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Burnier M. Physician and patient adherence in hypertension trials: a point of view on an important issue to resolve. Expert Rev Pharmacoecon Outcomes Res 2024; 24:749-758. [PMID: 38836304 DOI: 10.1080/14737167.2024.2363401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Randomized controlled trials (RCTs) are important sources of evidence that strongly influence guidelines for patient management, including for elevated blood pressure in adults. AREAS COVERED Critical questions regarding the interpretation of hypertension trial results have recently increased, especially for concerns over methodology. In particular, investigator adherence to the protocol and patient adherence to investigational drugs are often far from optimal. These issues may be ignored or underreported because physicians' behavior during trials is often not monitored and patients' medication adherence is neither measured adequately nor reported or analyzed in the final report or in the publication. This situation may lead to misinterpretations of study results and misevaluations of the safety and efficacy profile of new drugs. In this short review, the problem of measuring, reporting, and analyzing drug adherence in RCTs is discussed and illustrated with several examples in the field of hypertension. EXPERT OPINION The main conclusion is that drug adherence should always be measured in clinical trials, possibly with more than one method. In addition, prespecified analyses of adherence data should be included in the statistical plan of all trials to improve their overall quality.
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Affiliation(s)
- Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Hunt JH, Peay HL, Henderson GE. Facilitators and Barriers to Adherence to Anti-Retroviral Treatment Among Pregnant or Breastfeeding Women Living with HIV and Perinatally Infected Infants: A Scoping Review. AIDS Behav 2024:10.1007/s10461-024-04373-4. [PMID: 38767727 DOI: 10.1007/s10461-024-04373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
In 2022, 54% of 1.5 million children (age 0-14) living with HIV had access to anti-retroviral medication (ART). Adherence to ART for pregnant or breastfeeding HIV + women is critical for maintaining their personal health and to prevent mother-to-child-transmission (MTCT). For HIV + infants, adherence is essential to establish early viremic control and is contingent on caregiver administration. We conducted a scoping review to systematically identify and categorize the influences on ART adherence for pregnant or breastfeeding HIV + women and their HIV + infants. We searched databases in June 2023 and employed the Social-Ecological Model (SEM) to organize facilitators and barriers to adherence referenced in published articles. All articles published before 2016 were excluded due to updated guidelines from WHO on MTCT and ART. Our analysis included 52 articles. 50/52 took place in Africa and used cross-sectional and mixed-methods design. Barriers to adherence for pregnant or breastfeeding HIV + women included maternal education, self-efficacy, social support, and social/economic context. Barriers to infant adherence included development, nutrition, age of treatment initiation, disclosure, and ART side effects. Additional facilitators and barriers to adherence are presented at family, extra-familial, and socio-cultural SEM levels. Stigma was the most salient barrier referenced across the entire continuum of HIV care and all SEM levels. This review revealed a dearth of literature focusing on HIV + infants who are dependent on their caregivers for ART adherence and lack of a standard adherence measure. We identified multi-leveled influences on adherence impacting both the mother and infant and are amenable to public health intervention.
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Affiliation(s)
- Joanne H Hunt
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Holly L Peay
- Research Triangle International, Durham, NC, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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McGrady ME, Ignjatovic V, Jones S, Bruce A, Goldenberg NA, Rizzi M, Thornburg CD, Todd KE, Luchtman-Jones L. Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2024:S1538-7836(24)00217-4. [PMID: 38642706 DOI: 10.1016/j.jtha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
In response to growing recognition that nonadherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this article was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this article was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.
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Affiliation(s)
- Meghan E McGrady
- Center for Adherence and Self-Management, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Vera Ignjatovic
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Jones
- Haematology, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
| | - Aisha Bruce
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA; Departments of Pediatrics and Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mattia Rizzi
- Hematology/Oncology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, California, USA; Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California, USA
| | - Kevin E Todd
- Department of Pediatric Hematology/Oncology, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Krychtiuk KA, Andersson TL, Bodesheim U, Butler J, Curtis LH, Elkind M, Hernandez AF, Hornik C, Lyman GH, Khatri P, Mbagwu M, Murakami M, Nichols G, Roessig L, Young AQ, Schilsky RL, Pagidipati N. Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank. Am Heart J 2024; 270:23-43. [PMID: 38242417 DOI: 10.1016/j.ahj.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.
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Affiliation(s)
| | | | | | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, TX
| | | | - Mitchell Elkind
- American Heart Association, Dallas, TX; Columbia University, New York, NY
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Vrijens B, Pironet A, Tousset E. The Importance of Assessing Drug Exposure and Medication Adherence in Evaluating Investigational Medications: Ensuring Validity and Reliability of Clinical Trial Results. Pharmaceut Med 2024; 38:9-18. [PMID: 38135800 PMCID: PMC10824809 DOI: 10.1007/s40290-023-00503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 12/24/2023]
Abstract
The objective of this current opinion paper is to draw global attention to medication adherence, emphasizing its crucial role in drug trials. Frequently, trialists lean on traditional approaches to assess medication adherence, which, while comfortable, may only reveal what trialists desire rather than offering the essential insights needed for informed decision making in drug development. Understanding drug exposure and medication adherence is paramount when evaluating the effectiveness and safety of investigational medications. Without a comprehensive understanding of how patients adhere to their prescribed treatment regimens, the integrity and dependability of clinical trial results can be compromised. This paper emphasizes the need for measures that accurately and reliably assess medication intake behaviors, enabling the differentiation between minor dosing errors and significant deviations that may impact the drug's efficacy and safety. Accurate knowledge of drug exposure empowers researchers to make informed decisions, identify potential confounding factors, and appropriately interpret study outcomes, ultimately ensuring the validity and reliability of the research findings. By prioritizing drug exposure assessment and medication adherence measurement, clinical trials can enhance their scientific rigor, contribute to more accurate evaluations of investigational medications, and ultimately speed up the development process.
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Affiliation(s)
- Bernard Vrijens
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium.
- Department of Public Health, Liège University, Liège, Belgium.
| | | | - Eric Tousset
- AARDEX Group, 15/1, Rue Bois St Jean, 4102, Liège, Belgium
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Kirkland AE, Tomko RL, Green R, Browning BD, Ferguson PL, Liu H, Miranda R, Gray KM, Squeglia LM. Pairwise comparisons of three medication adherence outcomes in adolescents who use alcohol. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:2375-2385. [PMID: 38151786 PMCID: PMC10755249 DOI: 10.1111/acer.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/14/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Accurate assessment of medication adherence is important for understanding pharmacotherapy outcomes across all phases of adolescent substance use disorder (SUD) clinical trials. The objective of this study was to describe and assess the pairwise concordance between three commonly used non-biological medication adherence assessment methods in adolescents who use alcohol to inform the selection of medication adherence measures for use in future youth SUD trials. METHODS Participants (N = 32, 17-19-years-old) took N-acetylcysteine and placebo, in a randomized cross-over design, for 10 days each. Medication adherence was assessed (20 days total) via pill count, medication videos submitted twice daily, and the Medication Event Monitoring System (MEMS®). Lin's Concordance Correlation Coefficient (CCC) assessed concordance and Bland-Altman plots are reported. Linear mixed-effects models with main effects of medication, treatment block (first medication, second medication), and sequence were also run. RESULTS Medication videos yielded the lowest (64%) and pill count yielded the highest (89%) adherence estimates. CCC values indicated poor correspondence, except between pill count and MEMS. The Bland-Altman plots showed good pairwise agreement between all methods. Linear mixed-effects models indicated a difference between the first and second cross-over medication, with adherence estimates being lower for the second medication, regardless of whether it was N-acetylcysteine or placebo. CONCLUSIONS The study yielded important and practical information. First, incorporating more than one method of adherence assessment may capture estimated floor and ceiling adherence in the absence of a biological marker. This is particularly relevant for remote or hybrid studies where bio-marker collection is challenging. Selection of the assessment methods will depend on study goals. Second, the continuation of medication adherence research can benefit each phase of clinical trials and inform rigorous pharmacotherapy evaluation.
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Affiliation(s)
- Anna E. Kirkland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rachel L. Tomko
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - ReJoyce Green
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brittney D. Browning
- Department of Neuroscience, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pamela L. Ferguson
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Helen Liu
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert Miranda
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
| | - Kevin M. Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lindsay M. Squeglia
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Zhang L, Liu Y, Tian J. Patient Preferences and Their Influence on Chronic Hepatitis B-A Review. Patient Prefer Adherence 2023; 17:3119-3124. [PMID: 38053533 PMCID: PMC10695120 DOI: 10.2147/ppa.s433283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/25/2023] [Indexed: 12/07/2023] Open
Abstract
Chronic hepatitis B (CHB) is a common chronic viral infectious disease that requires long-term treatment to control the condition and prevent complications. To standardize treatment regimens for CHB, professional associations have established relevant guidelines, but they have often overlooked patient preferences. Historically, in the treatment process, medical decisions were predominantly made by physicians or health care administrators, with limited patient involvement, leading to the neglect of patient preferences. Patient attitudes, expectations, and needs are all influenced by their preferences, and patient preferences have a direct impact on treatment adherence. Understanding and respecting patient preferences are crucial to ensuring treatment effectiveness. This article will explore patient preferences in the treatment of CHB and elucidate the influence of patient preferences on treatment adherence, aiming to provide insights for the development of a more personalized and effective health care process.
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Affiliation(s)
- Lin Zhang
- Department of Infectious Diseases, The Affiliated Suqian First People’s Hospital of Nanjing Medical University, Suqian, Jiangsu Province, People’s Republic of China
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Yunyue Liu
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Jinping Tian
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu Province, People’s Republic of China
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, People’s Republic of China
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Lasala R, Santoleri F, Romagnoli A, Abrate P, Musicco F, Costantini A. Medication adherence reporting in pivotal clinical trials: overview of oral oncological drugs. Eur J Hosp Pharm 2023; 30:328-332. [PMID: 35058307 PMCID: PMC10647863 DOI: 10.1136/ejhpharm-2021-002998] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/20/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess how and to what extent adherence to medication is reported in pivotal clinical trials of oral cancer drugs. METHODS All drugs authorised by the European Medicines Agency from 1 January 2014 to 31 December 2019 were considered for analysis. For each pivotal trial we extracted the journal of publication, phase of the study, posology, mention of adherence within the main text of the published article or additional material and the terms in which the adherence was reported. RESULTS Thirty drugs were included in the analysis from 56 clinical trials. Eleven articles (19.6%) contained a mention of medication adherence in the main document, 26 (46.4%) in the supplementary material and 19 (33.9%) did not contain any reference to adherence. Seven studies reported medication adherence between the results, expressed as number of patients discontinuing treatment for non-compliance and mean or median percentage. CONCLUSIONS Medication adherence in pivotal clinical trials of oral oncological drugs is poorly represented. There should be a greater level of reporting in the results and it should be included among the minimum set of recommendations in reporting health research.
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Alves Leite de Barros KA, da Silva Praxedes MF, Pinho Ribeiro AL, Parreiras Martins MA. Effect and usability of mobile health applications for medication adherence in patients with heart failure: A systematic review. Int J Med Inform 2023; 178:105206. [PMID: 37708836 DOI: 10.1016/j.ijmedinf.2023.105206] [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: 05/29/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use. METHODS We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA). RESULTS Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias. CONCLUSION The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.
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Affiliation(s)
- Kátia Adriana Alves Leite de Barros
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Bairro Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Marcus Fernando da Silva Praxedes
- Centro de Ciências da Saúde, Universidade Federal do Recôncavo da Bahia, Av. Carlos Amaral, 1015, Bairro Cajueiro, Santo Antônio de Jesus, Bahia 44430-622, Brazil
| | - Antônio Luiz Pinho Ribeiro
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Bairro Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil; Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Bairro Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Maria Auxiliadora Parreiras Martins
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Bairro Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil; Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Bairro Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil; Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais 31270-901, Brazil.
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Hossain MB, Karim ME. Key considerations for choosing a statistical method to deal with incomplete treatment adherence in pragmatic trials. Pharm Stat 2023; 22:205-231. [PMID: 36637242 DOI: 10.1002/pst.2258] [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: 08/13/2021] [Revised: 05/27/2022] [Accepted: 07/15/2022] [Indexed: 02/01/2023]
Abstract
Pragmatic trials offer practical means of obtaining real-world evidence to help improve decision-making in comparative effectiveness settings. Unfortunately, incomplete adherence is a common problem in pragmatic trials. The commonly used methods in randomized control trials often cannot handle the added complexity imposed by incomplete adherence, resulting in biased estimates. Several naive methods and advanced causal inference methods (e.g., inverse probability weighting and instrumental variable-based approaches) have been used in the literature to deal with incomplete adherence. Practitioners and applied researchers are often confused about which method to consider under a given setting. This current work is aimed to review commonly used statistical methods to deal with non-adherence along with their key assumptions, advantages, and limitations, with a particular focus on pragmatic trials. We have listed the applicable settings for these methods and provided a summary of available software. All methods were applied to two hypothetical datasets to demonstrate how these methods perform in a given scenario, along with the R codes. The key considerations include the type of intervention strategy (point treatment settings, where treatment is administered only once versus sustained treatment settings, where treatment has to be continued over time) and availability of data (e.g., the extent of measured or unmeasured covariates that are associated with adherence, dependent confounding impacted by past treatment, and potential violation of assumptions). This study will guide practitioners and applied researchers to use the appropriate statistical method to address incomplete adherence in pragmatic trial settings for both the point and sustained treatment strategies.
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Affiliation(s)
- Md Belal Hossain
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, Canada
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Mantila KM, Pasmooij AM, Hallgreen CE, Mol PG, van Boven JF. Medication Adherence Measurement Methods in Registration Trials Supporting the Approval of New Medicines: A Cross-Sectional Analysis of Centralized Procedures in the European Union 2010-2020. Clin Pharmacol Ther 2022; 112:1051-1060. [PMID: 35816103 PMCID: PMC9795959 DOI: 10.1002/cpt.2709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/30/2022] [Indexed: 01/01/2023]
Abstract
Medication adherence is a key factor impacting efficacy and safety of medicines, yet how it is dealt with in European registration trials is unknown. A cross-sectional analysis of European Medicines Agency (EMA) marketing authorization dossiers for new medicines approved through centralized procedures in the European Union between 2010 and 2020 was performed. Data were extracted from European Public Assessment Reports and Clinical Study Reports. Clinical trials covering five therapeutic areas were included: diabetes, respiratory conditions, cardiovascular diseases, infectious diseases, and oncology. Outcomes included adherence assessment, measurement methods, and rates. Overall, 102 medicines studied in 253 clinical trials were reviewed. All but one study reported measuring adherence. Two hundred twenty trials (87%) measured adherence using quantitative methods, while 32 (13%) trials monitored adherence but did not further quantify. Reported adherence rates were high (> 90%) across trials yet marked disparities in measurement methods and definitions were found. The most frequently used adherence measurement method was pill/dose count (single method: 52.7%; in combination: 37.7%; with patient diary/report: 17.3%; electronic methods: 1.4%; bioanalytical methods: 4.1%). Patient diary/report (6.4%) and electronic methods (2.7%) were also used as single methods. Electronic methods were more often used in respiratory and anti-infective trials, while bioanalytical methods were more frequently used in diabetes. Overall, adherence is measured in EMA registration trials, yet the methods used and the way in which adherence rates are presented vary widely between trials and therapeutic areas. To better understand and compare efficacy of medicines, standardization of adherence definitions and measurement methods is needed.
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Affiliation(s)
- Katerina M. Mantila
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark,Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Dutch Medicines Evaluation BoardUtrechtThe Netherlands
| | | | - Christine Erikstrup Hallgreen
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Peter G.M. Mol
- Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Dutch Medicines Evaluation BoardUtrechtThe Netherlands
| | - Job F.M. van Boven
- Department of Clinical Pharmacy & PharmacologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands,Medication Adherence Expertise Center of the Northern Netherlands (MAECON)GroningenThe Netherlands
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Kostalova B, Mala-Ladova K, Sulkova SD, Denhaerynck K, De Geest S, Maly J. Comparison of different methods to assess tacrolimus concentration intra-patient variability as potential marker of medication non-adherence. Front Pharmacol 2022; 13:973564. [PMID: 36313323 PMCID: PMC9609782 DOI: 10.3389/fphar.2022.973564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background and objective: Non-adherence to tacrolimus commonly manifests as low drug concentrations and/or high intra-patient variability (IPV) of concentrations across multiple measurements. We aimed to compare several methods of tacrolimus IPV calculation and evaluate how well each reflects blood concentration variation due to medication non-adherence in kidney transplant recipients. Methods: This Czech single-center retrospective longitudinal study was conducted in 2019. All outpatients ≥18 years of age, ≥3 months post-transplant, and on tacrolimus-based regimens were approached. After collecting seven consecutive tacrolimus concentrations we asked participating patients to self-report adherence to immunosuppressants (BAASIS© scale). The IPV of tacrolimus was calculated as the medication level variability index (MLVI), the coefficient of variation (CV), the time-weighted CV, and via nonlinearly modeled dose-corrected trough levels. These patient-level variables were analyzed using regression analysis. Detected nonlinearities in the dose-response curve were controlled for by adding tacrolimus dosing and its higher-order terms as covariates, along with self-reported medication adherence levels. Results: Of 243 patients using tacrolimus, 42% (n = 102) reported medication non-adherence. Non-adherence was associated with higher CVs, higher time-weighted CVs, and lower dose-corrected nonlinearly modeled trough levels; however, it was not associated with MLVIs. All of the significant operationalizations suggested a weak association that was similar across the applied methods. Discussion and conclusion: Implementation non-adherence was reflected by higher CV or time-weighted CV and by lower blood concentrations of tacrolimus. As an additional tool for identifying patients at risk for non-adherence, simple IPV calculations incorporated into medical records should be considered in everyday clinical practice.
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Affiliation(s)
- Barbora Kostalova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Sylvie Dusilova Sulkova
- Department of Nephrology, University Hospital Hradec Kralove and Faculty of Medicine Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Kris Denhaerynck
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Josef Maly
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
- *Correspondence: Josef Maly,
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Current practice in the measurement and interpretation of intervention adherence in randomised controlled trials: A systematic review. Contemp Clin Trials 2022; 118:106788. [PMID: 35562000 DOI: 10.1016/j.cct.2022.106788] [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: 01/18/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ideally all participants in a randomised controlled trial (RCT) should fully receive their allocated intervention; however, this rarely occurs in practice. Intervention adherence affects Type II error so influences the interpretation of trial results and subsequent implementation. We aimed to describe current practice in the definition, measurement, and reporting of intervention adherence in non-pharmacological RCTs, and how this data is incorporated into a trial's interpretation and conclusions. METHODS We conducted a systematic review of phase III RCTs published between January 2018 and June 2020 in the National Institute for Health Research Journals Library for the Health Technology Assessment, Programme Grants for Applied Research, and Public Health Research funding streams. RESULTS Of 237 reports published, 76 met the eligibility criteria and were included. Most RCTs (n = 68, 89.5%) reported adherence, though use of terminology varied widely; nearly three quarters of these (n = 49, 72.1%) conducted a sensitivity analysis. Adherence measures varied between intervention types: behavioural change (n = 10, 43.5%), psychological therapy (n = 5, 83.3%) and physiotherapy/rehabilitation (n = 8, 66.7%) interventions predominately measured adherence based on session attendance. Whereas medical device and surgical interventions (n = 17, 73.9%) primarily record the number of participants receiving the allocated intervention, a third (n = 33, 67.3%) of studies reported a difference in findings between primary and sensitivity analyses. CONCLUSIONS Although most trials report elements of adherence, terminology was inconsistent, and there was no systematic approach to its measurement, analyses, interpretation, or reporting. Given the importance of adherence within clinical trials, there is a pressing need for a standardised approach or framework.
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Effect of Crocus sativus (Saffron) Intake on Top of Standard Treatment, on Disease Outcomes and Comorbidities in Patients with Rheumatic Diseases: Synthesis without Meta-Analysis (SWiM) and Level of Adherence to the CONSORT Statement for Randomized Controlled Trials Delivering Herbal Medicine Interventions. Nutrients 2021; 13:nu13124274. [PMID: 34959826 PMCID: PMC8706139 DOI: 10.3390/nu13124274] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/18/2022] Open
Abstract
Rheumatic diseases (RDs) are often complicated by chronic symptoms and frequent side-effects associated with their treatment. Saffron, a spice derived from the Crocus sativus L. flower, is a popular complementary and alternative medicine among patients with RDs. The present systematic review aimed to summarize the available evidence regarding the efficacy of supplementation with saffron on disease outcomes and comorbidities in patients with RD diagnoses. PubMed, CENTRAL, clinicaltrials.gov and the grey literature were searched until October 2021, and relevant randomized controlled trials (RCTs) were screened for eligibility using Rayyan. Risk of bias was assessed using the Cochrane’s Risk of Bias-2.0 (RoB) tool. A synthesis without meta-analysis (SWiM) was performed by vote counting and an effect direction plot was created. Out of 125 reports, seven fulfilled the eligibility criteria belonging to five RCTs and were included in the SWiM. The RCTs involved patients with rheumatoid arthritis, osteoarthritis and fibromyalgia, and evaluated outcomes related to pain, disease activity, depression, immune response, inflammation, oxidative stress, health, fatigue and functional ability. The majority of trials demonstrated some concerns regarding overall bias. Moreover, the majority of trialists failed to adhere to the formula elaborations suggested by the CONSORT statement for RCTs incorporating herbal medicine interventions. Standardization of herbal medicine confirms its identity, purity and quality; however, the majority of trials failed to adhere to these guidelines. Due to the great heterogeneity and the lack of important information regarding the standardization and content of herbal interventions, it appears that the evidence is not enough to secure a direction of effect for any of the examined outcomes.
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Baumgartner SL, Buffkin DE, Rukavina E, Jones J, Weiler E, Carnes TC. A Novel Digital Pill System for Medication Adherence Measurement and Reporting: Usability Validation Study. JMIR Hum Factors 2021; 8:e30786. [PMID: 34747709 PMCID: PMC8663639 DOI: 10.2196/30786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background Medication nonadherence is a costly problem that is common in clinical use and clinical trials alike, with significant adverse consequences. Digital pill systems have proved to be effective and safe solutions to the challenges of nonadherence, with documented success in improving adherence and health outcomes. Objective The aim of this human factors validation study is to evaluate a novel digital pill system, the ID-Cap System from etectRx, for usability among patient users in a simulated real-world use environment. Methods A total of 17 patients with diverse backgrounds who regularly take oral prescription medications were recruited. After training and a period of training decay, the participants were asked to complete 12 patient-use scenarios during which errors or difficulties were logged. The participants were also interviewed about their experiences with the ID-Cap System. Results The participants ranged in age from 27 to 74 years (mean 51 years, SD 13.8 years), and they were heterogeneous in other demographic factors as well, such as education level, handedness, and sex. In this human factors validation study, the patient users completed 97.5% (196/201) of the total use scenarios successfully; 75.1% (151/201) were completed without any failures or errors. The participants found the ID-Cap System easy to use, and they were able to accurately and proficiently record ingestion events using the device. Conclusions The participants demonstrated the ability to safely and effectively use the ID-Cap System for its intended use. The ID-Cap System has great potential as a useful tool for encouraging medication adherence and can be easily implemented by patient users.
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Affiliation(s)
| | | | | | - Jason Jones
- Tensentric, Inc., Boulder, CO, United States
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16
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Real-world Evidence for Adherence and Persistence with Atorvastatin Therapy. Cardiol Ther 2021; 10:445-464. [PMID: 34586613 PMCID: PMC8555050 DOI: 10.1007/s40119-021-00240-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Indexed: 12/17/2022] Open
Abstract
Atorvastatin, which has been approved by regulatory agencies for primary- and secondary-prevention patients with dyslipidemia, has historically been the most commonly prescribed statin and is now widely available in generic formulations. Despite widespread statin usage, many patients fail to attain recommended (LDL-C) targets. While several factors impact the successful treatment of dyslipidemia, suboptimal patient adherence is a major limiting factor to medication effectiveness. In this narrative review we sought to investigate patient adherence and persistence with atorvastatin in a real-world setting and to identify barriers to LDL-C goal attainment and therapy outcomes beyond the realm of clinical trials. Moreover, in light of growing generic usage, we carried out targeted literature searches to investigate the impact of generic atorvastatin availability on patient adherence/persistence, and on lipid and efficacy outcomes, compared with branded formulations. Unsurprisingly, real-world data suggest that patient adherence/persistence to atorvastatin is suboptimal, but few studies have attempted to address factors impacting adherence. Data from studies comparing adherence/persistence in patients prescribed branded or generic atorvastatin are limited and show no clear evidence that initiation of a specific preparation of atorvastatin impacts adherence/persistence. Furthermore, results from studies comparing adherence/persistence of patients who switched from the branded to the generic drug are conflicting, although they do suggest that switching may negatively impact adherence over the long term. Additional real-world studies are clearly required to understand potential differences in adherence and persistence between patients initiating treatment with branded versus generic atorvastatin and, moreover, the factors that influence adherence. Targeted education initiatives and additional research are needed to understand and improve patient adherence in a real-world setting.
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17
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Edward A, Campbell B, Manase F, Appel LJ. Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania. BMC Health Serv Res 2021; 21:834. [PMID: 34407820 PMCID: PMC8371775 DOI: 10.1186/s12913-021-06858-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/04/2021] [Indexed: 01/20/2023] Open
Abstract
Background Poor medication adherence is an extraordinarily common problem worldwide that contributes to inadequate control of many chronic diseases, including Hypertension (HT). Globally, less than 14% of the estimated 1.4 billion patients with HT achieve optimal control. A myriad of barriers, across patient, healthcare provider, and system levels, contributes to poor medication adherence. Few studies have explored the reasons for poor medication adherence in Tanzania and other African countries. Methods A qualitative study applying grounded theory principles was conducted in the catchment area of two semi-urban clinics in Dar es Salaam, Tanzania, to determine the perceived barriers to HT medication adherence. Ten key informant interviews were conducted with healthcare providers who manage HT patients. Patients diagnosed with HT (SBP ≥ 140 and DBP ≥ 90), were randomly selected from patient registers, and nine focus group discussions were conducted with a total 34 patients. Inductive codes were developed separately for the two groups, prior to analyzing key thematic ideas with smaller sub-categories. Results Affordability of antihypertensive medication and access to care emerged as the most important barriers. Fee subsidies for treatment and medication, along with health insurance, were mentioned as potential solutions to enhance access and adherence. Patient education and quality of physician counseling were mentioned by both providers and patients as major barriers to medication adherence, as most patients were unaware of their HT and often took medications only when symptomatic. Use of local herbal medicines was mentioned as an alternative to medications, as they were inexpensive, available, and culturally acceptable. Patient recommendations for improving adherence included community-based distribution of refills, SMS text reminders, and family support. Reliance on religious leaders over healthcare providers emerged as a potential means to promote adherence in some discussions. Conclusions Effective management of hypertensive patients for medication adherence will require several context-specific measures. These include policy measures addressing financial access, with medication subsidies for the poor and accessible distribution systems for medication refill; physician measures to improve health provider counseling for patient centric care; and patient-level strategies with reminders for medication adherence in low resource settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06858-7.
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Affiliation(s)
- Anbrasi Edward
- Department of International Health, Johns Hopkins University, Baltimore, USA.
| | - Brady Campbell
- University of Iowa Carver College of Medicine, Iowa City, USA
| | - Frank Manase
- Community Center for Preventive Medicine, Dar es Salaam, Tanzania
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, and Johns Hopkins School of Nursing, Baltimore, MD, USA
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18
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van Heuckelum M, van den Ende CHM, van Dulmen S, van den Bemt BJF. Electronic Monitoring Feedback for Improving Medication Adherence and Clinical Outcomes in Early Rheumatoid Arthritis: A Randomized Clinical Trial. Patient Prefer Adherence 2021; 15:1107-1119. [PMID: 34079231 PMCID: PMC8164714 DOI: 10.2147/ppa.s297170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/19/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Non-adherence to medication (range 30-107%) is a major issue in patients with rheumatoid arthritis (RA). Previous research has shown that electronic monitoring feedback (EMF) might be an effective strategy to improve medication adherence in chronic conditions. Therefore, this study investigated the effectiveness of electronic monitoring feedback in patients with early RA to improve medication adherence and clinical outcomes compared to usual care. METHODS An open-label randomized clinical trial was performed to compare EMF with standard care during a 12-month follow-up period on two sites of the Sint Maartenskliniek (Nijmegen and Boxmeer) in the Netherlands. Patients were eligible if they: (1) had a (working) diagnosis of early RA, (2) were currently using methotrexate, (3) were aged ≥18 years, and (4) had a life expectancy of ≥12 months. Primary outcome was the difference in proportion of non-adherent patients measured with the Compliance Questionnaire on Rheumatology after 12 months. Secondary outcomes were beliefs about medicines, medication adherence measured with the MMAS-8®, patients' health status, prescription of biologic DMARDs, and disease activity after 12 months. RESULTS Of the 367 initially-invited patients, 93 patients with early RA agreed to participate in this study. No significant difference was found in the proportion of non-adherent patients between the intervention arm and the usual care arm after 12 months follow-up (60.0% and 61.3%, p=0.93, respectively). Patients in the intervention arm tended to discontinue methotrexate earlier than patients in the usual care arm (median time in weeks: 15.7 (9.1-33.6) and 21.9 (19-28.4), respectively, p=0.31), whereas patients in the usual care arm tended to initiate biologic DMARDs earlier than those in the intervention arm (median time in weeks: 11.9 (5.7-22) and 17 (9.9-40.9), respectively, p=0.55). CONCLUSION This study illustrates the challenge of targeting non-adherence with EMF in patients with early RA and shares important lessons learned about designing adherence intervention trials with respect to study attrition, accounting for drug survival, intervention fidelity, intervention uptake, and technical aspects.
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Affiliation(s)
- Milou van Heuckelum
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Cornelia H M van den Ende
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
- Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands
- Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, the Netherlands
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Dockendorf MF, Hansen BJ, Bateman KP, Moyer M, Shah JK, Shipley LA. Digitally Enabled, Patient-Centric Clinical Trials: Shifting the Drug Development Paradigm. Clin Transl Sci 2021; 14:445-459. [PMID: 33048475 PMCID: PMC7993267 DOI: 10.1111/cts.12910] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022] Open
Abstract
The rapidly advancing field of digital health technologies provides a great opportunity to radically transform the way clinical trials are conducted and to shift the clinical trial paradigm from a site-centric to a patient-centric model. Merck's (Kenilworth, NJ) digitally enabled clinical trial initiative is focused on introduction of digital technologies into the clinical trial paradigm to reduce patient burden, improve drug adherence, provide a means of more closely engaging with the patient, and enable higher quality, faster, and more frequent data collection. This paper will describe the following four key areas of focus from Merck's digitally enabled clinical trials initiative, along with corresponding enabling technologies: (i) use of technologies that can monitor and improve drug adherence (smart dosing), (ii) collection of pharmacokinetic (PK), pharmacodynamic (PD), and biomarker samples in an outpatient setting (patient-centric sampling), (iii) use of digital devices to collect and measure physiological and behavioral data (digital biomarkers), and (iv) use of data platforms that integrate digital data streams, visualize data in real-time, and provide a means of greater patient engagement during the trial (digital platform). Furthermore, this paper will discuss the synergistic power in implementation of these approaches jointly within a trial to enable better understanding of adherence, safety, efficacy, PK, PD, and corresponding exposure-response relationships of investigational therapies as well as reduced patient burden for clinical trial participation. Obstacle and challenges to adoption and full realization of the vision of patient-centric, digitally enabled trials will also be discussed.
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20
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Tibble H, Flook M, Sheikh A, Tsanas A, Horne R, Vrijens B, De Geest S, Stagg HR. Measuring and reporting treatment adherence: What can we learn by comparing two respiratory conditions? Br J Clin Pharmacol 2020; 87:825-836. [PMID: 32639589 DOI: 10.1111/bcp.14458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 01/03/2023] Open
Abstract
Medication non-adherence, defined as any deviation from the regimen recommended by their healthcare provider, can increase morbidity, mortality and side effects, while reducing effectiveness. Through studying two respiratory conditions, asthma and tuberculosis (TB), we thoroughly review the current understanding of the measurement and reporting of medication adherence. In this paper, we identify major methodological issues in the standard ways that adherence has been conceptualised, defined and studied in asthma and TB. Between and within the two diseases there are substantial variations in adherence reporting, linked to differences in dosing intervals and treatment duration. Critically, the communicable nature of TB has resulted in dose-by-dose monitoring becoming a recommended treatment standard. Through the lens of these similarities and contrasts, we highlight contemporary shortcomings in the generalised conceptualisation of medication adherence. Furthermore, we outline elements in which knowledge could be directly transferred from one condition to the other, such as the application of large-scale cost-effective monitoring methods in TB to resource-poor settings in asthma. To develop a more robust evidence-based approach, we recommend the use of standard taxonomies detailed in the ABC taxonomy when measuring and discussing adherence. Regimen and intervention development and use should be based on sufficient evidence of the commonality and type of adherence behaviours displayed by patients with the relevant condition. A systematic approach to the measurement and reporting of adherence could improve the value and generalisability of research across all health conditions.
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Affiliation(s)
- Holly Tibble
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Mary Flook
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK.,Health Data Research UK, London, UK
| | - Athanasios Tsanas
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Rob Horne
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK.,Centre for Behavioural Medicine, Department for Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Bernard Vrijens
- AARDEX Group, Seraing, Belgium.,Liège University, Liège, Belgium
| | - Sabina De Geest
- Institute of Nursing Science, University of Basel, Basel, Switzerland.,Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Helen R Stagg
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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21
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Eliasson L, Clifford S, Mulick A, Jackson C, Vrijens B. How the EMERGE guideline on medication adherence can improve the quality of clinical trials. Br J Clin Pharmacol 2020; 86:687-697. [PMID: 32034923 DOI: 10.1111/bcp.14240] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 11/27/2019] [Accepted: 01/12/2020] [Indexed: 01/01/2023] Open
Abstract
Medication adherence in drug trials is suboptimal, affecting the quality of these studies and adding significant costs. Nonadherence in this setting can lead to null findings, unduly large sample sizes and the need for dose modification after a drug has been approved. Despite these drawbacks, adherence behaviours are not consistently measured, analysed or reported appropriately in trial settings. The ESPACOMP Medication Adherence Reporting Guideline (EMERGE) offers a solution by facilitating a sound protocol design that takes this crucial factor into account. This article summarises key evidence on traditional and newer measurements of adherence, discusses implementation in clinical trial settings and makes recommendations about the analysis and interpretation of adherence data. Given the potential benefits of this approach, the authors call on regulators and the pharmaceutical industry to endorse the EMERGE guideline.
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Affiliation(s)
| | | | - Amy Mulick
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Bernard Vrijens
- AARDEX Group, Seraing, Belgium.,Liège University, Liège, Belgium
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