Patient-reported outcome instruments that evaluate adherence behaviours in adults with asthma: a systematic review of measurement properties

A Systematic Review of Patient-Reported Adherence Measures in Asthma: Which Questionnaire Is Most Useful in Clinical Practice?

BACKGROUND

Suboptimal adherence to inhaled corticosteroid in asthma is a worryingly prevalent yet modifiable factor in uncontrolled disease. Several objective measures of adherence exist, but they are time-consuming. The use of patient-reported adherence measures (PRAMs) could therefore offer a time-efficient pragmatic approach to assessing adherence in clinical practice and potentially the appropriate interventions to improve it.

OBJECTIVES

To identify the PRAMs available for asthma and assess their psychometric quality, accessibility, and usefulness in clinical practice, as well as to provide recommendations for clinicians based on these findings.

METHODS

We conducted a systematic review of six databases. Articles included in this study were English language, full-text, original, asthma-specific PRAMs or development/validation studies of a generic PRAM that had been administered to adults with asthma, investigated inhaled corticosteroid adherence in adults (aged 18 years and older), and assessed at least one COnsensus-based Standards for the selection of health Measurement INstruments measurement property.

RESULTS

We included 15 PRAM developmental and/or validation studies in this systematic review. Studies evaluated a range of COnsensus-based Standards for the selection of health Measurement INstruments measurement properties, but none evaluated all of them.

CONCLUSIONS

Based on this review, we recommend that when a PRAM is used, it should be the Test of the Adherence to Inhalers. However, the Adherence Starts with Knowledge-20 and Adherence Starts with Knowledge-12 may also be useful. Our results highlight the need for PRAM developers to assess questionnaires robustly and provide guidance for clinicians regarding how to act on PRAM answers by developing materials such as decision support tool kits.

Asthma diagnosis using patient-reported outcome measures and objective diagnostic tests: now and into the future

PURPOSE OF REVIEW

The global prevalence of asthma continues to increase; however, asthma remains under-diagnosed and under-treated. This results in a significant burden on the healthcare system and preventable patient morbidity and mortality. Over-diagnosis of asthma based on clinical history alone also complicates patient management. This heightens the importance of a prompt and accurate asthma diagnosis. Therefore, a review of the literature was performed regarding both objective diagnostic testing for asthma and using patient-reported outcome measures.

RECENT FINDINGS

The cornerstone of asthma diagnosis remains spirometry with testing for bronchodilator reversibility testing for pediatric and adult populations. This test may need to be repeated at multiple time points due to its low sensitivity. Peak flow measurement, fractional exhaled nitric oxide testing, and allergy testing are useful adjuncts to the diagnosis and phenotyping of asthma. Bronchoprovocation testing is reserved for people with high clinical suspicion for asthma, but negative spirometry. Novel noninvasive testing modalities may play a diagnostic role in the future. The advent of remote digital health monitoring technology has resulted in revisiting patient-reported outcome measures for the diagnosis and monitoring of asthma.

SUMMARY

Overall, improved diagnostic tools for asthma are crucial for earlier recognition and treatment of the disease and improved patient care outcomes worldwide.

Qualitative Interviews to Support Development and Cognitive Debriefing of the Adelphi Adherence Questionnaire (ADAQ©): A Patient-Reported Measure of Medication Adherence Developed for Use in a Range of Diseases, Treatment Modalities, and Countries

PURPOSE

The Adelphi Adherence Questionnaire (ADAQ©) is a newly developed generic patient-reported outcome (PRO) assessment of medication adherence. The aim was to assess its content validity by conducting cognitive debriefing (CD) interviews with patients prescribed medication(s) of various treatment modalities in a range of therapy areas.

MATERIALS AND METHODS

Targeted literature/instrument review and concept elicitation interviews informed development of the ADAQ©. CD interviews were conducted with 57 adults from the United States of America (USA; n = 21), Spain (n = 18), and Germany (n = 18) who prescribed medication for hypertension, diabetes, depression, schizophrenia, asthma, multiple myeloma, psoriasis, and/or multiple sclerosis. Interviews were conducted in two rounds to explore the relevance and understanding of the item wording, instructions, recall period and response options. Verbatim transcripts were analysed in ATLAS.Ti using thematic analysis. Three expert clinicians provided guidance throughout the study.

RESULTS

ADAQ© items/instructions were well understood and relevant to participants. Key modifications following round 1 included revising instructions to refer to current medication(s) for one condition to reduce cognitive burden, removing two items with lower relevance (specifically those assessing running out of medication and social discouragement), and adding a response option for participants to indicate if they had stopped taking a medication. Minor wording modifications were made following round 2. Subgroup differences in item relevance were explored based on clinical characteristics. Cost of medication was more relevant amongst US participants.

CONCLUSION

Content validity of the ADAQ© was confirmed in demographically and clinically diverse participants. Psychometric properties of the ADAQ© will be explored in future studies.

Measuring adherence to therapy in airways disease

Non-adherence to medication is one of the most significant issues in all airways disease and can have a major impact on disease control as well as on unscheduled healthcare utilisation. It is vital that clinicians can accurately determine a patient's level of adherence in order to ensure they are gaining the maximal benefit from their therapy and also to avoid any potential for unnecessary increases in therapy. It is essential that measurements of adherence are interpreted alongside biomarkers of mechanistic pathways to identify if improvements in medication adherence can influence disease control. In this review, the most common methods of measuring adherence are discussed. These include patient self-report, prescription record checks, canister weighing, dose counting, monitoring drug levels and electronic monitoring. We describe the uses and benefits of each method as well as potential shortcomings. The practical use of adherence measures with measurable markers of disease control is also discussed.

Educational aims

To understand the various methods available to measure adherence in airways disease.To learn how to apply these adherence measures in conjunction with clinical biomarkers in routine clinical care.

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.

Validation of the Chinese Non-pharmacological Therapy Experience Scale in persons with intellectual disability

Aim

To validate the 4- and 7-point Chinese Non-pharmacological Therapy Experience Scales and test the psychometric properties of the scales on persons with intellectual disability.

Design

A validation study.

Methods

Sixty-seven persons with intellectual disability were recruited from six hostels or centres for persons with intellectual disability in Hong Kong. A total of 1,163 and 1,161 observations were collected by the trained observers with the 4-point and 7-point scales, respectively. The floor and ceiling effects, inter-rater reliability, internal consistency, responsiveness of both scales and the scale equivalence were examined.

Results

The Cronbach's α of the 4- and 7-point scales was .762 and .797, respectively. The correlation between the two scales was 0.906. The inter-rater reliability of the 4- and 7-point scales was 0.774 and 0.835, respectively. Neither scale had the floor or ceiling effects. The effect size of the 7-point scale was consistently higher than that of the 4-point scale.

Admission NarxCare Narcotics Scores are not Associated With Adverse Surgical Outcomes or Self-reported Patient Satisfaction Following Elective Spine Surgery

STUDY DESIGN

Retrospective cohort study OBJECTIVE.: The aim of this study was to investigate how elective spine surgery patient preoperative opioid use (as determined by admission NarxCare narcotics use scores) correlated with 30-day perioperative outcomes and postoperative patient satisfaction.

SUMMARY OF BACKGROUND DATA

The effect of preoperative narcotics usage on postoperative outcomes and patient satisfaction following spine surgery has been of question. The NarxCare platform analyzes the patients' state Physician Drug Monitoring Program (PDMP) records to assign numerical scores that approximate a patient's overall opioid drug usage.

METHODS

Elective spine surgery cases performed at a single institution between October 2017 and March 2018 were evaluated. NarxCare narcotics use scores at the time of admission were assessed. Patient characteristics, as well as 30-day adverse events, readmissions, reoperations, and mortality, were abstracted from the medical record. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data were also abstracted when available.Cases were binned based on the following ranges of admission NarxCare scores: 0, 1 to 99, 100 to 299, 300 to 499, and 500+. Multivariate logistic regressions were performed to compare the odds of having an adverse events, readmission, reoperation, and mortality between the different narcotics groups. One-way analysis of variance analyses were performed to compare HCAHPS survey response rates and HCAHPS survey results between the different narcotics score groups.

RESULTS

In total, 346 patients met criteria for inclusion in the study (NarxScore 0: n = 74, 1-99: n = 58, 300-499: n = 117, and 500+: n = 21). Multivariate logistic regressions did not detect statistically significant differential odds of experiencing adverse events, readmission, reoperation, or mortality between the different groups of admissions narcotics scores. Analyses of variance did not detect statistically significant differences in HCAHPS survey response rates, total HCAHPS scores, or HCAHP subgroup scores between the different narcotics score groups.

CONCLUSION

Although there are many reasons to address preoperative patient narcotic utilization, the present study did not detect perioperative outcome differences or patient satisfaction based on the narcotic use scores as stratified here.

LEVEL OF EVIDENCE

3.

Adherence stages measured by patient-reported outcome instruments in adults with asthma: a scoping review

Objective: Individuals who are adherent to their asthma inhaled maintenance medication: (1) initiate their treatment (take the first dose); (2) implement it (take it as per prescribed dosing regimen); and persist with it (take it for the entire prescribing period). To avoid unnecessary hospitalizations and costs, patient adherence should be routinely assessed. To this end, we aimed to identify patient-reported outcome instruments (PROs) used for measurement of patient adherence to inhaled maintenance medication in asthmatic adults and to report on the adherence stage that these instruments measured. Data sources: We conducted a scoping review of six databases. Study selection: We searched for studies in which PROs were used to measure patient adherence to inhaled maintenance medication in asthmatic participants aged ≥18 years. We extracted and synthesized data in order to list the available PROs and to report the adherence stages that these instruments measured. Results: We included 186 studies (87 PROs). Among all 87 instruments, none were found to measure all three adherence stages. We found that 1 measured initiation, 2 evaluated initiation and implementation, 74 assessed implementation, 7 measured implementation and persistence. The most used instrument (n = 41 studies or 22%) was the Self-Reported Medication-Taking Scale, which was found to assess implementation only. Conclusion: Our results suggest that no single PRO exists to measure initiation, implementation and persistence with asthma inhaled maintenance medication. Results from this review could therefore guide the development or refinement of PROs that would aim to measure all three adherence stages.

Patient-reported outcome instruments that evaluate adherence behaviours in adults with asthma: a systematic review of measurement properties

AIM

The aim of the present study was to identify systematically the measurement properties of patient-reported outcome instruments (PROs) that evaluate adherence to inhaled maintenance medication in adults with asthma.

METHODS

We conducted a systematic review of six databases. Two reviewers independently included studies on the measurement properties of PROs that evaluated adherence in asthmatic participants aged ≥18 years. Based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN), the reviewers: (i) extracted data on internal consistency, reliability, measurement error, content validity, structural validity, hypotheses testing, cross-cultural validity, criterion validity and responsiveness; (ii) assessed the methodological quality of the included studies; (iii) assessed the quality of the measurement properties (positive or negative); and (iv) summarized the level of evidence (limited, moderate or strong).

RESULTS

We screened 6068 records and included 15 studies (14 PROs). No studies evaluated measurement error or responsiveness. Based on methodological and measurement property quality assessments, we found limited positive evidence of: (i) internal consistency of the Adherence Questionnaire, Refined Medication Adherence Reason (MAR) scale, Medication Adherence Report Scale for Asthma (MARS-A) and Test of the Adherence to Inhalers (TAI); (ii) reliability of the TAI; and (iii) structural validity of the adherence questionnaire, MAR scale, MARS-A and TAI. We also found limited negative evidence of: (i) hypotheses testing of the Adherence Questionnaire; (ii) reliability of the MARS-A; and (iii) criterion validity of the MARS-A and TAI.

CONCLUSIONS

Our results highlighted the need to conduct further high-quality studies to evaluate the reliability, validity and responsiveness of the available PROs.