Adherence Metrics Research Articles

The influence of antidepressant and psychotherapy treatment adherence on future work leaves for patients with major depressive disorder

BackgroundDepression is the greatest contributor to worldwide disability. The purpose of this study was to understand the influence of antidepressant and psychotherapy treatment adherence on future work leaves for patients with major depressive disorder.MethodsPatients with a newly diagnosed major depressive disorder (n = 26,256) were identified in IBM® Watson™ MarketScan® medical and disability claims databases. Antidepressant and psychotherapy adherence metrics were evaluated in the acute phase of treatment, defined as the 114 days following the depression diagnosis. Multiple variable Cox proportional hazards regression models evaluated the influence of antidepressant and/or psychotherapy adherence on future injury or illness work leaves.ResultsThe majority of work leaves in the 2-year follow-up period occurred in the acute phase of treatment (71.2%). Among patients without a work leave in the acute phase and who received antidepressants and/or psychotherapy (n = 19,994), those who were adherent to antidepressant or psychotherapy treatment in the acute phase had a 16% (HR = 0.84, 95% CI = 0.77–0.91) reduced risk of a future work leave compared to treatment non-adherent patients. Patients who were non-adherent or adherent to antidepressant treatment had a 22% (HR = 1.22, 95% CI = 1.11–1.35) and 13% (HR = 1.13, 95% CI = 1.01–1.27) greater risk of a future work leave, respectively, than patients not receiving antidepressant treatment. Conversely, patients who were non-adherent or adherent to psychotherapy treatment had a 9% (HR = 0.91, 95% CI = 0.81–1.02) and 28% (HR = 0.72, 95% CI = 0.64–0.82) reduced risk of a future work leave, respectively, than patients not receiving psychotherapy treatment.ConclusionsThis analysis suggests that treatment adherence may reduce the likelihood of a future work leave for patients with newly diagnosed major depressive disorder. Psychotherapy appears more effective than antidepressants in reducing the risk of a future work leave.

0689 Use Of An Automated Scanning System To Select A Patient Interface

Abstract Introduction There is no universal process for selecting mask style, size, and fit, and there is considerable variance in clinician and patient mask preference and patient anatomy. Poor mask fit may negatively affect adherence. A three-dimensional (3D) facial scanner and proprietary analytical software were developed to bring efficiencies to mask selection. This study explored the impact of that system on initial mask success compared to standard practice. Methods This was an open-label, randomized-controlled study. Participants provided written informed consent. 3D Scanner Arm (3DA): Participants answered questions about sleeping habits then had 3D facial images taken. Proprietary software recommended a hierarchy of up to four Philips Respironics masks and sizes. Traditional Fitting Arm (TFA): A designated clinician selected and fit masks using their standard methods. Mask selection was assessed by applying therapy and soliciting patient and clinician feedback. Mask refits and adherence were tracked through 90 days. Five sleep centers recruited 115 participants into the 3DA (61 males, 51.1±13.4 years, BMI 35.2±7.0, diagnostic AHI 26.2±21.9) and 123 into the TFA (79 males, 51.1±11.9 years, BMI 35±7.9, diagnostic AHI 26.9±22.6). Results A significantly higher percentage of 3DA patients required only one mask fitting (with no refits) compared to TFA during the initial setup (89.6% vs. 54.5%, p<0.001) and through 90 days (62.6% vs 37.4%, p<0.001). 3DA subjectively rated confidence in and satisfaction with the scanner-selected mask significantly higher than TFA. Mask leak was lower in the 3DA compared to TFA (29.4±10.6 vs 32.3±11.4 L/M, p= 0.043). The CMS adherence rate tended to favor 3DA vs. TFA (66.7% vs. 55.3, p=0.083). There were no significant differences in AHI or other adherence metrics. Conclusion The 3D scanner system was successful in mask selection with lower mask leak and greater patient satisfaction and confidence. This tool may bring about operational efficiencies to the mask selection process. Support This study was sponsored by Philips Respironics

Approaches to Objectively Measure Antiretroviral Medication Adherence and Drive Adherence Interventions.

Traditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP. Pharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively. New and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.

Evaluating Success Factors of a Medication Adherence Tracker Pilot Program in Improving Part D Medication Adherence Metrics in a Medicare Advantage Plan: Importance of Provider Engagement.

Health plans and providers can increase quality by improving adherence to chronic disease medications included in star ratings among Medicare Advantage Part D (MAPD) plan enrollees. Research is needed to evaluate effective means of collaboration between health plans and providers. The Medication Adherence Tracker (MAT) is a health plan initiative to help primary care providers use outreach to improve their patients' adherence. To quantify the contribution of structural and process factors on the success of a health plan-initiated tracking system in improving chronic disease medication adherence over 6 months. The MAT quality improvement initiative was carried out in South Texas from June to December 2016. Health plan pharmacists used claims data to identify MAPD enrollees at risk of nonadherence to triple-weighted star medications: renin-angiotensin system antagonists, oral diabetes medications, and statins. Actionable reports were delivered biweekly to each provider, either by fax or in person, by embedded health plan nurses. Multivariable regression was used to evaluate sociodemographic and clinical factors as well as the role of provider outreach in increasing paid pharmacy claims and medication adherence as measured by proportion of days covered (PDC) > 0.8. Of 3,542 patients in 5 Texas physician-organized delivery system groups whose 67 providers received tracking reports from June through December 2016, 1,901 (54%) patients had more than 1 related prescription, and 3,064 (87%) received provider outreach on at least 1 prescription. 2,493 (70%) had at least 1 paid pharmacy claim. Provider outreach was associated with greater likelihood of paid prescription claims (relative risk [RR] = 4.59, 95% CI = 3.74-5.62) and greater year-end adherence (PDC > 0.8, RR = 1.86, 95% CI = 1.63-2.12) in multivariable predictive models. 95% CIs for age, gender, low-income subsidy eligibility, and number of prescriptions did not exclude the null value. Provider engagement is critical to effective health plan-provider partnerships to overcome barriers, change behavior, and improve chronic disease care quality and population outcomes. This study was funded by Cigna. The manuscript was prepared as a work for hire. Hong, Esse, Gallardo, Serna, Fosshat, and Mamvou are employees of CareAllies, a Cigna company. Bruce was employed by Cigna at the time of the study. Vadhariya reports a past internship at Regeneron Pharmaceuticals, unrelated to this work. Abughosh reports grants from Regeneron Pharmaceuticals, Valeant Pharmaceuticals, Sanofi, and BMS/Pfizer, unrelated to this work.

Testing a Real-Time Tenofovir Urine Adherence Assay for Monitoring and Providing Feedback to Preexposure Prophylaxis in Kenya (PUMA): Protocol for a Pilot Randomized Controlled Trial.

BackgroundThe worldwide expansion of preexposure prophylaxis (PrEP) with oral tenofovir-disoproxil-fumarate/emtricitabine will be critical to ending the HIV epidemic. However, maintaining daily adherence to PrEP can be difficult, and the accuracy of self-reported adherence is often limited by social desirability bias. Pharmacologic adherence monitoring (measuring drug levels in a biomatrix) has been critical to interpreting PrEP trials, but testing usually requires expensive equipment and skilled personnel. We have recently developed a point-of-care (POC) immunoassay to measure tenofovir in urine, allowing real-time adherence monitoring for the first time.ObjectiveThe goal of this study is to examine a point-of-care adherence metric in PrEP to support and increase adherence via a randomized controlled trial.MethodsThe paper describes the protocol for a pilot randomized controlled trial to test the acceptability, feasibility, and impact on long-term adherence of implementing a POC urine test to provide real-time adherence feedback among women on PrEP. Eligible women (n=100) will be HIV-negative, ≥18 years old, and recruited from a clinic in Kenya that provides PrEP. Participants will be randomized 1:1 to the intervention of providing real-time feedback via the assay versus standard of care adherence counseling. Acceptability by participants will be assessed by a quantitative survey, as well as by qualitative data collected via in-depth interviews (n=20) and focus group discussions (n=4 groups, 5-10 women each). Feasibility will be assessed by the proportion of women retained in the study, the mean number of missed visits, the proportion of planned urine assessments completed, and messages delivered, while in-depth interviews with providers (n=8) will explore the ease of administering the urine test. Tenofovir levels in hair will serve as long-term adherence metrics. A linear mixed-effects model will estimate the effect of the intervention versus standard of care on logarithmically transformed levels of tenofovir in hair.ResultsThis study has been funded by the National Institute of Health, approved by the Kenya Medical Research Institute Institutional Review Board, and will commence in June 2020.ConclusionsA novel urine assay to measure and deliver information on adherence to PrEP in real-time will be tested for the first time in this trial planned among women on PrEP in Kenya. Study findings will inform a larger-scale trial assessing the impact of real-time adherence monitoring/feedback on HIV prevention. Improving adherence to PrEP will have long-term implications for efforts to end the HIV epidemic worldwide.Trial RegistrationClinicalTrials.gov NCT03935464; https://clinicaltrials.gov/ct2/show/NCT03935464International Registered Report Identifier (IRRID)PRR1-10.2196/15029

Leveraging Digital Data to Inform and Improve Quality Cancer Care.

Efficient capture of routine clinical care and patient outcomes is needed at a population-level, as is evidence on important treatment-related side effects and their effect on well-being and clinical outcomes. The increasing availability of electronic health records (EHR) offers new opportunities to generate population-level patient-centered evidence on oncologic care that can better guide treatment decisions and patient-valued care. This study includes patients seeking care at an academic medical center, 2008 to 2018. Digital data sources are combined to address missingness, inaccuracy, and noise common to EHR data. Clinical concepts were identified and extracted from EHR unstructured data using natural language processing (NLP) and machine/deep learning techniques. All models are trained, tested, and validated on independent data samples using standard metrics. We provide use cases for using EHR data to assess guideline adherence and quality measurements among patients with cancer. Pretreatment assessment was evaluated by guideline adherence and quality metrics for cancer staging metrics. Our studies in perioperative quality focused on medications administered and guideline adherence. Patient outcomes included treatment-related side effects and patient-reported outcomes. Advanced technologies applied to EHRs present opportunities to advance population-level quality assessment, to learn from routinely collected clinical data for personalized treatment guidelines, and to augment epidemiologic and population health studies. The effective use of digital data can inform patient-valued care, quality initiatives, and policy guidelines. A comprehensive set of health data analyzed with advanced technologies results in a unique resource that facilitates wide-ranging, innovative, and impactful research on prostate cancer. This work demonstrates new ways to use the EHRs and technology to advance epidemiologic studies and benefit oncologic care.See all articles in this CEBP Focus section, "Modernizing Population Science."

Challenges in Designing and Delivering Diets and Assessing Adherence: A Randomized Controlled Trial Evaluating the 2010 Dietary Guidelines for Americans.

Controlled-feeding trials are challenging to design and administer in a free-living setting. There is a need to share methods and best practices for diet design, delivery, and standard adherence metrics. This report describes menu planning, implementing, and monitoring of controlled diets for an 8-wk free-living trial comparing a diet pattern based on the Dietary Guidelines for Americans (DGA) and a more typical American diet (TAD) pattern based on NHANES 2009-2010. The objectives were to 1) provide meals that were acceptable, portable, and simple to assemble at home; 2) blind the intervention diets to the greatest extent possible; and 3) use tools measuring adherence to determine the success of the planned and implemented menu. Menus were blinded by placing similar dishes on the 2 intervention diets but changing recipes. Adherence was monitored using daily food checklists, a real-time dashboard of scores from daily checklists, weigh-backs of containers returned, and 24-h urinary nitrogen recoveries. Proximate analyses of diet composites were used to compare the macronutrient composition of the composite and planned menu. Meeting nutrient intake recommendations while scaling menus for individual energy intake amounts and food portions was most challenging for vitamins D and E, the sodium-to-potassium ratio, dietary fiber, and fatty acid composition. Dietary adherence for provided foods was >95%, with no differences between groups. Urinary nitrogen recoveries were ∼80% relative to nitrogen intake and not different between groups. Composite proximate analysis matched the plan for dietary fat, protein, and carbohydrates. Dietary fiber was ∼2.5g higher in the TAD composite compared with the planned menu, but ∼7.4g lower than the DGA composite. Both DGA and TAD diets were acceptable to most participants. This conclusion was supported by self-reported consumption, quantitative weigh-backs of provided food, and urinary nitrogen recovery. Dietary adherence measures in controlled-feeding trials would benefit from standard protocols to promote uniformity across studies. The trial is registered at clinicaltrials.gov as NCT02298725.

Association of Visit Adherence and Visual Acuity in Patients With Neovascular Age-Related Macular Degeneration

Visit adherence has been shown to play a significant role in patient health outcomes. The effect of missing visits on visual acuity (VA) in individuals with neovascular age-related macular degeneration has yet to be characterized. To quantify the association between patients' adherence to randomized clinical trial visits and VA in individuals with neovascular age-related macular degeneration based on 4 visit adherence metrics. This is a secondary analysis of the Comparison of Age-Related Macular Degeneration Treatment Trial randomized clinical trial. Individuals with age-related macular degeneration were recruited from 44 clinical centers in the United States between February 2008 and December 2009. The 2-year study protocol required 1 visit every 4 weeks (every 21-35 days for a total of 26 visits) for monthly vs pro re nata treatments of bevacizumab vs ranibizumab. Analysis took place from November 2018 through May 2019. Visit adherence was measured in 4 ways: total number of missed visits, average number of days (avg days) between each visit, longest duration in days (max days) between visits, and visit constancy (the tally of 3-month periods with at least 1 visit attended). Average and max days were also categorized as on time (28-35 days), late (36-60 days), and very late (>60 days). Change in Early Treatment Diabetic Retinopathy Study VA between the baseline and the last visit. Linear multivariate regression models were applied to analyze the association between visit adherence and change in VA, controlling for age, sex, baseline VA, anti-vascular endothelial growth factor drug, number of injections, and dosing regimen. Of 1178 patients, the mean (SD) age was 79.1 (7.3) years, and 727 (61.7%) were women. The mean (SD) number of missed visits was 2.4 (3.1). Overall, 1091 patients (92.6%) had complete visit constancy during the entire study period. Average days were categorized with 1060 patients (90.0%) classified as on time, 108 (9.2%) were late, and 10 (0.8%) were very late. For max days between visits, 197 patients (16.7%) were on time, 773 (65.6%) were late, and 208 (17.7%) were very late. After controlling for covariates, the late (avg days = -6.1; max days = -2.0) and very late (avg days = -12.5; max days = -5.9) groups saw fewer letters in both the avg and max days categories than patients in the on-time group (P < .001). These results provide evidence to support the concept that visit adherence contributes to VA outcomes in neovascular age-related macular degeneration. The magnitude of the association of visit adherence with VA outcomes in this clinical scenario suggests that substantial effort should be expended to strive for visit adherence or therapeutic strategies that reduce the visit burden without compromising VA outcomes. ClinicalTrials.gov Identifier: NCT00593450.

Development and validation of the first point-of-care assay to objectively monitor adherence to HIV treatment and prevention in real-time in routine settings.

HIV prevention and treatment studies demonstrate that pharmacologic adherence metrics are more accurate than self-report. Currently available metrics use liquid-chromatography/tandem-mass-spectrometry (LC-MS/MS), which is expensive and laboratory-based. We developed a specific and sensitive antibody against tenofovir, the backbone of treatment and prevention, but conversion to a lateral flow assay (LFA) - analogous to a urine pregnancy test - is required for point-of-care testing. We describe the development of the first LFA to measure antiretroviral adherence in real-time. Previous work in a directly observed therapy study of providing tenofovir disoproxil fumarate (TDF) to HIV-noninfected volunteers at various simulated adherence patterns defined the appropriate cut-off for the LFA (1500 ng tenofovir/ml urine). We developed the LFA using a sample pad for urine; a conjugate pad coated with TFV-specific antibodies conjugated to colloidal gold nanoparticles; a nitrocellulose membrane striped with tenofovir-antigen (test line) and a control line; with an absorbent pad to draw urine across the reaction membrane. We tested 300 urine samples collected from the directly observed therapy study by this LFA and the gold-standard method of LC-MS/MS. The LFA demonstrated 97% specificity (95% CI 93-99%) and 99% sensitivity (94-100%) compared with LC-MS/MS. The LFA accurately classified 98% of patients who took a dose within 24 h as adherent. We describe the development and validation of the first point-of-care assay to measure short-term adherence to HIV prevention and treatment in routine settings. The assay is low-cost, easy-to-perform and measures the breakdown product (tenofovir) of both TDF and tenofovir alafenamide (TAF). This assay has the potential to improve HIV and PrEP outcomes worldwide by triggering differentiated service delivery with further study merited.

1033 Quality Metrics Adherence Assessment for Patients With Chronic Hepatitis B Virus Seen in Gastroenterology Clinics

INTRODUCTION: The American Association for the Study of Liver Disease (AASLD) guidelines for hepatitis B management have progressed over time. However, adherence to quality metrics for chronic hepatitis B (CHB) care needs to be evaluated, especially in settings where liver specific clinics are not part of the system. Our study aims to evaluate the adherence to quality of care metrics in CHB patients in a predominately African American patient population general Gastroenterology clinic in an academic medical center. METHODS: We performed a cohort chart review on 92 patients with ICD 9 or 10 codes for CHB. Patients co-infected with HIV were excluded from analysis as they were treated by Infectious Disease clinics. We identified 45 patients following up with our Gastroenterology clinic for CHB with a visit between 2017 and 2018. We gathered demographic data. Adherence metrics were collected including HAV vaccination, treatment guideline relevant metrics, timely measurement of alanine aminotransferase (ALT), Aspartate Aminotransferase (AST), platelets and hepatitis B virus DNA level check to monitor for treatment response HBV status. Hepatocellular carcinoma screening measure. RESULTS: Our patient population was 65% African American,17% Asian,13% Caucasian and 5% other races. All treated patients had &gt;2000 in HBV DNA levels and high ALT prior to treatment, whereas untreated patients had low HBV DNA and normal ALT with the exception of 1 patient under consideration for treatment. Hepatocellular cancer screening adherence was significantly high in both treated (80%) and untreated (84%) patients with 6 monthly imaging studies. Both treated and untreated patient had relatively high compliance (68%) with HAV vaccination. All the patients had ALT, AST and platelets so that APRI score could be checked every 6 months to provide an indirect assessment of fibrosis. Timely evaluation of fibrosis specific assessments has not been completed in most of the cases, and there was no consensus with respect to the preferred method for assessing fibrosis. CONCLUSION: Our finding reflects satisfactory adherence with AASLD guidelines particularly in areas of treatment indications, regular laboratory check, hepatocellular carcinoma screening and compliance with HAV vaccination. However, fibrosis evaluation was suboptimal according to guidelines. Given the access to Fibroscan in our practice, once yearly assessment is being recommended for our patients. Supported in part by an Investigator Initiated Grant from Gilead Sciences.

Discontinuation, persistence and adherence to subcutaneous biologics delivered via a homecare route to Scottish adults with rheumatic diseases: a retrospective study

ObjectivesTo understand patterns of subcutaneous (SC) biologics use over time in adults with inflammatory rheumatic musculoskeletal diseases receiving a homecare delivery service.DesignRetrospective cohort.SettingPatients in secondary care receiving SC biologics in...

Tenofovir concentrations in hair strongly predict virologic suppression in breastfeeding women.

Antiretroviral treatment (ART) adherence is often suboptimal in the perinatal period. We measured hair tenofovir (TFV) concentrations as a metric of adherence in postpartum women to understand patterns and predictors of adherence throughout this critical period. In addition, we examined the association between hair TFV concentrations and virologic outcomes. Between 12/2012 and 09/2016, hair samples were collected longitudinally from delivery through breastfeeding from women on ART in the Promoting Maternal and Infant Survival Everywhere study (NCT01061151) in sub-Saharan Africa. Hair TFV levels were measured using validated methods. Using generalized estimating equations, we estimated the association between hair TFV levels and virologic suppression (<400 copies/ml) over time and assessed predictors of hair TFV levels. Hair TFV levels were measured at 370 visits in 71 women from delivery through a median of 14 months (interquartile range 12-15) of breastfeeding. Levels ranged from below detection (0.002) to 1.067 ng/mg (geometric mean: 0.047). After at least 90 days on ART, 69 women had at least one viral load measured (median 5 measures, range 1-9); 18 (26%) experienced viremia at least once. Each doubling of TFV level more than doubled odds of concurrent virologic suppression [odds ratio 2.35, 95% confidence interval (CI): 1.44-3.84, P = 0.0006] and was associated with 1.43 times the odds of future suppression (95% CI: 0.75-2.73, P = 0.28). Relative to the first 3 months after delivery, hair levels were highest in months 6-12 (1.42-fold higher, 95% CI: 1.09-1.85, P = 0.01). Hair TFV levels strongly predicted concurrent virologic suppression among breastfeeding women. Objective adherence metrics can supplement virologic monitoring to optimize treatment outcomes in this important transition period.

Brief Report: Short-Term Adherence Marker to PrEP Predicts Future Nonretention in a Large PrEP Demo Project: Implications for Point-of-Care Adherence Testing.

Objective adherence metrics for tenofovir (TFV) disoproxil fumarate/emtricitabine (FTC)-based pre-exposure prophylaxis (PrEP) were critical for interpretation of efficacy in PrEP clinical trials, and there is increasing interest in using drug levels to tailor interventions for reengagement and adherence. Point-of-care immunoassays for TFV, which examine short-term adherence, are in development. However, the ability of poor short-term and long-term adherence to predict future PrEP nonretention is unknown. Secondary data analysis of a large, prospective multi-site U.S. PrEP demonstration project. An adjusted Cox-proportional hazards model examined the relationship of dried blood spot (DBS) levels of FTC-triphosphate (FTC-TP) or TFV-diphosphate (TFV-DP), measures of short-term and long-term PrEP adherence, respectively, with future study nonretention. Overall, 294 individuals (median age 33 years) contributed drug levels within the U.S. PrEP demonstration project. By the end of study, 27% were lost to follow-up, 25% had at least one undetectable FTC-TP level indicating poor short-term adherence, and 29% had a drug level indicating suboptimal long-term adherence (TFV-DP <700 fmol/punch). The strongest factor associated with future study nonretention using a binary drug-level cut-off was an undetectable DBS FTC-TP level (adjusted hazard ratio 6.3; 95% confidence interval 3.8 to 10.2). The suboptimal long-term adherence based on low DBS TFV-DP levels was also associated with nonretention (adjusted hazard ratio 4.3; 95% confidence interval: 2.4 to 7.6). Both short- and long-term metrics of PrEP adherence are strongly associated with future loss to follow-up in a U.S. demonstration project study. Short-term metrics of adherence, once available at the point-of-care, could be used to direct real-time tailored retention and adherence interventions.

A Quality Improvement Initiative to Reduce Safety Events Among Adolescents Hospitalized After a Suicide Attempt.

Self-harm among adolescents is a common problem, resulting in large numbers of patients admitted for medical stabilization after a suicide attempt. Because of limited mental health resources, these high-risk patients remain in inpatient settings once medically stabilized until psychiatric placement can be arranged. During this time, patients are at risk for safety events, including self-harm and elopement. Using quality improvement (QI) methodology, we aimed to reduce the frequency of significant safety events (SSEs) in this population by targeting modifiable risk factors and standardizing care. This was a QI study conducted at a medium-sized academic center. Key interventions included the development of the Pediatric Behavioral Health Safety Protocol, standardization of the patient safety search, and implementation of a daily Safety Huddle. Process measures were selected as metrics of use and adherence to the newly developed protocol. The rate of SSEs per 100 patient days was the primary outcome measure. There were 224 patients included in our study: 53 in the preimplementation and 171 in the postimplementation groups. Use of the Pediatric Behavioral Health Safety Protocol increased to 91.8% after implementation. The rate of SSEs per 100 patient days decreased from an average of 2.7 events per 100 patient days in the preimplementation period to 0.17 events per 100 patient days in the postimplementation period. The use of QI methodology to improve safety for adolescents admitted after a suicide attempt led to a substantial and sustainable reduction in the rate of SSEs at our institution.

MON-144 Free Diabetes Mhealth Apps and a Patient Survey: Is Medication Adherence a Concern?

Background: Medication adherence is important in the management of diabetes. There are 325,000 mobile health apps with 3.7B downloads in 2017. Purpose: To assess free diabetes mobile apps for adherence metrics and questionnaire(QN) to assess patient adherence and interest in apps. Methods: Google Play Store ranked the top 10 diabetes apps (DA) based on downloads. QN were distributed via MD offices, public places and internet (FB, Craigslist, Reddit). QN: age, gender, education. Q1: Do you take your medicines? Q2: Have you ever forgotten to take your medicines? Q3: What lifestyle changes advised by your doctor would you adhere to? Q4: If you had a perfect reminder, it would be a) voice, b)text, c)your doctor’s staff, d)no reminder; Q5: When do you want to be reminded? a)1x/day, b)1x/wk, c)1x/mo, d)no reminder; Q6: Would you pay for app to remind you? Q7: Do you have diabetes; Q8: If yes, what type of diabetes? Q9: Do you have high blood pressure? Results: Top 10 DA had downloads of 1 x106 to 100K: 1)mySugr, 2)Onetouch Reveal, 3)OntrackDiabetes, 4)Diabetes Connect, 5)Health2Sync, 6)Diabetes, 7)Glucose Buddy, 8)Diabetes:M, 9)Blood Glucose Tracker, 10)OneDrop Diabetes Management. 5/10 apps had push notification for reminders. Only 1 app, Diabetes:M, fulfulled most of DSME criteria (cal/carbs; med log; HbA1c/FBS;Lipids; BP: Wt; Ht; BMI; Exercise; Goals, Psych). 1/10 apps had rewards for compliance, No apps discussed HIPAA/ privacy. Features: 9/10:weight; 8/10: HbA1c ; 1/10: lipid; 7/10: exercise; 6/10: diet mgmt; 9/10: BP; 8/10: med list. None of the apps had psych/depression. Survey respondents(R) =302: age range: 18-94 yrs, avg=40.5 yrs sd 19.2. Females=167:Males=133. Education: college/post coll: 240(79.5%); HS and less: 52 (17.2%). For n=302: Q1(adherence) yes (Y) 252(83.4%),No 13(4.3%), sometimes 37(12.2%); Q2 (non-adherence): Y 210(69.5%), No 92 (30.5%); Q3 (lifestyle changes): Weight 168 (55.6%), Exercise 237 (78.5%), Stress 152 (50.3%), Carb control 142 (47.0%), Won’t change 18 (5.6%); Q4 (reminder): Voice 50 (16.6%), Text 203 (67.2%), Doctor’s staff 61 (20.1%), No reminder 30 (9.9%); Q5 (frequency of reminder): qday 107 (35.4%), qwk 104 (34.4%), qmonth 50 (16.6%), none 39 (12.9%); Q6 (pay for app): Y 51 (16.9%), No 248 (82.1%); Q7 (DM): Y 32 (10.6%), No 262 (86.8%), not know if diabetic 8 (2.6%); Q8 (type of DM): type 1 =5(1.7%), Type 2=24(7.9%), gestational=2(1.0%), No diabetes 262 (86.8%), not know if they have diabetes 9 (3.0%); Q9(HTN): Y 66 (21.9%), No 224 (74.2%),not know 12 (4.0%). Conclusion: Half of the apps address adherence, majority do not give rewards, or have all of DSME criteria. Most of the respondents were college educated, nondiabetic, would not pay for an app, and had forgotten to take their medications in the past. As MDs, we need to work with our pts to find the best, free apps for their diabetes medication adherence and diabetes management.

The association between pharmacy refill-adherence metrics and healthcare utilisation: a prospective cohort study of older hypertensive adults.

Methods that enable targeting and tailoring of adherence interventions may facilitate implementation in clinical settings. We aimed to determine whether community pharmacy refill-adherence metrics are useful to identify patients at higher risk of healthcare utilisation due to low antihypertensive adherence, who may benefit from an adherence intervention. We conducted a prospective cohort study, recruiting participants (n = 905) from 106 community pharmacies across the Republic of Ireland. Participants completed a structured interview at baseline and 12 months. Antihypertensive medication adherence was evaluated from linked pharmacy records using group-based trajectory modelling (GBTM) and proportion of days covered (PDC). Healthcare utilisation included self-reported number of hospital visits (emergency department visits and inpatient admissions) and general practitioner (GP) visits, over a 6-month period. Separate regression models were used to estimate the association between adherence and number of hospital/GP visits. The relative statistical fit of each model using different adherence metrics was determined using the Bayesian information criterion (BIC). For the number of hospital visits, significant associations were observed only for PDC but not for GBTM. Each 10% increase in refill-adherence by PDC was significantly associated with a 16% lower rate of hospital visits (adjusted incidence rate ratio 0.84, 95% CI 0.72-0.98, P = 0.036). Poorer adherence using both measures was associated with higher GP visits. Improvements in BIC favoured models using PDC. Medication refill-adherence, measured using PDC in community pharmacy settings, could be used to recognise poor antihypertensive adherence to enable effective targeting of clinical interventions to improve hypertension management and outcomes.

Low tenofovir level in urine by a novel immunoassay is associated with seroconversion in a preexposure prophylaxis demonstration project.

We examined the relationship between urine tenofovir (TFV) levels measured with a novel immunoassay, which permits point-of-care testing, with HIV seroconversion and objective adherence metrics in a large preexposure prophylaxis (PrEP) demonstration project. Secondary analysis of stored specimens from an open-label PrEP cohort study. We examined the association between undetectable urine TFV levels and HIV seroconversion in iPrEx open-label extension using generalized estimating equations. We examined rank correlations between levels of TFV and emtricitabine in urine, dried blood spots (DBS), and hair and determined the sensitivity and specificity of undetectable urine TFV for predicting dosing cut-offs in DBS. The median urinary TFV level was 15 000 ng/ml in those who remained HIV-negative (n = 105; interquartile range: 1000-45 000); 5500 in those who eventually seroconverted (n = 11; interquartile range: 1000-12 500); and all were undetectable at seroconversion (n = 9; P < 0.001). Decreasing strata of urine TFV levels were associated with future HIV seroconversion (P = 0.03). An undetectable urine TFV was 100% sensitive and 81% specific when compared with an undetectable DBS TFV-diphosphate level and 69% sensitive, but 94% specific when compared with low adherence by DBS (<2 doses/week). Urine TFV detection by a novel antibody-based assay was associated with protection from HIV acquisition among individuals on PrEP. Urine TFV levels were correlated with hair and DBS levels and undetectable urine TFV was 100% sensitive in detecting nonadherence. By implementing the immunoassay into a point-of-care strip test, PrEP nonadherence could be detected in real-time, allowing rapid intervention.

Impact of medication synchronization programs on proportion of days covered (PDC) scores and Medicare Part D medication-related adherence metrics

ObjectivesThis study aimed to determine if patients enrolled in a medication synchronization program have improvements in proportion of days covered (PDC) score for 3 of the Centers for Medicare and Medicaid Services adherence metrics medication classes: statins, renin-angiotensin-aldosterone system antagonists, and noninsulin diabetes medications. MethodsThis retrospective cohort study used data from members of a Medicare Advantage Prescription Drug plan, who took at least 1 of the key metric medications and had sufficient data to calculate a PDC score. The exposed cohort (“sync”) consisted of patients who enrolled in the medication synchronization program within the plan’s preferred pharmacy network, and the control group consisted of those who did not enroll in the program but met all other criteria. The primary end point was the change in PDC score from 2015 (baseline) to 2017 for each medication class. Secondary end points included the proportion of members with PDC scores of at least 85% and the association of adherence with annual medical and pharmacy costs. ResultsThe largest PDC score increases for the entire study population were seen in all 3 sync groups (RASA, diabetes, and statin) with corresponding statistically significant PDC score increases of 1.6%, 4.8%, and 2.9%, compared with −0.4%, 0.5%, and 1.3% changes in the control groups. In the multiple linear regression analysis, there were significant PDC score differences in the changes from baseline between the sync and control RASA, diabetes, and statin groups (P = 0.005, P = 0.01, and P < 0.001, respectively). The proportion of members achieving the acceptable PDC score threshold increased by 1.1% in the control group and by 4.1% in the sync group. ConclusionIn a population of patients with high baseline adherence, this medication synchronization program was associated with a statistically significant increase in adherence scores for statin, RASA, and noninsulin diabetes medications. There was no significant change in medical or pharmacy costs from the health plan perspective.

Pesky metrics: the challenges of measuring ART adherence among HIV-positive adolescents in South Africa

ABSTRACTThe global rollout of antiretroviral treatment (ART) for HIV is one of the largest public health interventions ever undertaken. As the rollout expands, a growing body of research has focused on adherence to ART: how is it measured, what are the flaws of these metrics, and how may these be improved? We provide an overview of current, critical developments in adherence research among adolescents, and of how research on adherence to ART among adolescents within hyper-epidemic contexts has challenged definitions and measurements of adherence. We then explore the development of adherence metrics within an interdisciplinary study about HIV-positive adolescents: the Mzantsi Wakho study. Tracing the conceptualisation and adaptation of adherence metrics within this study, we examine how qualitative and quantitative approaches may be combined to establish more comprehensive adherence metrics. Findings highlight the challenges and the imperatives of synthesising numerous methods, data points, and temporalities. They also point to the need for researchers to establish direct and continued participation by adolescents themselves to better conceptualise and measure adherence, as well as other health behaviours.

Knowledge and comfort change with an active learning activity on medication adherence calculations

Background and purposeMedication adherence is perhaps the most prominent quality measure applied to pharmacies. Teaching students about nonadherence usually takes the form of lectures and simulated pill taking exercises. While these approaches have value, activities are needed in other aspects of medication adherence. Educational activity and settingThis activity was used within a didactic course on endocrine therapeutics for second-year student pharmacists at a public pharmacy college. A 50-min didactic session was followed by an active learning session on medication adherence metrics, focused on the community pharmacy setting. The active learning session had students manually calculate the proportion of days covered and medication possession ratios for two refill histories and examine the output of one simulated adherence dashboard. Students completed an online survey via the course management website before and after the activity that assessed student knowledge of concepts that comprise the proportion of days covered (PDC) metric and three items on self-reported knowledge, comfort, and confidence. The pre and post survey were compared using chi-square and paired t-tests. FindingsA total of 90 pre-surveys and 77 post-surveys were completed, with 70 having both pre- and post- data for comparison of the scaled responses. There was a statistically significant improvement in student knowledge, comfort, and confidence scores as assessed by the surveys. DiscussionA hands-on approach using a calendar and a custom database workbook appeared to help most students improve their understanding of applied medication adherence calculations. SummaryA 50-min didactic background session on medication adherence metrics followed by a 50-min adherence metric calculation activity was effective in increasing student knowledge and confidence related to calculating adherence metrics.