Assessing Barriers to Medication Adherence in Pediatric and Adolescent and Young Adult (AYA) Patients on Anticoagulation

Adherence promotion is a critical component of adolescent and young adult (AYA) cancer care, but predictors of nonadherence that could be targeted in intervention efforts remain largely unknown. The purpose of this multi-site longitudinal observational study was to examine the relationship between barriers and medication adherence among AYAs with cancer. Sixty-five AYAs (ages 15-24years; mean age=18.97years, SD=2.51; Mmean time since diagnosis=1.42years, SD=1.95) with newly diagnosed or relapsed cancer completed self-report measures of barriers and adherence at quarterly study visits and used an electronic adherence monitoring device for 12months. Longitudinal mixed effects models were used to examine our primary hypothesis that greater barriers are related to lower adherence over time. Descriptive statistics were used to explore our secondary aim of describing the frequency and patterns of barriers endorsed by AYAs with cancer. After controlling for covariates (time, medication type, race, ethnicity, diagnosis, time since diagnosis), a greater number of barriers was associated with lower electronically monitored (β=-5.99, p=.005) and self-reported (β=-1.92, p<.001) adherence. The specific barriers endorsed by AYAs differed across participants, and the majority of AYAs endorsed an entirely different pattern of barriers than any other AYA in the study. Barriers are associated with nonadherence and may be a promising target for intervention. Individual variability across barriers, however, suggests that tailoring may be necessary, and a promising next step is to explore personalized approaches to adherence promotion.

Kidney Cancers in Adolescents &amp; Young Adults

Anticoagulants are indicated for treatment and prevention of several clinical conditions. Prior studies have examined anticoagulant utilization for specific indications and in community-dwelling populations. Decision-making regarding anticoagulant prescribing in the nursing home setting is particularly challenging because advanced age and clinical complexity places most residents at increased risk for adverse drug events. To estimate the prevalence of oral anticoagulant (OAC) use (overall, warfarin, direct oral anticoagulants (DOACs)) and identify factors associated with oral anticoagulant use among the general population of residents living in nursing homes. This point prevalence study was conducted among 506,482 residents in US nursing homes on 31 October 2016 who were enrolled in Medicare fee-for-service. Covariates including demographics, clinical conditions, medications, cognitive impairment and functional status were obtained from Minimum Data Set 3.0 assessments and Medicare Part A and D claims. Oral anticoagulant use was identified using dispensing dates and days supply information from Medicare Part D claims. Robust Poisson models estimated adjusted prevalence ratios (aPR) for associations between covariates and 1) any anticoagulant use, and 2) DOAC versus warfarin use. Overall, 11.8% of residents used oral anticoagulants. Among users, 44.3% used DOACs. Residents with body mass index (BMI) ≥40kg/m2 (aPR: 1.66; 95% CI: 1.61 -1.71), with functional dependency in activities of daily living, polypharmacy and higher CHA2 DS2 -VASc risk ischaemic stroke scores, had a higher prevalence of oral anticoagulant use. Women (aPR: 0.78; 95% CI: 0.76-0.79), residents with limited life expectancy (aPR 0.80; 95% CI: 0.76-0.83), those with moderate-to-severe cognitive impairment (aPR: 0.67; 95% CI: 0.65-0.68), those using NSAIDs or antiplatelets, and non-white racial/ethnic groups had a lower prevalence of anticoagulant use. Residents with higher levels of polypharmacy, BMI and age had a lower prevalence of DOAC use (versus warfarin). Approximately one in eight general nursing home residents use oral anticoagulants and among oral anticoagulant users, only slightly more residents used warfarin than DOACs. The lower prevalence of anticoagulation among women and non-white racial/ethnic groups raises concerns of potential inequities in quality of care. Lower oral anticoagulant use among residents with limited life expectancy suggests possible deprescribing at the end of life. Further research is needed to inform resident-centred shared decision-making that explicitly considers treatment goals and individual-specific risks and benefits of anticoagulation at all stages of the medication use continuum.

This study evaluated oral medication adherence among adolescents and young adults (AYAs) with cancer during a trial of a smartphone-based medication reminder application (app). Twenty-three AYAs receiving at least one prescribed, scheduled oral medication related to their outpatient cancer treatment participated in this 12-week single-group interrupted time series longitudinal design study. Baseline oral medication adherence was monitored using electronic monitoring caps for 4 weeks. Participants then used a medication reminder app and continued to have their oral medication adherence monitored for 8 weeks. Participants completed an electronically administered weekly survey addressing perceived adherence and reasons for nonadherence. Four adherence phenotypes were identified using visual graphical analysis of individual participants' weekly adherence: (1) high adherence during the preintervention and intervention periods (n = 13), (2) low preintervention adherence and improved adherence during the intervention period (n = 3), (3) low adherence during both periods (n = 6), and (4) high preintervention adherence and low adherence during the intervention period (n = 1). Growth curve models did not show significant changes in adherence by preintervention versus intervention trajectories (p > 0.05); however, the variance in adherence during the intervention narrowed for more highly adherent AYAs. "Forgetfulness" was the most frequently reported reason for nonadherence. Although overall adherence did not improve following use of the app, the variance decreased for more highly adherent participants. Additional or alternative interventions are needed for AYAs with persistently poor adherence. Assessment of adherence patterns may support individualized recommendation of tailored interventions.

Multiple Myeloma in Adolescent and Young Adults: A SEER and CIBMTR Analysis

Transferring from paediatric to adult care can be challenging. Adolescents and young adults (AYAs) with chronic health conditions need to develop a specific set of skills to ensure lifelong medical follow-up due to the chronicity of their condition. The Transition Readiness Assessment Questionnaire-French version (TRAQ-FR) is a 19-item questionnaire measuring such skills. The aims of the study were to (1) describe participant characteristics and (2) identify constructs related to, and predictors of, having learned domain-specific transition readiness skills. Participants included 216 AYAs aged 14-20 years (M = 15.93; SD = 1.35; 54.1% male) recruited from five outpatient clinics in a Canadian tertiary hospital. AYAs completed the TRAQ-FR, the Pediatric Quality of Life Inventory 4.0 (PedsQL) and a sociodemographic questionnaire. Descriptive, bivariate and binary logistic regression analyses were conducted. Overall, participants reported significantly higher scores on the Talking with Providers, Managing Daily Activities and Managing Medications subscales than on the Appointment Keeping and Tracking Health Issues subscales (F[41075] = 168.970, p < .001). At the item level, median scores (on a 5-point Likert scale) suggest that AYAs had begun practising five of the 19 skills (median scores ≥4; 'Yes, I have started doing this'), while a median score of 1 ('No, I don't know how') was found for one item ('Do you get financial help with school or work?'). At the subscale level, TRAQ-FR skills and skill gaps were related to AYAs' age, sex and PedsQL scores (ps < .05). Older and female AYAs were more likely to have begun practising specific TRAQ-FR subscale skills. Better psychosocial functioning was also related to having learned specific transition readiness skills. AYAs show several gaps in transition readiness. Targeted intervention in transition readiness skill development could take into account AYAs' age, sex and psychosocial functioning for a successful transfer to adult care.

The Reply

2.1 PSYCHOPHARMACOLOGICAL IMPORTANCE OF MEDICATION ADHERENCE AMONG ADOLESCENTS AND YOUNG ADULTS WITH BIPOLAR DISORDER

AF is the most common arrhythmia in clinical practice, with a large preponderance in the older (>75 years) adult population. Stroke is the most feared complication of AF, with huge corresponding morbidity and mortality. Anticoagulation is the mainstay for stroke prevention in AF, but is commonly underutilised in clinical practice due to the fear of intracerebral bleeding. Bleeding is the primary concern in older patients with conventional vitamin K antagonist use. Direct oral anticoagulants (DOACs) have been used for a decade in clinical practice and have been found to reduce major bleeds. The advantages of DOAC use in older patients include obviating the need for intermittent international normalised ratio monitoring, fewer drug interactions and reduction in intracerebral haemorrhage. The disadvantages of DOAC use include older patients having to take multiple doses per day and a lack of a universal antidote, as opposed to vitamin K antagonists. However, a lack of head-to-head trials among DOACs and specific randomised controlled trials in older patients preclude a definite conclusion regarding the ideal DOAC that should be used in the older population. Factor XI inhibition is an emerging approach for oral anticoagulation that holds promise for dissociating thrombosis from haemostasis. This provides an additional avenue for reducing bleeding in the older adult population.

Cancer is the leading cause of disease-related death among female adolescents and young adults (AYAs) and the second leading cause after heart disease among males in the United States. Despite recent improvements in survival outcomes, AYAs continue to experience poorer cancer survival rates compared with pediatric and older adult populations. Health care access and quality are substantially influenced by insurance coverage, and AYAs represent the age group with the highest proportion of uninsured individuals. The objective of this review was to examine the association between insurance status and cancer survival among AYAs to inform future policy interventions. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, peer-reviewed studies published in the United States between 2018 and 2024 were identified from PubMed, CINAHL, and Web of Science. Eligible studies examined associations between insurance status and survival outcomes among the AYA cancer population. Ten studies, encompassing 468,583 AYAs with cancer (60.1% female), were included. Individuals with Medicaid/public insurance, as well as those uninsured, exhibited poorer survival outcomes compared with those privately insured across multiple cancer types, including head and neck cancer, lymphoma, central nervous system tumors, hepatic carcinomas, sarcoma, germ cell, breast, thyroid, cervical, colorectal, uterine, ovarian, kidney, lung, and melanoma. Several associations appeared to be age-dependent (e.g., lymphoma). Findings from this review suggest that insurance status is associated with both short- and long-term cancer outcomes among AYAs. The results also highlight persistent challenges in accurately assessing and categorizing insurance status within this population.

BackgroundHypercoagulability and thromboembolism are prominent features of severe COVID‐19, and ongoing anticoagulant use might be protective.MethodsWe conducted a nationwide register‐based cohort study in Sweden, February through May, 2020, to assess whether ongoing direct oral anticoagulant (DOAC) use was associated with reduced risk of hospital admission for laboratory‐confirmed COVID‐19, or a composite of intensive care unit (ICU) admission or death due to laboratory‐confirmed COVID‐19.ResultsDOAC use (n = 103 703) was not associated with reduced risk of hospital admission for COVID‐19 (adjusted hazard ratio [aHR] [95% confidence interval] 1.00 [0.75–1.33] vs. nonuse atrial fibrillation comparator [n = 36 875]; and aHR 0.94 [0.80–1.10] vs. nonuse cardiovascular disease comparator [n = 355 699]), or ICU admission or death due to COVID‐19 (aHRs 0.76 [0.51–1.12], and 0.90 [0.71–1.15], respectively).ConclusionOngoing DOAC use was not associated with reduced risk of severe COVID‐19, indicating that prognosis would not be modified by early outpatient DOAC initiation.

Hemopericardium in the Setting of Direct Oral Anticoagulant Use: An Updated Systematic Review

Modern day adolescents and young adults (AYAs) connect with their peers via a number of increasingly novel ways, many of which involve social media. These online relationships are often translated offline to increase one's social standing and quality of in-person relationships. However, when an AYA is diagnosed with a chronic medical condition, like cancer, in-person relationships with peers become difficult and the online component of socialization is all that is left. Video testimonials are a way that some AYAs have chosen to reach out to their peers; however, little is known about what AYAs are saying in these videos and how they are using them to connect with peers on a more intimate level. This study examined the content of video testimonials of n = 25 AYA cancer patients and survivors. Transcripts of videos were coded by a team of researchers to identify themes and overall tone. Results suggested that films focused on struggles AYAs faced during their cancer journeys with a number of themes emerging; additionally, a hopeful tone was seen around the overall impact that cancer had on the patient's life. It may be the case that video testimonials are an effective way to allow AYA patients with a cancer history to explore their thoughts about their illness experience and fill an important social gap not available to them as they undergo treatment.

Although cancer remains the most common cause of disease-related death in adolescents and young adults (AYAs) in high-income countries, their overall survival rates continue to increase and now exceed 80% at 5 years in several high-income countries. This has been accomplished through progressive improvements in active treatment and supportive care, although accrual rates to therapeutic clinical trials remain disappointing. Recognition of the unique distribution of diseases in the AYA population with cancer and further understanding of the distinctive biology of cancers in AYAs will lead to continuing gains in clinical outcomes. Many of the challenges faced by AYAs with a diagnosis of malignant disease are shared by others with chronic medical conditions and even their healthy peers, such as a sense of invulnerability that may contribute to delays in diagnosis. A particular need for psychological support has been identified for AYAs with cancer, even after active therapy has been completed and especially in the context of palliative care. Notable needs also include fertility preservation and navigation through the multiple transitions in the cancer journey. Additionally, there is a "cost of cure." This is not only in the form of short-term, treatment-related morbidity and mortality but also in the burden of "late effects," including second cancers, that compromise quality of life and limit life expectancy. Establishing clinical programs devoted to AYAs with cancer, with complementary educational initiatives, will strengthen the advances made. It is anticipated that clinical trial accrual will increase substantially, providing further gains in survival. Likewise, addressing the challenges of survivorship, including secondary prevention of long-term morbidity and mortality, will lead to additional improvements in clinical outcomes. Transferring this knowledge to the care of an estimated 1 million incident cases of cancer in AYAs worldwide, most of whom do not live in high-income countries, remains a considerable challenge.

: Cancer remains the most common cause of disease-related death in adolescents and young adults (AYAs) in high-income countries, their overall survival now exceed 80%. Recognition of the unique distribution of diseases in the AYA population with cancer and further understanding of the distinctive biology of cancers in AYAs will lead to continuing gains in clinical outcomes. Many of the challenges faced by AYAs with a diagnosis of malignant disease are shared by others with chronic medical conditions and even their healthy peers, such as a sense of invulnerability that may contribute to delays in diagnosis. A particular need for psychological support has been identified for AYAs with cancer, even after active therapy has been completed and especially in the context of palliative care. Notable needs also include fertility preservation and navigation through the multiple transitions in the cancer journey. Additionally, the “cost of cure” in the form of short-term, treatment-related morbidity and mortality and late effects is also discussed. This talk aims to increase awareness in the challenges in the care of AYA will cancer but also will high light the important role of the pediatrician and primary care provider in the referral at the time of diagnosis and the importance of participation in clinical trials. In addition, it also aims to lay down the participation of the general practitioner in programs devoted to AYAs with cancer, with complementary educational initiatives in the years after treatment addressing the challenges of survivorship, including secondary prevention of long-term morbidity and mortality.