and AiCure, New York, NY (L.S., A.H.)
| | - Deepti Virmani
- From the Montefiore Medical Center, Bronx, New York (D.L.L., M.R.G., D.V.); and AiCure, New York, NY (L.S., A.H.)
| | - Adam Hanina
- From the Montefiore Medical Center, Bronx, New York (D.L.L., M.R.G., D.V.); and AiCure, New York, NY (L.S., A.H.)
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27
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Abraham O, Brothers A, Alexander DS, Carpenter DM. Pediatric medication use experiences and patient counseling in community pharmacies: Perspectives of children and parents. J Am Pharm Assoc (2003) 2017; 57:38-46.e2. [DOI: 10.1016/j.japh.2016.08.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 10/20/2022]
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28
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Plevinsky JM, Greenley RN, Fishman LN. Self-management in patients with inflammatory bowel disease: strategies, outcomes, and integration into clinical care. Clin Exp Gastroenterol 2016; 9:259-67. [PMID: 27601930 PMCID: PMC5003515 DOI: 10.2147/ceg.s106302] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Self-management, including medication adherence, is associated with improved health and outcomes for patients with inflammatory bowel disease. The concept of self-management is complex, but can be divided into those aspects that involve the individual patient, those that involve the provider–patient relationship, and those that encompass the social environment. At the individual level, enhancing problem-solving skills and self-efficacy have both been shown to improve self-management tasks, particularly adherence to treatment. However, it is critical to consider these domains from a lifespan perspective because these processes by which self-management can be improved are distinct for children, adolescents, young adults, and adults. A particular emphasis is placed on strategies to improve self-management of older adolescents and young adults as they transition from pediatric to adult providers. The review concludes with recommendations for providers, including rationale and techniques for assessing and promoting patient self-efficacy, encouraging the development of problem-solving skills, improving the patient–provider relationship, and enhancing social support. Providers are encouraged to utilize elements of problem-solving skills training, engage in collaborative relationships with their patients, and offer their patients recommendations for how to increase the quality of their social support networks as ways of increasing overall self-management.
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Affiliation(s)
- Jill M Plevinsky
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Rachel N Greenley
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Laurie N Fishman
- Department of Gastroenterology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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29
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Abstract
OBJECTIVES Guidelines recommend close follow-up during the treatment of childhood functional constipation. Only sparse evidence exists on how follow-up is best implemented. Our aim was to evaluate whether follow-up by phone or self-management through Web-based information improved treatment outcomes. METHODS In this randomized controlled trial, conducted in secondary care, 235 children, ages 2 to 16 years, who fulfilled the Rome III criteria of childhood constipation, were assigned to 1 of the 3 follow-up regimens: control group (no scheduled contact), phone group (2 scheduled phone contacts), and Web group (access to Web-based information). PRIMARY OUTCOME number of successfully treated children after 3, 6, and 12 months. SECONDARY OUTCOMES phone contacts, relapse, fecal incontinence, and laxative use. RESULTS After 3 and 6 months, significantly more children in the Web group (79.7%/75.9%) were successfully treated compared with the control and phone groups (59.7%/63.6% and 63.3%/64.6%) (P = 0.007/P = 0.03). No difference was found after 12 months (control, 72.7%; phone, 68.4%; Web group, 78.5%; P = 0.40). Extra phone consultations were significantly more frequent in the Web group (44.3%) compared with the control group (28.6%) (P = 0.04). Before 3 months, 45.5% of phone consultations were completed in the Web group versus 28.8% and 25.8% in the control and phone groups (P = 0.05/P = 0.02). Relapses, fecal incontinence, and laxative use were not different between interventions. CONCLUSIONS Improved self-management behavior caused by access to self-motivated Web-based information induced faster short-term recovery during the treatment of functional constipation. Patient empowerment rather than health care-promoted follow-up may be a step toward more effective treatment for childhood constipation.
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30
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McGrady ME, Brown GA, Pai ALH. Medication adherence decision-making among adolescents and young adults with cancer. Eur J Oncol Nurs 2015; 20:207-14. [PMID: 26372619 DOI: 10.1016/j.ejon.2015.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 08/05/2015] [Accepted: 08/31/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE Nearly half of all adolescents and young adults (AYAs) with cancer struggle to adhere to oral chemotherapy or antibiotic prophylactic medication included in treatment protocols. The mechanisms that drive non-adherence remain unknown, leaving health care providers with few strategies to improve adherence among their patients. The purpose of this study was to use qualitative methods to investigate the mechanisms that drive the daily adherence decision-making process among AYAs with cancer. METHODS Twelve AYAs (ages 15-31) with cancer who had a current medication regimen that included oral chemotherapy or antibiotic prophylactic medication participated in this study. Adolescents and young adults completed a semi-structured interview and a card sorting task to elucidate the themes that impact adherence decision-making. Interviews were transcribed verbatim and coded twice by two independent raters to identify key themes and develop an overarching theoretical framework. RESULTS Adolescents and young adults with cancer described adherence decision-making as a complex, multi-dimensional process influenced by personal goals and values, knowledge, skills, and environmental and social factors. Themes were generally consistent across medication regimens but differed with age, with older AYAs discussing long-term impacts and receiving physical support from their caregivers more than younger AYAs. CONCLUSIONS The mechanisms that drive daily adherence decision-making among AYAs with cancer are consistent with those described in empirically-supported models of adherence among adults with other chronic medical conditions. These mechanisms offer several modifiable targets for health care providers striving to improve adherence among this vulnerable population.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA.
| | - Gabriella A Brown
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Ahna L H Pai
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
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31
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Bannick AA, Laufman JD, Edwards HL, Ventimiglia J, Feldman GL. Outcomes of referrals to Child Protective Services for medical neglect in patients with phenylketonuria: Experiences at a single treatment center. Mol Genet Metab 2015; 115:151-6. [PMID: 26138304 DOI: 10.1016/j.ymgme.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/13/2015] [Accepted: 06/13/2015] [Indexed: 11/18/2022]
Abstract
Phenylketonuria (PKU) results in an accumulation of phenylalanine (phe) in the blood which can lead to multiple health consequences in affected individuals. Treatment for PKU is available; however adherence to medical management recommendations can be difficult. When recommendations are not followed and the health of a child is at risk, one intervention that may be necessary is a referral for medical neglect to the local child protective services (CPS) agency. This study summarizes the cases that were referred from our metabolic clinic at the Children's Hospital of Michigan to CPS, and the outcomes of that intervention. CPS referrals helped to improve adherence to medical management recommendations in the majority of cases, including a lower blood phe level for the child; however, at times that improvement did not occur until after a second referral and/or the child's temporary removal from the home.
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Affiliation(s)
- Allison A Bannick
- Department of Pediatrics, Division of Genetic and Metabolic Disorders, Detroit Medical Center, Children's Hospital of Michigan, 3950 Beaubien, Detroit, MI 48201, United States.
| | - Jason D Laufman
- Wayne State University School of Medicine, 540 East Canfield, Detroit, MI 48201, United States.
| | - Heidi L Edwards
- Department of Pediatrics, Division of Genetic and Metabolic Disorders, Detroit Medical Center, Children's Hospital of Michigan, 3950 Beaubien, Detroit, MI 48201, United States.
| | - June Ventimiglia
- Department of Pediatrics, Division of Genetic and Metabolic Disorders, Detroit Medical Center, Children's Hospital of Michigan, 3950 Beaubien, Detroit, MI 48201, United States.
| | - Gerald L Feldman
- Department of Pediatrics, Division of Genetic and Metabolic Disorders, Detroit Medical Center, Children's Hospital of Michigan, 3950 Beaubien, Detroit, MI 48201, United States; Center for Molecular Medicine and Genetics, Departments of Pediatrics and Pathology, Wayne State University School of Medicine, 540 E. Canfield, Detroit, MI 48201, United States.
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32
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Seng EK, Rains JA, Nicholson RA, Lipton RB. Improving Medication Adherence in Migraine Treatment. Curr Pain Headache Rep 2015; 19:24. [DOI: 10.1007/s11916-015-0498-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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33
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Klok T, Kaptein AA, Brand PLP. Non-adherence in children with asthma reviewed: The need for improvement of asthma care and medical education. Pediatr Allergy Immunol 2015; 26:197-205. [PMID: 25704083 DOI: 10.1111/pai.12362] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2015] [Indexed: 12/31/2022]
Abstract
Adherence to daily inhaled corticosteroid therapy is a key determinant of asthma control. Therefore, improving adherence to inhaled corticosteroids is the most effective method through which healthcare providers can help children with uncontrolled asthma. However, identifying non-adherent patients is difficult, and electronic monitoring is the only reliable method to assess adherence. (Non-)adherence is a complex behavioural process influenced by many interacting factors. Intentional barriers to adherence are common; driven by illness perceptions and medication beliefs, patients and parents deliberately choose not to follow the doctor's recommendations. Common non-intentional barriers are related to family routines, child-raising issues, and to social issues such as poverty. Effective interventions improving adherence are complex, because they take intentional and non-intentional barriers to adherence into account. There is evidence that comprehensive, guideline-based asthma self-management programmes can be successful, with excellent adherence and good asthma control. Patient-centred care focused on healthcare provider-patient/parent collaboration is the key factor determining the success of guided self-management programmes. Such care should focus on shared decision-making as this has been shown to improve adherence and healthcare outcomes. Current asthma care falls short because many physicians fail to adhere to asthma guidelines in their diagnostic approach and therapeutic prescriptions, and because of the lack of application of patient-centred health care. Increased awareness of the importance of patient-centred communication and increased training in patient-centred communication skills of undergraduates and experienced attending physicians are needed to improve adherence to daily controller therapy and asthma control in children with asthma.
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Affiliation(s)
- Ted Klok
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, the Netherlands.,Princess Amalia Children's Center, Isala Hospital, Zwolle, the Netherlands
| | - Adrian A Kaptein
- Unit of Psychology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L P Brand
- Princess Amalia Children's Center, Isala Hospital, Zwolle, the Netherlands.,UMCG Postgraduate School of Medicine, University Medical Center, University of Groningen, Groningen, the Netherlands
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34
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Snyder CK. Strategies to improve insulin adherence in adolescents with type 1 diabetes. J Pediatr Nurs 2015; 30:278-80. [PMID: 25448472 DOI: 10.1016/j.pedn.2014.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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