A novel compliance assessment technique. The randomized response interview

An evaluation of the spread and scale of PatientToc™ from primary care to community pharmacy practice for the collection of patient-reported outcomes: A study protocol

BACKGROUND

Medication non-adherence is a problem of critical importance, affecting approximately 50% of all persons taking at least one regularly scheduled prescription medication and costing the United States more than $100 billion annually. Traditional data sources for identifying and resolving medication non-adherence in community pharmacies include prescription fill histories. However, medication possession does not necessarily mean patients are taking their medications as prescribed. Patient-reported outcomes (PROs), measuring adherence challenges pertaining to both remembering and intention to take medication, offer a rich data source for pharmacists and prescribers to use to resolve medication non-adherence. PatientToc™ is a PROs collection software developed to facilitate collection of PROs data from low-literacy and non-English speaking patients in Los Angeles.

OBJECTIVES

This study will evaluate the spread and scale of PatientToc™ from primary care to community pharmacies for the collection and use of PROs data pertaining to medication adherence.

METHODS

The following implementation and evaluation steps will be conducted: 1) a pre-implementation developmental formative evaluation to determine community pharmacy workflow and current practices for identifying and resolving medication non-adherence, potential barriers and facilitators to PatientToc™ implementation, and to create a draft implementation toolkit, 2) two plan-do-study-act cycles to refine an implementation toolkit for spreading and scaling implementation of PatientToc™ in community pharmacies, and 3) a comprehensive, theory-driven evaluation of the quality of care, implementation, and patient health outcomes of spreading and scaling PatientToc™ to community pharmacies.

EXPECTED IMPACT

This research will inform long-term collection and use of PROs data pertaining to medication adherence in community pharmacies.

Adherence to growth hormone therapy: results of a multicenter study

OBJECTIVE

To evaluate the adherence to growth hormone (GH) therapy and identify the influencing factors and outcomes in children.

METHODS

A total of 217 GH-naïve patients in 6 pediatric endocrinology clinics were enrolled in the study. Structured questionnaires were filled out and patients were evaluated at the initiation and 3rd, 6th, and 12th months of therapy. Patients were categorized into 4 adherence segments based on percentage of doses omitted at each evaluation period, classified as excellent if 0%, good if 5%, fair if 5 to 10%, and poor if > 10%.

RESULTS

There was a decrement in adherence to GH therapy during the study period (P = .006). Patients who showed excellent and good adherence to therapy had better growth velocity and growth velocity standard deviation scores (SDSs) (P = .014 and P = .015, respectively). A negative correlation between growth velocity SDS and number of missed injections was also observed (r = -.412; P = .007). A positive correlation between delta insulin-like growth factor-1 (IGF-1) SDS and growth velocity was demonstrated (r = .239; P = .042). IGF-1 levels were significantly higher in patients who showed excellent and good adherence to therapy (P = .01). Adherence was better in boys than in girls (P = .035), but adherence rates were not associated with age, cause of GH treatment, socioeconomic status, person who administered the injections, type of injection device, or GH product.

CONCLUSION

Poor adherence to GH therapy was common in our group of patients and was one of the factors underlying suboptimal growth during therapy. Before considering other problems that can affect growth, clinicians should confirm good adherence to therapy.

Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis

BACKGROUND

Two-stage revisions of total hip arthroplasties complicated by chronic infection result in reinfection rates that are lower than those following single-stage revisions but may also result in increased surgical morbidity. Using a decision analysis, we compared single-stage and two-stage revisions to determine which treatment modality resulted in greater quality-adjusted life years (QALYs).

METHODS

A review of the literature on the treatment of patients with an infection at the site of a total hip arthroplasty provided probabilities; utility values for common postoperative health states were determined in a previously published study. With these data, we conducted a Markov cohort simulation decision analysis. Sensitivity analysis validated the model, and comparisons were made in terms of QALYs.

RESULTS

The twelve-month model favored direct-exchange revision over the two-stage approach, regardless of whether surgeon or patient-derived utilities were used (0.945 versus 0.896 and 0.897 versus 0.861 QALYs for the patient and surgeon models, respectively). Similar results were observed in a lifetime model with a ten-year life expectancy (7.853 versus 7.771, and 7.438 versus 7.362 QALYs, respectively). The findings were found to be robust in sensitivity analyses in which clinically relevant ranges of input variables were used.

CONCLUSIONS

This analysis favored the direct-exchange arthroplasty over the two-stage approach. This study should be considered hypothesis-generating for future randomized controlled trials in which, ideally, health end points will be considered in addition to the eradication of infection.

Improving self-report measures of medication non-adherence using a cheating detection extension of the randomised-response-technique

Medication non-adherence is a serious problem for medical research and clinical practice. Self-reports are only moderately valid, and objective methods are cumbersome and expensive to administer. We sought to improve self-reports of medication non-adherence using a cheating detection extension of the randomised-response-technique (RRT). This RRT variant encourages more honest responses by offering interviewees a higher degree of anonymity while simultaneously allowing us to estimate the proportion of respondents disobeying the RRT instructions. The 597 patients were asked to report their lifetime prevalence of medication non-adherence under one of two different questioning procedures, direct questioning or randomised-response. When questioned directly, only 20.9% of patients admitted to intentional medication non-adherent behaviour, as opposed to 32.7% of patients under RRT conditions. Additionally, the cheating detection extension revealed a significant proportion of patients (47.1%) disobeying the instructions in the RRT condition. Assuming that either none or all of them were non-adherent, a lower and upper bound of 32.7% and 79.8%, respectively, could be estimated for the lifetime prevalence of non-adherent behaviour. The results demonstrate that self-report measures as well as traditional variants of the RRT, which do not take cheating into account, may provide considerably distorted estimates of the prevalence of medication non-adherence.

The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence

Self-report tools for monitoring adherence can be useful in identifying patients who need assistance with their medications, assessing patient concerns, and evaluating new programs. The aim of this study is to test the validity of the Brief Medication Questionnaire (BMQ), a new self-report tool for screening adherence and barriers to adherence. The tool includes a 5-item Regimen Screen that asks patients how they took each medication in the past week, a 2-item Belief Screen that asks about drug effects and bothersome features, and a 2-item Recall Screen about potential difficulties remembering. Validity was assessed in 20 patients using the Medication Events Monitoring System (MEMS). Results varied by type of non-adherence, with the Regimen and Belief Screens having 80-100% sensitivity for "repeat" non-adherence and the Recall Screen having 90% sensitivity for "sporadic" non-adherence. The BMQ appears more sensitive than existing tools and may be useful in identifying and diagnosing adherence problems.

Respondent-specific information from the randomized response interview: compliance assessment

In situations in which researchers ask potentially embarrassing questions, respondents may feel uncomfortable with revealing certain behavior. Consequently, response rates or accuracy may be low. The "randomized response interview" (RRI) was developed to enable researchers to better elicit responses to such questions. The technique has clear potential in estimating population proportions engaging in embarrassing behavior. It does not appear to have been recognized that one may also obtain more respondent-specific information from the application of the RRI. This article indicates that while still only probabilistic, respondent-specific information is obtainable from the RRI.