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Burnier M. Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve. Expert Rev Pharmacoecon Outcomes Res 2024; 24:749-758. [PMID: 38836304 DOI: 10.1080/14737167.2024.2363401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Randomized controlled trials (RCTs) are important sources of evidence that strongly influence guidelines for patient management, including for elevated blood pressure in adults. AREAS COVERED Critical questions regarding the interpretation of hypertension trial results have recently increased, especially for concerns over methodology. In particular, investigator adherence to the protocol and patient adherence to investigational drugs are often far from optimal. These issues may be ignored or underreported because physicians' behavior during trials is often not monitored and patients' medication adherence is neither measured adequately nor reported or analyzed in the final report or in the publication. This situation may lead to misinterpretations of study results and misevaluations of the safety and efficacy profile of new drugs. In this short review, the problem of measuring, reporting, and analyzing drug adherence in RCTs is discussed and illustrated with several examples in the field of hypertension. EXPERT OPINION The main conclusion is that drug adherence should always be measured in clinical trials, possibly with more than one method. In addition, prespecified analyses of adherence data should be included in the statistical plan of all trials to improve their overall quality.
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Affiliation(s)
- Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Bandiera C, Pasquier J, Locatelli I, Schneider MP. Using a Semiautomated Procedure (CleanADHdata.R Script) to Clean Electronic Adherence Monitoring Data: Tutorial. JMIR Form Res 2024; 8:e51013. [PMID: 38776539 PMCID: PMC11153970 DOI: 10.2196/51013] [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: 07/19/2023] [Revised: 01/15/2024] [Accepted: 02/05/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Patient adherence to medications can be assessed using interactive digital health technologies such as electronic monitors (EMs). Changes in treatment regimens and deviations from EM use over time must be characterized to establish the actual level of medication adherence. OBJECTIVE We developed the computer script CleanADHdata.R to clean raw EM adherence data, and this tutorial is a guide for users. METHODS In addition to raw EM data, we collected adherence start and stop monitoring dates and identified the prescribed regimens, the expected number of EM openings per day based on the prescribed regimen, EM use deviations, and patients' demographic data. The script formats the data longitudinally and calculates each day's medication implementation. RESULTS We provided a simulated data set for 10 patients, for which 15 EMs were used over a median period of 187 (IQR 135-342) days. The median patient implementation before and after EM raw data cleaning was 83.3% (IQR 71.5%-93.9%) and 97.3% (IQR 95.8%-97.6%), respectively (Δ+14%). This difference is substantial enough to consider EM data cleaning to be capable of avoiding data misinterpretation and providing a cleaned data set for the adherence analysis in terms of implementation and persistence. CONCLUSIONS The CleanADHdata.R script is a semiautomated procedure that increases standardization and reproducibility. This script has broader applicability within the realm of digital health, as it can be used to clean adherence data collected with diverse digital technologies.
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Affiliation(s)
- Carole Bandiera
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Jérôme Pasquier
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Marie P Schneider
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
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McGrady ME, Ignjatovic V, Jones S, Bruce A, Goldenberg NA, Rizzi M, Thornburg CD, Todd KE, Luchtman-Jones L. Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2024:S1538-7836(24)00217-4. [PMID: 38642706 DOI: 10.1016/j.jtha.2024.04.003] [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: 02/01/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
In response to growing recognition that nonadherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this article was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this article was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.
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Affiliation(s)
- Meghan E McGrady
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
| | - Aisha Bruce
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA; Departments of Pediatrics and Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, California, USA; Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California, USA
| | - Kevin E Todd
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Al-Saleh S, Lee J, Rogers W, Insel K. Translation of a Successful Behavioral Intervention to a Digital Therapeutic Self-Management System for Older Adults. ERGONOMICS IN DESIGN 2024; 32:5-13. [PMID: 38487251 PMCID: PMC10936698 DOI: 10.1177/10648046211066409] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
Feature at a Glance: Nonadherence to hypertension medications is associated with negative health outcomes, which is of particular importance for older adults because of the high prevalence of hypertension in this population. To promote medication adherence among this group, we translated a behavioral intervention that improved adherence by 36% into a digital therapeutic self-management system. Design strategies included interviewing older adults, conducting usability evaluations after each iteration, and engaging a team of experts from nursing, cognitive psychology, pharmacy, human factors in aging, and software development. We outline our design process that can guide translation of other behavioral interventions into digital therapeutic platforms.
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Affiliation(s)
| | - Jeannie Lee
- Department of Pharmacy Practice & Science at the University of Arizona (UA) College of Pharmacy
- Division of Geriatrics, General Internal Medicine & Palliative Medicine at the UA College of Medicine
- Arizona Center on Aging
- Banner University Medical Center Geriatrics Clinic
| | - Wendy Rogers
- University of Illinois Urbana-Champaign
- McKechnie Family LIFE Home and the Health Technology Education Program
- Program Director of CHART (Collaborations in Health, Aging, Research, & Technology)
- Human Factors and Aging Laboratory
| | - Kathleen Insel
- Biobehavioral Health Science Division in the College of Nursing, University of Arizona
- University of Arizona Health Sciences Center sub-initiative "Next Generation Model of Health Aging."
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Huo M, Zhao R, Deng X, Wang Y, Liu Q, Yan J, Yu H. Psychometric assessment of the Adherence to Asthma Medication Questionnaire in asthma patients in China: a validation study. J Asthma 2024; 61:300-306. [PMID: 37830743 DOI: 10.1080/02770903.2023.2267142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Patients' medication adherence plays a critical role in the treatment and rehabilitation of disease. However, few tools are currently available that can be used to identify the reasons for their nonadherence with their medication regimens. It is possible to evaluate both the level of medication adherence of a patient as well as the reasons for it using the Adherence to Asthma Medication Questionnaire (AAMQ). The purpose of this study was to adapt the AAMQ for use in Chinese patients and a variety of asthma patients. METHODS A total of 242 asthma patients were recruited from Jinzhou in China. The Adherence to Asthma Medication Questionnaire was translated and back-translated using the Brislin translation model. Test-retest reliability, internal consistency, and stability all play a large role in determining the reliability of a scale. Confirmatory factor analysis was used to examine the scale's construct validity, and expert consultation was used to verify the scale's content validity. Statistics were deemed significant at p < 0.05. RESULTS The Cronbach's α value of the Chinese version of the AAMQ was 0.866, and the coefficient values for the three domains ranged between 0.702 and 0.798. The split-half reliability and stability values were 0.794 and 0.772, respectively. The content validity index of the scale (S-CVI) was 0.923, and the content validity index of the level of scale entry was 0.857-1.000. According to the confirmatory factor analysis, the chi-square degreed of freedom were 1.484, and the model fitting indices were all within normal limits. CONCLUSIONS The AAMQ had good reliability and validity for asthmatic patients. The results of the scale's assessment can be used as a criterion for medication adherence among asthmatic patients and to understand the causes. This study provides a reference for solving the problem of medication adherence among asthma patients and implementing targeted nursing measures. PATIENT OR PUBLIC CONTRIBUTION Gratitude is extended to all individuals collaborating in completing the survey and to the author.
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Affiliation(s)
- Mingshu Huo
- School of Nursing, Jinzhou Medical University, Liaoning, China
| | - Rui Zhao
- School of Nursing, Jinzhou Medical University, Liaoning, China
| | - Xiaoxue Deng
- School of Nursing, Jinzhou Medical University, Liaoning, China
| | - Ying Wang
- Department of Respiratory Medicine, The First Affiliated Hospital of Jinzhou Medical University, Liaoning, China
| | - Qiaoli Liu
- School of Nursing, Jinzhou Medical University, Liaoning, China
| | - Jiarong Yan
- School of Nursing, Jinzhou Medical University, Liaoning, China
| | - Hongyu Yu
- School of Nursing, Jinzhou Medical University, Liaoning, China
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Moharir S, Akotkar L, Aswar U, Kumar D, Gawade B, Pal K, Rane R. Improved Pharmacokinetic and Pharmacodynamic Profile of Deuterium-Reinforced Tricyclic Antidepressants Doxepin, Dosulepin, and Clomipramine in Animal Models. Eur J Drug Metab Pharmacokinet 2024; 49:181-190. [PMID: 38172422 DOI: 10.1007/s13318-023-00870-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Doxepin, dosulepin, and clomipramine are tricyclic antidepressants (TCAs) that act as serotonin and noradrenaline reuptake inhibitors. The metabolites formed by N-dealkylation of these tricyclic antidepressants contribute to overall poor pharmacokinetics and efficacy. Deuteration of the methyl groups at metabolically active sites has been reported to be a useful strategy for developing more selective and potent antidepressants. This isotopic deuteration can lead to better bioavailability and overall effectiveness. The objective is to study the effect of site-selective deuteration of TCAs on their pharmacokinetic and pharmacodynamic profile by comparison with their nondeuterated counterparts. METHODS In the current study, the pharmacokinetic profile and antidepressant behavior of deuterated TCAs were evaluated using the forced swim test (FST) and tail suspension test (TST), using male Wistar rats and male Swiss albino mice, respectively; additionally, a synaptosomal reuptake study was carried out. RESULTS Compared with the nondeuterated parent drugs, deuterated forms showed improved efficacy in the behavior paradigm, indicating improved pharmacological activity. The pharmacokinetic parameters indicated increased maximum concentration in the plasma (Cmax), elimination half-life (t1/2), and area under the concentration-time curve (AUC) in deuterated compounds. This can have a positive clinical impact on antidepressant treatment. Synaptosomal reuptake studies indicated marked inhibition of the reuptake mechanism of serotonin (5-HT) and norepinephrine. CONCLUSIONS Deuterated TCAs can prove to be potentially better molecules in the treatment of neuropsychiatric disorders as compared with nondeuterated compounds. In addition, we have demonstrated a concept that metabolically active, site-selective deuteration can be beneficial for improving the pharmacokinetic and pharmacodynamic profiles of TCAs. A further toxicological study of these compounds is needed to validate their future clinical use.
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Affiliation(s)
- Shreyash Moharir
- Department of Pharmaceutical Chemistry, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, 411038, India
| | - Likhit Akotkar
- Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, 411038, India
| | - Urmila Aswar
- Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, 411038, India
| | - Dileep Kumar
- Department of Pharmaceutical Chemistry, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, 411038, India
| | - Bapu Gawade
- Cleanchem Lifesciences Pvt. Ltd., Kopar-Khairane, Navi Mumbai, 400710, India
| | - Kavita Pal
- Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Kharghar, Navi Mumbai, 410210, India
| | - Rajesh Rane
- Department of Pharmaceutical Chemistry, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, 411038, India.
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Vrijens B, Pironet A, Tousset E. The Importance of Assessing Drug Exposure and Medication Adherence in Evaluating Investigational Medications: Ensuring Validity and Reliability of Clinical Trial Results. Pharmaceut Med 2024; 38:9-18. [PMID: 38135800 PMCID: PMC10824809 DOI: 10.1007/s40290-023-00503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
The objective of this current opinion paper is to draw global attention to medication adherence, emphasizing its crucial role in drug trials. Frequently, trialists lean on traditional approaches to assess medication adherence, which, while comfortable, may only reveal what trialists desire rather than offering the essential insights needed for informed decision making in drug development. Understanding drug exposure and medication adherence is paramount when evaluating the effectiveness and safety of investigational medications. Without a comprehensive understanding of how patients adhere to their prescribed treatment regimens, the integrity and dependability of clinical trial results can be compromised. This paper emphasizes the need for measures that accurately and reliably assess medication intake behaviors, enabling the differentiation between minor dosing errors and significant deviations that may impact the drug's efficacy and safety. Accurate knowledge of drug exposure empowers researchers to make informed decisions, identify potential confounding factors, and appropriately interpret study outcomes, ultimately ensuring the validity and reliability of the research findings. By prioritizing drug exposure assessment and medication adherence measurement, clinical trials can enhance their scientific rigor, contribute to more accurate evaluations of investigational medications, and ultimately speed up the development process.
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Affiliation(s)
- Bernard Vrijens
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium.
- Department of Public Health, Liège University, Liège, Belgium.
| | | | - Eric Tousset
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium
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Kirkland AE, Tomko RL, Green R, Browning BD, Ferguson PL, Liu H, Miranda R, Gray KM, Squeglia LM. Pairwise comparisons of three medication adherence outcomes in adolescents who use alcohol. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:2375-2385. [PMID: 38151786 PMCID: PMC10755249 DOI: 10.1111/acer.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/14/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Accurate assessment of medication adherence is important for understanding pharmacotherapy outcomes across all phases of adolescent substance use disorder (SUD) clinical trials. The objective of this study was to describe and assess the pairwise concordance between three commonly used non-biological medication adherence assessment methods in adolescents who use alcohol to inform the selection of medication adherence measures for use in future youth SUD trials. METHODS Participants (N = 32, 17-19-years-old) took N-acetylcysteine and placebo, in a randomized cross-over design, for 10 days each. Medication adherence was assessed (20 days total) via pill count, medication videos submitted twice daily, and the Medication Event Monitoring System (MEMS®). Lin's Concordance Correlation Coefficient (CCC) assessed concordance and Bland-Altman plots are reported. Linear mixed-effects models with main effects of medication, treatment block (first medication, second medication), and sequence were also run. RESULTS Medication videos yielded the lowest (64%) and pill count yielded the highest (89%) adherence estimates. CCC values indicated poor correspondence, except between pill count and MEMS. The Bland-Altman plots showed good pairwise agreement between all methods. Linear mixed-effects models indicated a difference between the first and second cross-over medication, with adherence estimates being lower for the second medication, regardless of whether it was N-acetylcysteine or placebo. CONCLUSIONS The study yielded important and practical information. First, incorporating more than one method of adherence assessment may capture estimated floor and ceiling adherence in the absence of a biological marker. This is particularly relevant for remote or hybrid studies where bio-marker collection is challenging. Selection of the assessment methods will depend on study goals. Second, the continuation of medication adherence research can benefit each phase of clinical trials and inform rigorous pharmacotherapy evaluation.
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Affiliation(s)
- Anna E. Kirkland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rachel L. Tomko
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - ReJoyce Green
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brittney D. Browning
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pamela L. Ferguson
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Helen Liu
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert Miranda
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
| | - Kevin M. Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lindsay M. Squeglia
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Bolgarina Z, Gonzalez-Gonzalez LF, Rodroiguez GV, Camacho A. Cranberry Supplements for Urinary Tract Infection Prophylaxis in Pregnant Women: A Systematic Review of Clinical Trials and Observational Studies on Efficacy, Acceptability, Outcomes Measurement Methods, and Studies' Feasibility. Cureus 2023; 15:e46738. [PMID: 38022216 PMCID: PMC10631496 DOI: 10.7759/cureus.46738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
Cranberry supplements are commonly used to prevent urinary tract infections (UTIs). However, their usefulness is uncertain in pregnant women. We aimed to comprehensively summarize the current knowledge on cranberry supplements' efficacy and acceptability during pregnancy in addition to the outcomes measurement methods and studies' feasibility. To achieve it, we searched PubMed, PMC, and Europe PMC databases plus screened citations followed by critical appraisal of included eligible English-written primary studies that (1) focused on pregnant women supplemented with any cranberry supplements; (2) provided data on cranberry supplements' efficacy, acceptability, outcomes measurement methods, and studies' feasibility; (3) included human subjects; and (4) published worldwide. Two randomized clinical trials (RCTs) and one nested cohort study, including 1156 pregnant women in total, contributed to our analysis. A tendency toward UTI reduction was demonstrated, although the results' validity was impacted by significant juice-induced gastrointestinal intolerance (23%; 44 of 188 subjects). Changing the form of supplementation from cranberry juice to capsules reduced the issue, causing side effects in one of 49 subjects (2%). Nevertheless, both RCTs still experienced significant recruitment and retention problems, which were at 33% and 59% on average, respectively. Newly acquired safety data on 919 more subjects suggests no increased risks of all malformations, vaginal bleeding, and neonatal complications. Investigating cranberry capsules' efficacy as a non-antibacterial option for UTI prevention in pregnant women has become a feasible and important direction with the current advancement in understanding cranberry supplements' actions, recommended doses plus regimens, and their safety in the population. We reviewed the challenges and discovered knowledge gaps and the implementation strategies for future studies.
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Affiliation(s)
- Zoryana Bolgarina
- Principles and Practice of Clinical Research, Harvard T.H. Chan School of Public Health, Boston, USA
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | | | | | - Alejandro Camacho
- Principles and Practice of Clinical Research, Harvard T.H. Chan School of Public Health, Boston, USA
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Huh KY, Lee H, Lee S, Yu K, Kim KH, Kim H. Exploration of smart adherence-monitoring methods in vitamin D-deficient patients: A pilot feasibility clinical study. Clin Transl Sci 2023; 16:1866-1875. [PMID: 37461832 PMCID: PMC10582656 DOI: 10.1111/cts.13594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/26/2023] Open
Abstract
Treatment adherence is an underestimated determinant of treatment success. Poor treatment adherence can also affect the efficacy of clinical trials. A combination of multiple adherence-monitoring methods is required to ensure robustness. We investigated whether multiple adherence-monitoring methods, including a novel smartwatch-based monitoring method, would yield reliable and concordant results. In this open, randomized, decentralized clinical trial, vitamin D-deficient individuals were randomized to an App - only group (an electronic medication diary) or an App + Watch group (i.e., App and smartwatch-based monitoring) groups after a week run-in period. The participants received vitamin D supplements (1000 IU) for 12 weeks (two consecutive periods of 6 weeks) with two pill counts (at the sixth week) and biweekly blood samplings for serum 25(OH) vitamin D concentration. Adherence was assessed and compared between the methods. Sixteen participants were enrolled, of which 13 completed the study. Serum 25(OH) vitamin D levels comparably increased in both groups until the first 7 weeks but trended higher in the App + Watch group in the second period. The number of doses recorded by the pill count and App did not differ significantly between the run-in and Period 1 (p = 0.5534) but became significantly discrepant in Period 2 (p = 0.0225). In contrast, the concordance for smartwatch-based monitoring was consistent in either period (p = 0.5898 and p = 0.5839, respectively). We explored multiple adherence-monitoring methods in this pilot feasibility clinical study. Smartwatch-based adherence monitoring may be an objective and sensitive method for measuring treatment adherence.
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Affiliation(s)
- Ki Young Huh
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | | | - SeungHwan Lee
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | - Kyung‐Sang Yu
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulKorea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular SurgerySeoul National University College of Medicine and HospitalSeoulKorea
| | - Heejin Kim
- Clinical Trials CenterSeoul National University HospitalSeoulKorea
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Denhaerynck K, Dobbels F, Košťálová B, De Geest S. Psychometric Properties of the BAASIS: A Meta-analysis of Individual Participant Data. Transplantation 2023; 107:1795-1809. [PMID: 36949037 PMCID: PMC10358438 DOI: 10.1097/tp.0000000000004574] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/16/2022] [Accepted: 12/11/2022] [Indexed: 03/24/2023]
Abstract
BACKGROUND Nonadherence to immunosuppressives, a risk factor for poor posttransplant outcomes, can be assessed by self-report using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS). Available in written and interview versions, and previously validated on content, the BAASIS is widely used in research and clinical practice. The aim of this study was to investigate its psychometric properties. METHODS Using a literature search and our BAASIS database, this meta-analysis identified completed studies in adult transplant recipients whose data were usable to examine the BAASIS' reliability and 3 validity aspects: (1) relationships with other variables (electronic monitoring, other self-report scales, tacrolimus blood-level variability, collateral report, depressive symptoms, psycho-behavioral constructs, and interventions); (2) response processes; and (3) internal structure. Testing used random-effects logistic regressions. RESULTS Our sample included 12 109 graft recipients from 26 studies. Of these 26, a total of 20 provided individual participant data. Evidence of the BAASIS' stability over time supports its reliability. Validity testing of relationships with other variables showed that BAASIS-assessed nonadherence was significantly associated with the selected variables: electronically monitored nonadherence ( P < 0.03), other self- and collaterally-reported nonadherence ( P < 0.001), higher variability in tacrolimus concentrations ( P = 0.02), higher barriers ( P < 0.001), lower self-efficacy ( P < 0.001), lower intention ( P < 0.001), and higher worries ( P = 0.02). Nonadherence also decreased after regimen change interventions ( P = 0.03). Response process evaluation indicated good readability and slightly higher nonadherence with the written version. Structurally, items on taking and timing shared variability. CONCLUSIONS The BAASIS shows good validity and reliability as a self-report instrument to assess medication nonadherence in transplantation.
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Affiliation(s)
- Kris Denhaerynck
- Institute of Nursing Science, Department of Public Health, University of Basel, Switzerland
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Barbora Košťálová
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Prague, Czech Republic
| | - Sabina De Geest
- Institute of Nursing Science, Department of Public Health, University of Basel, Switzerland
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Sharma JR, Dludla PV, Dwivedi G, Johnson R. Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication. Glob Heart 2023; 18:17. [PMID: 36968302 PMCID: PMC10038111 DOI: 10.5334/gh.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/16/2023] [Indexed: 03/29/2023] Open
Abstract
Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.
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Affiliation(s)
- Jyoti R. Sharma
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Phiwayinkosi V. Dludla
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Girish Dwivedi
- Medical School, University of Western Australia, Harry Perkins Institute of Medical Sciences, Fiona Stanley Hospital, Verdun Street, Nedlands WA, 6009, Australia
| | - Rabia Johnson
- Biomedical Research and Innovation Platform, South African Medical Research Council, Tygerberg 7505, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
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13
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Mantila KM, Pasmooij AM, Hallgreen CE, Mol PG, van Boven JF. Medication Adherence Measurement Methods in Registration Trials Supporting the Approval of New Medicines: A Cross-Sectional Analysis of Centralized Procedures in the European Union 2010-2020. Clin Pharmacol Ther 2022; 112:1051-1060. [PMID: 35816103 PMCID: PMC9795959 DOI: 10.1002/cpt.2709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/30/2022] [Indexed: 01/01/2023]
Abstract
Medication adherence is a key factor impacting efficacy and safety of medicines, yet how it is dealt with in European registration trials is unknown. A cross-sectional analysis of European Medicines Agency (EMA) marketing authorization dossiers for new medicines approved through centralized procedures in the European Union between 2010 and 2020 was performed. Data were extracted from European Public Assessment Reports and Clinical Study Reports. Clinical trials covering five therapeutic areas were included: diabetes, respiratory conditions, cardiovascular diseases, infectious diseases, and oncology. Outcomes included adherence assessment, measurement methods, and rates. Overall, 102 medicines studied in 253 clinical trials were reviewed. All but one study reported measuring adherence. Two hundred twenty trials (87%) measured adherence using quantitative methods, while 32 (13%) trials monitored adherence but did not further quantify. Reported adherence rates were high (> 90%) across trials yet marked disparities in measurement methods and definitions were found. The most frequently used adherence measurement method was pill/dose count (single method: 52.7%; in combination: 37.7%; with patient diary/report: 17.3%; electronic methods: 1.4%; bioanalytical methods: 4.1%). Patient diary/report (6.4%) and electronic methods (2.7%) were also used as single methods. Electronic methods were more often used in respiratory and anti-infective trials, while bioanalytical methods were more frequently used in diabetes. Overall, adherence is measured in EMA registration trials, yet the methods used and the way in which adherence rates are presented vary widely between trials and therapeutic areas. To better understand and compare efficacy of medicines, standardization of adherence definitions and measurement methods is needed.
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Affiliation(s)
- Katerina M. Mantila
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark,Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Dutch Medicines Evaluation BoardUtrechtThe Netherlands
| | | | - Christine Erikstrup Hallgreen
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Peter G.M. Mol
- Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Dutch Medicines Evaluation BoardUtrechtThe Netherlands
| | - Job F.M. van Boven
- Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Medication Adherence Expertise Center of the Northern Netherlands (MAECON)GroningenThe Netherlands
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14
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Smith-Diaz N, Stocker SL, Stamp LK, Dalbeth N, Phipps-Green AJ, Merriman TR, Wright DFB. An allopurinol adherence tool using plasma oxypurinol concentrations. Br J Clin Pharmacol 2022. [PMID: 36036094 DOI: 10.1111/bcp.15516] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/06/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS This study aimed to develop and evaluate an allopurinol adherence tool based on steady-state oxypurinol plasma concentrations, allopurinol's active metabolite. METHODS Plasma oxypurinol concentration were simulated stochastically from an oxypurinol pharmacokinetic model for allopurinol doses of 100-800 mg daily, accounting for differences in renal function, diuretic use, and ethnicity. For each scenario, the 20th percentile for peak and trough concentrations defined the adherence threshold, below which imperfect adherence was assumed. Predictive performance was evaluated using both simulated low adherence and against data from 146 individuals with paired oxypurinol plasma concentrations and adherence measures. Sensitivity and specificity (S&S), negative and positive predictive values (NPV, PPV) and receiver operating characteristic (ROC) area under the curve (AUC) were determined. The predictive performance of the tool was evaluated externally using RESULTS: The allopurinol adherence tool produced S&S values for trough thresholds of 89-98% and 76-84%, respectively, and 90%-98% and 76-83% for peak thresholds. PPV and NPV were 79-84% and 88-94% respectively for trough and 80-85% and 89-98% for peak concentrations. The ROC AUC values ranged from 0.84-0.88 and 0.86-0.89 for trough and peak concentrations, respectively. S&S values for the external evaluation were found to be 75.8% and 86.5%, respectively, producing a ROC AUC of 0.8113. CONCLUSION A tool to identify people with gout who require additional support to maintain adherence using plasma oxypurinol concentrations was developed and evaluated. The predictive performance of the tool is suitable for adherence screening in clinical trials and may have utility in some clinical practice settings.
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Affiliation(s)
| | | | - Lisa K Stamp
- Department of Medicine, University of Otago - Christchurch, Christchurch, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | | | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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15
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Salisbury KR, Ranpariya VK, Feldman SR. Accountability in reminder-based adherence interventions: A review. PATIENT EDUCATION AND COUNSELING 2022; 105:2645-2652. [PMID: 34953618 DOI: 10.1016/j.pec.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Interventions to elicit accountability capitalize on social behaviors to improve adherence but are distinct from reminders. However, little is known about the impact of accountability in reminder-based adherence interventions. Through a literature review, we aim to identify the frequency and effectiveness of accountability in reminder-based intervention studies. METHODS PubMed and PsycArticles were searched for reminder-based adherence studies. Articles were categorized as reminder-only or reminder with accountability studies. Studies were characterized by outcome measures, and differences between control and intervention groups were compared for studies that used electronic monitoring devices. RESULTS 165 studies met the inclusion criteria; 154 used reminders without accountability (93%). 79 of the 154 reminder-only studies (51%) improved adherence in intervention groups compared to controls. Eleven of the 165 studies (6.6%) included an accountability aspect. The intervention group had better adherence than controls in 10 out of the 11 reminder with accountability studies (91%). CONCLUSIONS Although distinct from reminders, accountability can be incorporated in reminder-based interventions. However, it is not commonly included in reminder-based interventions. PRACTICE IMPLICATIONS It is important to consider accountability's effects on encouraging patient medication adherence. The addition of accountability interventions may further boost adherence, but few studies currently incorporate these types of interventions.
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Affiliation(s)
- Katherine R Salisbury
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA.
| | - Varun K Ranpariya
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, USA; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, USA; Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, USA; Department of Dermatology, University of Southern Denmark, Odense, Denmark
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16
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Chen SC, Cheng HL, Han LF, Wu GT, Zhang RY, Suen LKP, Chen X, Yeung WF. Parent-administered pediatric tuina for the treatment of attention deficit hyperactivity disorder symptoms: Process evaluation of a pilot randomized controlled trial. Complement Ther Med 2022; 70:102854. [PMID: 35842070 DOI: 10.1016/j.ctim.2022.102854] [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: 10/27/2021] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A pilot randomized controlled trial (RCT) was conducted in mainland China to examine the feasibility, acceptability, and preliminary effects of parent-administered pediatric tuina on attention deficit hyperactivity disorder (ADHD) symptoms in preschool children. An embedded process evaluation was performed to explore barriers and facilitators in the implementation, identify additional questions, and refine the study design for a future fully powered study. METHODS The process evaluation comprises the following parts: (a) self-reported questionnaires on parents (n = 43), traditional Chinese medicine (TCM) practitioners (n = 2), outcome assessor (n = 1), and research assistant (n = 1); (b) parent logbook on parent-administered pediatric tuina (n = 32); and (c) focus group interview sessions (n = 15). Accomplishment of the self-report questionnaires was voluntary for all participants and compulsory for research personnel and TCM practitioners. The parent logbook on the intervention was filled out by all participants in the intervention group. Participants of focus group interviews were selected via purposive sampling, and data were analyzed with template analysis. Qualitative findings were summarized in tables, while the mean was calculated to reflect the quantitative findings. RESULTS Perceived benefits, acceptability of parents and children, and professional support from the research team facilitated the implementation of the intervention. Meanwhile, the TCM pattern identification using online mode may limit the accuracy and lead to parents doubting the precision of the TCM pattern. This limitation was regarded as a major barrier. Parents perceived improvements in terms of children's appetite, sleep quality, and parent-child relationship. Participants were generally satisfied with the settings of parent-administered pediatric tuina and showed satisfactory adherence to the implementation. CONCLUSIONS Implementation of parent-administered pediatric tuina intervention is feasible and acceptable. The intervention can be refined by improving the TCM pattern identification procedure and adjusting outcome settings in a fully powered study in the future.
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Affiliation(s)
- Shu-Cheng Chen
- School of Nursing, The Hong Kong Polytechnic University, HKSAR, China
| | - Hui-Lin Cheng
- School of Nursing, The Hong Kong Polytechnic University, HKSAR, China
| | - Le-Fei Han
- School of Global Health, Chinese Center for Tropical Diseases Research, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guo-Tao Wu
- Faculty of Psychology, Southwest University, Chongqing, China
| | - Ru-Yi Zhang
- Department of Psychology, University of Victoria, Canada
| | | | - Xi Chen
- School of Nursing, The Hong Kong Polytechnic University, HKSAR, China
| | - Wing-Fai Yeung
- School of Nursing, The Hong Kong Polytechnic University, HKSAR, China.
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17
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Delameillieure A, Wuyts WA, Pironet A, Dobbels F. Electronically monitored medication adherence in idiopathic pulmonary fibrosis: prevalence, predictors and outcomes. ERJ Open Res 2022; 8:00030-2022. [PMID: 35923422 PMCID: PMC9339768 DOI: 10.1183/23120541.00030-2022] [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: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/05/2022] Open
Abstract
Medication adherence studies in idiopathic pulmonary fibrosis (IPF) are limited, use cross-sectional designs and report discontinuation rates. We prospectively investigated adherence to pirfenidone in IPF patients using electronic monitoring, which provides insights on whether and when the medication was taken on a day-by-day basis. We investigated the impact of nonadherence on lung function and selected predictors for nonadherence based on the COM-B behavioural model. The longitudinal statistical analyses included generalised estimation equations and linear mixed effects models. 55 patients initiating pirfenidone were followed-up for 2 years after diagnosis (76.4% men, mean age 71.1 years (range 50–87 years), mean forced vital capacity (FVC) 88% predicted (sd 18.3), mean diffusing capacity of the lung for carbon monoxide (DLCO) 58.1% predicted (sd 14.7)). Our data showed an association (p=0.03) between the proportion of days with three pirfenidone intakes (i.e. dosing adherence) and FVC % predicted, whereby a high dosing adherence seemed necessary to maintain stable or improving FVC % predicted values. 58.2% of the participants were able to implement at least 90% correct dosing days, yet adherence significantly decreased over time. Too short dosing intervals had negative effects on lung function outcomes. Knowledge on IPF and self-reported adherence were significantly associated with electronically measured adherence. In conclusion, nonadherence is prevalent and might negatively affect lung function. Further research is needed on the impact of nonadherence on outcomes and its predictors, so that tailored interventions can be developed. Meanwhile, a self-report questionnaire could be used to identify adherence issues and teams should equip patients with knowledge about their treatment and how to take it. This study used electronic monitoring systems for the first time in IPF patients to assess taking and timing of pirfenidone. Medication nonadherence is a prevalent issue that increases over time and is associated with patients’ lung function outcomes.https://bit.ly/3wEFUlq
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18
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Tong A, Oberbauer R, Bellini MI, Budde K, Caskey FJ, Dobbels F, Pengel L, Rostaing L, Schneeberger S, Naesens M. Patient-Reported Outcomes as Endpoints in Clinical Trials of Kidney Transplantation Interventions. Transpl Int 2022; 35:10134. [PMID: 35669971 PMCID: PMC9163311 DOI: 10.3389/ti.2022.10134] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/17/2022] [Indexed: 12/13/2022]
Abstract
Patient-reported outcomes (PROs) that assess individuals' perceptions of life participation, medication adherence, disease symptoms, and therapy side effects are extremely relevant in the context of kidney transplantation. All PROs are potentially suitable as primary or secondary endpoints in interventional trials that aim to improve outcomes for transplant recipients. Using PRO measures (PROMs) in clinical trials facilitates assessment of the patient's perspective of their health, but few measures have been developed and evaluated in kidney transplant recipients; robust methodologies, which use validated instruments and established frameworks for reporting, are essential. Establishing a core PROM for life participation in kidney transplant recipients is a critically important need, which is being developed and validated by the Standardized Outcomes in Nephrology (SONG)-Tx Initiative. Measures involving electronic medication packaging and smart technologies are gaining traction for monitoring adherence, and could provide more robust information than questionnaires, interviews, and scales. This article summarizes information on PROs and PROMs that was included in a Broad Scientific Advice request on clinical trial design and endpoints in kidney transplantation. This request was submitted to the European Medicines Agency (EMA) by the European Society for Organ Transplantation in 2016. Following modifications, the EMA provided its recommendations in late 2020.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fergus J. Caskey
- Department of Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Lionel Rostaing
- Department of Nephrology, Dialysis and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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19
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Grayek EN, Fischhoff B, Davis AL, Krishnamurti T. The value of adherence information during clinical pharmaceutical trials. Clin Trials 2022; 19:326-336. [PMID: 35510559 DOI: 10.1177/17407745221084127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIMS The quality of the evidence used to evaluate a drug's safety and efficacy depends, in part, on how well participants adhere to the prescribed drug-taking regime. There are multiple approaches to measure adherence in clinical trials, varying in their cost and accuracy. We demonstrate a method for evaluating the cost-effectiveness of common adherence monitoring methods, considering the costs and data quality for drugs that differ in how forgiving they are of nonadherence. METHODS We propose a simulation approach to estimate the value of evidence about adherence, considering both costs of collection and potential errors in interpreting clinical trial results. We demonstrate the approach with a simulated clinical trial of nitrendipine, a common calcium channel blocker. We consider two trial designs, one using pretrial adherence to "enrich" the trial sample and one without an enrichment strategy. We use scenarios combining high and low values of two key properties of a clinical trial: participant adherence and drug forgiveness. RESULTS Under the conditions of these simulations, the most cost-effective adherence monitoring approach depends on both trial participant adherence and drug forgiveness. For example, the enrichment strategy is not cost-effective for the base scenario (high forgiveness and high adherence), but is for other scenarios. We also estimate the effects of evaluable patient analysis, a controversial procedure that excludes nonadherent participants from the analyses, after a trial is completed. CONCLUSIONS Our proposed approach can guide drug regulators and developers in designing efficient clinical trials and assessing the impact of nonadherence on trial results. It can identify cost-effective adherence-monitoring methods, given available knowledge about the methods, drug, and patients' expected adherence.
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Affiliation(s)
- Emily N Grayek
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Alexander L Davis
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Tamar Krishnamurti
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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20
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Donoghue K, Hermann L, Brobbin E, Drummond C. The rates and measurement of adherence to acamprosate in randomised controlled clinical trials: A systematic review. PLoS One 2022; 17:e0263350. [PMID: 35113930 PMCID: PMC8812903 DOI: 10.1371/journal.pone.0263350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/17/2022] [Indexed: 12/03/2022] Open
Abstract
AIM The current research aims to systematically review the rates of adherence reported in randomised controlled clinical trials of acamprosate. It also sought to determine the reliability of the adherence monitoring and measurement methods used in these trials. METHODS The protocol for this review was pre-registered (PROSPERO: CRD42021230011). A search of the literature was conducted using OVID MEDLINE, Embase and PsycINFO from database inception to January 2021. Randomised controlled trials with a minimum sample size of 10 per treatment arm that compared the efficacy of acamprosate with placebo or other active medication in adults with a diagnosis of alcohol dependence were included. Data on rates of adherence, methods of measurement and monitoring of adherence was extracted from eligible studies independently in duplicate by two reviewers. A weighted mean adherence rate was calculated. The reliability of adherence monitoring methods was determined by calculating an adherence-assurance score based on the adherence monitoring method used. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS Fifteen studies met the eligibility criteria involving 4,450 participants (2,480 participants in the placebo arms). A mean adherence rate of 88% (54.2-95.0%) was reported across studies that reported the percentage of medication taken. A mean adherence rate of 84.9% (56.4-91.3%) was reported for trials that reported the percentage of participants taking more than 80% of medication prescribed. There is low confidence in the methods used to monitor adherence with all clinical trials having a low adherence-assurance rating. Risk of bias was judged to be high for all included studies. CONCLUSIONS Adherence to acamprosate in clinical trials can be poor with low confidence in the methods used to measure it. Adherence rates therefore might not be accurate, which has implications for determining the efficacy of acamprosate.
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Affiliation(s)
- Kim Donoghue
- Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- * E-mail:
| | - Laura Hermann
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- Institute of Clinical and Applied Health Research, University of Hull, Hull, United Kingdom
| | - Eileen Brobbin
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Colin Drummond
- National Addictions Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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21
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Abstract
BACKGROUND Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort. OBJECTIVE The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics. METHODS This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index. RESULTS The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001). CONCLUSION Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed. IMPLICATION FOR PRACTICE Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.
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22
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Eziefula C, Shah FT, Anie KA. Promoting Adherence to Iron Chelation Treatment in Beta-Thalassemia Patients. Patient Prefer Adherence 2022; 16:1423-1437. [PMID: 35698633 PMCID: PMC9188463 DOI: 10.2147/ppa.s269352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/29/2022] [Indexed: 01/19/2023] Open
Abstract
Thalassaemia is one of the commonest inherited genetic disorders world-wide with around 25,000 births of the most severely affected transfusion dependent children annually. Patients with transfusion dependent thalassaemia require regular blood transfusions to maintain life but because of this will develop iron overload. To remove the excess iron, patients are required to take iron chelation therapy (ICT). ICT requires lifelong adherence to treatment to prevent end organ damage from developing. Many of these preventable complications make adherence to therapy more complex for patients. In this review, we focus on two commonly encountered patient scenarios and discuss how different psychological models and a relational theory can be used to understand and support adherence to treatment.
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Affiliation(s)
- Chinea Eziefula
- Camden & Islington NHS Foundation Trust, London, UK
- Psychology Services, Whittington Health NHS Trust, London, UK
| | - Farrukh T Shah
- Department of Haematology, Whittington Health NHS Trust, London, UK
- Medical Director for Transfusion, NHSBT, London, UK
- Correspondence: Farrukh T Shah, Department of Haematology, Whittington Health, Magdala Avenue, London, N19 5NF, Tel +44 0207 288 5144, Email
| | - Kofi A Anie
- London North West University Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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23
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Hamrahian SM, Maarouf OH, Fülöp T. A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider. Patient Prefer Adherence 2022; 16:2749-2757. [PMID: 36237983 PMCID: PMC9552797 DOI: 10.2147/ppa.s368784] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.
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Affiliation(s)
- Seyed Mehrdad Hamrahian
- Department of Medicine - Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
- Correspondence: Seyed Mehrdad Hamrahian, Department of Medicine - Nephrology, Thomas Jefferson University, 33S 9th Street, Suite 700, Philadelphia, PA, 19107, USA, Tel +1 215-503 3000, Fax +1 215-503 4099, Email
| | - Omar H Maarouf
- Department of Medicine - Nephrology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tibor Fülöp
- Department of Medicine - Nephrology, Medical University of South Carolina, Charleston, SC, USA
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24
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Lasala R, Santoleri F. Association between adherence to oral therapies in cancer patients and clinical outcome: A systematic review of the literature. Br J Clin Pharmacol 2021; 88:1999-2018. [PMID: 34784654 DOI: 10.1111/bcp.15147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/23/2023] Open
Abstract
AIMS Adherence to therapy is a key factor in successful treatment. The aim of this systematic review is to assess the extent to which patients with better adherence to oral therapy have better clinical outcomes among cancer patients. METHODS All studies published in PubMed up to 20 October 2020, which considered the use of oral anticancer drugs for cancer patients and which correlated treatment adherence with a clinical outcome, were considered. RESULTS From the 42 studies considered in the systematic review, 14 were for oncological indications and 28 for haematological indications. There was considerable variance in calculation methods, outcomes considered, and in the definitions of adherence. However, it emerged that most studies reported a significant correlation between adherence to therapy and clinical outcome. CONCLUSION As adherence to therapy is a key factor in achieving a better clinical outcome, future studies with large samples, robust endpoints and the use of at least two methods of assessing adherence would be desirable in order to produce more robust evidence.
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Baumgartner SL, Buffkin DE, Rukavina E, Jones J, Weiler E, Carnes TC. A Novel Digital Pill System for Medication Adherence Measurement and Reporting: Usability Validation Study. JMIR Hum Factors 2021; 8:e30786. [PMID: 34747709 PMCID: PMC8663639 DOI: 10.2196/30786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background Medication nonadherence is a costly problem that is common in clinical use and clinical trials alike, with significant adverse consequences. Digital pill systems have proved to be effective and safe solutions to the challenges of nonadherence, with documented success in improving adherence and health outcomes. Objective The aim of this human factors validation study is to evaluate a novel digital pill system, the ID-Cap System from etectRx, for usability among patient users in a simulated real-world use environment. Methods A total of 17 patients with diverse backgrounds who regularly take oral prescription medications were recruited. After training and a period of training decay, the participants were asked to complete 12 patient-use scenarios during which errors or difficulties were logged. The participants were also interviewed about their experiences with the ID-Cap System. Results The participants ranged in age from 27 to 74 years (mean 51 years, SD 13.8 years), and they were heterogeneous in other demographic factors as well, such as education level, handedness, and sex. In this human factors validation study, the patient users completed 97.5% (196/201) of the total use scenarios successfully; 75.1% (151/201) were completed without any failures or errors. The participants found the ID-Cap System easy to use, and they were able to accurately and proficiently record ingestion events using the device. Conclusions The participants demonstrated the ability to safely and effectively use the ID-Cap System for its intended use. The ID-Cap System has great potential as a useful tool for encouraging medication adherence and can be easily implemented by patient users.
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Affiliation(s)
| | | | | | - Jason Jones
- Tensentric, Inc., Boulder, CO, United States
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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Takeuchi H, Sanches M, Borlido C, Agid O, Remington G. Antipsychotic nonadherence measured by electronic adherence monitoring in stabilized chronic schizophrenia: Clinical implications. Schizophr Res 2021; 237:202-207. [PMID: 34563881 DOI: 10.1016/j.schres.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/16/2021] [Accepted: 08/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There have been a number of studies investigating antipsychotic adherence measured by electronic adherence monitoring (EAM) in patients with schizophrenia. However, no study has looked at overall adherence and both baseline and endpoint illness/symptom severity. METHODS We performed a secondary analysis of our previous study to examine antipsychotic adherence, as measured by EAM, and illness/symptom severity at baseline and endpoint in patients with schizophrenia. Adherence rates were defined as the proportion of adherent days over 3 months. Adherent days were defined as the subject having taken the medication at the prescribed time, with 2 tolerance margins operationally defined i.e., ±3 h and ±12 h. In addition, a dichotomous version of adherence was defined i.e., if he/she was adherent greater than 80% of the days. Illness severity and symptom severity were assessed using the Brief Psychiatric Rating Scale (BPRS) total score and the Clinical Global Impression - Severity of illness (CGI-S) scale score, respectively. RESULTS A total of 111 patients were enrolled in the study. Neither continuous or dichotomous adherence rates were significantly associated with baseline or endpoint illness/symptom severity (all Ps ≥ 0.05). The results remained unchanged when adjusting for clinico-demographic characteristics. CONCLUSION Antipsychotic adherence, as measured by EAM, was not associated with illness/symptom severity at baseline and endpoint in patients with chronic schizophrenia, whose clinical status and adherence pattern were stabilized. This suggests that individuals may be able to achieve clinical stability in the face of maintenance antipsychotic treatment despite variations in adherence.
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Affiliation(s)
- Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Canada
| | - Marcos Sanches
- Biostatistical Consulting Service, Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, Canada
| | - Carol Borlido
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Canada
| | - Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Gary Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.
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Adherence is a key factor for interpreting the results of exercise interventions. Physiotherapy 2021; 113:8-11. [PMID: 34555674 DOI: 10.1016/j.physio.2021.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/04/2021] [Accepted: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Adherence may be an important factor to consider when interpreting the results of an exercise intervention. This article will discuss the importance of measuring and reporting adherence to exercise interventions that are designed to improve targeted health outcomes. Additionally, we will propose and describe a universal method to measure and report adherence to exercise interventions.
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29
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Busby J, Matthews JG, Chaudhuri R, Pavord ID, Hardman TC, Arron JR, Bradding P, Brightling CE, Choy DF, Cowan DC, Djukanovic R, Hanratty CE, Harrison TW, Holweg CT, Howarth PH, Fowler SJ, Lordan JL, Mansur AH, Menzies-Gow A, Niven RM, Robinson DS, Walker SM, Woodcock A, Heaney LG. Factors affecting adherence with treatment advice in a clinical trial of patients with severe asthma. Eur Respir J 2021; 59:13993003.00768-2021. [PMID: 34561291 PMCID: PMC9202483 DOI: 10.1183/13993003.00768-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
Background Understanding why patients with severe asthma do not follow healthcare provider (HCP) advice to adjust treatment is critical to achieving personalised disease management. Methods We reviewed patient choice to follow HCP advice to adjust asthma treatment in a UK-based randomised, controlled, single-blind (study participant), multicentre, parallel group 48-week clinical study comparing biomarker-directed treatment adjustment with standard care in severe asthma. Results Of 1572 treatment advisories (291 participants), instructions were followed in 1377 cases (87.6%). Patients were more likely to follow advice to remain on treatment (96.7%) than to either reduce (70.3%) or increase (67.1%) their treatment, with 64% of patients following all treatment advice. Multivariate analysis associated belonging to an ethnic minority group (OR 3.10, 95% CI 1.68–5.73) and prior study medication changes (two or more changes: OR 2.77, 95% CI 1.51–5.10) with failure to follow treatment advice. In contrast, emergency room attendance in the prior year (OR 0.54, 95% CI 0.32–0.92) was associated with following treatment advice. The largest effect was seen with transition onto or off oral corticosteroids (OR 29.28, 95% CI 16.07–53.36) when compared with those requested to maintain treatment. Centre was also an important determinant regarding the likelihood of patients to follow treatment advice. Conclusions Belonging to an ethnic minority group and multiple prior treatment adjustments were associated with not following HCP treatment advice. Patients also responded differently to HCP advice across UK specialist centres. These findings have implications for the generalisability of models of care in severe asthma and require further focused studies. Belonging to a minority ethnic group, multiple prior medication changes, being treated at a specific clinical centre, introduction of systemic corticosteroids and increased asthma symptoms were associated with resistance to asthma treatment modificationhttps://bit.ly/3gYb66S
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Affiliation(s)
- John Busby
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | | | - Rekha Chaudhuri
- NHS Greater Glasgow and Clyde Health Board, Gartnavel General Hospital, and University of Glasgow, Glasgow, UK
| | - Ian D Pavord
- Nuffield Department of Medicine, Oxford Respiratory NIHR BRC, The University of Oxford, Oxford, UK
| | | | | | - Peter Bradding
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christopher E Brightling
- Department of Respiratory Sciences, Institute for Lung Health and Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David F Choy
- Genentech Inc., South San Francisco, California, USA
| | - Douglas C Cowan
- NHS Greater Glasgow and Clyde, Stobhill Hospital, Glasgow, UK
| | - Ratko Djukanovic
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Catherine E Hanratty
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Tim W Harrison
- Nottingham Respiratory NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - Peter H Howarth
- School of Clinical and Experimental Sciences, University of Southampton, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James L Lordan
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Adel H Mansur
- University of Birmingham and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Robert M Niven
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | | | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
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Krause AV, Bertram A, Nöhre M, Bauer-Hohmann M, Schiffer M, de Zwaan M. Use of an electronic medication monitoring device to estimate medication adherence in kidney transplant patients. Transl Behav Med 2021; 11:842-851. [PMID: 33710349 DOI: 10.1093/tbm/ibaa122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Electronic medication monitoring devices (EMD) have been used as a gold standard for assessing medication adherence. We used a wireless EMD (SimpleMed+), assessed its usability in patients after kidney transplantation (KTx), evaluated adherence, and analyzed concordance with other adherence measures. Fifty-five patients (53% female, mean age 46 years) at least 6 months after KTx agreed to use the EMD over a period of 8 weeks. Self-reported adherence was measured with the BAASIS, and immunosuppressant trough level variability was assessed prior to and again during the study period. Fourteen patients stopped using the EMD or were low users (<70%). These non-completers reported that using the EMD would interfere with their daily activities. Taking-adherence of the completers was high with 98.3% (±1.9) over the entire study period. Timing-adherence was somewhat lower (94.6% ± 7.9) and decreased during the second half of the study. We found statistically significant correlations between EMD results and self-reported adherence with moderate effect sizes, but no significant association with trough level variability. The low usage of the EMD supports the need to assess the practicability of an EMD before applying it in research and clinical routine. Taking- and timing-adherence of KTx patients using the EMD was satisfactory. Self-reported adherence might be a good enough estimate of medication adherence.
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Affiliation(s)
- Anna Viktoria Krause
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hanover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hanover, Germany
| | - Anna Bertram
- Integrated Research and Treatment Center Transplantation (IFB-Tx), Hanover, Germany.,Department of Nephrology and Hypertension, Hannover Medical School, Hanover, Germany.,Department of Nephrology, Angiology and Rheumatology, KRH Regional Hospital Hannover Siloah, Hanover, Germany
| | - Mariel Nöhre
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Maximilian Bauer-Hohmann
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Mario Schiffer
- Department of Nephrology and Hypertension, Hannover Medical School, Hanover, Germany.,Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hanover, Germany
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Abstract
The COVID-19 pandemic has been a catalyst for the implementation of decentralized clinical trials (DCTs) enabled by digital health technologies (DHTs) in the field while curtailing in-person interactions and putting significant demands on health care resources. DHTs offer improvements in real-time data acquisition remotely while maintaining privacy and security. Here, we describe the implications of technologies, including edge computing, zero-trust environments, and federated computing in DCTs enabled by DHTs. Taken together, these technologies—in the setting of policy and regulation that enable their use while protecting the users—extend the scope and accelerate the pace of clinical research.
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Mahfoud F, Azizi M, Ewen S, Pathak A, Ukena C, Blankestijn PJ, Böhm M, Burnier M, Chatellier G, Durand Zaleski I, Grassi G, Joner M, Kandzari DE, Kirtane A, Kjeldsen SE, Lobo MD, Lüscher TF, McEvoy JW, Parati G, Rossignol P, Ruilope L, Schlaich MP, Shahzad A, Sharif F, Sharp ASP, Sievert H, Volpe M, Weber MA, Schmieder RE, Tsioufis C, Wijns W. Proceedings from the 3rd European Clinical Consensus Conference for clinical trials in device-based hypertension therapies. Eur Heart J 2021; 41:1588-1599. [PMID: 32211888 PMCID: PMC7174031 DOI: 10.1093/eurheartj/ehaa121] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/19/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, F-75015 Paris, France.,APHP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France.,F-CRIN INI-CRCT Network, Nancy, France
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Atul Pathak
- F-CRIN INI-CRCT Network, Nancy, France.,Department of Cardivascular Medicine, INSERM 1048, Princess Grace Hospital (CHPG), Avenue Pasteur, 98000 Monaco, Monaco
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Gilles Chatellier
- Université de Paris, INSERM CIC1418, F-75015 Paris, France.,APHP, Hôpital Européen Georges Pompidou, Clinical Trial Unit, F-75015 Paris, France
| | | | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Michael Joner
- Deutsches Herzzentrum München, Munich, Germany.,Deutsches Zentrum für Herz- und Kreislauf-Forschung (DZHK) e.V. (German Center for Cardiovascular Research), Partner Site Munich, Munich, Germany
| | | | - Ajay Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | | | - Melvin D Lobo
- William Harvey Research Institute, Centre for Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, Zürich, Switzerland.,Royal Brompton and Harefield Hospital Trust, Imperial College London, London, UK
| | | | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca-Istituto Auxologico Italiano, IRCCS, Milano, Italy
| | - Patrick Rossignol
- F-CRIN INI-CRCT Network, Nancy, France.,Université de Lorraine, Inserm, Centre d'Investigations cliniques-plurithématique 1433, Inserm U1116, Nancy, France.,CHRU Nancy, Nancy, France
| | - Luis Ruilope
- Institute of Research i+12 and CIBER CV, Hospital 12 de Octubre and Faculty of Sport Medicine, European University, Madrid, Spain
| | - Markus P Schlaich
- Dobney Hypertension Centre, The University of Western Australia-Royal Perth Hospital Campus, Perth, Australia.,Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Atif Shahzad
- National University of Ireland Galway, Galway, Ireland.,Galway University Hospital, Galway, Ireland
| | - Faisal Sharif
- National University of Ireland Galway, Galway, Ireland.,Galway University Hospital, Galway, Ireland
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, UK.,University of Exeter, Exeter, UK
| | - Horst Sievert
- CardioVascular Center Frankfurt CVC, Frankfurt, Germany.,Anglia Ruskin University, Chelmsford, UK.,University California San Francisco UCSF, San Francisco, USA.,Yunnan Hospital Fuwai, Kunming, China
| | - Massimo Volpe
- Sapienza University of Rome-Sant'Andrea Hospital Rome and IRCCS Neuromed, Pozzilli, Italy
| | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital, Erlangen, Germany
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William Wijns
- The Lambe Institute for Translational Medicine, National University of Ireland Galway, Galway, Ireland
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Leshno A, Gaton D, Singer R, Eliasi E, Vorobichik-Berar O, Madgar S, Stern O, Jaber W, Kapelushnik N, Skaat A. A novel EyePhone© App for improving adherence to glaucoma therapy. Graefes Arch Clin Exp Ophthalmol 2021; 259:1253-1262. [PMID: 33528649 DOI: 10.1007/s00417-021-05091-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/28/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Despite advances in glaucoma treatment options, patient adherence and compliance remain very low. The EyePhone© App is a free non-commercial reminder application designed specifically for the needs of glaucoma patients. In this study, we evaluated its usefulness in improving adherence to medical treatment among glaucoma patients. METHODS This is a prospective multicenter interventional study. Glaucoma patients were recruited from a tertiary center and a large community glaucoma service center. After a short explanation, the EyePhone© App was installed on their smartphone device, and the notifications for the current medical treatment were entered. After enrollment and at 1-month follow-up, subjects completed the Morisky Medication Adherence Scale (MMAS-8) and the Quality of Life and Glaucoma 17-item (GlauQOL-17) questionnaires for evaluation of adherence and QOL, respectively. RESULTS In the study, 133 patients (71 men and 62 women) aged 62±15.5 years and using 2.0±0.9 IOP-lowering drugs participated. The proportion of highly adherent subjects improved from 29.3% (39/133) at baseline to 42.1% (56/133) at follow-up (P < 0.001), and the proportion of poorly adherent subjects decreased from 29.3 (39/133) to 20.3% (27/133) at follow-up (P = 0.012). QOL also improved, as evidenced by a significant increase in the GlauQOL-17 score (P < 0.05). In a subgroup of patients for whom IOP measurements were available, IOP reduced by 0.92 mmHg (P = 0.069). CONCLUSIONS Significant improvements in glaucoma adherence and QOL were achieved among poorly adherent glaucoma patients after 1 month of using the EyePhone© App.
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Affiliation(s)
- Ari Leshno
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Dan Gaton
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
- Glaucoma Institute, "Clalit" Healthcare Services, Century Tower, Tel Aviv, Israel
| | - Reut Singer
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elior Eliasi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofri Vorobichik-Berar
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Shiran Madgar
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Ori Stern
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Wasim Jaber
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Kapelushnik
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Skaat
- The Sam Rothberg Glaucoma Center, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schnadower D, Roskind CG, VanBuren JM, Powell EC, Norris JG, Tarr PI, Sapien RE, O’Connell KJ, Chun TH, Rogers AJ, Bhatt SR, Mahajan P, Gorelick MH, Vance C, Dean JM, Freedman SB. Factors Associated With Nonadherence in an Emergency Department-based Multicenter Randomized Clinical Trial of a Probiotic in Children With Acute Gastroenteritis. J Pediatr Gastroenterol Nutr 2021; 72:24-28. [PMID: 32804911 PMCID: PMC10171126 DOI: 10.1097/mpg.0000000000002904] [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] [Indexed: 12/10/2022]
Abstract
ABSTRACT Nonadherence in clinical trials affects safety and efficacy determinations. Predictors of nonadherence in pediatric acute illness trials are unknown. We sought to examine predictors of nonadherence in a multicenter randomized trial of 971 children with acute gastroenteritis receiving a 5-day oral course of Lactobacillus rhamnosus GG or placebo. Adherence, defined as consuming all doses of the product, was reported by the parents and recorded during daily follow-up contacts. Of 943 patients with follow-up data, 766 (81.2%) were adherent. On multivariate analysis, older age (OR 1.19; 95% CI: 1.00-1.43), increased vomiting duration (OR 1.23; 95% CI: 1.05-1.45), higher dehydration score (OR 1.23, 95% CI: 1.07-1.42), and hospitalization following ED discharge (OR 4.16, 95% CI: 1.21--14.30) were factors associated with nonadherence; however, those with highest severity scores were more likely to adhere (OR 0.87, 95% CI: 0.80-0.95). These data may inform strategies and specific targets to maximize adherence in future pediatric trials.
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Affiliation(s)
- David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati OH
| | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - John M. VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jesse G. Norris
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Phillip I. Tarr
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Robert E. Sapien
- Division of Emergency Medicine, Children’s National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - Karen J. O’Connell
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children’s Hospital and Brown University, Providence, RI
| | - Thomas H. Chun
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor
| | - Alexander J. Rogers
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Seema R. Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati OH
| | - Prashant Mahajan
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, CA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Design and conduct of confirmatory chronic pain clinical trials. Pain Rep 2020; 6:e845. [PMID: 33511323 PMCID: PMC7837951 DOI: 10.1097/pr9.0000000000000854] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022] Open
Abstract
The purpose of this article is to provide readers with a basis for understanding the emerging science of clinical trials and to provide a set of practical, evidence-based suggestions for designing and executing confirmatory clinical trials in a manner that minimizes measurement error. The most important step in creating a mindset of quality clinical research is to abandon the antiquated concept that clinical trials are a method for capturing data from clinical practice and shifting to a concept of the clinical trial as a measurement system, consisting of an interconnected set of processes, each of which must be in calibration for the trial to generate an accurate and reliable estimate of the efficacy (and safety) of a given treatment. The status quo of inaccurate, unreliable, and protracted clinical trials is unacceptable and unsustainable. This article gathers aspects of study design and conduct under a single broad umbrella of techniques available to improve the accuracy and reliability of confirmatory clinical trials across traditional domain boundaries.
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Kably B, Billaud EM, Boutouyrie P, Azizi M. Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up? Curr Hypertens Rep 2020; 22:96. [PMID: 33052474 DOI: 10.1007/s11906-020-01105-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs. RECENT FINDINGS Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.
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Affiliation(s)
- Benjamin Kably
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Eliane M Billaud
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Pierre Boutouyrie
- Université de Paris, F-75006, Paris, France
- Pharmacology Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
- Inserm U970, Paris Centre de Recherche Cardiovasculaire-PARCC, F-75015, Paris, France
| | - Michel Azizi
- Université de Paris, F-75006, Paris, France.
- Hypertension Unit, DMU CARTE, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France.
- Inserm, CIC 1418, F-75015, Paris, France.
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Valgimigli M, Garcia-Garcia HM, Vrijens B, Vranckx P, McFadden EP, Costa F, Pieper K, Vock DM, Zhang M, Van Es GA, Tricoci P, Baber U, Steg G, Montalescot G, Angiolillo DJ, Serruys PW, Farb A, Windecker S, Kastrati A, Colombo A, Feres F, Jüni P, Stone GW, Bhatt DL, Mehran R, Tijssen JGP. Standardized classification and framework for reporting, interpreting, and analysing medication non-adherence in cardiovascular clinical trials: a consensus report from the Non-adherence Academic Research Consortium (NARC). Eur Heart J 2020; 40:2070-2085. [PMID: 29992264 DOI: 10.1093/eurheartj/ehy377] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 07/04/2018] [Indexed: 01/02/2023] Open
Abstract
Non-adherence has been well recognized for years to be a common issue that significantly impacts clinical outcomes and health care costs. Medication adherence is remarkably low even in the controlled environment of clinical trials where it has potentially complex major implications. Collection of non-adherence data diverge markedly among cardiovascular randomized trials and, even where collected, is rarely incorporated in the statistical analysis to test the consistency of the primary endpoint(s). The imprecision introduced by the inconsistent assessment of non-adherence in clinical trials might confound the estimate of the calculated efficacy of the study drug. Hence, clinical trials may not accurately answer the scientific question posed by regulators, who seek an accurate estimate of the true efficacy and safety of treatment, or the question posed by payers, who want a reliable estimate of the effectiveness of treatment in the marketplace after approval. The Non-adherence Academic Research Consortium is a collaboration among leading academic research organizations, representatives from the U.S. Food and Drug Administration and physician-scientists from the USA and Europe. One in-person meeting was held in Madrid, Spain, culminating in a document describing consensus recommendations for reporting, collecting, and analysing adherence endpoints across clinical trials. The adoption of these recommendations will afford robustness and consistency in the comparative safety and effectiveness evaluation of investigational drugs from early development to post-marketing approval studies. These principles may be useful for regulatory assessment, as well as for monitoring local and regional outcomes to guide quality improvement initiatives.
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Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Hector M Garcia-Garcia
- Interventional Cardiology Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium.,Faculty of Medicine and Life Sciences Hasselt University, Hasselt, Belgium
| | | | - Francesco Costa
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.,Department of Clinical and Experimental Medicine, Policlinic "G Martino", University of Messina, Italy
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriel Steg
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Andrew Farb
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Antonio Colombo
- Interventional Cardiology Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Department, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Fausto Feres
- Division of Cardiology, Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Peter Jüni
- Institute of Primary Health Care, Toronto, Canada
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jan G P Tijssen
- European Cardiovascular Research Institute, Rotterdam, The Netherlands.,Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Sarr M, Gueye D, Mboup A, Diouf O, Bao MDB, Ndiaye AJ, Ndiaye BP, Hawes SE, Tousset E, Diallo A, Jones F, Kane CT, Thiam S, Ndour CT, Gottlieb GS, Mboup S. Uptake, retention, and outcomes in a demonstration project of pre-exposure prophylaxis among female sex workers in public health centers in Senegal. Int J STD AIDS 2020; 31:1063-1072. [PMID: 32819210 PMCID: PMC7750667 DOI: 10.1177/0956462420943704] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Senegal pre-exposure prophylaxis (PrEP) Demonstration Project was an open-label cohort study assessing the delivery of daily oral PrEP to HIV-negative female sex workers (FSWs) in four Ministry of Health (MoH)-run clinics in Dakar, Senegal. We assessed uptake, retention in care, and adherence over up to 12 months of follow-up as well as HIV infection rates. Between July and November 2015, 350 individuals were approached and 324 (92.6%) were preliminarily eligible. Uptake was high, with 82.4% of eligible participants choosing to enroll and take PrEP. The mean age of those enrolled was 37.7 years (SD = 8.7), and approximately half had not attended school (41.2%). Among the 267 participants who were prescribed PrEP, 79.9 and 73.4% were retained in PrEP care at 6 and 12 months, respectively. Older age among FSWs was found to be the only significant predictor of lower discontinuation. We did not find significant differences in retention by site, education, condom use, or HIV risk perception. There were no new HIV infections at follow-up. Our results showed evidence of high interest in PrEP and very good PrEP retention rates among FSWs at 12-month follow-up when offered in MoH-run clinics, with older age as the only significant predictor of higher PrEP retention. This highlights the role that these clinics can play in expanding PrEP access nationwide.
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Affiliation(s)
- Moussa Sarr
- Westat, Inc., Rockville, MD, USA
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
- Moussa Sarr, 1600 Research Blvd, WB 258,
Rockville, MD 20850, USA.
| | - Daouda Gueye
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Aminata Mboup
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Ousmane Diouf
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Mame D Bousso Bao
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Anna Julienne Ndiaye
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Birahim P Ndiaye
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
| | - Stephen E Hawes
- Departments of Epidemiology and Global Health, School of Public
Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Coumba T Kane
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
- Faculte de Médicine et de Pharmacie, Université Cheikh Anta
Diop, Dakar, Sénégal
| | - Safiatou Thiam
- Conseil national de lutte contre le sida (CNLS), Dakar,
Sénégal
| | - Cheikh T Ndour
- Division de Lutte contre le Sida et les IST, Ministère de la
Santé et de l’Action Sociale, Dakar, Sénégal
| | - Geoffrey S Gottlieb
- Department of Medicine, Allergy and Infectious Diseases, Center
for Emerging and Re-Emerging Infectious Diseases and Department of Global
Health, University of Washington, Seattle, WA, USA
| | - Souleymane Mboup
- IRESSEF: Institut de Recherche en Santé de Surveillance
Epidémiologique et de Formations, Dakar, Sénégal
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Takeuchi H, Borlido C, Sanches M, Teo C, Harber L, Agid O, Remington G. Adherence to clozapine vs. other antipsychotics in schizophrenia. Acta Psychiatr Scand 2020; 142:87-95. [PMID: 32627168 DOI: 10.1111/acps.13208] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND To date, there have been no studies evaluating adherence to clozapine with electronic adherence monitoring (EAM) such as the Medication Event Monitoring System (MEMS® ). METHODS In outpatients with schizophrenia, we conducted a 3-month prospective study investigating antipsychotic adherence with EAM (eCAP® ). Participants were treated with different oral antipsychotics, including clozapine, and blind to EAM monitoring; all were on antipsychotic monotherapy administered once daily. Outcome measures included adherence rate, missed dose, and medication gap. Adherence trajectory patterns were also analyzed for clozapine vs. other antipsychotics collectively. RESULTS A total of 111 patients were included in the study; 33 and 78 patients received clozapine or other antipsychotics, respectively. Adherence rates, defined as proportion of days that the subject took the medication at the prescribed time ± 3 h and proportion of subjects with ≥80% adherence, were numerically higher in patients receiving clozapine vs. other antipsychotics (72.0% vs. 65.1%, P = 0.10; 49.5% vs. 35.7%, P = 0.11, respectively). Along similar lines, some of the missed dose and medication gap outcomes were significantly better in patients receiving clozapine vs. other antipsychotics. Three adherence trajectory patterns were identified for both clozapine and other antipsychotics, with two shared by both groups (i.e., low adherence with a slight decrease over time; high and stable adherence). CONCLUSION Findings suggest that in patients with schizophrenia clozapine adherence is at least comparable, if not slightly better, compared with other antipsychotics.
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Affiliation(s)
- H Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - C Borlido
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - M Sanches
- Biostatistical Consulting Service, Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - C Teo
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - L Harber
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - O Agid
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - G Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
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41
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Yaegashi H, Kirino S, Remington G, Misawa F, Takeuchi H. Adherence to Oral Antipsychotics Measured by Electronic Adherence Monitoring in Schizophrenia: A Systematic Review and Meta-analysis. CNS Drugs 2020; 34:579-598. [PMID: 32219681 DOI: 10.1007/s40263-020-00713-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Poor adherence to oral antipsychotics is common in patients with schizophrenia; nonetheless, there has been no systematic review or meta-analysis on medication adherence measured by electronic adherence monitoring (EAM), considered by many as the 'gold standard' assessment. METHODS We systematically searched MEDLINE and Embase to identify studies investigating adherence to oral antipsychotics using EAM in patients with schizophrenia spectrum disorder. There were no exclusion criteria. We looked at the methodology in each study and defined which type of adherence was used in the study. Data on medication adherence, definition of satisfactory adherence (i.e., the threshold set in terms of the percentage of times medication was taken as prescribed), and factors associated with adherence were extracted for the included studies. Further, data on the rates of medication adherence were quantitatively synthesized. RESULTS A total of 19 studies involving 2184 patients were included. EAM-measured medication adherence was classified into three outcome types: taking adherence, regimen adherence, and timing adherence. The meta-analysis yielded oral antipsychotic adherence rates (defined as a continuous variable) of 71.1% for taking adherence [from seven studies, n = 256, 95% confidence interval (CI) 58.0-84.1], 70.0% for regimen adherence (from five studies, n = 174, 95% CI = 63.6-76.4), and 64.9% for timing adherence (from four studies, n = 212, 95% CI 53.2-76.6), respectively. The proportions of patients with oral antipsychotic adherence, when defined as a dichotomous variable, ranged from 50 to 78.3% for the 70% threshold for satisfactory adherence, 29.8-75.7% for the 75% threshold, and 47.8-75.7% for the 80% threshold. Factors associated with poor medication adherence were greater symptom severity, more frequent dosing regimen, poorer insight, and more negative drug attitude. CONCLUSIONS Oral antipsychotic adherence rates in schizophrenia, defined as a continuous variable and measured by EAM, were in the range of 70%, lower than the 80% threshold used widely to define satisfactory adherence.
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Affiliation(s)
| | - So Kirino
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Gary Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | - Hiroyoshi Takeuchi
- Yamanashi Prefectural Kita Hospital, Yamanashi, Japan. .,Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Getz K, Smith Z, Shafner L, Hanina A. Assessing the Scope and Predictors of Intentional Dose Non-adherence in Clinical Trials. Ther Innov Regul Sci 2020; 54:1330-1338. [PMID: 33258096 DOI: 10.1007/s43441-020-00155-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although there is broad agreement that the accurate estimation of non-adherence rates in clinical trials is essential to determining the dose-response relationship, treatment safety and efficacy effects, no accurate estimates have ever been produced. METHODS This study used a novel platform combining artificial intelligence and virtual patient monitoring to identify and quantify the scope of unreported intentional non-adherence in clinical trials of new medical therapies. Nearly 260,000 observations were drawn from a convenience sample of 2976 study volunteers participating in 23 clinical trials of psychiatric, neurological and neuromuscular diseases. RESULTS The results indicate that 4% of all confirmed doses were intentionally non-adherent, 48% of all study volunteers had at least one intentionally non-adherent dose and 5% of study volunteers were intentionally non-adherent for more than one-third of all doses required. CONCLUSIONS Several factors were associated with, and predictive of, unreported intentional non-adherence including clinical trial phase; clinical trial duration; geographic location where the study was conducted; and investigative site enrollment volume. The findings also show that although the overall rate of intentional non-adherence does not change over the course of a clinical trial, study volunteers who deliberately chose not to take their first dose had a mean intentional non-adherence rate five times higher than that observed among those who were first dose adherent. Implications of the study results are discussed.
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Affiliation(s)
- Kenneth Getz
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, 75 Kneeland Street, Suite 1100, Boston, MA, 02111, USA.
| | - Zachary Smith
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, 75 Kneeland Street, Suite 1100, Boston, MA, 02111, USA
| | - Laura Shafner
- AiCure, 19 West 24th Street, 11th Floor, New York, NY, 10010, USA
| | - Adam Hanina
- AiCure, 19 West 24th Street, 11th Floor, New York, NY, 10010, USA
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Niechciał E, Acerini CL, Chiesa ST, Stevens T, Dalton RN, Daneman D, Deanfield JE, Jones TW, Mahmud FH, Marshall SM, Neil HAW, Dunger DB, Marcovecchio ML. Medication Adherence During Adjunct Therapy With Statins and ACE Inhibitors in Adolescents With Type 1 Diabetes. Diabetes Care 2020; 43:1070-1076. [PMID: 32108022 PMCID: PMC7282885 DOI: 10.2337/dc19-0884] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 01/26/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Suboptimal adherence to insulin treatment is a main issue in adolescents with type 1 diabetes. However, to date, there are no available data on adherence to adjunct noninsulin medications in this population. Our aim was to assess adherence to ACE inhibitors and statins and explore potential determinants in adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS There were 443 adolescents with type 1 diabetes recruited into the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) and exposed to treatment with two oral drugs-an ACE inhibitor and a statin-as well as combinations of both or placebo for 2-4 years. Adherence was assessed every 3 months with the Medication Event Monitoring System (MEMS) and pill count. RESULTS Median adherence during the trial was 80.2% (interquartile range 63.6-91.8) based on MEMS and 85.7% (72.4-92.9) for pill count. Adherence based on MEMS and pill count dropped from 92.9% and 96.3%, respectively, at the first visit to 76.3% and 79.0% at the end of the trial. The percentage of study participants with adherence ≥75% declined from 84% to 53%. A good correlation was found between adherence based on MEMS and pill count (r = 0.82, P < 0.001). Factors associated with adherence were age, glycemic control, and country. CONCLUSIONS We report an overall good adherence to ACE inhibitors and statins during a clinical trial, although there was a clear decline in adherence over time. Older age and suboptimal glycemic control at baseline predicted lower adherence during the trial, and, predictably, reduced adherence was more prevalent in subjects who subsequently dropped out.
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Affiliation(s)
- Elżbieta Niechciał
- Department of Pediatric Diabetes, Endocrinology and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Scott T Chiesa
- Institute of Cardiovascular Science, University College London, London, U.K
| | - Tracey Stevens
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - R Neil Dalton
- Evelina Children's Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, U.K
| | - Denis Daneman
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - John E Deanfield
- Institute of Cardiovascular Science, University College London, London, U.K
| | - Timothy W Jones
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Farid H Mahmud
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Sally M Marshall
- Institute of Cellular Medicine (Diabetes), Faculty of Clinical Medical Sciences, Newcastle University, Newcastle upon Tyne, U.K
| | - H Andrew W Neil
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, U.K
| | - David B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, U.K.,Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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Eliasson L, Clifford S, Mulick A, Jackson C, Vrijens B. How the EMERGE guideline on medication adherence can improve the quality of clinical trials. Br J Clin Pharmacol 2020; 86:687-697. [PMID: 32034923 DOI: 10.1111/bcp.14240] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 11/27/2019] [Accepted: 01/12/2020] [Indexed: 01/01/2023] Open
Abstract
Medication adherence in drug trials is suboptimal, affecting the quality of these studies and adding significant costs. Nonadherence in this setting can lead to null findings, unduly large sample sizes and the need for dose modification after a drug has been approved. Despite these drawbacks, adherence behaviours are not consistently measured, analysed or reported appropriately in trial settings. The ESPACOMP Medication Adherence Reporting Guideline (EMERGE) offers a solution by facilitating a sound protocol design that takes this crucial factor into account. This article summarises key evidence on traditional and newer measurements of adherence, discusses implementation in clinical trial settings and makes recommendations about the analysis and interpretation of adherence data. Given the potential benefits of this approach, the authors call on regulators and the pharmaceutical industry to endorse the EMERGE guideline.
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Affiliation(s)
| | | | - Amy Mulick
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Bernard Vrijens
- AARDEX Group, Seraing, Belgium.,Liège University, Liège, Belgium
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Abstract
The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.
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Affiliation(s)
- Michel Burnier
- From the Service of Nephrology and Hypertension, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.B.)
| | - Brent M Egan
- Department of Medicine, Care Coordination Institute, University of South Carolina School of Medicine, Greenville, SC (B.M.E.)
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Makris E, Hu L, Jones GB, Wright JM. Moving the Dial on Heart Failure Patient Adherence Rates. Patient Prefer Adherence 2020; 14:2407-2418. [PMID: 33324042 PMCID: PMC7733338 DOI: 10.2147/ppa.s283277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Heart failure remains a substantive contributor to patient morbidity and mortality rates worldwide and represents a significant burden on the healthcare ecosystem. Faced with persistent physical symptoms and debilitating social consequences, patients follow complex treatment regimens and often have difficulty adhering to them. PURPOSE In this manuscript, we review factors which contribute to low adherence rates and advance potential single- and multi-factor-based interventions. It is hoped that these observations can lead to improvements in managed care of this vulnerable population of patients. METHODS A narrative review of the primary literature was performed on contributing factors with primary focus on the period 2015-2020 using available databases and search engines. Adherence pain points identified were mapped against a series of potential solutions which are presented. RESULTS Enhancement of treatment adherence relies on two approaches viz. single-factor and multi-factor solutions. Single factors identified include electronic reminders, enhanced health education, financial incentives, gamification strategies, community drivers, persona-based modeling, and burden relief of poly pharmacy. Multi-factor solutions combine two or more of the seven approaches offering the potential for flexible interventions tailored to the individual. DISCUSSION AND CONCLUSION Heart failure patients with poor adherence have increased mortality, hospitalization needs, and healthcare costs. This review highlights current single-factor and multi-factor adherence methods. Against a backdrop of diversity of approaches, multi-factor solutions cast the widest net for positively influencing adherent behaviors. A key enabler lies in the development and leveraging of patient personas in the synthesis of successful intervention methods. Deployable solutions can also be envisioned in clinical trials where adherence tracking represents an essential component.
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Affiliation(s)
- Eleanna Makris
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
| | - Lucy Hu
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
| | - Graham B Jones
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
- Clinical and Translational Science Institute, Tufts University Medical Center, Boston, MA02111, USA
- Correspondence: Graham B Jones Email
| | - Justin M Wright
- TRD Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ07936, USA
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Gewandter JS, Dworkin RH, Turk DC, Devine EG, Hewitt D, Jensen MP, Katz NP, Kirkwood AA, Malamut R, Markman JD, Vrijens B, Burke L, Campbell JN, Carr DB, Conaghan PG, Cowan P, Doyle MK, Edwards RR, Evans SR, Farrar JT, Freeman R, Gilron I, Juge D, Kerns RD, Kopecky EA, McDermott MP, Niebler G, Patel KV, Rauck R, Rice ASC, Rowbotham M, Sessler NE, Simon LS, Singla N, Skljarevski V, Tockarshewsky T, Vanhove GF, Wasan AD, Witter J. Improving Study Conduct and Data Quality in Clinical Trials of Chronic Pain Treatments: IMMPACT Recommendations. THE JOURNAL OF PAIN 2019; 21:931-942. [PMID: 31843583 DOI: 10.1016/j.jpain.2019.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Abstract
The estimated probability of progressing from phase 3 analgesic clinical trials to regulatory approval is approximately 57%, suggesting that a considerable number of treatments with phase 2 trial results deemed sufficiently successful to progress to phase 3 do not yield positive phase 3 results. Deficiencies in the quality of clinical trial conduct could account for some of this failure. An Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting was convened to identify potential areas for improvement in trial conduct in order to improve assay sensitivity (ie, ability of trials to detect a true treatment effect). We present recommendations based on presentations and discussions at the meeting, literature reviews, and iterative revisions of this article. The recommendations relate to the following areas: 1) study design (ie, to promote feasibility), 2) site selection and staff training, 3) participant selection and training, 4) treatment adherence, 5) data collection, and 6) data and study monitoring. Implementation of these recommendations may improve the quality of clinical trial data and thus the validity and assay sensitivity of clinical trials. Future research regarding the effects of these strategies will help identify the most efficient use of resources for conducting high quality clinical trials. PERSPECTIVE: Every effort should be made to optimize the quality of clinical trial data. This manuscript discusses considerations to improve conduct of pain clinical trials based on research in multiple medical fields and the expert consensus of pain researchers and stakeholders from academia, regulatory agencies, and industry.
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Affiliation(s)
| | | | | | | | | | | | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts; Tufts University, Boston, Massachusetts
| | - Amy A Kirkwood
- CR UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK
| | | | - John D Markman
- University of Rochester Medical Center, Rochester, New York
| | | | | | | | - Daniel B Carr
- Tufts University School of Medicine, Boston, Massachusetts
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | | | | | - Scott R Evans
- George Washington University, Washington, District of Columbia
| | - John T Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roy Freeman
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Ian Gilron
- Queen's University, Kingston, Ontario, Canada
| | - Dean Juge
- Horizon Pharma, Lake Forest, Illinois
| | | | | | | | | | | | - Richard Rauck
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Neil Singla
- Lotus Clinical Research, Pasadena, California
| | | | | | | | - Ajay D Wasan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Witter
- National Institutes of Health, Bethesda, Maryland
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Leggett C, Giles L, Anderson JJA, Doogue M, Couper J, Pena AS. Adherence to metformin is reduced during school holidays and weekends in children with type 1 diabetes participating in a randomised controlled trial. Arch Dis Child 2019; 104:890-894. [PMID: 31079072 DOI: 10.1136/archdischild-2018-316303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/16/2019] [Accepted: 04/24/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Non-adherence to treatment in childhood chronic illness has serious consequences for health and healthcare costs. Accurate detailed objective data on adherence are minimal in this age group. OBJECTIVE To evaluate medication adherence using electronic monitoring systems in children with type 1 diabetes (T1D). DESIGN A cohort study of 90 T1D children (aged 13.6±2.5 years, 41 males) from two paediatric diabetes clinics, participated in a 12-month double-blind, randomised, placebo-controlled trial (1:1 allocation). This cohort provided 28 336 days of study observations; 7138 school holiday and 8875 weekend/public holiday days. METHOD Adherence to intervention (metformin (n=45) or placebo (n=45)) was measured objectively by Medication Event Monitoring Systems (MEMS) including proportion of medication doses taken and daily adherence patterns and by tablet count at 3, 6 and 12 months. The trial was completed in June 2015. RESULTS There was an average (SD) of 363.3 (42) days of MEMS observations available for each study participant (94.1 (12.6) school holiday days and 117.1 (13.4) weekend/public holiday days). Adherence reduced during school holidays (adjusted OR (aOR) 0.81; 95% CI 0.72 to 0.91; p<0.001) and during weekends/public holidays (aOR 0.74; 95% CI 0.69 to 0.80; p<0.001). Adverse effects to the intervention did not affect overall adherence (aOR 0.77; 95% CI 0.3 to 2.01; p=0.6). Age, gender, body mass index, diabetes duration, insulin dose, HbA1c (Haemoglobin A1c) or socioeconomic status did not predict adherence. CONCLUSION Medication adherence was reduced during school holidays and on weekends in children with T1D. Clinical characteristics including socioeconomic status and the presence of adverse effects did not predict adherence. TRIAL REGISTRATION NUMBER ACTRN12611000148976.
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Affiliation(s)
- Catherine Leggett
- SA Pharmacy, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Lynne Giles
- School of Public Health, University of Adelaide, Robinson Institute, Adelaide, South Australia, Australia
| | - Jemma Jay Angela Anderson
- Endocrinology and Diabetes Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Discipline of Paediatrics, University of Adelaide, Robinson Research Institute, Adelaide, South Australia, Australia
| | - Matthew Doogue
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Jennifer Couper
- Endocrinology and Diabetes Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Discipline of Paediatrics, University of Adelaide, Robinson Research Institute, Adelaide, South Australia, Australia
| | - Alexia Sophie Pena
- Endocrinology and Diabetes Department, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Discipline of Paediatrics, University of Adelaide, Robinson Research Institute, Adelaide, South Australia, Australia
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Mallayasamy S, Chaturvedula A, Fossler MJ, Sale ME, Hendrix CW, Haberer JE. Assessment of Demographic and Socio-Behavioral Factors on Adherence to HIV Pre-Exposure Prophylaxis Using a Markov Modeling Approach. Front Pharmacol 2019; 10:785. [PMID: 31354496 PMCID: PMC6639421 DOI: 10.3389/fphar.2019.00785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/17/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: Adherence is important for the effectiveness of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP). The objective of the current work is to assess the impact of multiple demographic and socio-behavioral factors on the adherence to tenofovir-based PrEP among HIV serodiscordant couples in East Africa using Markov mixed-effects modeling approach. Methods: The Partners Demonstration Project was a prospective, open-label, implementation science-driven study of HIV PrEP among heterosexual HIV serodiscordant couples in Kenya and Uganda. The uninfected partner received oral PrEP according to the “bridge to antiretroviral therapy [ART]” strategy (i.e., until the infected partner had been on ART for ≥6 months). Adherence was monitored electronically; demographic and socio-behavioral data were collected during study visits. Analyzed data reflect 12 months of follow-up per participant. A two-state, first-order, discrete time Markov model was developed with longitudinal adherence data characterized by “dose taking (1)” and “dose missing (0).” Covariate effects were linearly added in the logit domain of transition probability parameters (P01 and P10) in the model. The full covariate model was initially developed, followed by backward elimination process to reduce the model. All significant covariates reported by a prior primary statistical analysis of the same data were included in the full covariate model. Results: The model included data from 920 participants, who were predominantly male (65%). Significant covariates associated with higher adherence were 25 years or older [odds ratio (OR) for P10, 0.61], female sex (OR for P10, 0.67), participant wanting the relationship with the partner to succeed (OR for P10, 0.79; OR for P01, 1.45), and sex with partner either with 100% or <100% condom use compared to those reported no sex (OR for P10, 0.84; OR for P01, 1.21). Significant covariates associated with lower adherence were partner on ART >6 months (OR for P01, 0.86; OR for P10, 1.34), subject in the study for >6 months (OR for P01, 0.8; OR for P10, 1.25), and problematic alcohol use (OR for P01, 0.63; OR for P10, 1.16). Conclusion: The developed Markov model provides a mechanistic understanding of relationship between demographic, socio-behavioral covariates, and PrEP adherence, by indicating the pattern of adherence influenced by each factor over time. Such data can be used for further intervention development to promote PrEP adherence.
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Affiliation(s)
| | | | - Michael J Fossler
- UNT System College of Pharmacy, UNTHSC, Fort Worth, TX, United States.,Trevena Inc, King of Prussia, PA, United States
| | - Mark E Sale
- UNT System College of Pharmacy, UNTHSC, Fort Worth, TX, United States.,Nuventra, Raleigh, NC, United States
| | - Craig W Hendrix
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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50
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Relationship Between Anticoagulant Medication Adherence and Satisfaction in Patients With Stroke. J Neurosci Nurs 2019; 51:229-234. [DOI: 10.1097/jnn.0000000000000463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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