Is the MARS questionnaire a reliable measure of medication adherence in childhood asthma?

Non-adherence to urate lowering therapy in gout after 5 years is related to poor outcomes: results from the NOR-Gout study

OBJECTIVES

Patients with gout need to adhere to medication over time to achieve good outcomes. We assessed self-reported adherence to medication with urate lowering therapy (ULT) 5 years after a treat-to-target intervention and studied how non-adherence was related to baseline demographic and disease variables.

METHODS

Patients in the NOR-Gout observational study were included after a recent gout flare and serum urate >360 µmol/l. Patients [mean age 56.2 (S.D. 13.6), 94.5% males, 17.2% with tophi] attended tight-control visits over one year with escalating urate lowering therapy using a treat-to-target strategy. Five-year follow-up included the Medication Adherence Report Scale (MARS-5) questionnaire (range 5-25) for adherence. Flares and SUA target achievement were compared for 5-year adherence to medication.

RESULTS

At 5 years most of the 163 patients used ULT (95.1%). MARS-5 adherence scores after 5 years were high (median 24, interquartile range 22-25). Patients in the lowest MARS-5 quartile had, compared with the highest quartile, more often a flare during the last year of follow-up (33.3% vs 9.5%, P = 0.004) and reached the 5-yr serum urate treatment target less frequently (45.2% vs 87.5%, P < 0.001). Baseline lower age (OR 0.56, 95%CI 0.39-0.79), non-European origin (OR 0.22, 95%CI 0.06-0.80), lower SF-36 mental health scores (OR 0.94, 95%CI 0.91-0.98) and less joint pain during last flare (OR 0.73, 95%CI 0.58-0.92) were independent risk factors for non-adherence to medication.

CONCLUSIONS

Patients reported high adherence to medication after 5 years. Non-adherence was related to more flares and less urate target achievement. Younger age and non-European origin were associated with non-adherence.

Insights into adherence to medication and lifestyle recommendations in an international cohort of patients with catecholaminergic polymorphic ventricular tachycardia

AIMS

In patients with catecholaminergic polymorphic ventricular tachycardia (CPVT), a rare inherited arrhythmia syndrome, arrhythmic events can be prevented by medication and lifestyle recommendations. In patients who experience breakthrough arrhythmic events, non-adherence plays an essential role. We aimed to investigate the incidence and potential reasons for non-adherence to medication and lifestyle recommendations in a large, international cohort of patients with CPVT.

METHODS AND RESULTS

An online multilingual survey was shared with CPVT patients worldwide by their cardiologists, through peer-recruitment, and on social media from November 2022 until July 2023. Self-reported non-adherence was measured using the validated Medication Adherence Rating Scale (MARS) and a newly developed questionnaire about lifestyle. Additionally, validated questionnaires were used to assess potential reasons for medication non-adherence. Two-hundred-and-eighteen patients completed the survey, of whom 200 (92%) were prescribed medication [122 (61%) female; median age 33.5 years (interquartile range: 22-50)]. One-hundred-and-three (52%) were prescribed beta-blocker and flecainide, 85 (43%) beta-blocker, and 11 (6%) flecainide. Thirty-four (17%) patients experienced a syncope, aborted cardiac arrest or appropriate implantable cardioverter defibrillator shock after diagnosis. Nineteen (13.4%) patients were exercising more than recommended. Thirty (15%) patients were non-adherent to medication. Female sex [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.3-12.0, P = 0.019], flecainide monotherapy compared to combination therapy (OR 6.8, 95% CI 1.6-31.0, P = 0.010), and a higher agreement with statements regarding concerns about CPVT medication (OR 1.2, 95% CI 1.1-1.3, P < 0.001) were independently associated with non-adherence.

CONCLUSION

The significant rate of non-adherence associated with concerns regarding CPVT-related medication, emphasizes the potential for improving therapy adherence by targeted patient education.

Measurement of adherence to inhaled corticosteroids by self-report and electronic medication monitoring

OBJECTIVE

Poor adherence to daily inhaled corticosteroids (ICS) is an important factor contributing to asthma morbidity. Assessing adherence in clinical settings using self-reported adherence often overestimates actual adherence. Electronic monitoring devices (EMDs) are objective means of assessing adherence, but are not routinely used in practice. Here, we aimed to establish adherence rates to ICS using EMDs in an inner-city, minority population in the Bronx, NY, and to compare two methods of self-reported adherence with EMD-measured adherence.

METHODS

Patients with physician-confirmed persistent asthma and daily ICS prescription were recruited. Self-reported adherence to ICS was measured by parental report for children and self-report for adults and the Medication Adherence Report Scale for Asthma (MARS-A). Two weeks after enrollment, EMD data were accessed for analysis. Daily adherence was calculated based on the number of puffs actuated per day as captured by EMD divided by the prescribed number of puffs.

RESULTS

41 children and 40 adults participated. Median EMD-measured ICS adherence was 41% (children) and 43% (adults). This was significantly lower than the median self-reported adherence (100% for children, p < 0.001; 100% for adults, p < 0.001). MARS-A score in children did not correlate with EMD adherence data (p = 0.18), while in adults, this correlation tended to be more consistent (p = 0.07).

CONCLUSIONS

Adherence to daily ICS as measured using EMD is low in this population. In both adults and children, self-reported adherence was a poor indicator of true adherence. Further efforts using objective measures of medication adherence for patients with high asthma morbidity may be warranted to guide therapeutic decisions.

Transanal Irrigation in Children: Treatment Success, Quality of Life, Adherence, Patient Experience, and Independence

OBJECTIVES

To investigate the clinical effectiveness and patient experience of transanal irrigation (TAI) in children with constipation or fecal incontinence.

METHODS

Combined retrospective and cross-sectional study including pediatric patients who used a Navina TAI system. We retrospectively collected baseline characteristics and data on treatment success at 1- and 6-month follow-up (FU). Treatment success was defined as defecating at least 3 times per week and having less than 1 episode of fecal incontinence per week. We cross-sectionally assessed health-related quality of life (HRQoL), treatment adherence, treatment satisfaction (Treatment Satisfaction Questionnaire for Medication [TSQM]), illness perceptions, medication beliefs, and patient empowerment with validated questionnaires.

RESULTS

Thirty-four patients were included (median age at start TAI: 11 years old [range, 6-18]), 32 in the retrospective review, and 26 in the cross-sectional survey (median of 3 years after initiation). Most patients were diagnosed with functional constipation (n = 26; 76%) or a neurogenic bowel disorder (n = 6; 18%). Treatment success rates significantly improved at each FU compared with baseline (baseline: 4/25 [16%]; 1-month FU: 12/16 [75%], P = 0.008; 6-month FU: 11/18 [61%], P = 0.016; cross-sectional FU: 13/26 [50%], P = 0.008). HRQoL scores were high (PedsQL median, 73 [IQR, 54-85]). Adherence (defined as Medication Adherence Report Scale [MARS] ≥ 23) was low (36%), whereas TSQM effectiveness scores were high (median, 69 [IQR, 47-86]). The majority of children (61%) reported an increase in independence since TAI treatment. Patient empowerment (GYPES) levels were similar to those reported in children with other chronic conditions.

CONCLUSIONS

TAI with a Navina system is an effective bowel management system for children with intractable constipation or fecal incontinence.

Psychometric evaluation of the medication adherence report scale in caregivers of low-income, urban, African American children with poorly controlled asthma

OBJECTIVE

Accurately assessing asthma medication usage among low-income, urban, African American children is essential to reduce asthma health disparities. The purpose of this study was to examine the factor structure of the five-item Medication Adherence Report Scale (MARS), in a sample of caregivers of low-income, urban, African American youth with poorly controlled asthma.

METHOD

Using baseline data from a randomized clinical trial evaluating the efficacy of an environmental control educational intervention, confirmatory factor analysis (CFA) was conducted to ascertain the MARS factor structure. Construct validity was assessed using a regression model inclusive of caregiver-reported medication adherence, Asthma Medication Ratio (AMR), asthma control, and caregiver perception of asthma control as predictors of the MARS.

RESULTS

Caregivers were female (97%) and 27.4% had an annual income under $10,000. The mean MARS score was 21.88 ± 3.33 out of a possible range of 5-25, representing high adherence. Confirmatory factor analysis indicated that a five-item one-factor model marginally fit the data based on the fit indices: χ² (5) = 31.71, p < 0.001; RMSEA ≤ 0.161; CFI = 0.986; TLI = 0.971; and WRMR = 0.979. The MARS was associated with another caregiver-reported measure of medication adherence but not associated with AMR, asthma control, or caregiver perception of asthma control.

CONCLUSIONS

The MARS demonstrated marginal fit in CFA and may not be clinically indicated in light of the lack of associations with objective measures of asthma medication adherence and asthma control.

Serum Inhaled Corticosteroid Detection for Monitoring Adherence in Severe Asthma

BACKGROUND

Daily inhaled corticosteroids (ICSs) are fundamental to asthma management, but adherence is low.

OBJECTIVES

To investigate (1) whether LC-MS/MS could be used to detect ICSs in serum and (2) whether serum levels related to markers of disease severity.

METHODS

We collected blood samples over an 8-hour period from patients with severe asthma prescribed at least 1000 μg daily of beclomethasone dipropionate equivalent. Following baseline sampling, patients were observed taking their usual morning dose. Subsequent blood samples were obtained 1, 2, 4, and 8 hours postinhalation and analyzed by LC-MS/MS. Correlations between serum ICS levels and severity markers were investigated.

RESULTS

A total of 60 patients were recruited (41 females; 39 prescribed maintenance prednisolone; mean age, 49 ± 12 years; FEV₁, 63 ± 20 %predicted). Eight hours postinhalation, all patients using budesonide (n = 10) and beclomethasone dipropionate (15), and all but 1 using fluticasone propionate (28), had detectable serum drug levels. Fluticasone furorate was detected in 2 patients (of 4), ciclesonide in none (of 7). Low adherence by repeat prescription records (<80%) was identified in 43%. Blood ICS levels correlated negatively with exacerbation rate, and (for fluticasone propionate only) positively with FEV₁ %predicted.

CONCLUSIONS

Commonly used ICSs can be reliably detected in the blood at least 8 hours after dosing, and could therefore be used as a measure of adherence in severe asthma. Higher exacerbation rates and poorer lung function (for fluticasone propionate) were associated with lower blood levels.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE

To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

DATA SOURCES

Articles available in electronic databases, published from inception to April 2021.

STUDY SELECTIONS

Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

RESULTS

Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it.

CONCLUSIONS

Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

When adherence and inhalation technique matter: Difficult-to-control pediatric asthma in low- to middle-income countries

Despite relatively recent advances in our understanding of the physiopathology of asthma and the availability of highly effective controller medications, such as inhaled corticosteroids (ICS), currently many pediatric patients fail to control their asthma, especially in low- and middle-income countries (LMICs). Although some of these difficult-to-control asthmatic children have severe therapy-resistant asthma, most of them experience poor asthma control due to various modifiable factors, among which poor adherence to inhaled controller therapy and inadequate inhaler technique are the most common. Although electronic monitoring devices have been considered to be essential tools in identifying patients with severe therapy-resistant asthma, their high cost and low availability have currently limited their use in clinical practice. For these reasons, clinicians might consider using validated self-reported questionnaires and the weight of inhaler canisters and as alternative and valid options for assessing adherence to inhaled controller therapy. Furthermore, clinicians might consider adopting validated instruments as an objective measurement of the adequacy of inhaler technique. Although recognizing poor adherence does not automatically lead to improved adherence, it is usually an essential first step in effectively targeting adherence behavior, especially if the reasons for low or erratic compliance are explored by means of non-judgmental doctor-patient communication. These recommendations could assist in overcoming our inability to have pediatric asthmatic patients use ICS and in avoiding escalating their controller therapy toward more expensive medications, eventually reaching the use biologics. Promoting the rational and cost-effective use of asthma controller therapy could help to optimize the limited health resources in many LMICs.

Nonadherence to inhaled corticosteroids: A characteristic of the pediatric obese-asthma phenotype?

BACKGROUND

Children with excess weight and asthma tend to respond less well to inhaled corticosteroids (ICS) than children with normal weight, potentially resulting in nonadherence to ICS.

OBJECTIVES

To assess whether excess weight (body mass index ≥85th percentile) was associated with general, unintentional, and intentional nonadherence to ICS in children with asthma.

METHODS

We analyzed data from 566 children aged 4-13 years with asthma, who used ICS as maintenance therapy, from the cross-sectional Pharmacogenetics of Asthma medication in Children: Medication with Anti-inflammatory effects study. General nonadherence was measured objectively with the proportion of days covered (<50%) and subjectively with the parent-reported Medication Adherence Rating Scale (MARS <21) reflecting parent-reported nonadherent behavior. Unintentional and intentional nonadherence were defined as forgetting to take medication and deliberately changing or skipping doses, respectively, from specific items of the MARS. We performed logistic regression analyses, stratifying estimates by asthma severity and age group.

RESULTS

Excess weight was associated with a trend towards increased odds of parent-reported nonadherent behavior (odds ratio [OR]: 1.54; 95% confidence interval [CI]: 0.84-2.81) and objectively measured general nonadherence, but only in moderate-to-severe asthma (OR: 1.71; 95% CI: 0.84-3.48). The odds of intentional, but not unintentional, nonadherence seemed to be greater in children with excess weight than normal weight (OR: 1.94; 95% CI: 0.94-4.01), and the association appeared to be stronger in younger (OR: 2.17; 95% CI 1.00-4.73) versus older children (OR: 1.18; 95% CI: 0.36-3.94).

CONCLUSIONS

Excess weight was associated with general nonadherence to ICS, but only in children with moderate-to-severe asthma, and nonadherent behavior, which seemed to be intentional.

Medication Adherence in Patients With Severe Asthma Prescribed Oral Corticosteroids in the U-BIOPRED Cohort

BACKGROUND

Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high.

RESEARCH QUESTIONS

What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity?

STUDY DESIGN AND METHODS

Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry.

RESULTS

Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV₁, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels.

INTERPRETATION

Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.

Assessment of adherence to asthma controllers in children and adolescents

BACKGROUND

Low adherence to asthma controllers is known to increase the risk of uncontrolled disease and poor health outcomes. We aimed to study risk factors of long-term adherence to preventive medications in children and adolescents with asthma.

METHODS

Adherence was assessed during a two-year period in 155 children with asthma followed in a tertiary pediatric asthma outpatient clinic using percentage of days covered (PDC) based on physician prescriptions and pharmacy claims data. The risk factor analysis included age, sex, ethnicity, BMI, atopic comorbidity, spirometry incentives, and fractional exhaled nitric oxide (FeNO).

RESULTS

Ninety-five children, 50 (53%) males, mean age of 16.3 years (SD, 2.36), received at least one prescription for asthma controllers in the study period. Fifty-two (54%) children were classified as non-adherent with a PDC cutoff at 80%. Adherence was negatively associated with age: adherence ratio (AR) 0.84 (95% CI, 0.73-0.95), P = .008; forced expiratory volume in 1 second (FEV1): AR per L 0.6 (0.91-1.0), P = .03; unfilled inhaled beta-2-agonist prescription: AR 0.45 (0.23-0.89), P = .02; and FeNO level: AR per ppb 0.98 (0.97-0.99), P = .03, where age and FeNO retained significance in multivariate analysis. Type and number of asthma controllers were not associated with adherence.

CONCLUSIONS

This study shows low adherence to preventive medication among half of the children with asthma, which is associated with increasing age and FeNO level. Therefore, an extra effort should be directed toward teenagers transitioning from pediatric to adult medicine and toward inhaled corticosteroid-treated patients with elevated FeNO to increase their adherence to asthma controllers.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

BACKGROUND

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

OBJECTIVE

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

CONCLUSIONS

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

A data-driven typology of asthma medication adherence using cluster analysis

Asthma preventer medication non-adherence is strongly associated with poor asthma control. One-dimensional measures of adherence may ignore clinically important patterns of medication-taking behavior. We sought to construct a data-driven multi-dimensional typology of medication non-adherence in children with asthma. We analyzed data from an intervention study of electronic inhaler monitoring devices, comprising 211 patients yielding 35,161 person-days of data. Five adherence measures were extracted: the percentage of doses taken, the percentage of days on which zero doses were taken, the percentage of days on which both doses were taken, the number of treatment intermissions per 100 study days, and the duration of treatment intermissions per 100 study days. We applied principal component analysis on the measures and subsequently applied k-means to determine cluster membership. Decision trees identified the measure that could predict cluster assignment with the highest accuracy, increasing interpretability and increasing clinical utility. We demonstrate the use of adherence measures towards a three-group categorization of medication non-adherence, which succinctly describes the diversity of patient medication taking patterns in asthma. The percentage of prescribed doses taken during the study contributed to the prediction of cluster assignment most accurately (84% in out-of-sample data).

Latent Class Analysis of School-Age Children at Risk for Asthma Exacerbation

BACKGROUND

Factors responsible for asthma exacerbations in children are complex and may differ from those that drive asthma severity.

OBJECTIVE

To identify latent classes of children at risk for asthma exacerbation and determine whether latent class assignment is useful in the prediction of future exacerbation.

METHODS

Latent class analysis was performed on 513 children aged 6 to 17 years at risk for asthma exacerbation, with 31 variables encompassing demographics, medical history, treatment, symptoms, lung function, sensitization, and type 2 inflammation. Primary and secondary outcomes included exacerbation occurrence by 12 months and time to first exacerbation, respectively.

RESULTS

Four latent classes were identified with differing demographic features, sensitization and type 2 inflammatory markers, prior exacerbation severity and health care utilization, and lung function. Exacerbations occurred in 22.4% of class 1 ("lesser sensitization with normal lung function"), 27.9% of class 2 ("lesser sensitization with prior severe exacerbation and normal lung function"), 45.3% of class 3 ("multiple sensitization with reversible airflow limitation"), and 64.3% of class 4 ("multiple sensitization with partially reversible airflow limitation") (P < .001). Time to exacerbation also followed similar trends and was shortest in the latent classes with multiple sensitization and airflow limitation (P < .001). Outcomes were driven largely by children with exacerbation-prone asthma (defined as ≥3 exacerbations in the prior year), who were present in each class but most strongly represented in classes 3 and 4.

CONCLUSIONS

Children at risk for asthma exacerbation are a heterogeneous group. Sensitization, prior exacerbation severity, and lung function variables may be particularly useful in identifying children at greatest risk for future exacerbation.

Education makes people take their medication: myth or maxim?

Education on its own doesn't make people take their treatment as intended. However, when it follows shared decision making, in which patient and doctor together agree on the best course of therapeutic action, education helps patients take their treatment. http://bit.ly/2G2XswD.

Adherence to insulin pump treatment declines with increasing age in adolescents with type 1 diabetes mellitus

AIM

This study assessed the impact of illness perceptions, emotional responses to the disease and its management, and patient characteristics on the adherence to optimal insulin pump management in adolescents with type 1 diabetes mellitus.

METHODS

From May to December 2013 and May 2015 to September 2016, we investigated 90 adolescents (50% boys), 12-18 years with type 1 diabetes. We analysed the association of optimal adherence to insulin pump therapy to age, gender, diabetes duration, results of questionnaires relating to fear and problems of self-testing, illness perceptions, emotional distress and family conflicts. Optimal adherence was defined as bolusing insulin on average ≥2.5/3 main meals/d.

RESULTS

Adolescents with suboptimal adherence were on average 1.8 years older (95% Confidence Interval 1.09-2.50 years, P < .001) than those with optimal adherence. After adjustment for age, no other patient or parent factors were related to optimal adherence.

CONCLUSION

Adherence to insulin pump self-management in adolescents with type 1 diabetes declined with increasing age, illustrating the challenges of transition of self-management from parents to the adolescent patient themselves.

Development and Psychometric Evaluation of an Instrument Assessing Barriers to Growth Hormone Treatment (BAR-GHT)

Purpose: This paper presents development and validation of a new patient reported outcome measure (PRO), the Barriers to Growth Hormone Therapy (BAR-GHT) in a patient (child/adolescent) and a parent version. The BAR-GHT was developed to measure problems and potential barriers to GHT. Methods: The development and validation of the BAR-GHT was conducted according to the Food and Drug Administration (FDA) Guidance on the development of PROs. Concept elicitation included a literature review and open-ended interviews with young patients, parents, and clinical experts. Qualitative data were analyzed based on grounded theory principles and draft items were rated in terms of their importance and clarity. The instruments underwent psychometric validation in a German clinic-based patient population of children and adolescents who inject themselves and in a parent sample who inject their child. The statistical analysis plan included exploratory factor analysis, reliability, and validity. Results: 29 patients, 22 parents, and 4 clinical experts participated in the concept elicitation, 156 children and adolescents aged 8-18 years and 146 parents completed the validation study. Exploratory factor analysis resulted in six domains: Fear, Public Embarrassment, Annoyance, Daily Routine, Supplies, and Travel. Internal consistencies and test-retest reliabilities of the total score of both the patient version and the parent version were >0.8. Convergent and discriminant validity was demonstrated. Conclusions: The final 19-item BAR-GHT for patients aged 8-18 years and the 16-item version for parents can be considered reliable and valid PROs of barriers to GHT. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03672617. Universal Trial Number (UTN) of the International Clinical Trials Registry Platform (ICTRP, www.who.int): U1111-1210-1036.

Adherence to diet and medication and the associated factors among patient with chronic heart failure in a multi-ethnic society

OBJECTIVE

To investigate diet adherence, medication adherence and self-care behaviour among patients with chronic heart failure (CHF) in a multi-ethnic society and identify the significant factors associated with their diet and medication adherence.

METHODS

A cross-sectional descriptive correlational study was conducted with a convenience sample of 107 patients with CHF recruited from two cardiology wards of a public tertiary hospital in Singapore. Study variables were measured using the Dietary Sodium Restriction Questionnaire, the Medication Adherence Rating Scale-5 items and the European Heart Failure Self-care Behaviour Scale-12 items.

RESULTS

Our sample reported positive attitudes towards diet adherence, poor self-care behaviour, and good medication adherence. The multiple linear regression results indicated that lower income, Chinese ethnicity, diabetic complications, current smoking, lower New York Heart Association classification I and II, and poorer self-care behaviour predicted poorer diet adherence. In addition, absence of hypertension, having non-myocardial infarction as a cause of CHF, and moderately diminished ejection fraction were identified as significant predictors of poorer medication adherence.

CONCLUSION

The findings from this study have established the need to improve current education and rehabilitation programmes for patients with CHF by addressing those factors significantly influencing their adherence to diet and medication.

Assessing methods of measuring medication adherence in chronically ill children-a narrative review

Nonadherence in children who use long-term medication is a serious problem and assessing adherence is an important step to provide solutions to this problem. Medication adherence can be measured by several methods, including (a) self-report questionnaires or structured interviews, (b) therapeutic drug monitoring (TDM), (c) electronic devices, and (d) pick-up/refill rates. The objective of this narrative review is to provide an overview of the literature about methods for the measurement of medication adherence in chronically ill children and adolescents. Therefore, we conducted a literature search by using multiple databases. Four methods of monitoring medication adherence are presented for the most described chronic diseases: asthma, HIV/AIDS, epilepsy, diabetes mellitus and ADHD. First, 10 commonly used self-report questionnaires and structured interviews are described, including the main characteristics, (dis)advantages and their validation studies. Second, the use of TDM in pediatric trials for medication adherence measurement is discussed. New sampling methods (e.g. dried blood spot) and sampling matrices (e.g. hair, saliva and urine) have shown their benefits for TDM in children. Third, electronic devices to measure medication adherence in children are presented, being developed for several drug administration routes. Fourth, the analyses, advantages and disadvantages of pharmacy data are discussed. The usage of this data requires specific calculations and interpretations to assess adherence. As presented in this review, every adherence method has specific (dis)advantages. When deciding which adherence method is applicable, validity and generalizability should be taken into account. Combining multiple methods seems to offer the best solution in the daily clinical practice.

Adherence to medication in children and adolescents with asthma: methods for monitoring and intervention

INTRODUCTION

Poor adherence in children with asthma is a major cause of asthma attacks and poor control, leads to large health-care costs, and has been identified as a factor in asthma deaths. However, it is difficult to detect and frequently overlooked leading to inappropriate escalation of asthma treatment. There is a need for cost effective ways to monitor adherence in order to intervene to change this modifiable behavior. Areas covered: Several measurement tools have been developed to assess adherence in adults and children with asthma. The current methods for measuring adherence, both subjective and objective, have several flaws and even the current gold standard, electronic monitoring devices (EMDs), has limitations. This review will outline and critique the adherence monitoring tools and highlight ways in which they have been used for the purpose of intervention. Expert commentary: Although advances have been made in adherence monitoring, we still have some way to go in creating the ideal monitoring tool. There are no validated tailored self-monitoring questionnaires for children with asthma and most objective measures, such as prescription refill rate and weighing canisters, overestimate adherence. Current EMDs, although useful, need improved accuracy to ensure that both actuation and inhalation are measured, and the devices need to be affordable for use in routine health-care practice.

Use and Effects of Patient Access to Medical Records in General Practice Through a Personal Health Record in the Netherlands: Protocol for a Mixed-Methods Study

BACKGROUND

In the Dutch health care system, general practitioners hold a central position. They store information from all health care providers who are involved with their patients in their electronic health records. Web-based access to the summary record in general practice through a personal health record (PHR) may increase patients' insight into their medical conditions and help them to be involved in their care.

OBJECTIVE

We describe the protocol that we will use to investigate the utilization of patients' digital access to the summary of their medical records in general practice through a PHR and its effects on the involvement of patients in their care.

METHODS

We will conduct a multilevel mixed-methods study in which the PHR and Web-based access to the summary record will be offered for 6 months to a random sample of 500 polypharmacy patients, 500 parents of children aged <4 years, and 500 adults who do not belong to the former two groups. At the patient level, a controlled before-after study will be conducted using surveys, and concurrently, qualitative data will be collected from focus group discussions, think-aloud observations, and semistructured interviews. At the general practice staff (GP staff) level, focus group discussions will be conducted at baseline and Q-methodology inquiries at the end of the study period. The primary outcomes at the patient level are barriers and facilitators for using the PHR and summary records and changes in taking an active role in decision making and care management and medication adherence. Outcomes at the GP staff level are attitudes before and opinions after the implementation of the intervention. Patient characteristics and changes in outcomes related to patient involvement during the study period will be compared between the users and nonusers of the intervention using chi-square tests and t tests. A thematic content analysis of the qualitative data will be performed, and the results will be used to interpret quantitative findings.

RESULTS

Enrollment was completed in May 2017 and the possibility to view GP records through the PHR was implemented in December 2017. Data analysis is currently underway and the first results are expected to be submitted for publication in autumn 2019.

CONCLUSIONS

We expect that the findings of this study will be useful to health care providers and health care organizations that consider introducing the use of PHR and Web-based access to records and to those who have recently started using these.

TRIAL REGISTRATION

Netherlands Trial Registry NTR6395; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6395 (Archived by WebCite at http://www.webcitation.org/71nc8jzwM).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/10193.

Adherence to Polyethylene Glycol Treatment in Children with Functional Constipation Is Associated with Parental Illness Perceptions, Satisfaction with Treatment, and Perceived Treatment Convenience

OBJECTIVES

To assess treatment adherence in children with functional constipation and to evaluate the association with parental beliefs about medication, illness perceptions, treatment satisfaction, and satisfaction with information about medication.

STUDY DESIGN

A cross-sectional survey was administered among parents of children with functional constipation treated with polyethylene glycol. Adherence was measured via the Medication Adherence Report Scale (MARS-5, score 5-25), with greater scores indicating better adherence (scores ≥23 were defined as adherent). Beliefs about medication, illness perceptions, satisfaction with treatment, and satisfaction with information about treatment were measured with the Beliefs about Medication Questionnaire, the Brief Illness Perception Questionnaire, the Treatment Satisfaction Questionnaire for Medication (TSQM), and the Satisfaction with Information about Medication Questionnaire. Associations between the questionnaire scores and adherence (MARS-5 score as a continuous variable) were analyzed with regression analyses.

RESULTS

In total, 43 of 115 included children (37%) were adherent (MARS-5 ≥23). Spearman rank correlation test revealed a statistically significant correlation between TSQM-convenience, TSQM-satisfaction, Brief Illness Perception Questionnaire question 8 (emotions), and the MARS-5 score (r_s 0.342, P = .000; r_s 0.258, P = .006; r_s -0.192, P = .044), which suggests that parental perceived treatment convenience, satisfaction with treatment, and illness perceptions may affect adherence in children with functional constipation. In the hierarchical multivariate regression model, 22% of the variability of the MARS-5 score could be explained by the selected predictors. The TSQM-convenience score contributed the most to the model (β: 0.384, P = .000).

CONCLUSIONS

Parents reported low adherence rates in their children with functional constipation. Treatment inconvenience, dissatisfaction with treatment, and the emotional impact of functional constipation may negatively influence treatment adherence.

Improving adherence to asthma medications: current knowledge and future perspectives

PURPOSE OF REVIEW

Poor adherence to asthma controller medications, particularly inhaled corticosteroids, has been well known for decades and is a major cause of uncontrolled asthma and increased healthcare utilization. This review presents recent evidence on factors leading to nonadherence in specific age groups, parents of young children, adolescents and young adults, adults, and the elderly. Novel management strategies including electronic sensors with associated smart phone applications for adherence improvement are discussed.

RECENT FINDINGS

Interventions to promote adherence must include a focus on issues important to the patient. Parents are concerned about adverse effects and the difficulty of medication administration in their child; adolescents and young adults need help with organizational skills and social barriers; adults may be more receptive to the need for daily medication after an acute exacerbation and acceptance of their disease; the elderly may have medication misuse issues associated with cognitive decline and other comorbidities related to aging. In all age groups, a trusting relationship with the provider is the key. New digital devices to track adherence may provide feedback to the patient and provider to evaluate and to promote adherence.

SUMMARY

Personalized approaches are required to address adherence barriers in target populations. Research on specific needs and barriers in target populations and development of appropriate strategies for use of new digital technology for adherence monitoring is needed.