Portuguese version of the Medication Adherence Report Scale (MARS-9): Validation in a population of chronic pain patients

Using the 5-Item Medication Adherence Report Scale (MARS-5) to Screen for Non-adherence to Vitamin and Mineral Supplementation After Bariatric Surgery

INTRODUCTION

Poor adherence to recommended vitamin and mineral supplementation after bariatric surgery is common and challenging for healthcare professionals to identify. There are several questionnaires for self-reporting of adherence to chronic medication, but none has so far been evaluated for assessment of adherence to vitamin and mineral supplementation after bariatric surgery. The aim of this study was to assess the accuracy of the 5-item Medication Adherence Report Scale (MARS-5) in measuring adherence to vitamin and mineral supplementation post bariatric surgery (gastric bypass or sleeve gastrectomy).

METHOD

The psychometric properties of MARS-5 for vitamin and mineral supplementation were validated in two cohorts: one at 1 year post bariatric surgery (n = 120) and the other at 2 years post-surgery (n = 211). MARS-5 was compared to pharmacy refill data for vitamin B12 and combined calcium/vitamin D as reference.

RESULTS

Correlation analyses demonstrated that the MARS-5 had acceptable validity compared to objectively measured adherence rates from pharmacy refill data (calculated as continuous, multiple-interval measures of medication availability/gaps-coefficient ranged from 0.49 to 0.54). Internal reliability (Cronbach's α) was high: 0.81 and 0.95, respectively. There was a clear ceiling effect where one out of three had a maximum score on MARS-5.

CONCLUSION

MARS-5 demonstrated acceptable psychometric properties for assessment of adherence to vitamin and mineral supplementation post bariatric surgery.

Medication adherence in patients with cluster headache and migraine: an online survey

To examine factors for adherent and non-adherent behavior in patients with cluster headache and migraine. Adults with cluster headache or migraine were included in this anonymous online survey using a questionnaire accessed via homepages of headache support groups. Medication adherence in preventive treatment was measured with the Medication Adherence Report Scale (MARS-D). Factors for non-adherent behavior were examined (subjective socioeconomic status, psychological comorbidities, self-efficacy, coping, side effects, expectations of treatment, information on medical treatment, and trust in the physician/treatment concept). 200 participants (n = 58 with cluster headache, n = 142 with migraine) were included. The rate of medication adherence in preventive treatment was 32.8% for participants with cluster headache and 20.4% for migraine. The most common reasons for low adherence in participants with cluster headache were altering the prescribed medication dose (34%) or taking less than instructed (14%), which was mostly due to insufficient benefit from the medication or side effects. Positive expectations of medical treatment (p ≤ 0.05) correlated significantly with adherent behavior in cluster headache. Furthermore, the adherence-promoting factors coping and self-efficacy were more pronounced in patients with cluster headache than in those with migraine (p < 0.05). This study is the first to comprehensively investigate medication adherence and factors influencing adherent/non-adherent behavior in patients with cluster headache. Patients with cluster headache had similar adherence levels to patients with migraine, but had higher resources of adherence-promoting factors.

Portuguese Version of the Intentional Non-Adherence Scale: Validation in a Population of Chronic Pain Patients

Objective: Despite the effectiveness of pain medicines, nonadherence to prescribed medication remains a major problem faced by healthcare systems. The aim of present study was to perform the translation, cultural adaptation, and validation of the Intentional Non-Adherence Scale (INAS) for the European Portuguese language in a sample of chronic pain patients.

Methods: A Portuguese version of the INAS scale was constructed through a process of translation, back translation, and expert’s panel evaluation. A total of 133 chronic pain patients were selected from two chronic pain clinics from tertiary hospitals in Porto, Portugal. The protocol interview included the assessment of pain beliefs (PBPI), beliefs about medicine (BMQ), medication adherence (MARS-P9), and two direct questions about adherence previously validated.

Results: The internal consistency in all subscales was α = 0.902 for testing treatment; α = 0.930 for mistrust treatment; α = 0.917 for resisting treatment; and α = 0.889 for resisting illness. Exploratory and confirmatory factor analysis revealed a four-factor structure that explained 74% of the variance. The construct validity of the INAS was shown to be adequate, with the majority of the previously defined hypotheses regarding intercorrelations with other measures confirmed.

Conclusion: The Portuguese version of INAS could be a valuable and available instrument for Portuguese researchers and clinicians to assess the intentional nonadherence determinants during the management of chronic pain.

Barriers and Adherence to Pain Management in Advanced Cancer Patients

AIM

To assess patients' barriers to pain management and analgesic medication adherence in patients with advanced cancer.

METHODS

This was a prospective cross-sectional study in patients with advanced cancer receiving chronic opioid therapy. Age, gender, cancer diagnosis, Karnofsky level, and educational status were recorded. The Brief Pain Inventory (BPI), Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Barriers Questionnaire II (BQ-II), Medication Adherence Rating Scale (MARS), and Hospital Anxiety and Depression Scale (HADS) were the measurement instruments used.

RESULTS

One-hundred-thirteen patients were analyzed. The mean age was 68 (±13) years, and 59 (52%) were male. The mean Karnofsky status was 51.4 (standard deviation [SD] 11.5). The mean score for BQ-II items was 1.77 (SD 0.7). The BQ-II score was independently related to the HADS-Depression score (P = 0.033) and the total HADS score (P = 0.049). Negative side-effects and attitudes toward psychotropic medication globally prevailed among MARS items. These items were independently associated with gender (P = 0.030), pain (P = 0.003), and depression (P = 0.047).

CONCLUSION

Barriers to pain management were mild. Psychological factors such as depression were the main factor associated with barriers. Poor adherence to analgesic medication was mostly manifested as negative side-effects and attitudes toward psychotropic medication, was more frequent observed in females, and was associated with the ESAS items pain and depression.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Non-Adherence to Pharmacotherapy: A Prospective Multicentre Study About Its Incidence and Its Causes Perceived by Chronic Pain Patients

OBJECTIVE

Pharmacological interventions remain the cornerstone of chronic pain treatment; however, nearly 40% of the prescription medicines are not taken as prescribed. The present study aims at understanding and describing non-adherence from the perspective of chronic pain patients during a 1-year follow-up study.

METHODS

A cohort of 950 consecutive patients referred to a first consultation in Multidisciplinary Chronic Pain Clinics was followed with a standardized protocol for 1 year. This included assessment of pain characteristics; prescribed medication; therapeutic adherence; effectiveness of treatment, non-adherence and its perceived reasons; clinical outcomes and quality of life. We used a mixed methods approach, including qualitative and quantitative analyses.

RESULTS

Forty-nine percent of the 562 patients who responded to all assessments during follow-up were adherent after 1 year of chronic pain treatment. The core associations between each "non-adherence reason" and Anatomical Therapeutic Chemical Code (ATC) group were perceived side effects (p=0.019) and delayed start (p=0.022) for narcotic analgesics (opioids); perceived non-efficacy (p=0.017) and delayed start (p=0.004) for antiepileptics and anticonvulsants; perceived low necessity (p=0.041) and delayed start (p=0.036) for analgesics antipyretics; change in prescriptions because of a new clinical condition for antidepressants (p=0.024); high concerns (p=0.045) and change in prescriptions because of a new clinical condition (p<0.001) for non-steroidal anti-inflammatory drugs; delayed start (p=0.016) and financial constraints (p=0.018) for other medications.

DISCUSSION

This study emphasizes the patient's perspective regarding non-adherence to pharmacological treatment of chronic pain, providing valuable and novel information to be used in future interventions to help patients make an informed choice about their adherence behavior.

Parent and Teacher Training Increases Medication Adherence for Primary School Children With Attention-Deficit/Hyperactivity Disorder

Objective: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological disorder for which effective and safe medication is recommended as first-line treatment. However, many parents and teachers do not believe that ADHD is a disorder or do not accept medication treatment in China. Treatment is often short term or intermittent. Our study aimed to investigate the clinical effect of employing a 4-week, session-based training for both parents and teachers in improving medication adherence for primary school children with ADHD. Methods: From January 2018 to December 2018, a total of 5,118 primary school children were screened. Among 211 children diagnosed with ADHD, 116 were assigned to the intervention group and 95 to the control group. This study provided systematic training for parents and teachers in the intervention group. The training consisted of education about the disorder and ADHD behavioral intervention for both parents and teachers as well as classroom management techniques for just the teachers. A cluster randomized controlled trial (RCT) was conducted to investigate the effect of this training at 6 months follow-up. The study determined medication adherence using a questionnaire and scoring with a rating scale at baseline and at the 6 month follow-up endpoint. The questionnaire was self-report. Results: The study population had a relatively low rate of attention deficit hyperactivity disorder (4.1%) compared to the generally accepted prevalence. After the training, more parents and teachers believed that ADHD is a neurobiological disorder and that medication is the first line treatment. At 6 months follow-up, the Medication Adherence Report Scale (MARS) score for the intervention group was 22.8 ± 0.75 and 16.5 ± 1.63 for the control group (t = 5.217, P < 0.01). Based on parents' reports and medical records, 82 children (70.69%) were continuously taking medication for 6 months in the intervention group, while only 35 children (36.84%) were doing so in the control group. In the intervention group, the mean SNAP-IV score was 1.98 ± 0.42 at baseline but 0.99 ± 0.31 at 6-month follow-up. In the control group, the mean SNAP-IV score was 1.89 ± 0.47 at baseline but 1.37 ± 0.42 at 6-months follow-up (F = 2.67, P = 0.009). Factors influencing medication adherence for children with ADHD were parent's beliefs, teacher's beliefs, socioeconomic status, adverse effect, insurance coverage, gender, and trust of the medical system. Conclusions: Our findings indicate that comprehensive training programs improve the understanding of ADHD and medication adherence for both children's parents and teachers, providing a promising approach for improving clinical efficacy for children with ADHD.