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Kibbons AM, Moore R, Choi L, Zuckerman AD. Patient-Tailored Interventions to Improve Specialty Medication Adherence: Results from a Prospective Randomized Controlled Trial. Am J Med 2023; 136:694-701.e1. [PMID: 37028694 PMCID: PMC10794990 DOI: 10.1016/j.amjmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Specialty medication nonadherence results in poor clinical outcomes and increased costs. This study evaluated the impact of patient-tailored interventions on specialty medication adherence. METHODS A pragmatic, randomized controlled trial was conducted at a single-center health-system specialty pharmacy from May 2019 to August 2021. Participants included recently nonadherent patients prescribed self-administered specialty medications from multiple specialty clinics. Eligible patients were stratified by historical clinic rates of nonadherence and randomized 1:1 to usual care or intervention arms. Intervention patients received patient-tailored interventions and 8 months of follow-up. A Wilcoxon test was used to analyze the difference in 6-, 8-, and 12-month post-enrollment adherence, calculated using proportion of days covered, between the intervention and usual care arms. RESULTS Four hundred and thirty eight patients were randomized. Baseline characteristics were similar between groups: mostly women (68%), white (82%), with a median age of 54 years (interquartile range, 40, 64). The most common reasons for nonadherence in the intervention arm were memory (37%) and unreachability (28%). There was a significant difference in median proportion of days covered between patients in the usual care and intervention arms at 8-months (0.88 vs 0.94, P < .001), 6-months (0.90 vs 0.95, P = .003), and 12-months post-enrollment (0.87 vs 0.93, P < .001). CONCLUSIONS Patient-tailored interventions resulted in significant specialty medication adherence improvement compared with standard of care. Specialty pharmacies should consider targeting nonadherent patients for adherence interventions.
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Affiliation(s)
| | - Ryan Moore
- Vanderbilt University Medical Center, Nashville, United States
| | - Leena Choi
- Vanderbilt University Medical Center, Nashville, United States
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2
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Erickson JM, Kamke-Jordan A, Lancaster IJ, Palou-Torres A, Esch M, Gonzalez A, Charlson J, Bingen K. Medication self-management behaviors of adolescents and young adults with cancer. Support Care Cancer 2023; 31:390. [PMID: 37300714 DOI: 10.1007/s00520-023-07863-8] [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: 02/11/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Adolescents and young adults (AYAs) with cancer are challenged to manage complex medication regimens during treatment. The aims of the study are to (1) describe the medication self-management behaviors of AYAs with cancer and (2) examine the barriers and facilitators to AYAs' optimal use of medications, including their self-efficacy to manage medications. METHODS This cross-sectional study enrolled 30 AYAs (18-29 years) with cancer who were receiving chemotherapy. Participants electronically completed a demographic form, a health literacy screen, and the PROMIS Self-efficacy for Medication Management instrument. They completed a semi-structured interview to answer questions about their medication self-management behaviors. RESULTS Participants (53% female, mean age = 21.9 y) had a variety of AYA cancer diagnoses. Over half (63%) had limited health literacy. Most AYAs had accurate knowledge about their medications and average self-efficacy for managing medications. These AYAs were managing an average of 6 scheduled and 3 unscheduled medications. Oral chemotherapy was prescribed for 13 AYAs; other medications were for prevention of complications and symptom management. Many AYAs relied on a parent for obtaining and paying for medications, used multiple reminders to take medications, and used a variety of strategies to store and organize medications. CONCLUSION AYAs with cancer were knowledgeable and confident about managing complex medication regimens but needed support and reminders. Providers should review medication-taking strategies with AYAs and ensure a support person is available.
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Affiliation(s)
- Jeanne M Erickson
- University of Wisconsin-Milwaukee College of Nursing, Milwaukee, WI, USA.
| | | | | | - Akasha Palou-Torres
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Marloe Esch
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alyssa Gonzalez
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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3
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Zeng XL, Heneghan MB, Badawy SM. Adherence to Oral Chemotherapy in Acute Lymphoblastic Leukemia during Maintenance Therapy in Children, Adolescents, and Young Adults: A Systematic Review. Curr Oncol 2023; 30:720-748. [PMID: 36661705 PMCID: PMC9858168 DOI: 10.3390/curroncol30010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common malignancy in children and young adults. Treatment is long and involves 2-3 years of a prolonged maintenance phase composed of oral chemotherapies. Adherence to these medications is critical to achieving good outcomes. However, adherence is difficult to determine, as there is currently no consensus on measures of adherence or criteria to determine nonadherence. Furthermore, there have been few studies in pediatric B-ALL describing factors associated with nonadherence. Thus, we performed a systematic review of literature on oral chemotherapy adherence during maintenance therapy in ALL following PRISMA guidelines. Published studies demonstrated various objective and subjective methods of assessing adherence without generalizable definitions of nonadherence. However, the results of these studies suggested that nonadherence to oral maintenance chemotherapy was associated with increased risk of relapse. Future studies of B-ALL therapy should utilize a uniform assessment of adherence and definitions of nonadherence to better determine the impact of nonadherence on B-ALL outcomes and identify predictors of nonadherence that could yield targets for adherence improving interventions.
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Affiliation(s)
- Xiaopei L. Zeng
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
| | - Mallorie B. Heneghan
- Division of Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, University of Utah, Salt Lake City, UT 84132, USA
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
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Toma MM, Bungau SG, Tit DM, Moisi MI, Bustea C, Vesa CM, Behl T, Stoicescu M, Brisc CM, Purza LA, Gitea D, Diaconu CC. Use of anticoagulant drugs in patients with atrial fibrillation. Does adherence to therapy have a prognostic impact? Biomed Pharmacother 2022; 150:113002. [PMID: 35462339 DOI: 10.1016/j.biopha.2022.113002] [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: 02/23/2022] [Revised: 04/10/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Anticoagulant therapy represents a pivotal element that strongly influences the thromboembolic risk of non-valvular atrial fibrillation (NVAF) subjects. The main purpose of this review was to identify issues and suggest strategies to improve the oral anticoagulants (OACs) treatment adherence, which is the most important predictor of NVAF outcome. Advantages, efficacy, and impact of these drugs on patients' prognosis were revealed in important clinical trials on large cohorts of patients and are often prescribed nowadays. A real-life data registry, the Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) analyzed the profile and outcome of patients diagnosed with NVAF receiving oral antithrombotic treatment. The observations gathered in the registry were crucial for identifying relevant elements that clinicians must improve, such as adherence strategies and predisposing factors that correlated with stroke. Adherence to OACs in AF patients is essential from the viewpoint of clinical efficacy and safety. Major adverse events and negative outcome are correlated with a weak anticoagulation control caused by an ineffective treatment adherence strategy. Solving the issue of oral anticoagulation adherence is possible using new technologies, but future directions should be explored. Mobile phone applications centered on patients' needs, telemedicine programs that evaluate patients' evolution and detect adverse reactions or events, encouraging an adequate management of the event without interruption of OACs, represent perspectives with a major impact on treatment adherence.
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Affiliation(s)
- Mirela Marioara Toma
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania.
| | - Simona Gabriela Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Delia Mirela Tit
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Madalina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, 140401 Punjab, India.
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Cristina Mihaela Brisc
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Lavinia Anamaria Purza
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Camelia Cristina Diaconu
- Department 5, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania; Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania.
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Carr E, Rosengarten L. Teenagers and Young Adults with Cancer: An Exploration of Factors Contributing to Treatment Adherence. J Pediatr Oncol Nurs 2021; 38:190-204. [PMID: 33769898 PMCID: PMC8172305 DOI: 10.1177/1043454221992302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
This systematic appraisal explores the literature surrounding treatment adherence in teenagers and young adults (TYAs) with cancer, with the aim of identifying influential factors that could affect adherence rates. This area is particularly important due to the increased risk of relapse and death associated with nonadherent behavior. In addition, TYAs are found to be the age group least likely to adhere to medical regimes. A comprehensive review of the literature was conducted and seven studies met the inclusion criteria, the articles were then critiqued using a data extraction form and eight themes were generated and discussed. This review highlights the complexities and difficulties in measuring adherence, as well as the key factors affecting adherence, before identifying implications for practice. Good communication and relationships are crucial between all parties involved in TYAs’ care including the patients, professionals, parents, and peers. A model of adherence was adapted on the basis of the result of the systematic review, other literature pertaining to adherence in TYAs, and the clinical experience of the authors. Personal factors and external factors, along with treatment factors and interactions with the system all have an effect on the patient's response or ability to adhere. It is apparent that there is a need for more high-quality qualitative and quantitative research in this area, with an emphasis on finding interventions that directly improve adherence specific to this age group.
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Affiliation(s)
- Elizabeth Carr
- Safari Day Unit, 156793Lincoln County Hospital, Lincoln, UK
| | - Leah Rosengarten
- Faculty of Health and Life Sciences, 5995Northumbria University, Newcastle upon Tyne, UK
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Wiener L, Canter K, Long K, Psihogios AM, Thompson AL. Pediatric Psychosocial Standards of Care in action: Research that bridges the gap from need to implementation. Psychooncology 2020; 29:2033-2040. [PMID: 32748495 PMCID: PMC8447234 DOI: 10.1002/pon.5505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/26/2020] [Accepted: 07/22/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To describe innovative models of psychosocial care delivery that align with published Standards of Psychosocial Care of Children with Cancer and their Families, in efforts to bridge the divide between research and practice. METHODS The Mattie Miracle Cancer Foundation, in partnership with the American Psychosocial Oncology Society reviewed 22 letters of intent and 13 full grants and awarded small grants to researchers with high quality projects that aimed to implement any of the published 15 Standards of Care. For three of the highest rated funded research projects, we describe the Standard implemented, the novel research design and implementation strategies, and how the research findings might inform the development, implementation, and dissemination of effective solutions for bridging Standard-to-practice gaps. RESULTS The first study presented is an innovative eHealth intervention for parents of children with cancer designed to improve family functioning and decrease symptoms of acute distress, anxiety, and posttraumatic stress. The second study addresses the acceptability and feasibility of using daily text message assessments of oral chemotherapy adherence in adolescents and young adults with leukemia, and the third creates a blueprint for providing psychosocial services to siblings, including ways to overcome common implementation barriers. CONCLUSIONS Several themes emerged from the studies presented, including (1) attention to barriers to previous attempts at implementation; (2) technology's role in delivering care; (3) the need for stakeholder involvement; and (4) consideration for multi-pronged solutions that address heterogeneity in care settings. Next steps for integrating the Standards of Psychosocial Care into clinical practice are discussed.
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Affiliation(s)
- Lori Wiener
- National Cancer Institute, Bethesda, Maryland
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7
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Heneghan MB, Hussain T, Barrera L, Cai SW, Haugen M, Duff A, Shoop J, Morgan E, Rossoff J, Weinstein J, Hijiya N, Cella D, Badawy SM. Applying the COM-B model to patient-reported barriers to medication adherence in pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28216. [PMID: 32068338 DOI: 10.1002/pbc.28216] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/10/2020] [Accepted: 01/28/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Adherence to oral chemotherapy, including 6-mercaptopurine (6-MP), is suboptimal in pediatric acute lymphoblastic leukemia (ALL), which is associated with increased risk of relapse. Study objectives were to examine self-reported adherence to 6-MP and related barriers to adherence, mapped to the capability, opportunity, motivation, and behavior (COM-B) model for behavior change. PROCEDURE Forty-nine parents (median, 39 years old; 76% females) and 15 patients (median, 17 years old, 20% females) completed the study survey. RESULTS Suboptimal adherence was reported in 43% of parents and 73% of patients. Most parents and patients (80% and 90%, respectively) reported ≥1 adherence barrier. Parents reported difficulty helping their child meet others with ALL (43%), contacting community organizations (39%), and meeting other parents (37%). Patients reported difficulty finding out what their medications are (40%), finding out what 6-MP does (47%), and meeting other patients (40%). Using the COM-B, we found that parents and patients endorsed barriers in multiple components, especially physical (55%, 67%) and social opportunity (56%, 47%), highlighting that barriers to adherence may be multifaceted. CONCLUSIONS Our results suggest that parents and patients with ALL face various prevalent barriers to medication adherence and provide insight into the development of behavioral interventions focused on promoting adherence, which is essential to prevent relapse and optimize health outcomes in ALL.
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Affiliation(s)
- Mallorie B Heneghan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Tasmeen Hussain
- Division of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leonardo Barrera
- Mary Ann and J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Stephanie W Cai
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maureen Haugen
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ashley Duff
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jenny Shoop
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Elaine Morgan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jenna Rossoff
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joanna Weinstein
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nobuko Hijiya
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - David Cella
- Northwestern University, Department of Medical Social Sciences, Feinberg School of Medicine, Chicago, Illinois
| | - Sherif M Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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8
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The Relationship between Health Disparities, Psychosocial Functioning and Health Outcomes in Pediatric Hematology-Oncology and Stem Cell Transplant Populations: Recommendations for Clinical Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072218. [PMID: 32224963 PMCID: PMC7178256 DOI: 10.3390/ijerph17072218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/20/2020] [Accepted: 03/22/2020] [Indexed: 01/09/2023]
Abstract
Not only do racial and ethnic minority children and adolescents with chronic illness experience disparities in health status and health outcomes, they also experience significant healthcare disparities, including differences in healthcare coverage, access to care, and quality of care. It is well known that the interaction between psychosocial functioning, health behaviors and ethnic and racial disparities, ultimately leads to worse health and psychosocial outcomes in pediatric and AYA chronic illness patient populations, including increased rates of morbidity and mortality. Investigating the impact of racial and ethnic factors on health outcomes, and strategies for reducing these disparities, is of the utmost importance, specifically in life-threatening conditions like cancer and sickle cell disease. This commentary underscores the relative importance of identifying factors that could reduce disparities between minority and non-minority populations. This present paper will focus on the dynamic relationships between health disparities, psychosocial factors and health outcomes within pediatric cancer, sickle cell disease and bone marrow transplant populations, and will offer recommendations for healthcare professionals working with these vulnerable patient populations. The primary goal of this commentary is to provide recommendations for enhancing cultural competency and humility for those working with highly vulnerable patient populations.
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9
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When Multiple Objective Measures of Medication Adherence Indicate Incongruent Adherence Results: An Example with Pediatric Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061956. [PMID: 32192028 PMCID: PMC7142654 DOI: 10.3390/ijerph17061956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 12/18/2022]
Abstract
Previous research suggests that children and adolescents with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) often have difficulty adhering to complex treatment regimens during the maintenance phase of therapy. Measurement of treatment adherence can be done via objective (e.g., electronic monitoring (EM), pharmacological assays) or subjective methods (patient, parent, or physician reports). This paper provides an illustration of recommended strategies for comparing discrepancies between two objective measures of medication adherence (e.g., behavioral adherence using electronic monitoring versus pharmacological adherence using 6-mercaptopurine (6MP) metabolite data) within a relatively large cohort of pediatric patients with ALL or LBL (N = 139) who had longitudinal data for both measures of medication adherence over a 15-month period. Additionally, individual- and family-level factors such as gender, socioeconomic status, household environment, and dose intensity will be examined to identify possible sources of discrepancies between adherence measures. This information will provide practical advice for physicians, healthcare providers, and psychologists in identifying nonadherence and the caveats therein so patients achieve the best possible health outcomes.
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10
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Longitudinal Patterns of Social Problem-Solving Skills in an Ethnically Diverse Sample of Pediatric Patients with Cancer and their Caregivers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17051581. [PMID: 32121378 PMCID: PMC7084745 DOI: 10.3390/ijerph17051581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/16/2022]
Abstract
Pediatric patients with acute lymphoblastic leukemia and lymphoblastic lymphoma are prescribed a daily oral chemotherapy medication named 6-mercaptopurine. Adherence to this medication is vital for survival and decreased risk for disease relapse. Adaptive problem-solving strategies are important for adhering to this complex regimen. This manuscript examined ethnic and racial differences in social problem-solving domains (Social Problem-Solving Inventory) among patients aged 7–19 years old who were diagnosed with cancer; and, their caregivers (N = 139). This was a 15-month longitudinal study. We also examined differences in medication adherence based on behavioral adherence measures. Our study found significant differences between minority and non-minority reporters across multiple social problem-solving domains (p < 0.05). However, there were no significant differences observed for medication adherence. Our findings underscore the importance of implementing culturally sensitive interventions in clinical care that could ultimately positively impact health behaviors, interactions with healthcare providers, and long-term health outcomes.
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11
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Lowres N, Giskes K, Hespe C, Freedman B. Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal. Korean Circ J 2019; 49:883-907. [PMID: 31535493 PMCID: PMC6753021 DOI: 10.4070/kcj.2019.0234] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Katrina Giskes
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, The University of Sydney Concord Clinical School, Concord, Australia
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Kenyon CC, Gruschow SM, Quarshie WO, Griffis H, Leach MC, Zorc JJ, Bryant-Stephens TC, Miller VA, Feudtner C. Controller adherence following hospital discharge in high risk children: A pilot randomized trial of text message reminders. J Asthma 2018; 56:95-103. [PMID: 29437489 DOI: 10.1080/02770903.2018.1424195] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To assess the feasibility of a mobile health, inhaled corticosteroid (ICS) adherence reminder intervention and to characterize adherence trajectories immediately following severe asthma exacerbation in high-risk urban children with persistent asthma. METHODS Children aged 2-13 with persistent asthma were enrolled in this pilot randomized controlled trial during an asthma emergency department (ED) visit or hospitalization. Intervention arm participants received daily text message reminders for 30 days, and both arms received electronic sensors to measure ICS use. Primary outcomes were feasibility of sensor use and text message acceptability. Secondary outcomes included adherence to prescribed ICS regimen and 30-day adherence trajectories. Group-based trajectory modeling was used to examine adherence trajectories. RESULTS Forty-one participants (mean age 5.9) were randomized to intervention (n = 21) or control (n = 20). Overall, 85% were Black, 88% had public insurance, and 51% of the caregivers had a high school education or less. Thirty-two participant families (78%) transmitted medication adherence data; of caregivers who completed the acceptability survey, 25 (96%) chose to receive daily reminders beyond that study interval. Secondary outcome analyses demonstrated similar average daily adherence between groups (intervention = 36%; control = 32%, P = 0.73). Three adherence trajectories were identified with none ever exceeding 80% adherence. CONCLUSIONS Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.
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Affiliation(s)
- Chén C Kenyon
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Siobhan M Gruschow
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - William O Quarshie
- c Healthcare Analytics Unit , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Heather Griffis
- c Healthcare Analytics Unit , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Michelle C Leach
- d Sidney Kimmel Medical College , Thomas Jefferson University , Philadelphia , Pennsylvania
| | - Joseph J Zorc
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Tyra C Bryant-Stephens
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania
| | - Victoria A Miller
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Chris Feudtner
- a PolicyLab and Department of Pediatrics , The Children's Hospital of Philadelphia , Philadelphia , Pennsylvania.,b Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania
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13
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Britto MT, Rohan JM, Dodds CM, Byczkowski TL. A Randomized Trial of User-Controlled Text Messaging to Improve Asthma Outcomes: A Pilot Study. Clin Pediatr (Phila) 2017; 56:1336-1344. [PMID: 28056541 DOI: 10.1177/0009922816684857] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We enrolled 64 patients age 12 to 22 years with a diagnosis of poorly controlled persistent asthma in a 6-month longitudinal crossover study. During the 3 intervention months, participants created personalized text messages to be sent to their phones. Adherence was objectively monitored in 22 of the participants. The adolescent participants gave high ratings on the acceptability of the text messaging system. Asthma control improved from baseline to month 1 regardless of whether teens were in the texting or control group. While participants were in the texting group, their quality of life improved and worry about their asthma decreased. Receiving the text intervention resulted in an increase in adherence of 2.75% each month relative to no intervention, but the improvements were not sustained. There was modest improvement in asthma control and quality of life outcomes, as well as improved adherence during the texting intervention.
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Affiliation(s)
- Maria T Britto
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jennifer M Rohan
- 2 Boston Children's Hospital, Boston, MA, USA.,3 Harvard Medical School, Boston, MA, USA
| | - Cassandra M Dodds
- 1 Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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14
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Wu YP, Stenehjem DD, Linder LA, Yu B, Parsons BG, Mooney R, Fluchel MN. Adherence to Oral Medications During Maintenance Therapy Among Children and Adolescents With Acute Lymphoblastic Leukemia: A Medication Refill Analysis. J Pediatr Oncol Nurs 2017; 35:86-93. [PMID: 29188741 DOI: 10.1177/1043454217741877] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Adherence to oral medications during maintenance therapy is essential for pediatric patients with acute lymphoblastic leukemia. Self-reported or electronic monitoring of adherence indicate suboptimal adherence, particularly among particular sociodemographic groups. This study used medication refill records to examine adherence among a national sample of pediatric patients with acute lymphoblastic leukemia. Patients in a national claims database, aged 0 to 21 years with a diagnosis of acute lymphoblastic leukemia and in the maintenance phase of treatment, were included. Medication possession ratios were used as measures of adherence. Overall adherence and adherence by sociodemographic groups were examined. Adherence rates were 85% for 6-mercaptopurine and 81% for methotrexate. Adherence was poorer among patients 12 years and older. Oral medication adherence rates were suboptimal and similar to or lower than previously documented rates using other methods of assessing adherence. Refill records offer a promising avenue for monitoring adherence. Additional work to identify groups most at-risk for poor adherence is needed. Nurses are well positioned to routinely monitor for medication adherence and to collaborate with the multidisciplinary team to address barriers to adherence.
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Affiliation(s)
- Yelena P Wu
- 1 University of Utah, Salt Lake City, UT, USA
| | - David D Stenehjem
- 1 University of Utah, Salt Lake City, UT, USA.,3 Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, MN, USA
| | - Lauri A Linder
- 1 University of Utah, Salt Lake City, UT, USA.,2 Primary Children's Hospital, Salt Lake City, UT, USA
| | - Bin Yu
- 1 University of Utah, Salt Lake City, UT, USA
| | | | - Ryan Mooney
- 1 University of Utah, Salt Lake City, UT, USA
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15
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Rohan JM, Fukuda T, Alderfer MA, Wetherington Donewar C, Ewing L, Katz ER, Muriel AC, Vinks AA, Drotar D. Measuring Medication Adherence in Pediatric Cancer: An Approach to Validation. J Pediatr Psychol 2017; 42:232-244. [PMID: 27189694 DOI: 10.1093/jpepsy/jsw039] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/12/2016] [Indexed: 12/27/2022] Open
Abstract
Objective This study described the prospective relationship between pharmacological and behavioral measures of 6-mercaptopurine (6MP) medication adherence in a multisite cohort of pediatric patients diagnosed with cancer ( N = 139). Methods Pharmacological measures (i.e., metabolite concentrations) assessed 6MP intake. Behavioral measures (e.g., electronic monitoring) described adherence patterns over time. Results Three metabolite profiles were identified across 15 months: one group demonstrated low levels of both metabolites (40.8%) consistent with nonadherence and/or suboptimal therapy; two other groups demonstrated metabolite clusters indicative of adequate adherence (59.2%). Those patients whose metabolite profile demonstrated low levels of both metabolites had consistently lower behavioral adherence rates. Conclusions To our knowledge, this was the first study to prospectively validate a pharmacological measure of medication adherence with a behavioral adherence measure in a relatively large sample of pediatric patients with cancer. Using multiple methods of adherence measurement could inform clinical care and target patients in need of intervention.
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Affiliation(s)
- Jennifer M Rohan
- Department of Psychology, University of Cincinnati, Cincinnati, OH, USA.,Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, University of Cincinnati School of Medicine, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Cente, OH, USA
| | - Melissa A Alderfer
- Division of Oncology, The Children's Hospital of Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvani, Philadelphia, PA, USA
| | - Crista Wetherington Donewar
- Center for Pediatric Psychiatry, Children's Medical Center Dallas, Texas, USA.,UT Southwestern Medical Center, Dallas, Texas, USA
| | - Linda Ewing
- Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
| | - Ernest R Katz
- Division of General Pediatrics, Children's Hospital Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anna C Muriel
- Division of Psychosocial Oncology, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Alexander A Vinks
- Department of Pediatrics, University of Cincinnati School of Medicine, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Cente, OH, USA
| | - Dennis Drotar
- Department of Psychology, University of Cincinnati, Cincinnati, OH, USA
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16
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Pai ALH, Rausch J, Drake S, Morrison CF, Lee JL, Nelson A, Tackett A, Berger S, Szulczewski L, Mara C, Davies S. Poor Adherence Is Associated with More Infections after Pediatric Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2017; 24:381-385. [PMID: 29102720 DOI: 10.1016/j.bbmt.2017.10.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 10/19/2017] [Indexed: 10/18/2022]
Abstract
We prospectively examined rates of outpatient oral medication adherence in children after hematopoietic stem cell transplant (post-HSCT). For 6 months after first discharge post-HSCT, 50 patients (aged 0 to 16 years) and their primary caregivers agreed to store 1 oral medication in an electronic pill bottle that date and time stamps each bottle opening. Demographics, disease, donor type, and prescribed post-HSCT medication regimen were collected via chart review. For each patient percent adherence was calculated by dividing the number of doses taken as indicated by the electronic pill bottle by the number of doses prescribed for the same time period. Average percent adherence ranged from 63% at 1 month after discharge to 57% at 6 months after discharge. For patients who received an allogeneic transplant, lower adherence was associated (P < .005) with higher infection rates, after controlling for age and time since transplant. No such relationship was observed for patients who received an autologous transplant. This study demonstrates that poor oral medication adherence is prevalent, persistent, and, for patients receiving an allogeneic transplant, associated with increased incidence of infections during the outpatient treatment period. This study highlights the need for further research examining factors that hinder medication adherence as well as monitoring, promoting, and intervening to maximize medication adherence throughout the HSCT course.
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Affiliation(s)
- Ahna L H Pai
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio.
| | - Joseph Rausch
- Center for Biobehavioral Health, Nationwide Children's Hospital, Cincinnati, Ohio
| | - Sarah Drake
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Caroline F Morrison
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer L Lee
- Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam Nelson
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alayna Tackett
- Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Suzanne Berger
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lauren Szulczewski
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Constance Mara
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Stella Davies
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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17
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Remission in Pediatric Inflammatory Bowel Disease Correlates With Prescription Refill Adherence Rates. J Pediatr Gastroenterol Nutr 2017; 64:575-579. [PMID: 27299424 DOI: 10.1097/mpg.0000000000001304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the study was to use pharmacy benefit management (PBM) prescription claims data to assess refill adherence in pediatric inflammatory bowel disease (IBD) and correlate adherence with clinical outcomes in pediatric IBD. METHODS We identified 362 pediatric patients with IBD seen at Washington University from 9/1/2012 to 8/31/2013 and matched them within Express Scripts' member eligibility files for clients allowing use of prescription drug data for research purposes. Maintenance IBD medication possession ratios (MPR) were determined through PBM prescription claims data and chart review. Demographic and prospectively captured physician global assessments (PGA) were retrospectively extracted from the medical record. MPR was analyzed as continuous data and also dichotomized as greater or less than 80%. RESULTS Among our 362 patients, we matched 228 (63%) within Express Scripts' eligibility data files. Of those, 78 patients were continuously eligible for benefits and had at least one outpatient prescription IBD medication prescribed. Their mean MPR was 0.63 ± 0.31 (standard deviation) and 40% had an MPR ≥80%. Patients in clinical remission had a higher mean MPR than those with an active PGA (0.72 ± 0.28 vs 0.51 ± 0.32, P = 0.002) and patients whose MPR were ≥80% were more likely to have a PGA of remission than those with whose MPR were <80% (84% vs 43%, P = <0.001). CONCLUSIONS We found a significant association between refill adherence and clinical remission. Nonadherence was common and was more common in adolescents. Use of PBM databases to identify and intervene on patients with poor adherence may improve outcomes in pediatric IBD.
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18
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Adams SA, Leach MC, Feudtner C, Miller VA, Kenyon CC. Automated Adherence Reminders for High Risk Children With Asthma: A Research Protocol. JMIR Res Protoc 2017; 6:e48. [PMID: 28347975 PMCID: PMC5387114 DOI: 10.2196/resprot.6674] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/23/2016] [Accepted: 12/13/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of inhaled corticosteroid (ICS) medications has been shown to improve asthma control and reduce asthma-related morbidity and mortality. Two recent randomized trials demonstrated dramatic improvements in ICS adherence by monitoring adherence with electronic sensors and providing automated reminders to participants to take their ICS medications. Given their lower levels of adherence and higher levels of asthma-related emergency department (ED) visits, hospitalizations, and death, urban minority populations could potentially benefit greatly from these types of interventions. OBJECTIVE The principal objective of this study will be to evaluate the feasibility, acceptability, and limited efficacy of a text message (short message service, SMS) reminder intervention to enhance ICS adherence in an urban minority population of children with asthma. We will also assess trajectories of ICS adherence in the 2 months following asthma hospitalization. METHODS Participants will include 40 children aged 2-13 years, who are currently admitted to the Children's Hospital of Philadelphia (CHOP) for asthma, and their parent or legal guardian. Participants will be assigned to intervention and control arms using a 1:1 randomization scheme. The intervention arm will receive daily text message reminders for a 30-day intervention phase following hospitalization. This will be followed by a 30-day follow-up phase, in which all participants may choose whether or not to receive the text messages. Feasibility will be assessed by measuring (1) retention of the participants through the study phases and (2) perceived usefulness, acceptability, and preferences regarding the intervention components. Limited efficacy outcomes will include percent adherence to prescribed ICS regimen measured using Propeller Health sensors and change in parent-reported asthma control. We will perform an exploratory analysis to assess for discrete trajectories of adherence using group-based trajectory modeling (GBTM). RESULTS Study enrollment began in December 2015 and the intervention and follow-up phases are ongoing. Results of the data analysis are expected to be available by December 2016. CONCLUSIONS This study will add to the literature by providing foundational feasibility data on which elements of a mobile health text-message reminder intervention may need to be modified to suit the needs and constraints of high-risk urban minority populations. TRIAL REGISTRATION Clinicaltrials.gov NCT02615743; https://www.clinicaltrials.gov/ct2/show/study/NCT02615743 (Archived with WebCite at http://www.webcitation.org/6ji59rAXN).
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Affiliation(s)
- Sarah A Adams
- The Children's Hospital of Philadelphia, PolicyLab and Center for Pediatric Clinical Effectiveness, Philadelphia, PA, United States
| | - Michelle Chan Leach
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, PolicyLab and Center for Pediatric Clinical Effectiveness, Philadelphia, PA, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Victoria A Miller
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Chén Collin Kenyon
- The Children's Hospital of Philadelphia, PolicyLab and Center for Pediatric Clinical Effectiveness, Philadelphia, PA, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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19
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Comparison of self-report and electronic monitoring of 6MP intake in childhood ALL: a Children's Oncology Group study. Blood 2017; 129:1919-1926. [PMID: 28153823 DOI: 10.1182/blood-2016-07-726893] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 12/29/2016] [Indexed: 01/02/2023] Open
Abstract
Adequate exposure to oral 6-mercaptopurine (6MP) during maintenance therapy for childhood acute lymphoblastic leukemia (ALL) is critical for sustaining durable remissions; accuracy of self-reported 6MP intake is unknown. We aimed to directly compare self-report to electronic monitoring (Medication Event Monitoring System [MEMS]) and identify predictors of overreporting in a cohort of 416 children with ALL in first remission over 4 study months (1344 patient-months for the cohort) during maintenance therapy. Patients were classified as "perfect reporters" (self-report agreed with MEMS), "overreporters" (self-report was higher than MEMS by ≥5 days/month for ≥50% of study months), and "others" (not meeting criteria for perfect reporter or overreporter). Multivariable logistic regression examined sociodemographic and clinical characteristics, 6MP dose intensity, TPMT genotype, thioguanine nucleotide levels, and 6MP nonadherence (MEMS-based adherence <95%) associated with the overreporter phenotype; generalized estimating equations compared 6MP intake by self-report and MEMS. Self-reported 6MP intake exceeded MEMS at least some of the time in 84% of patients. Fifty patients (12%) were classified as perfect reporters, 98 (23.6%) as overreporters, 2 (0.5%) as underreporters, and 266 (63.9%) as others. In multivariable analysis, the following variables were associated with the overreporter phenotype: non-white race: Hispanic, odds ratio (OR), 2.4, P = .02; Asian, OR, 3.1, P = .02; African American, P < .001; paternal education less than college (OR, 1.4, P = .05); and 6MP nonadherence (OR, 9.4, P < .001). Self-report of 6MP intake in childhood ALL overestimates true intake, particularly in nonadherent patients, and should be used with caution.
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20
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Morrison CF, Martsolf DM, Wehrkamp N, Tehan R, Pai ALH. Medication Adherence in Hematopoietic Stem Cell Transplantation: A Review of the Literature. Biol Blood Marrow Transplant 2017; 23:562-568. [PMID: 28087458 DOI: 10.1016/j.bbmt.2017.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/03/2017] [Indexed: 12/13/2022]
Abstract
Adherence to oral medications has been repeatedly shown to fall below the recommended 80% to 95% in pediatric and adult cancer populations. The purpose of this review is to report the state of the science about oral medication adherence during the acute phase of hematopoietic stem cell transplantation across the lifespan. An exhaustive search of the literature yielded 5 records for inclusion in the review. Two studies examined adherence in pediatrics, 2 in adults, and 1 included both pediatric and adult patients. Three studies were descriptive and 2 were interventional in design. The rate of adherence to oral medications ranged from 33% to 94.7%. Adherence decreased over time in all studies except in 1 pharmacist-led intervention study. Different methods were used to measure adherence, but most relied on self-report. Further research is needed in medication adherence in hematopoietic stem cell transplantation to better understand facilitators, barriers, and relationships to health outcomes.
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Affiliation(s)
- Caroline F Morrison
- Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | | | - Nicole Wehrkamp
- College of Nursing, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca Tehan
- College of Nursing, University of Cincinnati, Cincinnati, Ohio
| | - Ahna L H Pai
- Center for the Promotion of Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
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21
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Kenyon CC, Chang J, Wynter SA, Fowler JC, Long J, Bryant-Stephens TC. Electronic Adherence Monitoring in a High-Utilizing Pediatric Asthma Cohort: A Feasibility Study. JMIR Res Protoc 2016; 5:e132. [PMID: 27335355 PMCID: PMC4935791 DOI: 10.2196/resprot.5362] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 04/30/2016] [Accepted: 05/19/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inner-city, minority children with asthma have the highest rates of morbidity and death from asthma and the lowest rates of asthma controller medication adherence. Some recent electronic medication monitoring interventions demonstrated dramatic improvements in adherence in lower-risk populations. The feasibility and acceptability of such an intervention in the highest-risk children with asthma has not been studied. OBJECTIVE Our objective was to assess the feasibility and acceptability of a community health worker-delivered electronic adherence monitoring intervention among the highest utilizers of acute asthma care in an inner-city practice. METHODS This was a prospective cohort pilot study targeting children with the highest frequency of asthma-related emergency department and hospital care within a local managed care Medicaid plan. The 3-month intervention included motivational interviewing, electronic monitoring of controller and rescue inhaler use, and outreach by a community health worker for predefined medication alerts. We measured acceptability by using a modified technology acceptability model and changes in asthma control using the Asthma Control Test (ACT). Given prominent feasibility issues, we describe qualitative patterns of medication use at baseline only. RESULTS We enrolled 14 non-Hispanic black children with a median age of 3.5 years. Participants averaged 7.8 emergency or hospital visits in the year preceding enrollment. We observed three distinct patterns of baseline controller use: 4 patients demonstrated sustained use, 5 patients had periodic use, and 5 patients lapsed within 2 weeks. All participants initiated use of the electronic devices; however, no modem signal was transmitted for 5 or the 14 participants after a mean of 45 days. Of the 9 (64% of total) caregivers who completed the final study visit, all viewed the electronic monitoring device favorably and would recommend it to friends, and 5 (56%) believed that the device helped to improve asthma control. ACT scores improved by a mean of 2.7 points (P=.05) over the 3-month intervention. CONCLUSIONS High-utilizer, minority families who completed a community health worker-delivered electronic adherence intervention found it generally acceptable. Prominent feasibility concerns, however, such as recruitment, data transmission failure, and lost devices, should be carefully considered when designing interventions in this setting.
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Affiliation(s)
- Chén Collin Kenyon
- Center for Pediatric Clinical Effectiveness and PolicyLab, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
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22
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Pai ALH, McGrady ME. Assessing Medication Adherence as a Standard of Care in Pediatric Oncology. Pediatr Blood Cancer 2015; 62 Suppl 5:S818-28. [PMID: 26700926 DOI: 10.1002/pbc.25795] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 11/08/2022]
Abstract
Poor adherence to pediatric cancer treatment protocols may prevent children and adolescents from realizing the potential benefits of therapy. This paper presents the evidence for a standard of care for supporting medication adherence. Databases were reviewed for articles examining adherence and including children and/or adolescents with cancer. Fourteen articles (i.e., qualitative, quantitative, review, and randomized clinical trials) were evaluated for rigor. There is moderate-quality evidence to support a strong recommendation for adherence to be assessed routinely and monitored throughout the treatment. Integrating the proposed clinical procedures into standard clinical care may improve outcomes for children and adolescents with cancer.
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Affiliation(s)
- Ahna L H Pai
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Meghan E McGrady
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Behavioral Medicine and Clinical Psychology, Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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23
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McGrady ME, Brown GA, Pai ALH. Medication adherence decision-making among adolescents and young adults with cancer. Eur J Oncol Nurs 2015; 20:207-14. [PMID: 26372619 DOI: 10.1016/j.ejon.2015.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 08/05/2015] [Accepted: 08/31/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE Nearly half of all adolescents and young adults (AYAs) with cancer struggle to adhere to oral chemotherapy or antibiotic prophylactic medication included in treatment protocols. The mechanisms that drive non-adherence remain unknown, leaving health care providers with few strategies to improve adherence among their patients. The purpose of this study was to use qualitative methods to investigate the mechanisms that drive the daily adherence decision-making process among AYAs with cancer. METHODS Twelve AYAs (ages 15-31) with cancer who had a current medication regimen that included oral chemotherapy or antibiotic prophylactic medication participated in this study. Adolescents and young adults completed a semi-structured interview and a card sorting task to elucidate the themes that impact adherence decision-making. Interviews were transcribed verbatim and coded twice by two independent raters to identify key themes and develop an overarching theoretical framework. RESULTS Adolescents and young adults with cancer described adherence decision-making as a complex, multi-dimensional process influenced by personal goals and values, knowledge, skills, and environmental and social factors. Themes were generally consistent across medication regimens but differed with age, with older AYAs discussing long-term impacts and receiving physical support from their caregivers more than younger AYAs. CONCLUSIONS The mechanisms that drive daily adherence decision-making among AYAs with cancer are consistent with those described in empirically-supported models of adherence among adults with other chronic medical conditions. These mechanisms offer several modifiable targets for health care providers striving to improve adherence among this vulnerable population.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA.
| | - Gabriella A Brown
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Ahna L H Pai
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, MLC 7039, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
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24
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Wysocki T. Introduction to the special issue: Direct observation in pediatric psychology research. J Pediatr Psychol 2014; 40:1-7. [PMID: 25427552 DOI: 10.1093/jpepsy/jsu104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Tim Wysocki
- Center for Health Care Delivery Science, Nemours Children's Health System, Jacksonville
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