Tool For Adherence Research Articles

Validation of the Special Projects of National Significance Adherence Tool in HIV/AIDS Patients

Adherence to highly active antiretroviral therapy (HAART) is crucial for success. Therefore, having validated tools to help assess adherence is necessary. The Health Resources and Services Administration assessed adherence as a Special Project of National Significance (SPNS). As a result of their study, a 3-question survey was developed as a simple tool to assess adherence in patients with HIV/AIDS. To validate the SPNS adherence survey as an accurate and effective way to assess adherence and to determine whether any other independent variables correlate with a significant reduction in viral load. The study was a retrospective chart review of 300 patients actively enrolled in an HIV/AIDS clinic from January 2007 to September 2007. Patients were eligible for the study if they had been on HAART for at least 6 months, were > or =18 years old, and had completed at least 2 surveys. A total of 74 patients met the criteria; the majority were male (75.3%) and African American (91.9%). Twenty-six (35.1%) patients had scores < or =10, indicating poorer adherence, and 48 (64.9%) patients had scores > or =11. The mean number of antiviral plus other medications was 4.4. Dosing of HAART drugs was once (5 nonadherent, 23 adherent pts.) and twice (21, 25 pts., respectively) daily, and mean number of different antiretroviral tablets/capsules being taken was 1.7 and 1.5, respectively. The nonadherent patients' average viral load was 15,202.3 copies/mL, while the adherent patients' average viral load was 163.8 copies/mL (p = 0.001) The SPNS score was significantly associated with HIV-RNA viral load (-0.482, p < 0.001). There also was a significant association between a higher HIV-RNA viral load and the total number of medications a patient was taking, as well as the number of different antiretroviral tablets/capsules being taken (0.299, p = 0.01; 0.249, p = 0.03). There was no significant difference in HIV-RNA viral load when comparing age, sex, race, income, and frequency of HIV drug dosing. The SPNS survey is a valid and simple tool in measuring adherence that can aid health-care professionals in assessing adherence to HAART.

The B-SMART Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients-Part 2: Adherence, Relationships, and Triage

Elizabeth Oyekan, PharmD, FCSHP; Ananda Nimalasuriya, MD; John Martin, MD; Ron Scott, MD; R James Dudl, MD; Kelley Green, RN, PhD Fall 2009 - Volume 13 Number 4 Introduction Thousands of people fail to achieve the desired therapeutic outcomes fr

The B-SMART Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients— Part 1: Barriers, Solutions, and Motivation

Research shows that the combination of education, empowerment of patients by providing tools and feedback, and ongoing encouragement given to patients will significantly improve adherence to therapy plans and improve outcomes than any one component alone.9,12,34 To complete this B-SMART approach to medication optimization, part 2 of this article in the Spring 2009 issue will discuss: Adherence Tools: Tools and reminders to keep patients on track; Relationships: Building positive relationships; and Triage: Direct patients' medication management plan into the broader health care system.

Adherence to anti-diabetic drug therapy and self management practices among type-2 diabetics in Nigeria

To describe the pattern of anti-diabetic drug prescribing; ascertain the level of glycemic control, adherence with prescribed anti-diabetic medications, and diabetes self management practices among patients with type-2 diabetes in a tertiary care setting in Nigeria. University College Hospital (UCH); a 900 bed teaching hospital with medical residents located in Ibadan, southwestern Nigeria. The study consisted of two phases. A cross-sectional review of randomly selected 200 case notes of type 2 diabetic patients that attended the Endocrinology clinic over 3 month; and crosssectional interviews, with a pre-tested Adherence and Self-Management Monitoring Tool (ASMMT), of 200 consecutive patients that presented their drug prescriptions at the satellite pharmacy unit over a 4 week period at a 900-bed teaching hospital located in Ibadan, South-Western Nigeria. Oral Hypoglycemic Agents (OHA) were prescribed for 86% (171) of cohorts while insulin and OHA was prescribed in 14% (29). About 70.8% (121) of patients on OHA were on combination therapy. The most frequently prescribed OHA combination was glibenclamide and metformin (95.8%). Glibenclamide was prescribed as twice daily regimen in 69% of cohorts. The most frequently documented side effect was hypoglycemia (60.3%). Only 44% (88) of cohorts had adequate glycemic control; of these, 93% (82) were adjudged adherent with prescribed anti-diabetic drugs. Interviews with the structured ASMMT revealed that 59% of patients were non-adherent with the previous anti-diabetic drugs due to lack of finance (51.7%); side effects (34.5%); perceived inefficacy of prescribed anti-diabetic drugs leading to self-medication with local herbs (13.8%). Only 20% of non-adherent patients claimed disclosure to physicians during consultation. The identified factors for non-disclosure were lack of privacy during consultation (58%); and short consultation time (42%). The knowledge and practice of critical components of diabetes self-management behaviours were generally low among the cohort studied. However, it was significantly higher among patient judged adherent with their prescribed anti-diabetic medications (P < 0.05). Majority of patients with type 2 diabetes in an ambulatory tertiary care setting in Nigeria are managed with OHA combinations, mainly glibenclamide and metformin. While the current prescribing strategy achieved glycemic control in about one third of patients, majority are still not meeting the recommended blood glucose targets due to poor adherence with prescribed drug regimen, and poor knowledge and practice of successful self-management.

Evaluating Adherence to Highly Active Antiretroviral Therapy with Use of Pill Counts and Viral Load Measurement in the Drug Resources Enhancement against AIDS and Malnutrition Program in Mozambique

Maintaining treatment adherence among the growing number of patients receiving antiretroviral treatment in Africa is a dramatic challenge. The objective of our study was to explore the results of a computerized pill count method and to test the validity, sensitivity, and specificity of this method with respect to viral load measurement in an African setting. We performed a prospective, observational study involving patients who received first-line highly active antiretroviral therapy in Mozambique from 1 April 2005 through 31 March 2006. Enrolled patients had received treatment for at least 3 months before the study. For defining treatment adherence levels, pill counts were used, and the results were analyzed with viral load measurements at the end of the observation period. The study involved 531 participants. During the 12 months of observation, 137 patients left the program or discontinued first-line therapy. Of the remaining 394 patients, 284 (72.1%) had >95% treatment adherence; of those 284 patients, 274 (96.5%) had a final viral load <1000 copies/mL. A Cox proportional hazards analysis revealed that the relationship between >95% treatment adherence and the final viral load was closer than that between >90% treatment adherence and viral load. Treatment adherence >95% maximizes the results of the nonnucleoside reverse-transcriptase inhibitor-based regimen. The pill count method appears to be a reliable and economic tool for monitoring treatment adherence in resource-limited settings.

Factor structure and validity of the Medication Adherence Questionnaire (MAQ) with cigarette smokers trying to quit

The Medication Adherence Questionnaire (MAQ) is a scale used to evaluate adherence to medications. The present study assessed the factor structure and validity of the MAQ with cigarette smokers. A principal components analysis was conducted on MAQ scores from a sample of smokers presenting for treatment in a clinical trial of naltrexone and nicotine patch for smoking cessation (N = 385). Indices of convergent and predictive validity were tested using electronic medication caps for naltrexone, nicotine patch counts, plasma drug levels of naltrexone, and treatment outcomes. The principal components analysis revealed two factors. Factor 1, labeled "unintentional nonadherence," measured the extent to which individuals were nonadherent because they were careless or forgot to take their medications. Factor 2, labeled "purposeful nonadherence," assessed nonadherence related to purposefully stopping medication use after feeling better or worse. Only the second factor was shown to have good convergent and predictive validity. Specifically, this factor was related to pill-taking behavior measured with electronic medication caps and drug plasma levels and nicotine patch use based on nicotine patch count data, and it was associated with smoking cessation outcome. Thus the purposeful nonadherence factor of the MAQ may be used as a brief screening tool for medication adherence with cigarette smokers seeking treatment. Information obtained with this questionnaire could be used to counsel patients regarding the importance of medication adherence.

HAART Adherence Strategies for Methadone Clients Who Are HIV-Positive

Research demonstrates that injection drug users with HIV and/or AIDS have difficulty adhering to complex regimens of HIV medications. Because of the risk of increased viral resistance associated with irregular medication adherence, there is considerable clinical need to assist clients who abuse substances in taking their antiretroviral medications on time and as directed. This article outlines intervention strategies to improve medication adherence among clients who are in methadone maintenance. In this treatment manual, the authors delineate contingency management procedures, including voucher incentives and a fishbowl lottery prize system. They also describe intervention elements and adherence tools for medication coaching. The purpose of this manual is to describe the intervention procedures for clinicians and to serve as a resource for drug abuse treatment programs that serve clients who are HIV-positive.

Beyond Efficacy: The STAR☆D Trial

Psychiatrists have a range of treatments to offer patients with depression. Randomized controlled trials have demonstrated the efficacy of tricyclic antidepressants, SSRIs, cognitive behavior therapy, and interpersonal therapy. For each of these interventions, one can say with some confidence that at least 40% of a cohort with depression will show statistically significant reductions in unbiased ratings of depression. This information, while entirely commendable in the world of research, is far from satisfactory in the world of practice where an individual clinician needs to make treatment decisions to help an individual patient. The practical questions that the clinician might ask include: For this specific patient, what is the best of the available treatments? What magnitude of response can my patient realistically expect in 4 or 6 weeks? And what should I do if my patient is not sufficiently better in this period: continue or switch treatments? If the first treatment does not work, what is the next best option? Trivedi and colleagues have addressed these questions in a landmark study, part of which is published in this issue of the Journal. Their results from the first phase of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial signify a new approach to clinical trials as part of an NIMH effort to support research with direct, practical value to clinicians. These trials, variously called “practical trials” or “effectiveness trials,” differ from traditional efficacy trials in several ways (1,2). Whereas traditional efficacy trials have strict inclusion criteria, usually compare a drug against placebo, and limit outcome to rating scales, effectiveness trials include a broad spectrum of patients (including suicidal patients in depression trials), compare active treatments rather than active treatment against placebo, and focus on real-world outcomes such as measures of functioning. In addition, these new trials often test effectiveness with self-declared patients in primary care settings where most depressed patients receive treatment. Traditional efficacy trials generally study symptomatic volunteers recruited via advertisements, and the setting is either in academic health centers or commercial clinical research organizations. The STAR*D trial enrolled 4,041 outpatients with nonpsychotic depression at 23 psychiatric and 18 primary care sites. All patients began with a 12-week course of the SSRI citalopram, administered according to a treatment manual that allowed individualized management of doses within a preplanned schedule. The STAR*D trial focused specifically on achieving remission from depression rather than partial improvement. Phase 1 examined this first 12 weeks of treatment to identify those who achieved remission. Among the patients who did not achieve remission or could not tolerate citalopram, Phase 2 compared several different strategies that entailed either replacing citalopram with a different treatment or augmenting citalopram with an additional treatment, including cognitive therapy. Those without sufficient improvement were offered up to two additional levels of treatment. Those who achieved an adequate response were followed for 1 year to evaluate long-term outcomes with these various treatments.

Adherence to HAART: Perspectives from clients in treatment support programs

The development of highly active antiretroviral therapy (HAART) has resulted in dramatic decreases in morbidity and mortality for HIV-infected individuals. Because the long-term efficacy of HAART is dependent on near perfect adherence, many providers offer services to support adherence, including education, regimen review, counseling, and reminder tools. Little is known regarding the utilization or efficacy of these services. In this paper, we report on data collected during 32 open-ended interviews conducted with individuals receiving services through the New York State Treatment Adherence Demonstration Project. Participants in the project reported deriving benefits from a broad range of project activities. Educational efforts helped clients to recognize HIV as a manageable, rather than terminal, illness. Information and tools focused on specific regimens provided clients with concrete knowledge and skills. Effective communication with medical providers and pharmacists was facilitated by adherence staff who proactively advocated for client needs. Program-based social support was particularly valuable for many participants, helping them to retain needed motivation and strength. Educational, practical, and supportive services were all considered valuable to clients participating in adherence support programs. A mix of services may best meet the range of needs found among persons taking HAART.

Beyond Efficacy: The STAR*D Trial

Beyond Efficacy: The STAR*D Trial

The cost of HIV medication adherence support interventions: Results of a cross-site evaluation

The objective of this study was to determine the direct cost of HIV adherence support programmes participating in a cross-site evaluation in the US. Data on the frequency, type, and setting of adherence encounters; providers’ professions; and adherence tools provided were collected for 1,122 patients enrolled in 13 interventions at 9 sites. The site staff estimated the average duration of each type of encounter and national wage rates were used for labour costs. The median (range) adherence encounters/year among interventions was 16.5 (4.3–104.6) per patient; encounters lasted 24.6 (8.9–40.9) minutes. Intervention direct cost was correlated with the average frequency of encounters (r = 0.57), but not with encounter duration or providers’ professions. The median direct cost/month was $35 ($5–$58) per patient, and included direct provider costs (66%); incentives (17%); reminders and other tools (8%); and direct administrative time, provider transportation, training, and home delivery (9%). The median direct cost/month from a societal perspective, which includes patient time and travel costs, was $47 ($24–$114) per patient. Adherence interventions with moderate efficacy costing ≤$100/month have been estimated to meet a cost-effectiveness threshold that is generally accepted in the US. Payers should consider enhanced reimbursement for adherence support services.

Physician adherence to JNC 7 guidelines and blood pressure control

The purpose of this study was to: 1) measure physician adherence to JNC 7 guidelines using a newly developed tool and 2) compare hypertension care in patients with controlled and uncontrolled blood pressure (BP). A tool comprised of 26 explicit, evidence-based criteria was developed using an expert panel. Criteria included care elements for the domains of diagnosis, drug-therapy, follow-up and monitoring of hypertension. Abstracts were constructed from medical records of patients at the VAMC and seven university-affiliated family medicine clinics and included demographics, meds, medical conditions, lab results, clinic visits and consults. A formal algorithm was used to score adherence to each applicable criterion. Domain scores and an overall adherence score were calculated for each patient, with a higher score indicating greater adherence, (range 0 -100%). The sample included 177 men and women with controlled (n=33) and uncontrolled (n=144) BP (average age= 64.9 years; range= 29–90). Across all subjects, the mean adherence score for patients with controlled BP was significantly higher than for patients with uncontrolled BP (60.7 vs. 54.3, p=0.043). There was also a signficant difference between the mean scores for patients < 65 years old with controlled (68.4) vs. uncontrolled (53.3) BP (p<0.007). However, there was no difference in adherence scores for patients > 65 years of age with controlled (56.3) vs. uncontrolled (55.2) BP (p<0.678). Overall, a 10% increase in adherence score was associated with an 18% increase in the odds of BP control (OR=1.18; p=0.109). For patients < 65 years old, there was a significant association between adherence score and the odds of having controlled BP (OR=1.63; p=0.028). There were no differences in individual domain scores of patients with controlled BP vs. uncontrolled BP. These findings provide preliminary evidence that more adherent processes of care are associated with the outcome of controlled BP. In addition, the adherence tool provides a quantitative, numerical evaluation of the care provided to an individual patient. Physicians, researchers and institutions can use the tool to assess overall practice and direct changes to areas of care in most need of improvement.

Predictors of Virologic Success in Patients Completing a Structured Antiretroviral Adherence Program

This study describes the effects of a structured, educational/motivational antiretroviral adherence program on virologic and immunologic parameters in HIV-infected patients. Patients were referred because of either self- or provider-identified barriers to adherence. All patients completed 6 to 8 weekly sessions with a nurse or adherence counselor, followed by four quarterly sessions. Sessions included an adherence assessment, individualized patient education, review of adherence strategies, motivational messages, anticipatory planning, and adherence tools. The 58 patients had a mean enrollment CD4 (+) count of 223 cells/mm (3) and mean viral load of 196,454 copies/ml. At the last follow-up, the mean CD4 (+) count increased to 308 cells/mm (3) (p <.001), and mean viral load decreased to 43,309 (p <.001). Thirty (51.7%) patients achieved a viral load < 50 copies/ml at any point during follow-up. Factors associated with final viral load < 50 copies/ml included not being a cigarette smoker, receiving lamivudine in one's final regimen, and having an HIV risk behavior other than male-male sex.

Assessing Medication Adherence in Adolescents with HIV When Electronic Monitoring Is Not Feasible

The purpose of this study was to compare and contrast three different methods for measuring self-reported antiretroviral medication adherence, correlate individual reports of adherence with measures of viral load, and identify the degree of concordance among self-reported medication adherence tools. Thirty-five adolescents between the ages of 11 and 21 years (mean age, 15.4) enrolled in National Cancer Institute (NCI) HIV primary treatment protocols participated in the study. Adherence approaches consisted of a clinical nurse rating (CNR), a Retrospective Self-Report Interview (RSI; using two different scoring criteria), and a 24-hour recall phone interview (Daily Phone Diary [DPD]). These were chosen because of their potential to be integrated within a clinical setting. Reported perfect adherence to protease inhibitors ranged from 31% to 54% depending on the measure used. There was little agreement between measures. Teenagers who reported perfect protease inhibitor adherence on both RSI-doses taken and DPD were approximately 5 times more likely to have a viral load less than 10,000 copies per milliliter. Advantages and disadvantages of each adherence method and clinical and research recommendations are discussed.

Assessing Medication Adherence in Adolescents with HIV When Electronic Monitoring Is Not Feasible

The purpose of this study was to compare and contrast three different methods for measuring self-reported antiretroviral medication adherence, correlate individual reports of adherence with measures of viral load, and identify the degree of concordance among self-reported medication adherence tools. Thirty-five adolescents between the ages of 11 and 21 years (mean age, 15.4) enrolled in National Cancer Institute (NCI) HIV primary treatment protocols participated in the study. Adherence approaches consisted of a clinical nurse rating (CNR), a Retrospective Self-Report Interview (RSI; using two different scoring criteria), and a 24-hour recall phone interview (Daily Phone Diary [DPD]). These were chosen because of their potential to be integrated within a clinical setting. Reported perfect adherence to protease inhibitors ranged from 31% to 54% depending on the measure used. There was little agreement between measures. Teenagers who reported perfect protease inhibitor adherence on both RSI-doses taken and DPD were approximately 5 times more likely to have a viral load less than 10,000 copies per milliliter. Advantages and disadvantages of each adherence method and clinical and research recommendations are discussed.

Selection of explicit criteria for a JNC-7 guideline adherence tool

P-305 Key Words: Adherence, Expert Panel, Primary Care

A nursing tool for adherence and recovery in psychosis: a pilot study.

Clients with psychotic disorders are at great risk for relapse and rehospitalization. This risk is magnified by poor adherence to medications, as well as refusal to accept optimal treatment planning, including more beneficial atypical medications. Adherence can be even more compromised because of clients' poor insight into these illnesses and their inability to recognize the potential for recovery that exists when taking medications as prescribed. This poor insight makes effective collaboration in treatment more difficult and is an exceptionally troubling impediment to successful treatment. Currently, there are few effective strategies to improve insight into psychosis. We have developed the Levels of Recovery from Psychotic Disorders Scale (LORS) as a teaching tool. It is designed to identify strengths and weaknesses in insight in order to provide the basis for an intervention to enhance and promote change. This article reviews the relevant literature on adherence and insight in this population of clients with psychotic disorders. It also reviews a pilot study comparing the LORS to the BASIS-32. The findings provide the basis for future studies using the LORS to enhance insight, adherence, and recovery.

Antiretroviral medication adherence and persistence with respect to adherence tool usage.

Adherence to complex drug regimens over an extended period is a key factor in reaping the health benefits of highly active antiretroviral therapy (HAART). Forgetting a dose is the most commonly stated reason for suboptimal adherence, indicating a potential benefit of reminder devices. We examined antiretroviral drug adherence and duration of therapy with respect to adherence tool usage. Adherence was monitored for 12 months in a cohort of patients, using pharmacy refill data. Seventy-eight subjects were administered a questionnaire with regard to tool use at least once at 6 and/or 12 months; patients who replied to the questionnaire were eligible for this study. Persistence of remaining on therapy was obtained from the subjects, charts. The tools included individualized schedules, dosettes and electronic reminder devices, which were offered free of charge to all patients. Of the 64 subjects who entered this study, 60.9% (n = 39) used at least one adherence tool. The median adherence in those using tools was 95%; three quarters showed greater than 91% adherence. Adherence rates with respect to individual tools did not differ significantly for schedules and dosettes, with medians of 95% (n = 31) and 94% (n = 13), respectively. Median adherence with electronic reminders was 76% (n = 5). Seventy-four percent of patients remained on therapy after 12 months of study. Taking into consideration previous antiretroviral treatment, actual persistence at 12 months was 87%. Employing and individualizing strategies, including adherence tools, to enhance patient adherence to complex regimens in addition to counseling and follow-up, has resulted in good adherence rates and persistence.

Long-term patient adherence to antiretroviral therapy.

To measure patient adherence to antiretroviral therapy over a two-year period and to identify factors impacting adherence. In a regional HIV treatment center, 100 consecutive patients starting any new antiretroviral agent were enrolled in this study, which consisted of a one-year retrospective data review and a one-year prospective component. The tools used for evaluating adherence were the monthly prescription refill data and a patient questionnaire. Data analyzed included overall adherence, adherence to individual antiretrovirals, and change in adherence over time, as well as factors reported as influencing adherence. Greater than 80% adherence in taking prescribed doses was seen in 75% of patients during the retrospective phase of the study; adherence increased to 84% in the prospective phase. Throughout the prospective phase of the study, monthly median adherence rates were 98-100%. Suboptimal adherence secondary to pill fatigue or number of daily pills did not occur. Reported nonadherence to dietary restrictions varied among drugs. The primary cause given for poor adherence was difficulty remembering followed by inconvenient dosing schedule and difficulty scheduling administration times around meals. At least one adherence tool was used by 61% of patients. A diagnosis of AIDS was associated with lower adherence in our patient population (p = 0.039); substance abuse and psychiatric history had no influence. Adherence to antiretroviral treatment regimens did not diminish over the two years studied. Several patients with poor adherence were identified, emphasizing the importance of addressing this issue both prior to and throughout treatment. A personalized approach by healthcare providers can optimize patient adherence to antiretroviral therapy by providing careful drug selection in addition to routine follow-up and the provision of information, feedback, and reminder systems.

α‐Ａｌ２Ｏ３被覆工具の高密着性化機構の研究

Microstructure of α-Al2O3-coated turning inserts whose tool lives were longer than K-Al2O3-coated ones have been investigated. These inserts were coated successively with a TiN layer, a MT(moderate temperature)-Ti(C, N)layer, a bonding layer, and a α-Al2O3 layer on cemented carbide inserts by using chemical vapor deposition(CVD). X-ray diffraction, SEM and TEM were used to characterize the coatings, and following characteristics were found.(1) Epitaxial growth was observed in a column of MT-Ti(C, N) twinned grains, bonding layer twinned grains and α-Al2O3 grains by cross-section TEM, where(100)-planes of the α-Al2O3 grains were parallel with(110)-planes of both the MT-Ti(C, N)grains and the bonding layer grains, and(003)lattice fringes of the α-Al2O3 grains continue almost linearly from {111} lattice fringes of the bonding layer grains.(2) (120)-planes of the α-Al2O3 grains and (211)-planes of both the MT-Ti(C, N)grains and the bonding layer grains in the column were parallel to the substrate, too.(3) Many steps at the surface of vertical-plane-shape protrusions formed along the twin boundaries on the surface of the bonding layer, might promote the epitaxial growth of α-Al2O3 grains on the bonding. layer.(4) The above mentioned microstructure agrees with X-ray diffraction results on the MT-Ti(C, N) layer and the α-Al2O3 layer. This may mean that the epitaxial growth will be found in many columns in the α-Al2O3-coated turning inserts.The above mentioned epitaxial growth and the protrusions between the bonding layer grains and the α-Al2O3 grains are considered to be the cause for improved α-Al2O3 layer adherence and longer tool life.