Poor Adherence Rates Research Articles

Participant experiences of an internet-based intervention and randomised control trial: interview study

BackgroundThere are an increasing number of interventions being delivered online, and an expanding body of research to assess the effectiveness of such interventions. Yet, little is known about the motivations for participating in online research. Furthermore, internet interventions and online research studies are characterised by poor adherence and high attrition rates. This study aimed to explore participant motivations for taking part in an online trial of an internet intervention and the reasons for continuing.MethodsSemi-structured telephone interviews were conducted with twenty members of the intervention arm of an internet-based randomised control trial evaluating an online cognitive behavioural tool to improve mental wellbeing. The qualitative interviews were analysed using the Framework Approach to identify themes and subthemes, through familiarization with the data, identifying a thematic framework, charting, indexing, mapping and interpreting the data.ResultsA number of key themes emerged. Trusted brands were key to participants feeling secure in engaging with the trial due to the association with institutions such as the UK National Health Service and the lead University conducting the research. Participants had a number of motivations for signing up with the study; altruism, low mood and as a replacement for a physical health professional. Participants felt the need for the language used in the intervention to be tailored to them as individuals. The majority of those interviewed also described multiple benefits from the intervention, which could have been a reason for them to persist.ConclusionThe nascent field of research on internet delivered healthcare needs to take account of participant views, as have been identified in this trial and future studies would benefit from applying its findings.

Intravaginal ring eluting tenofovir disoproxil fumarate completely protects macaques from multiple vaginal simian-HIV challenges

Topical preexposure prophylaxis interrupts HIV transmission at the site of mucosal exposure. Intermittently dosed vaginal gels containing the HIV-1 reverse transcriptase inhibitor tenofovir protected pigtailed macaques depending on the timing of viral challenge relative to gel application. However, modest or no protection was observed in clinical trials. Intravaginal rings (IVRs) may improve efficacy by providing long-term sustained drug delivery leading to constant mucosal antiretroviral concentrations and enhancing adherence. Although a few IVRs have entered the clinical pipeline, 100% efficacy in a repeated macaque vaginal challenge model has not been achieved. Here we describe a reservoir IVR technology that delivers the tenofovir prodrug tenofovir disoproxil fumarate (TDF) continuously over 28 d. With four monthly ring changes in this repeated challenge model, TDF IVRs generated reproducible and protective drug levels. All TDF IVR-treated macaques (n = 6) remained seronegative and simian-HIV RNA negative after 16 weekly vaginal exposures to 50 tissue culture infectious dose SHIV162p3. In contrast, 11/12 control macaques became infected, with a median of four exposures assuming an eclipse of 7 d from infection to virus RNA detection. Protection was associated with tenofovir levels in vaginal fluid [mean 1.8 × 10(5) ng/mL (range 1.1 × 10(4) to 6.6 × 10(5) ng/mL)] and ex vivo antiviral activity of cervicovaginal lavage samples. These observations support further advancement of TDF IVRs as well as the concept that extended duration drug delivery devices delivering topical antiretrovirals could be effective tools in preventing the sexual transmission of HIV in humans.

HCV infected prisoners: should they be still considered a difficult to treat population?

BackgroundThe prevalence of chronic hepatitis C virus (HCV) infection in the Italian correctional population is estimated to be around 38%. In this setting HCV infection treatment is controversial because of several factors such as active drug substance abuse, psychiatric illness, length of treatment, risk of re-infection, poor adherence and low success rate.MethodsA retrospective data review of 159 inmates, positive for anti-Hepatitis C virus (HCV) antibody, evaluated to National Institute for Infectious Diseases “L. Spallanzani” (INMI) from January 2006 to December 2009, was conducted to evaluate rate of completion (feasibility) and outcome efficacy of chronic Hepatitis C Virus (HCV) infection treatment with Pegylated Interferon and Ribavirin in five correctional facilities in Rome.ResultsOf the 159 inmates evaluated in the study period, 50, all male (median age 39 years) were treated. Twenty patients (40%) did not complete treatment: 15 showed no response and therapy was stopped, 5 patients (10%) interrupted treatment because of adverse reactions. The global feasibility was 60%. The overall sustained virologic response (SVR) was 50% (32% for genotype 1 and 68% for genotype other than 1). The main predictors of SVR at the Multivariable Logistic Regression Odds Ratio (MLR-OR) were a better pretreatment histological diagnosis (absence of bridging fibrosis or cirrhosis [MLR-OR 11.85; 95% CI 1.96-71.62) and a HCV genotype other than 1 (MLR-OR 5.87; 95% CI 1.49-23.17).ConclusionsChronic HCV infection treatment in correctional facilities is feasible and effective and should be strongly recommended, in combination with preventive measures, in appropriately screened patients because it represents an important opportunity to treat a population with a high prevalence of chronic HCV infection among whom treatment options post incarceration may be limited.

New pharmacological approaches for obesity management

Obesity, which results from an imbalance between calorie intake and expenditure, now affects over 500 million individuals worldwide. Lifestyle and behavioural interventions aimed at reducing calorie intake and/or increasing energy expenditure have limited long-term effectiveness due to complex and persistent hormonal, metabolic and neurochemical adaptations that defend against weight loss and promote weight regain. Surgical treatments for obesity, although highly effective, are unavailable or unsuitable for the majority of individuals with excess adiposity. Accordingly, few effective treatment options are available to most individuals with obesity. In the past, the use of antiobesity drugs, seemingly the logical choice to fill this therapeutic gap, has been limited because of a lack of efficacy, poor long-term adherence rates and serious adverse effects. In 2012, the FDA approved two new medications-lorcaserin and phentermine-topiramate controlled release-and is currently reviewing the resubmission of naltrexone sustained release-bupropion sustained release. This Review presents the available data on the efficacy and safety of these three medications and discusses future perspectives and challenges related to pharmacological weight management.

Effect of fertility concerns on tamoxifen use in young survivors of breast cancer.

572 Background: For premenopausal patients with ER+ breast cancer, a 5-year course of tamoxifen results in a 47% reduction in annual recurrence risk and a 26% reduction in annual mortality. Despite these benefits, adherence rates for tamoxifen are low, particularly among younger women. We hypothesize that fertility concerns are causally related to the poor tamoxifen adherence rates observed among young breast cancer survivors. Methods: With IRB approval, a retrospective analysis of 535 women with breast cancer between 2000-2012 was undertaken. Patients were younger than age 46, premenopausal and had ER+ breast cancer. 138 patients did not complete a 5-year course. Patient and provider factors that influenced tamoxifen initiation and adherence were reviewed: (1) evidence of referral to a fertility specialist; (2) documentation of discussion about tamoxifen-related fertility concerns; (3) agreement to take tamoxifen; (4) duration of tamoxifen use. Phone interviews conducted with 27 patients focused on lack of initiation or early discontinuation. The Log-rank (Mantel-Cox) test was used to compare Kaplan-Meier curves and generate hazard ratios. Results: Of the 138 patients who did not complete 5 years of therapy, 38 (27.5%) failed to initiate or discontinued tamoxifen secondary to fertility concerns. Only 114 (21.3%) charts documented referral to a fertility specialist. Patients who expressed a desire to maintain fertility or to have children in the future (115 patients, 21.5%) were more likely to discontinue tamoxifen treatment (HR=2.7, p=0.001). Other critical factors included being unmarried (HR=1.9, p=0.011) and lack of college education (HR=2.5, p=0.0008). Major themes from phone interviews: (1) patients felt they were not adequately informed about fertility preservation and had to pursue information independently; (2) patients did not initiate/resume tamoxifen postpartum because of inadequate physician guidance. Conclusions: Concerns about fertility have a significant negative impact on the initiation and adherence to tamoxifen for young breast cancer patients. Efforts to improve tamoxifen adherence among young cancer patients should include prioritization of fertility preservation as part of the treatment plan.

HIV-1 drug resistance in antiretroviral-naive patients in sub-Saharan Africa

We read with interest the Correspondence by Anthony Amoroso and colleagues1 on high HIV-1 drug resistance in Uganda.2 We recognise their alternative interpretation of our study findings, that besides long community exposure to antiretroviral drugs, poor adherence rates, suboptimum patient retention in care, treatment interruptions, and resultant poor viral suppression outcomes during the antiretroviral therapy scale-up could have exacerbated the development of drug resistance at the community level.

Depression among people living with human immunodeficiency virus infection/acquired immunodeficiency syndrome in Benin City, Nigeria: A comparative study

Depression is a common co-morbidity among persons living with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) (PLWHAs). It is associated with poor treatment adherence and higher mortality rates. Few reports have, however, emanated from developing countries where socioeconomic factors may confound this association. We conducted a cross-sectional comparative study of PLWHAs and apparently healthy staff of three LGA's. The depression module of the Schedule for the Clinical Assessment in Neuropsychiatry (SCAN) and the Beck Depression Inventory (BDI) was used to diagnose depression and depression symptom severity, respectively. Depression was commonly co-morbid among individuals with HIV/AIDS. It was five times more common in PLWHAs than in apparently healthy populations (29.3% vs. 7.3%, OR: 5.25, 95% CI: 2.50-11.76). A similar trend was observed for depression symptom severity. Among PLWHAs, depression was significantly more likely among females (OR: 7.91, 95% CI: 1.83-71.00, P < 0.01), those unemployed (OR: 2.94, 95% CI: 0.18-1.82, P < 0.04), and with an illness duration >3 years (OR: 7.90, P < 0.0001). Having at least one child (OR: 2.79, 95% CI: 1.25-6.16, P < 0.001) and living with others (OR: 4.71, 95% CI: 1.51-15.52, P < 0.003) significantly reduced depression risk. Depression was commonly co-morbid among PLWHAs studied. Clinicians should be aware of risk factors for depression among PLWHAs in order to improve treatment outcomes.

Redeeming Behaviours: A Push, Not a Shove

By now, it's no secret that Canadians are struggling to maintain a healthy body weight, eat right and get enough physical activity to promote their health and prevent the early onset of or to manage, chronic disease. Considered with our tendency to have poor adherence rates to prescribed medications and difficulties overcoming addictive substances, this struggle threatens to shorten our life spans and overburden our healthcare system. To turn the tide, layered and coordinated initiatives at the population level are needed that educate, motivate and support individuals to embrace healthy living. In this commentary, the authors respond to Oliver's recent paper on the utility of user financial incentives and architectural choice interventions as mechanisms for facilitating voluntary behaviour change. They concur with many of his ideas and argue that a more comprehensive approach, particularly adhering to the principles and strategies of social marketing, is needed to stimulate and sustain behaviour change.

Unrecognised tuberculosis at antiretroviral therapy initiation is associated with lower CD4+ T cell recovery

To investigate whether an unrecognised diagnosis of tuberculosis (TB) at the start of antiretroviral therapy (ART) influences subsequent CD4+ T cell (CD4) count recovery in an urban HIV clinic in Uganda. In a retrospective cohort study, a multivariable polynomial mixed effects model was used to estimate CD4 recovery in the first 96 weeks of ART in two groups of patients: prevalent TB (started ART while on TB treatment), unrecognised TB (developed TB within 6 months after start ART). Included were 511 patients with a median baseline CD4 count of 57 cells/mm(3) (interquartile range: 22-130), of whom 368 (72%) had prevalent TB and 143 (28%) had unrecognised TB. Compared with prevalent TB, unrecognised TB was associated with lower CD4 count recovery at 96 weeks: -22.3 cells/mm(3) (95% confidence interval -43.2 to -1.5, P = 0.036). These estimates were adjusted for gender, age, baseline CD4 count and the use of zidovudine-based regimen. Unrecognised TB at the time of ART initiation resulted in impaired CD4 recovery compared with TB treated before ART initiation. More vigilant screening with more sensitive and rapid TB diagnostics prior to ART initiation is needed to decrease the risk of ART-associated TB and sub-optimal immune reconstitution.

Abstract A87: “I didn't know what to think. I thought I was going to die.” Latinas' understanding and attitudes toward an abnormal Pap test result.

Abstract Background and purpose: There is a disproportionate burden of cervical cancer among Latinas compared with non-Latino White women. This is thought to be attributed to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The purpose of this study is to assess knowledge, attitudes, barriers and facilitators to follow up after an abnormal Pap test result in Latinas. Study Design: We conducted 26 semi-structured interviews among Latinas aged 21 to 64 years old who had an abnormal Pap test result in rural Eastern Washington. Interviews were conducted in the participants' preferred language. Interviews were transcribed verbatim and uploaded into Atlas.ti for coding and analysis. Results/Outcome: One of the main themes that emerged as a potential barrier to follow up was misconceptions and secrecy around an abnormal Pap test result. Upon receiving the result, all women instantly believed they had cancer, and many felt desperate and embarrassed to talk to close family and friends. Transportation, lack of insurance and pain from the procedures were also mentioned as very important barriers to follow up. For those participants who had shared their result, family support was mentioned as a key facilitator to follow up. Interestingly, trusting oneself and having faith in God were also mentioned by some as facilitators to follow up. Within our participants, unlike previous studies, “Fatalismo” did not emerge as a barrier. Impact: Understanding the barriers and facilitators to follow up care after an abnormal Pap test as well attitudes and knowledge of the implications of an abnormal Pap test can help us improve the education and outreach strategies used in reaching the Latina population. Discussion: Latinas seem to have misconceptions about the implications of having an abnormal Pap. There are important cultural barriers that derive from these misconceptions that may be affecting the uptake and follow up of cervical cancer screening in this population. Our results will inform an intervention to increase cervical cancer screening in Latinas in Eastern Washington. Citation Format: Elizabeth Carosso, Javiera Martinez, Matthew Banegas, Gloria Coronado, Beti Thompson. “I didn't know what to think. I thought I was going to die.” Latinas' understanding and attitudes toward an abnormal Pap test result. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A87.

859 DOES A COMBINATION PILL OF ANTIHYPERTENSIVE DRUGS IMPROVE MEDICATION ADHERENCE IN JAPANESE?

Objectives: In order to achieve target blood pressure levels to prevent cardiovascular disease, combination therapy of antihypertensive drugs is often required, although it is thought that requiring a patient to take many different pills would reduce adherence to the medication regimen. We have investigated whether or not antihypertensive treatment with a single pill combining antihypertensive drugs would improve medication adherence and blood pressure control. Methods: A total of 207 hypertensive subjects were randomly assigned to a combination pill group (losartan 50 mg/ hydrochlorothiazide 12.5 mg; n = 103) or a control group (an angiotensin receptor blocker and a thiazide diuretic; n = 104). Medication adherence was evaluated by pill counts at 1, 3, and 6 months after randomization. Results: The mean adherence rates over 6 months were not different between the two groups: 98% in the combination pill group and 98 % in the control group. Moreover, the two groups included similar numbers of subjects with relatively poor adherence rates (<90%) in each treatment period. Mean blood pressures over the 6-month treatment period were not different between the groups: 131/75 mmHg in the combination pill group and 130/75 mmHg in the control group (p = 0.84/0.96). Conclusions: There were no appreciable effects of the combination pill of antihypertensive drugs on medication adherence or blood pressure control in Japanese patients over 6 months.

Second-generation long-acting injectable antipsychotic agents: an overview

For over 40 years, antipsychotic drugs have been used as long-term maintenance treatment to control symptoms and reduce relapse rates in patients with schizophrenia. ‘First-generation’ oral agents such as haloperidol...

Medication adherence among hypertensive patients of primary health clinics in Malaysia

PurposePoor adherence to prescribed medications is a major cause for treatment failure, particularly in chronic diseases such as hypertension. This study was conducted to assess adherence to medications in patients undergoing hypertensive treatment in the Primary Health Clinics of the Ministry of Health in Malaysia. Factors affecting adherence to medications were studied, and the effect of nonadherence to blood pressure control was assessed.Patients and methodsThis was a cross-sectional study to assess adherence to medications by adult patients undergoing hypertensive treatment in primary care. Adherence was measured using a validated survey form for medication adherence consisting of seven questions. A retrospective medication record review was conducted to collect and confirm data on patients’ demographics, diagnosis, treatments, and outcomes.ResultsGood adherence was observed in 53.4% of the 653 patients sampled. Female patients were found to be more likely to adhere to their medication regime, compared to their male counterparts (odds ratio 1.46 [95% confidence intervals [CI]: 1.05–2.04; P < 0.05]). Patients in the ethnic Chinese were twice as likely (95% CI: 1.14–3.6; P < 0.05) to adhere, compared to those in the Indian ethnic group. An increase in the score for medicine knowledge was also found to increase the odds of adherence. On the other hand, increasing the number of drugs the patient was taking and the daily dose frequencies of the medications prescribed were found to negatively affect adherence. Blood pressure control was also found to be worse in noncompliers.ConclusionThe medication adherence rate was found to be low among primary care hypertensive patients. A poor adherence rate was found to negatively affect blood pressure control. Developing multidisciplinary intervention programs to address the factors identified is necessary to improve adherence and, in turn, to improve blood pressure control.

Cervical cancer screening and adherence to follow-up among Hispanic women study protocol: a randomized controlled trial to increase the uptake of cervical cancer screening in Hispanic women

BackgroundIn the US, Hispanic women have a higher incidence of, and mortality from, cervical cancer than non-Hispanic white women. The reason for this disparity may be attributable to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The 'Cervical Cancer Screening and Adherence to Follow-up Among Hispanic Women' study is a collaboration between a research institution and community partners made up of members from community based organizations, the Yakima Valley Farm Workers Clinic and the Breast, Cervical, and Colon Health Program of the Yakima District . The study will assess the efficacy of two culturally-appropriate, tailored educational programs designed to increase cervical cancer screening among Hispanic women, based in the Yakima Valley, Washington, US.Methods/designA parallel randomized-controlled trial of 600 Hispanic women aged 21–64, who are non-compliant with Papanicolau (Pap) test screening guidelines. Participants will be randomized using block randomization to (1) a control arm (usual care); (2) a low-intensity information program, consisting of a Spanish-language video that educates women on the importance of cervical cancer screening; or (3) a high-intensity program consisting of the video plus a ‘promotora’ or lay-community health educator-led, home based intervention to encourage cervical cancer screening. Participants who attend cervical cancer screening, and receive a diagnosis of an abnormal Pap test will be assigned to a patient navigator who will provide support and information to promote adherence to follow-up tests, and any necessary surgery or treatment. Primary endpoint: Participants will be tracked via medical record review at community-based clinics, to identify women who have had a Pap test within 7 months of baseline assessment. Medical record reviewers will be blinded to randomization arm. Secondary endpoint: An evaluation of the patient navigator program as a method to improve adherence and reduce time to follow-up among participants who receive an abnormal Pap test result. An additional secondary endpoint is the cost-effectiveness of the two different intensity intervention programs.DiscussionThis culturally sensitive intervention aims to increase compliance and adherence to cervical screening in a Hispanic population. If effective, such interventions may reduce incidence of cervical cancer.Trial registrationNCT01525433

Knee Osteoarthritis and Exercise Adherence: A Review

Individuals with knee osteoarthritis, a painful debilitating joint disease affecting many aging adults, are commonly encouraged to pursue a variety of exercise regimens. However, very few studies have specifically focused on barriers and facilitators of exercise adherence as related to knee osteoarthritis. This review focuses on what is known about exercise adherence, as well as those factors that influence exercise adherence, both generally, and in the context of knee osteoarthritis. To this end, a wide array of related studies were retrieved and reviewed. The objective was to better understand the relationship between this disabling health condition and exercise, and factors that might specifically determine long-term exercise participation among this population. Results of this search revealed: 1) strong support for the application of exercise to allay the progression and/or severity of knee osteoarthritis and its consequences, but poor adherence rates in reality; 2) a vast array of disease-associated, as well as other exercise adherence barriers; 3) many recommendations for promoting exercise adherence including improving the nature of the patient-provider relationship, and the importance of individualized exercise prescriptions. It is concluded that life-long exercise is crucial for maximizing the well-being and function of adults with knee osteoarthritis, but recommendations to exercise are often pursued inconsistently. To encourage exercise adherence among this cohort, a comprehensive individualized assessment, active patient involvement in the decision-making process, and long-term monitoring are indicated.

Knee Osteoarthritis and Exercise Adherence: A Review

Individuals with knee osteoarthritis, a painful debilitating joint disease affecting many aging adults, are commonly encouraged to pursue a variety of exercise regimens. However, very few studies have specifically focused on barriers and facilitators of exercise adherence as related to knee osteoarthritis. This review focuses on what is known about exercise adherence, as well as those factors that influence exercise adherence, both generally, and in the context of knee osteoarthritis. To this end, a wide array of related studies were retrieved and reviewed. The objective was to better understand the relationship between this disabling health condition and exercise, and factors that might specifically determine long-term exercise participation among this population. Results of this search revealed: 1) strong support for the application of exercise to allay the progression and/or severity of knee osteoarthritis and its consequences, but poor adherence rates in reality; 2) a vast array of disease-associated, as well as other exercise adherence barriers; 3) many recommendations for promoting exercise adherence including improving the nature of the patient-provider relationship, and the importance of individualized exercise prescriptions. It is concluded that life-long exercise is crucial for maximizing the well-being and function of adults with knee osteoarthritis, but recommendations to exercise are often pursued inconsistently. To encourage exercise adherence among this cohort, a comprehensive individualized assessment, active patient involvement in the decision-making process, and long-term monitoring are indicated. Keywords: disease, rehabilitation, health, intervention, outcomes, joint, Adherence, disability, physical activity, Pain, osteoarthritis, Knee

Adherence to treatment with second-line therapies, dasatinib and nilotinib, in patients with chronic myeloid leukemia

Background and objective:Previous studies have shown that long-term outcomes are more favorable for patients newly diagnosed with chronic myeloid leukemia (CML) if a complete cytogenetic response is achieved within ≤12 months of diagnosis. Because continuous and adequate dosing is important to achieve this outcome, it is important to understand treatment adherence as part of managing long-term CML therapy. While studies regarding imatinib suggest that adherence varies widely, data addressing adherence to newer breakpoint cluster region–Abelson (BCR-ABL) inhibitors (dasatinib and nilotinib) are sparse. This study evaluates real-world adherence in patients diagnosed with CML receiving dasatinib or nilotinib as second-line therapy.Research design and methods:Using the HealthCore Integrated Research Database (HIRDSM), patients with ≥1 International Classification of Diseases, 9th edition/revision, Clinical Modification (ICD-9-CM) code for CML (205.1x ) and ≥1 prescription for imatinib from January 1, 2001 to June 30, 2010 were identified. Analysis was limited to patients who switched to second-line dasatinib or nilotinib. Dasatinib exposure was stratified by dose (≤100 mg/day or ≥140 mg/day) to account for dasatinib label changes.Main outcome measures:Medication possession ratio (MPR) was used to calculate adherence and Cox proportional hazard models were used to quantify poor rates of adherence (i.e. MPR <85%).Results:Of 2064 imatinib-exposed patients, 197 received dasatinib (≤100 mg/day, n = 112; ≥140 mg/day, n = 85) and 53 received nilotinib (400 mg BID, n = 46; 400 mg QD, n = 7) as second-line therapy. Mean exposure durations were 276 days for dasatinib (≤100 mg, 275 days; ≥140 mg, 276 days) and 170 days for nilotinib. Cox proportional hazard models quantifying rates of poor adherence (MPR < 85%) comparing nilotinib with dasatinib (adjusted for age, sex, duration of previous imatinib exposure, number of concomitant medications, presence of cardiovascular disease or diabetes) calculated hazard ratios of 1.6 (95% confidence interval [CI], 1.0–2.4) for nilotinib versus dasatinib overall, 1.9 (95% CI, 1.2–3.0) for nilotinib versus dasatinib ≤100 mg, and 1.2 (95% CI, 0.7–2.0) for nilotinib versus dasatinib ≥140 mg.Conclusions:While this study is limited by use of claims data to identify CML and adherence, claims based data have been widely used to evaluate the association between treatment use and clinical outcomes. When stratified by dose, patients receiving second-line nilotinib were almost two times more likely to have poor adherence compared with patients receiving second-line dasatinib at the current approved dose of 100 mg once daily.

Does a Combination Pill of Antihypertensive Drugs Improve Medication Adherence in Japanese?

In order to achieve target blood pressure levels to prevent cardiovascular disease, combination therapy of antihypertensive drugs is often required, although it is thought that requiring a patient to take many different pills would reduce adherence to the medication regimen. Whether antihypertensive treatment with a single pill combining antihypertensive drugs would improve medication adherence and blood pressure control was investigated. A total of 207 hypertensive subjects were randomly assigned to a combination pill group (losartan 50mg/hydrochlorothiazide 12.5mg; n=103) or a control group (an angiotensin receptor blocker and a thiazide diuretic; n=104). Medication adherence was evaluated by pill counts at 1, 3, and 6 months after randomization. The mean adherence rates over 6 months were not different between the 2 groups: 98% in the combination pill group and 98% in the control group. Moreover, the 2 groups included similar numbers of subjects with relatively poor adherence rates (<90%) in each treatment period. The mean blood pressures over the 6-month treatment period were not different between the groups: 131/75 mmHg in the combination pill group and 130/75 mmHg in the control group (P=0.84/0.96). There were no appreciable effects of the combination pill of antihypertensive drugs on medication adherence or blood pressure control in Japanese patients over a 6-month period.

Big Brother is Washing…Video Surveillance for Hand Hygiene Adherence, Through the Lenses of Efficacy and Privacy

The mundane act of performing hand hygiene is critically important for the prevention of healthcare-associated infections. Historically, healthcare personnel have low rates of compliance despite widespread and longstanding recognition, both that hand hygiene adherence is the crux of strategies that reduce hospital infection rates [1–4], as well as the fact that adherence to hand hygiene recommendations is a clear expectation of healthcare institutions, accrediting agencies, and patients [5]. A number of studies have attempted to identify the reasons for poor hand hygiene adherence rates and several additional studies have attempted to pinpoint barriers to universal performance of hand hygiene. Among other obstacles, healthcare personnel may underestimate the consequences of inadequate hand hygiene [6] or may misunderstand the purpose of hand hygiene [7]. In any event, healthcare workers routinely miss opportunities to prevent healthcare-associated infections by failing to perform hand hygiene at critical times. Healthcare-associated infections do not carry fingerprints or time stamps to identify the offending healers who failed the patient. Absent that, as Didier Pittet [7] has written, ‘‘Hand hygiene performance remains the only measure to judge the degree of system safety—and the only possibility for those concerned to know how they are performing.’’ Facilities and entrepreneurs have turned to creative strategies for monitoring and improving compliance [8–10]. In this issue of Clinical Infectious Diseases, Armellino et al describe a novel strategy of video surveillance of hand hygiene coupled with real-time, aggregate compliance feedback [11]. Motionactivated video cameras were strategically located throughout a medical intensive care unit. Monitoring and measuring compliance was outsourced to observers in India, and was done for a baseline prefeedback period followed by a 21-month period of observation and feedback. Clinical staff were categorized broadly by the presence or absence of white coats (attending physicians) and scrubs or uniforms (‘‘other healthcare professionals’’). If staff members spent more than 60 seconds in a patient room, they were rated on performance of hand hygiene within 10 seconds of entering or leaving. As observers abroad scored staff by category, real-time adherence scores were updated on electronic boards in the unit hallway. The study team collected more than 60 000 observations—a stunning volume that dwarfs the data collected by other hand hygiene monitoring programs in the literature. In the 4-month prefeedback period, the hand hygiene adherence rate was 6.5%. Strikingly, this extremely low adherence rate represents the baselinemeasured hand hygiene compliance rate in a hospital in which hand hygiene is a ‘‘condition of employment’’ [11]. The initially observed rate is so low that improvement to the mediocre US national average of 40% would have represented substantial improvement. The video observation–immediate feedback strategy, however, was associated with an overall compliance rate of 81.6% in the first 4 months, and 87.9% in the subsequent 17 months of the study. These data are consonant with Pittet’s observation about the critical role of feedback in convincing healthcare personnel to improve their hand hygiene adherence [4]. A casual glance at the striking success of this program would suggest that this Received 12 September 2011; accepted 23 September 2011; electronically published 21 November 2011. Correspondence: David K. Henderson, MD, Deputy Director for Clinical Care, NIH Clinical Center, Bldg. 10, Room 6-1480, 10 Center Dr., Bethesda, MD 20892 (dkh@nih.gov). Clinical Infectious Diseases 2012;54(1):8–9 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2011. DOI: 10.1093/cid/cir781

Deficiencies in the Management of Iron Deficiency Anemia During Childhood

Abstract 3154 Background:Iron deficiency anemia (IDA) is a common hematologic problem worldwide, potentially leading to cognitive delays, fatigue, seizures, and, when severe, high output heart failure. While IDA frequently is encountered in both the primary care setting and specialty clinics, its management is not evidence based. As a result, the diagnosis and treatment of IDA is often suboptimal. To help inform future clinical trials, we retrospectively characterized the clinical course of IDA in young patients (pts) referred to our center. Methods:Using our comprehensive hematology database, the records of children ≤ 18 years (yrs) of age with IDA seen in our outpatient clinic between January 1, 2006 and June 30, 2010 were identified and carefully reviewed. Results:Of 217 IDA pts in the database, 215 had evaluable records, 20 of whom were determined to have an alternative diagnosis. Of 195 evaluable pts, 64% were ≤4 yrs old at their first clinic visit and 31% were age 11–18 yrs. Pts ≤ age 4 yrs were 63% male and 60% Hispanic, whereas those age 11–18 yrs were 83% female and 37% Hispanic, 35% African-American, and 15% Caucasian.Causes of IDA in 128 pts ≤ 4 yrs were excessive consumption of cow milk (68%), breast feeding without iron supplementation (13%), overall iron-poor diet beyond 12 months (16%), prematurity (5%), and suspected malabsorption (6%). Causes of IDA in 60 pts aged 11–18 yrs were menorrhagia (43%), other blood loss (20%), iron-poor diet (22%), and poor iron absorption (7%). Some pts in both age groups had multiple causes of IDA, and in 17 the cause of the anemia was not clear.129 pts (66%) were referred to us directly by their primary care physician (PCP), and 49 (25%) by the emergency department (ED), 37 of whom had been sent there by their PCP for evaluation of anemia. Prior to their first visit to our center, 115 pts (59%) had received at least one trial of iron therapy, 62 with ferrous sulfate, 27 with carbonyl iron, 5 with iron polysaccharide, and 15 with an iron-containing multivitamin. For the pts ≤ 4 yrs of age where the precise dose of elemental iron prescribed by the PCP was known (n=59), greater than half of the pts were prescribed doses of iron outside of the accepted therapeutic range (3–6 mg/kg/day) (see figure). The pts’ mean Hb concentration before referral to our clinic (last recorded Hb measured either by the PCP or the ED) was 7.8 g/dl (n=170). [Display omitted] Following evaluation in our hematology clinic, 86% of patients were treated with ferrous sulfate. However, 17% of such pts ≤ 4 yrs of age still received iron doses outside of the accepted therapeutic range. At the time of their first and last visits to the hematology clinic the mean Hb values were 9.0 g/dl and 11.3 g/dl respectively. One third of pts had documented poor adherence with iron therapy, due to poor tolerability (19%), gastrointestinal upset (11%), misunderstanding of prescribed dose (14%), and use of a lower dose than prescribed due to parental discretion (41%). 40% of pts were lost to follow up. Summary and Conclusions:Among pts referred for IDA to our academic specialty clinic, Hispanic male toddlers and Hispanic or African-American female adolescents were disproportionately represented. Most toddlers had nutritional IDA while most adolescents had menorrhagia. Pts often received sub-therapeutic doses of iron before referral. After hematology clinic evaluation, most children demonstrated improvement of IDA; however, inappropriate dosing and non-adherence with oral iron therapy were high, and many pts were lost to follow up.Insufficient screening and prevention of IDA remains problematic. Additionally, when IDA is suspected it is often inadequately treated or inappropriately referred to the ED or the hematology clinic, where treatment is associated with poor adherence and high attrition rates. Future research must focus on all of these deficiencies to prevent the many immediate and long-term sequelae of IDA. Disclosures:No relevant conflicts of interest to declare.