Re-phrasing the question: A simple tool for evaluation of adherence to therapy in patients with inflammatory bowel disease

Medication Non-Adherence in Inflammatory Bowel Disease: A Systematic Review Identifying Risk Factors and Opportunities for Intervention

Inflammatory bowel disease (IBD) is treated with medications to induce and maintain remission. However, many people with IBD do not take their prescribed treatment. Identifying factors associated with IBD medication adherence is crucial for supporting effective disease management and maintaining remission. Quantitative and qualitative studies researching IBD medication adherence between 2011 and 2023 were reviewed. In total, 36,589 participants were included in 79 studies. The associated non-adherence factors were contradictory across studies, with rates notably higher (72-79%) when measured via medication refill. Non-adherence was lower in high-quality studies using self-report measures (10.7-28.7%). The frequent modifiable non-adherence risks were a poor understanding of treatment or disease, medication accessibility and an individual's organisation and planning. Clinical variables relating to non-adherence were the treatment type, drug regime and disease activity. Depression, negative treatment beliefs/mood and anxiety increased the non-adherence likelihood. The non-modifiable factors of limited finance, younger age and female sex were also risks. Side effects were the main reason cited for IBD non-adherence in interviews. A large, contradictory set of literature exists regarding the factors underpinning IBD non-adherence, influenced by the adherence measures used. Simpler medication regimes and improved accessibility would help to improve adherence. IBD education could enhance patient knowledge and beliefs. Reminders and cues might minimise forgetting medication. Modifying risks through an adherence support intervention could improve outcomes.

Tensions in caring for chronic patients' medication adherence: A qualitative study in Cyprus

Medication adherence (MA) to recommended treatment is a multi-faceted problem and an ongoing challenge for healthcare providers (HCPs) to monitor. This qualitative study with 10 HCPs in Cyprus aims to explore HCPs' perceptions and strategies used on addressing medication non-adherence (MNA) in patients with chronic conditions. Two main themes emerged from the analysis reflecting the ways that HCPs described their reactions to MNA of their patients: (1) "Relying on information provision to improve MA" and (2) "Trying to understand patients' perspective." HCPs reported empathizing with patients and engaging in discussions to understand patients' perspective and reasons for MNA, so as to explore alternative solutions. Simultaneously, some HCPs reflected that the techniques used to improve MA are solely centered around information on medication and side-effects. HCPs experienced an internal conflict between providing patient-centered care versus using directive approaches to improve MA. Findings suggest how HCPs could thoroughly address patients' individual barriers.

Pilot study evaluating feasibility and utility of pharmacist-driven oral antineoplastic agent monitoring program

INTRODUCTION

Oncologists are increasingly prescribing oral antineoplastic agents which have benefits and challenges impacting patient outcomes. Practice guidelines recommend monitoring symptoms and adherence without outlining any specific tools or methods for monitoring. Pharmacists are successful in monitoring patients on therapy and improving outcomes. We aimed to assess the feasibility and utility of a pharmacist-delivered and medical record-integrated adherence and symptom monitoring program for patients on oral antineoplastic agents.

METHODS

This single-center, prospective, interventional study designed and implemented an adherence and monitoring program. A pharmacist contacted patients twice between clinic visits for three months. During telephone encounters, patients were verbally screened for medication adherence and assessed for new or changing symptoms using the Edmonton Symptom Assessment System as a signal of possible adverse events. We measured feasibility via patient enrollment, completed proportion of scheduled contacts, and pharmacist time. Utility was assessed through patient adherence, satisfaction surveys, healthcare resource utilization, and pharmacist interventions (i.e., patient education, adherence assistance, and symptom management).

RESULTS

Fifty-one patients participated. Ninety-one percent of scheduled patient contacts were completed. Edmonton Symptom Assessment System was administered by pharmacy personnel 102 times. Patient-reported adherence was 100%. Overall satisfaction was 85% and 100%, for patients and physicians, respectively. Fifty-one (98%) pharmacist recommendations were accepted. There were 14 total utilizations of healthcare resources-5.2 per 1000 patient days.

CONCLUSIONS

This study suggests a pharmacist monitoring program for patients taking oral antineoplastic agents is feasible and provides utility. Further research is needed to evaluate whether this program improves safety, adherence, and outcomes in patients using oral antineoplastic agents.

Impact of an intervention program on drug adherence in patients with ulcerative colitis: Randomized clinical trial

AIMS

Evaluate the impact of an intervention program in non-adherent patients with ulcerative colitis.

METHODS

Parallel controlled randomized clinical trial (1:1), approved by the ethics committee (No. 3.068.511/2018) and registered at The Brazilian Clinical Trials Registry (No. RBR-79dn4k). Non-adherent ulcerative colitis patients according to the Morisky-Green-Levine-test were included. Recruitment began in August 2019 until August 2020, with 6-month follow-up. All participants received standard usual care, and additionally the intervention group received educational (video, educational leaflet, verbal guidance) and behavioral interventions (therapeutic scheme, motivational and reminder type short message services). Researchers were blinded for allocation prior to data collection at Visits 1 and 2 (0 and 6 months). Primary outcome: 180-day adherence rate, with relative risk 95%CI. Secondary outcome: 180-day quality of life according to SF-36 domains, using Student's t test. Variables with p<0.20 were selected for regression. Analysis included data from August/2019 to May/2021.

RESULTS

Forty-six and 49 participants were allocated in control and intervention groups, respectively. Two were excluded due to intervention refusal, and 4 and 6 were lost to follow-up in control and intervention groups. There was no post-intervention adherence rate difference, even after adjustment for type of non-adherence (unintentional/both/intentional) as confounder, or if considered as adherent the intervention group participants lost in follow-up. Interventions promoted better quality of life scores even after multivariate analysis for "Pain", when adjusted for ulcerative colitis severity, sex, and marital status (β = 18.352, p = 0.004), "Vitality", when adjusted for ulcerative colitis severity (β = 10.568, p = 0.015) and "Emotional Aspects", when adjusted for disease severity, income, and education (β = 24.907, p = 0.041).

CONCLUSIONS

The intervention program was not able to produce a significant medication adherence rate difference between comparative groups, however, there was a significant improvement in quality of life. Study limitations may include: sample size calculated to identify differences of 30%, leading to a possible insufficient power; non blinded participants, exposing the results to the risk of performance bias; outcomes based on self-reported data.

Self-reported treatment effectiveness for Crohn's disease using a novel crowdsourcing web-based platform

BACKGROUND AND AIMS

Internet and social media platforms have become an unprecedented source for sharing self-experience, potentially allowing the collection and integration of health data with patient experience. StuffThatWorks (STW) is an online open platform that applies machine learning and the power of crowdsourcing, where patients with chronic medical conditions can self-report and compare their individual outcomes using a structured online questionnaire. We aimed to conduct a cross-sectional, international, crowdsourcing, artificial-intelligence (AI) web-based study of patients with Crohn's disease (CD) self-reporting their outcomes.

METHODS

A proprietary STW Bayesian inference model was built to measure improvement in CD severity (on scale of 1-5) for each treatment and ranked treatments using effectiveness. The effectiveness of first-line biological treatments was analyzed by multiple comparisons and by calculating odds ratios and 95% confidence intervals for each treatment pair.

RESULTS

We included 7593 self-reported CD patients for the analysis. Most of the participants were female (75.8%) and from English-speaking countries (95.7%). Overall, anti-TNF drugs were the most reported tried treatment (52.8%). Infliximab (IFX) was ranked as the most effective treatment by the STW effectiveness model followed by bowel surgery (second), adalimumab (ADA, third), ustekinumab (UST, 4rd), and vedolizumab (VDZ, fifth). In paired comparison analyses, IFX was most effective, ADA had similar effectiveness compared to UST and all three were more effective than VDZ.

CONCLUSION

We present the first online crowdsourcing AI platform-based study of self-reported treatment effectiveness in CD. Net-based crowdsourcing patient-reported outcome platforms can potentially help both clinicians and patients select the best treatment for their condition.

Adherence to r-hGH Therapy in Pediatric Growth Hormone Deficiency: Current Perspectives on How Patient-Generated Data Will Transform r-hGH Treatment Towards Integrated Care

Pediatric growth hormone (GH) deficiency is a licensed indication for replacement therapy with recombinant human growth hormone (r-hGH). Treatment, consisting of daily subcutaneous injections, extends from the time of diagnosis until cessation of linear growth at completion of puberty. Suboptimal adherence to r-hGH therapy is common and has been well documented to substantially impair the growth response and achievement of the optimal goal which is attainment of adult height within the genetic target range. The causes of poor adherence are complex and include disease-, patient-, doctor-, and treatment-related factors. Interventions for suboptimal adherence are important for a long-term successful outcome and can include both face-to-face and digital strategies. Face-to-face interventions include behavioral change approaches such as motivational interviewing and non-judgmental assessment. Medical and nursing staff require training in these techniques. Digital solutions are rapidly advancing as evidenced by the electronic digital auto-injector device, easypod® (Merck Healthcare KGaA, Darmstadt, Germany), which uses the web-based easypod® connect platform allowing adherence data to be transmitted electronically to healthcare professionals (HCPs), who can then access GH treatment history, enhancing clinical decisions. Over the past 10 years, the multi-national Easypod® Connect Observational Study has reported high levels of adherence (>85%) from up to 40 countries. The easypod® connect system can be supported by a smartphone app, growlink™, which facilitates the interactions between the patients, their care team, and patient support services. HCPs are empowered by new digital techniques, however, the human-digital partnership remains essential for optimal growth management. The pediatric patient on r-hGH therapy will benefit from these innovations to enhance adherence and optimize long-term response.

Patients' perspectives on medication for inflammatory bowel disease: a mixed-method systematic review

Inflammatory bowel disease (IBD) is a lifelong chronic disease that frequently requires long-term medical treatment to maintain remission. Patient perspectives on IBD medication are important to understand as nonadherence to IBD medication is common. We aim to synthesize the evidence about patients' perspectives on medication for IBD. A mixed-method systematic review was conducted on Scopus, EMBASE, Web of Science, and CINAHL. The convergent integrated approach to synthesis and integration of qualitative and quantitative findings was used for data analysis. Twenty-five articles from 20 countries were included in this review (20 quantitative, 3 qualitative, and 2 mixed-method studies). Patients have identified a lack of knowledge in the areas of efficacy, side effects, and characteristics of medications as key elements. Some negative views on IBD medication may also be present (e.g. the high number of pills and potential side effects). Lack of knowledge about medication for IBD was identified as a common issue for patients. Health services delivery for IBD should take into consideration these patients' perspectives. A focus on improving patient education in these areas could help empower patients and alleviate doubts resulting in better disease management and improved healthcare outcomes.

Lost in Transition: Pharmacist Roles in Identifying and Evaluating Medication-Related Problems During Hospital Discharge Follow-up Visits in a Primary Care Setting

Objectives: The objective of this study was to identify and evaluate medication-related problems (MRPs) found during hospital discharge transitions of care visits in a primary care setting. Design, Settings, and Participants: This retrospective cohort took place within a federally qualified health center (FQHC) where pharmacists are part of the interprofessional transitions of care team to help patients transition back to primary care after being discharged from the hospital. Pharmacists utilized standardized forms to document MRPs, potential and adverse drug events, and interventions made during the visit. This study quantifies the role that pharmacists can have by conducting medication reconciliation during postdischarge primary care visits. Patients included in this study were 18 years and older with at least 5 medications. Outcome Measures: The outcomes of this study include the number and type(s) of MRPs, number and severity of potential adverse drug events (pADEs) and adverse drug events (ADEs) that were identified, as well as the number and type of recommendations or interventions made by the pharmacist. The MRP types and pADE/ADE severity were classified and stratified using predetermined definitions. Results: During the 4-month study period from October 1, 2018 to February 4, 2019, 134 visits were completed. Outcomes included a total of 454 MRPs, with an average of 3 identified per visit. The most common MRPs were medication list in electronic health record inaccurate (79.1% of visits), poor adherence (32.1% of visits), and refills needed (30.6% of visits). A total of 72 pADEs and 27 ADEs were identified, with 524 recommendations made. Conclusion: Pharmacists serve a unique role during transitions of care by identifying MRPs. Pharmacists are an integral part of a patient's health care team by making recommendations or interventions related to these MRPs. FQHCs and other primary care settings should consider integrating pharmacists into a collaborative transitions of care team.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Does Weekend Hospital Admission Affect Upper Gastrointestinal Hemorrhage Outcomes?: A Systematic Review and Network Meta-Analysis

BACKGROUND

Compared with weekday admissions, weekend admissions are consistently associated with worse patient outcomes, known as the "weekend effect." The weekend effect may have adverse health consequences, including death. To determine the potential impact of the weekend effect on primary (ie, mortality) and secondary outcomes of patients with upper gastrointestinal hemorrhage (UGIH).

MATERIALS AND METHODS

This was a network meta-analysis based on cohort studies. Databases were searched for studies published up to April 2018. The predefined primary outcome was mortality (30-d mortality and in-hospital mortality). The secondary efficacy outcomes were rebleeding rates, use of endoscopic therapy, need for surgery or angiography, mean length of hospital stay, and time to endoscopy. The study protocol was registered with PROSPERO (No. CRD42018094660).

RESULTS

In total, 25 studies, including 28 analyses (N=1,203,202 patients), were eligible. The results revealed a tendency toward increased 30-day mortality and increased in-hospital mortality among weekend admissions. In a subgroup analysis, there were significance differences in mortality according to the study location (ie, Europe) and UGIH type (ie, variceal UGIH), with these subgroups having elevated mortality rates. Moreover, weekday admissions were associated with a significant decrease in rebleeding rates. In the network meta-analysis, the study location (in Europe or Asia) and type of UGIH (ie, variceal UGIH) were associated with an increased likelihood of high in-hospital mortality among weekend admissions.

CONCLUSIONS

The evidence derived from this network meta-analysis supports the idea that weekend admissions are associated with an increased risk of death, especially among variceal UGIH patients in European hospitals.

Pilot Testing Of A Brief Pre-Consultation Screener For Improving The Identification And Discussion Of Medication Adherence In Routine Consultations

OBJECTIVE

One of the challenges in being able to identify and manage medication adherence problems in routine practice is that patients are often reluctant to "admit to" non-adherence, particularly when asked in a direct way. The study reported in this paper has been designed as part of an attempt to address this problem by examining the value of a new brief medicines use screener in helping patients to identify and discuss adherence issues in a clinical setting.

METHODS

145 Patients with type 2 diabetes completed the new screener (MMWFU) together with an adherence self-report scale (MMAS4) and medication beliefs questionnaire (BMQ). Correlations between the scales were assessed together with an assessment of the sensitivity and specificity of the new screener.

RESULTS

126 (88%) of the sample identified at least one medicines-related issue on the MMWFU, which showed strong correlations with the MMAS4 and BMQ Concerns scales, as well as good sensitivity and specificity against the MMAS4.

CONCLUSION

The results indicate that the new screener can serve as a fairly sensitive indicator of non-adherence and its determinants. Future studies will be needed to establish how well it performs in other clinical settings.