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Top of pageAbstractThe objective of this study is to establish the efficacy of adherence therapy (AT) compared with treatment as usual (TAU) in reducing blood pressure (BP) in non-compliant hypertensive patients. MEDICATION ADHERENCE TIME TOOL: IMPROVING HEALTH OUTCOMESA Resource from the American College of Preventive MedicineMedication Adherence Main MenuCLINICAL REFERENCEThe following Clinical Reference Document provides the evidence to support the Medication Adherence Time Tool. Copyright ? 2006 American Society on Aging and American Society of Consultant Pharmacists Foundation; all rights reserved.
The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4 is a reliable and valid instrument to assess patients' satisfaction with medication, providing scores on four scales a€“ side effects, effectiveness, convenience and global satisfaction.
A total of 3,387 subjects were invited to participate in the study from an online panel who self-reported taking a prescribed antihypertensive medication. The IVRS-administered TSQM-9 was found to be a reliable and valid measure to assess treatment satisfaction in naturalistic study designs, in which there is potential that the administration of the side effects domain of the TSQM would interfere with routine clinical care. BackgroundPatient satisfaction with their medication is shown to affect treatment-related behaviors, such as their likelihood of continuing to use their medication, to use their medication correctly and to adhere with medication regimens [1a€“7]. MethodsStudy sampleStudy subjects were recruited from an online population of patients, reporting to be hypertensive, identified by Synovate Healthcare (Chicago, Illinois, USA). When you travel or leave home, do you sometimes forget to bring along your [health concern] medication?
When you feel like your [health concern] is under control, do you sometimes stop taking your medicine?
All translations, adaptations, computer programs, and scoring algorithms, and any other related documents of the Morisky Medication Adherence Scale (MMAS 4- and 8-item versions), are owned and copyrighted by, and the intellectual property of, Donald E. One item of the 8-item Morisky scale related to stopping medication because of feeling worse with the medication ('Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?' was not included in the modified Morisky scale due to similar concerns about the item interfering with the treatment process in a naturalistic study design. ResultsStudy subjectsA total of 2,135 subjects (63.0%) out of the 3,387 subjects that were contacted, agreed to participate in the study. Modified Morisky scale observed scoresTable 2 also describes the modified Morisky scale score at time 1. Test-retest reliability of the TSQM-9Table 2 describes the test-retest reliability of each of the domains of the TSQM-9 using the intraclass correlation coefficient (ICC). Convergent validity of the TSQM-9Convergent validity of the TSQM-9 was assessed by correlation of the modified Morisky scale score and the TSQM-9 domain scores at time 1 using the Spearman rank-order correlation coefficient.
DiscussionThis study provides evidence of the reliability and validity of the IVRS-administered abbreviated 9-item TSQM without the side effects domain (TSQM-9).
ConclusionThe IVRS-administered TSQM-9 was found to be a reliable and valid measure to assess treatment satisfaction in naturalistic study designs, when there is potential for the side effects domain of the TSQM to interfere with routine clinical care and the objectives of the study.
Otsuka Pharmceutical Europe Ltd, Pfizer, received honoraria from AstraZeneca, Bristol-Myers Squibb, Jannsen Cilag, Eli Lilly and Co. World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. In naturalistic studies, administering the TSQM with the side effects domain could provoke the physician to assess the presence or absence of adverse events in a way that is clinically atypical, carrying the potential to interfere with routine medical care.
The subjects were asked to complete the IVRS-administered TSQM-9 at the start of the study, along with the modified Morisky scale, and again within 7 to 14 days.
Although a number of disease-specific measures of patients' treatment satisfaction (TS) and treatment satisfaction with their medication (TS-M) have been reported in the literature [8a€“18], very few studies have attempted to assess a more general measure of TS-M that would permit comparisons across medication types and patient conditions.
Thinking over the past two weeks, were there any days when you did not take your [health concern] medicine? A total 968 subjects (45.3%) out of the 2,135 responders were screen failures since they did not pass the study eligibility questions.
Modified Morisky scale score has a range of 0 to 7, with higher scores indicating higher adherence to medication. As satisfaction with medication is expected to be positively associated with medication adherence, a moderate-to-high positive correlation between the scores is expected. There was evidence of construct validity based on structural equation modeling findings of the observed data fitting the Decisional Balance Model of Treatment Satisfaction even without the side effects domain.
To obtain the approved formatted versions of the instrument as well as numerous translations, please contact Murtuza Bharmal, Ph.D.
A focus on exploring patients’ beliefs about illness and treatment and providing specific information about the disease (hypertension) and its treatments (medication and life-style modification) are also strongly advocated for example, by using face-to-face education sessions or information leaflets. As a result, an abbreviated 9-item TSQM (TSQM-9), derived from the TSQM Version 1.4 but without the five items of the side effects domain was created.
Standard psychometric analyses were conducted; including Cronbach's alpha, intraclass correlation coefficients, structural equation modeling, Spearman correlation coefficients and analysis of covariance (ANCOVA). There was evidence of construct validity of the TSQM-9 based on the structural equation modeling findings of the observed data fitting the Decisional Balance Model of Treatment Satisfaction even without the side effects domain.
The Treatment Satisfaction Questionnaire for Medication (TSQM) is a widely used generic measure to assess TS-M and has been psychometrically validated in a heterogeneous sample [19, 20].The development of the TSQM along with the conceptual framework of TS and patients' satisfaction with their medication has been described in detail earlier [19, 20]. Professor of Community Health Sciences, UCLA School of Public Health, Los Angeles, CA 90095-1772. Of the 1,167 that were enrolled in the study, a total of 396 subjects (33.9%) completed all the study procedures (required assessments at time 1 and time 2) and were used in the current analysis (see Figure 1). Given the 4-week recall period used in the TSQM-9, subjects completing TSQM-9 at time 1 and a second assessment within 7 to 14 days had a sufficient overlap in time period for assessing satisfaction between the two time periods, and thus not expected to have any bias in the test-retest reliability analysis.Known-group validity of the TSQM-9Known-group validity analysis determines the ability of the TSQM-9 to discriminate among patients known to differ in their satisfaction with medication. TSQM-9 domains had high internal consistency as evident from Cronbach's alpha values of 0.84 and over.
This guidance is based largely on observational research and to date there has been little experimental evidence to establish the clinical benefit of such a consultation style. Treatment adherence was monitored with MEMS and the validity of the following adherence measures was assessed: isoniazid urine test, urine colour test, Morisky scale, Brief Medication Questionnaire, adapted AIDS Clinical Trials Group (ACTG) adherence questionnaire, pill counts and medication refill visits. INTRODUCTION - DIMENSIONS OF PATIENT ADHERENCEPatient adherence to a medication regimen is central to good patient outcomes. In this study, an interactive voice response system (IVRS)-administered TSQM-9 was psychometrically evaluated among patients taking antihypertensive medication.
TSQM-9 domains had high internal consistency as evident from Cronbach's alpha values of 0.84 and greater. In the development of the TSQM, an initial set of 55 items were drafted to represent the conceptual framework of TS-M identified based on qualitative research which included the concepts of effectiveness, symptom relief, side effects, convenience, tolerability, impact on daily life and functioning and global satisfaction [19]. These subjects, considered healthcare panelists, must consent and be 18 years of age or older to participate.This study was approved by an independent ethics committee. The model tested included a measurement model, which described the relationship of the manifest variables that measure the latent constructs (Effectiveness, Convenience and Global Satisfaction), and a causal model, which described the relationship of the latent constructs with each other. The individual standardized parameter estimates for the paths in the model were high and most greater than 0.70.
TSQM-9 domains also demonstrated good test-retest reliability, with high intraclass correlation coefficients exceeding 0.70. TSQM-9 domains also demonstrated good test-retest reliability with high intraclass correlation coefficients exceeding 0.70. The study recruited subjects with a goal of achieving at least 300 completed subjects as an accepted sample size for validation studies [22].Study designOut of the 25,600 healthcare panelists that met the inclusion criteria for the study, a random sample of 3,387 subjects were sent an email invitation in which a web link directed them to the TSQM-9 study enrollment website, within which the study rationale, objectives and procedures were fully described. For testing the above model using structural equation modeling (SEM), as recommended by Hatcher, the variances of the exogenous variables (latent constructs) need to be specified as free parameters to be estimated [24].
Since only one individual was classified as high complier (modified Morisky scale score = 7), this group was excluded from the known-group validity analysis.
As expected, the TSQM-9 domains were able to differentiate between individuals who were medium and low compliers with a moderate effect size. As expected, the TSQM-9 domains were able to differentiate between individuals who were low, medium and high compliers of medication, with moderate to high effect sizes.
However, the use of the TSQM with the side effects domain has a potential to interfere with real-world outcomes which are central to naturalistic study designs. To participate in the TSQM-9 validation study, subjects confirmed in this website that they had read the description of the study design and required procedures and they wished to continue with the enrollment process.
As expected, TSQM-9 domain scores were significantly different between the two groups, with higher scores (greater satisfaction) among medium compliers compared to low compliers. There was also evidence of convergent validity, with significant correlations with the medication adherence scale.The TSQM-9 was developed due to the need for using a measure of treatment satisfaction that was designated to minimize interference in routine clinical care in the context of naturalistic study designs.
Theoretically, these techniques amplify the personally relevant benefits of treatment, modify illness and treatment beliefs and resolve ambivalence towards taking medication.Considering two of the AT techniques, generating discrepancy and checking beliefs, in more detail. Provider discussions help patients understand their illness and weigh the risks and benefits of treatment. There was evidence of convergent validity with significant correlations with the medication adherence scale. For example, a recent study in patients treated with antiepileptic drugs found that a significant higher rate of adverse event reporting occurred among patients who were administered a checklist versus those reporting them spontaneously. Briefly, based on the Decisional Balance Model of Treatment Satisfaction, dimensions of treatment experience (effectiveness, convenience and side effects) are weighted by individuals to predict global satisfaction and subsequent treatment adherence. The specified model was confirmed as overidentified with number of data points (information = 45) exceeding the number of parameters to be estimated (parameters estimated = 20) [24].
All Cronbach's alpha values exceeded 0.80 at time 1 and time 2, demonstrating good internal consistency [30]. The side effect domain of the TSQM Version 1.4 queries the patient about their experience in relation to side effects and has a potential to provoke the physician to assess the presence or absence of adverse events in a way that is clinically atypical, affecting the naturalistic design of a study [21].
The therapist can amplify the personally relevant benefits of medication by generating discrepancy between what the patients says is important to them (for example, being able to work, not visiting hospital so frequently, not worrying family) and what they actually do that is, not taking medication. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The study also found that reporting of adverse events resulted in changing treatment administered [21].
Upon receipt of the 'opt-in' response, subjects were automatically directed to a confirmation of study eligibility web page, where they answered a few brief questions confirming study eligibility and provided their primary contact telephone number. In the TSQM-9, since the side effect domain of the TSQM is not included, it becomes important to assess the construct validity of the TSQM-9 using the Decisional Balance Model of Treatment Satisfaction, with respect to the ability of its scales to predict treatment satisfaction even without the side effect domain.Structural equation modeling (SEM) helps to model the hypothetical relationships between observed and latent variables.
It should be noted that we do not recommend the use of TSQM-9 over the earlier versions of the TSQM in clinical studies where there is no such possibility of the side effects domains interfering with study objectives and where the outcome of investigational drugs are being studied. Identifying strategies for improving medication adherence are the responsibility of all involved, but the focus of this Time Tool is on the providera€™s role in medication adherence.
The study findings demonstrate the potential of a questionnaire like the TSQM with its side effect domain to interfere with naturalistic studies which are designed to collect data from the usual clinical practice environment with minimum interference to the behaviors of study participants (both patients and physicians).In the real world, physicians must collect and report suspected adverse events to medications already on the market according to established guidelines for adverse event reporting and their own professional discretion. The eligibility questions included confirmation on whether they had hypertension and whether they were taking prescription medications for their hypertension.Once eligibility was confirmed via the website, the subject was sent a confirmation email that provided a reiteration of study procedures, a toll-free telephone number and a unique randomized access code which enabled secure access to the telephone-based interactive voice response system (IVRS) within which the study questions were implemented. The measurement and structural model to be tested is pre-specified by defining the relationships among the variables (ie, items) and latent constructs (ie, scales), and then tested by examining the fit between the specified model and the correlation or covariance patterns that are observed in the data. Clearly, based on the conceptual framework of TS-M, patient's perception of side effects with their medication is an important component of satisfaction with their medication.
Step 1, the patient is asked to rate the conviction (as a percentage), with which they hold a belief (for example, the patient says they are 60% sure most medication is addictive). Thus, in a naturalistic study of the usual care of hypertension management, the administration of a questionnaire, such as the TSQM, which queries the patient about their experience in relation to side effects, has a potential to provoke the physician to assess the presence or absence of adverse events in a way that is not typical for clinical practice, as demonstrated in the study by CarreA±o and colleagues [21]. Subjects were invited to call the IVRS as soon as possible (preferably the same day as study enrollment). Each study subject was instructed to call the IVRS and enter study data twice: the first assessment (time 1) and a second assessment within 7 to 14 days (time 2). The fit of the specified model was evaluated by reviewing two criteria, the global fit measures including the Bentler's comparative fit index (CFI), the Bentler and Bonett's non-normed fit index (NNFI) and chi-square, and the magnitude of the individual standardized parameter estimates for the paths in the model.
As a result, even without the side effects items, the TSQM-9 allows for patients to weigh the pros and cons of medication and the less favorable aspects of patients' experiences with their medications would be captured.In this study, we found that the convenience domain had strongest association with medication adherence followed by effectiveness and global satisfaction. Adherence (measured by pill counting) was also improved in the AT group by 37% at 11 weeks compared with TAU. Blood pressure indices and cardiovascular disease in the Asia Pacific region: A pooled analysis.
The TSQM-9 has been developed to provide a suitable measure of treatment satisfaction with medication in such naturalistic studies where measuring patient-reported side effects has a potential to interfere with the study objectives.
During the first call, subjects completed the TSQM-9 and the modified Morisky Scale questions [23]. To demonstrate a good model fit, the chi-square test should be non-significant, and the CFI and NNFI should be close to or exceeding 0.90 [24, 25].
In previous TSQM validation analysis, global satisfaction had the strongest association with medication adherence [20]. The objective of this study was to psychometrically validate the interactive voice response system (IVRS)-administered abbreviated 9-item TSQM (TSQM-9) in a sample of patients taking hypertensive medications. Direct confrontation or challenge of the belief is avoided.Each consultation follows a standard structure (review of previous meeting and homework, set agenda, task (for example, exploring ambivalence), feedback and setting homework). The 14 questions were selected from an original set of 55 questions obtained from literature review and focus groups. Test-retest reliability of the TSQM-9 was assessed using the intraclass correlation coefficient using data from the two time periods (time 1 and time 2) that were separated by 7 to 14 days. In an asymptomatic chronic condition like hypertension, the convenience domain becomes an important factor for medication adherence given that the patient has to take their medications daily without any apparent symptomatic changes in their condition.One of the limitations of this study was that it was conducted in a homogenous sample of patients using hypertensive medications. Attention to adherence is especially important in the current economic climate where we are seeing an uptick in patients foregoing medications by not filling or refilling prescriptions and hoarding medications due to high costs [8]. The four scales of the TSQM include the effectiveness scale (questions 1 to 3), the side effects scale (questions 4 to 8), the convenience scale (questions 9 to 11) and the global satisfaction scale (questions 12 to 14). Assuming that there is no significant change in the factors that affect patient satisfaction with medication during the short time interval in the two administrations of the TSQM-9, patient responses from the two time periods were expected to have a high correlation.Known-group validity analysis was conducted to determine the ability of the TSQM-9 to discriminate among patients known to differ in their satisfaction with medication. Since the TSQM is a generic measure of patients' satisfaction with their medication, validation in a more heterogeneous representative sample, containing, for example, patients with different chronic medical conditions would have improved the robustness of results. Considering all of the factors listed in Table 1 that contribute to poor adherence, on the surface, it would appear that the provider role is very small. In the TSQM-9, the five items related to side effects of medication were not included, which creates a need to psychometrically assess the performance of the abbreviated instrument.The TSQM-9 domain scores were calculated as recommended by the instrument authors, which is described in detail elsewhere [19, 20]. It is expected that individuals that are more compliant are likely to be more satisfied with their medication. Future studies on the performance of the TSQM-9 in other patient populations are recommended. The TSQM-9 domain scores range from 0 to 100 with higher scores representing higher satisfaction on that domain.Modified Morisky scaleThe modified Morisky scale is a 7-item instrument to assess self-reported patient adherence modified from the validated 8-item Morisky scale developed to assess adherence related to antihypertensive medication [23]. In this study, differences were observed on demographic characteristic between responders to the study invitation and non-responders. Impact of high-normal blood pressure on the risk of cardiovascular disease in a Japanese urban cohort: The Suita Study.
Patients who trust their physicians have better two-way communication with their physician. Convergent validity of the TSQM-9 was assessed by the correlation of the modified Morisky scale score and the TSQM-9 domain scores at time 1 using the Spearman rank-order correlation coefficients.


An item from the original Morisky scale related to stopping medication because of feeling worse with the medication was dropped due to similar concerns about the item interfering with the treatment process in a naturalistic study design [21].
Records were selected for assessment on the basis that the patients had been seen recently in the clinics.
Numerous studies show that physician trust is more important than treatment satisfaction in predicting adherence to prescribed therapy and overall satisfaction with care [8]. However, as discussed earlier, deleting this item resulted in minimal change in the internal consistency of scale as well as the sensitivity and specificity of the scale for identifying lower vs. Records were assessed in reverse date order of last clinic appointment, and assessment of potential participants was stopped when sufficient numbers had been recruited to the study.
The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. Physician trust correlates positively with acceptance of new medications, intention to follow physician instructions, perceived effectiveness of care, and improvements in self-reported health status.
Potential participants were screened with the Morisky Medication Adherence Scale25 (MMAS) before the trial. Patients were excluded if they had:complications of hypertension, had diabetes, congestive heart failure and renal impairment.
Statistically, the odds of patient adherence are 2.26 times higher if a physician communicates well.
These patients were excluded because their treatment regime was more likely to be complex, introducing more potential confounders that might not be adequately dealt with by randomisation.mental illness or any other long-term health conditions for example, asthma, Parkinson's disease, epilepsy, cancer and chronic obstructive pulmonary disease.
Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories.
Communication contributes to a patienta€™s understanding of illness and the risks and benefits of treatment.
Hopefully, as providers try to communicate with patients, these terms will rarely enter the conversation. Rather, providers will probably ask, "Are you taking your medication as directed?a€? or "Did you take all of your pills?a€? The term adherence is often used in place of compliance as it is viewed as a nonjudgmental statement of fact rather than of blame of the patient, prescriber, or treatment. On entry of a valid PIN, the system generated a unique Study Code and randomly allocate the patients to either the AT or TAU arm of the trial.
However, Cramera€™s recent (2008) review of terminology found no authoritative support for the assumption that adherence is a less derogatory term than compliance or whether it is preferred by patients [10]. Feinstein (1990) quizzically remarks about the superiority of terms: "Adherence seems too sticky. Clinical Guidelines and Evidence Review for Medicines Adherence: Involving Patients in Decisions about Prescribed Medicines and Supporting Adherence. The extent to which a patienta€™s behavior (in terms of taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice.
AT was delivered by FA who received one-to-one training in AT over seven sessions each lasting 1 h from RG who developed the intervention.
Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Compliance, which is a synonym for adherence, suggests a process in which dutiful patients passively follow the advice of their providers and is sometimes substituted with the word adherence as the trend moves toward patient-centered care. These were assessed using a questionnaire developed by the study's authors.OutcomesThe primary outcome, for this study, was the difference in SBP from baseline to follow-up (11 weeks after randomisation). If the results of this study are positive, subsequent trials should then test the durability of the intervention.
Our secondary measures were the difference in DBP, medication adherence rates and BMQ from baseline to follow-up (11 weeks after randomisation). Underuse includes:Delay or not filling a prescription (primary medication non-adherence) Not picking up a prescription Skipping doses Splitting pills, stopping a medication early Not refilling a prescriptionTable 2. BP was measured by a nurse blinded to the group allocation and time of intervention at baseline and 11 weeks. The BP was measured using a stethoscope with mercury sphygmomanometer twice from the right upper arm of a seated patient who had been resting for more than 10 min.
The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Consider these other statistics: Overall, about 20% to 50% of patients are nonadherent to medical therapy [14] People with chronic conditions only take about half of their prescribed medicine [5] Adherence to treatment regimens for high blood pressures is estimated to be between 50 and 70 percent [15] 1 in 5 patients started on warfarin therapy for atrial fibrillation discontinue therapy within 1 year Underuse of anticoagulant therapy for prevention of thromboembolism is attributed to the risk factors of younger age, male gender, low overall stroke risk, poor cognitive function, homelessness, higher educational attainment, employment and reluctant receptivity of medical information [16] Rates of adherence have not changed much in the last 3 decades, despite WHO and Institute of Medicine (IOM) improvement goals Overall satisfaction of care is not typically a determining factor in medication adherence Adherence drops when there are long waiting times at clinics or long time lapses between appointments [17] Patients with psychiatric disabilities are less likely to be compliant Figure 2.
Measuring adherence is difficult because most available direct and indirect measures have limitations. Based on IMS Health data] [18]Nonadherence results in an economic burden of $100 to $300 billion per year [19] Annually, nonadherence costs $2,000 per patient in physician visits [20] The rate of nonadherence is expected to increase as the burden of chronic disease increases Nonadherence accounts for 10% to 25% of hospital and nursing home admissions (Figure 3). Direct adherence measures, such as tests to measure drug levels in plasma or urine, cover brief medication intake periods only.
The BMQ has established validity and is routinely used as an outcome measure in adherence research. MEMS medication bottles contain a microelectronic chip that registers the date and time of every bottle opening. Assuming that bottle openings represent medication intake, MEMS provides a detailed profile of the patient's adherence behaviour. Hence, adherence requires the patient to believe there is a benefit to the medicine being prescribed and agree with instructions on how to take it. Although there was very little missing data (six patients died, three discontinued AT and one lost to follow-up, Figure 1) this was dealt with by multiple imputation of missing data being based on iterative chain equation modelling including all available outcome measures and their baseline values and treatment arm.
Five imputed data sets were created, which were then analysed and combined using Rubin's equations.37 The differences in change of BP and BMQ were assessed using an unadjusted analysis and after adjusting for possible prognostic factors (gender, education, economic status and medical insurance status) using an analysis of covariance.
The prescribera€™s role is to gain trust from the patient, understand the patienta€™s belief system, find a way to treat within this belief system, interactively obtain agreement from the patient on when and how to take prescribed medication, and discuss cost issues to insure the medication is obtained and that instructions are followed. Adherence rate and medication change were similarly analysed using logistic regression with only treatment arm as a covariate, as an unadjusted analysis and an adjusted analysis was based on included prognostic factors. Cardiovascular risk factor trends and potential for reducing coronary heart disease mortality in the United States of America. Patients on community-based DOT are supposed to collect their medication once a week in the first two months of treatment and once every two weeks in the remaining four months.
Studies have shown that some patients are interrupted by their physician after an average of 22 seconds.
Six patients (three in each group) died before the end of the study, three withdrew from the AT intervention and one patient in the AT group was lost to follow-up (see participant flow diagram). It has also been shown that if allowed to speak freely, the average patient would speak initially for less than two minutes. MEMS was used as a gold standard to validate several other adherence measures (single and in combinations) in this patient group. Patience and a free flowing conversation can result in a long-term payoff of better adherence resulting in better patient outcomes, fewer follow-up visits, and shorter, more focused subsequent interactions. Improving adherence to guidelines for hypertension drug prescribing: cluster-randomized controlled trial of general versus patient-specific recommendations.
The adherence measures were selected for their applicability in the Tanzanian setting and included an isoniazid (INH) urine test, a urine colour test for rifampicin, the Brief Medication Questionnaire (BMQ), the Morisky scale, an adapted version of the AIDS Clinical Trials Group (ACTG) adherence questionnaire, pill counts and clinic attendance for medication refills.
In addition to prescribers, the office staff has a role in boosting patient adherence to medication.
Because of the imbalance between treatment groups at baseline in terms of gender, economic status, education and medical insurance, an analysis was conducted adjusting for these factors and the baseline value of the outcome. Wroth et al, (2006) evaluated correlates of medication adherence in a rural setting and found that when patients felt welcomed and comfortable by the staff, they were more likely to fill their prescriptions [5]. Expectation Without Intervention Is A Prescription For FailureProviders expect their patients to follow their directions for taking medication explicitly.
However, according to research, even medical professionals dona€™t have a perfect record when it comes to medication taking.
There was no significant difference in the average adherence rate between individuals on monotherapy compared with those prescribed two or more antihypertensive medications in either the AT or TAU groups.Our proposed mechanism of action is that AT will positively influence attitudes and beliefs about medications, which will improve adherence, and which will, in turn, reduce BP. Adult outpatients who consecutively presented at one of the study sites with newly diagnosed tuberculosis and who had chosen community-based DOT were eligible to participate.
One survey found that adherence was 77% for short-term medications and 84% for long-term medications among doctors and nurses [23]. Eligible patients were informed about the study procedures by trained clinic staff and asked to sign an informed consent form.
It seems unreasonable, then, to expect that patients can achieve better adherence than providers without provider intervention. They were told that their tuberculosis medication would be provided in a medication bottle with a microelectronic chip that registers every bottle opening. They were asked not to use the MEMS bottle for other medication, to open it only to take out medication, and to bring the bottle to every medication refill visit. Numerous studies show that simple interventions are the most effective in fostering medication adherence [24]. Atreja, et al (2005) grouped adherence-promoting interventions under the mnemonic SIMPLE, which helps categorize efforts to improve patient adherence. Although the sample size of 136 patients was modest the confidence intervals for the effect are narrow due to the small variation in BP in this population. Medication refill visits were conducted in accordance with routine practice, except that the medication blisters were cut into pieces to make them fit in the MEMS bottle. The nurses registered the dates of the patients' clinic visits for medication refills and the number of tablets remaining at each visit.
Medications taken once-a-day are preferred, but if the increased cost of a once-a-day is a major barrier, this is not a solution Match regimen to patientsa€™ activities of daily living. At these visits, patients submitted a sample of urine and were asked to fill out the BMQ and Morisky scale (in weeks 4, 8 and 12) or the ACTG adherence questionnaire (in week 16).
If taking fewer pills is not an option, a provider should try to match medication taking to activities the patient does daily, such as taking pills at a meal time or before bed Recommend all medications be taken at same time of day (if there are no interactions or food absorption issues) Avoid prescribing medications with special requirements (bedtime dosing, avoiding meals) Investigate customized packing for patients (dose dispending units of medication) Break the medication regimen down into simple steps that can be introduced sequentially.
At completion of treatment, the patients filled out a questionnaire about their experience with the use of MEMS bottles.
Be sure the patient understands every step Encourage the use of adherence aids such as medication organizers (pill reminders) and alarms [16] Consider changing the situation (more conversations, more repetition, change treatment) versus changing the patient. It may also be that patients recruited to pharmaceutical trials tend to be selected for adherent behaviours; consequently there may be less potential room for improvement (the ceiling effect).
In other words, a provider should adjust the treatment to the patient versus the patient to the treatment [24] I a€“ Impart knowledge. The patients in our study were specifically selected for their non-adherence to their medication at baseline, and as compliance levels improved so dramatically in the AT group, we may be observing close to the maximum change capable of being achieved by these antihypertensive drugs.Causal mechanismThe hypertensive patients all began the study with relatively neutral beliefs about medication, but poor adherence behaviours.
Adherence is enhanced when a patient understands their condition and the benefits of treatment. Those in the AT group shifted their opinions so that overall they disagreed with statements regarding the intrinsically harmful nature of medicines, and overall agreed with statements regarding the intrinsically beneficial nature of medicines. MEMS data were used to calculate adherence rates (by dividing the number of days on which at least one bottle opening was registered by the total number of monitored days and multiplied by 100) and to differentiate between adherent and non-adherent patients for validation of the other adherence measures.
Focus on patient-provider shared decision making Encourage discussions with physician, nurse, and pharmacist Provide clear instructions (written and verbal) for all prescriptions Limit instructions to 3 or 4 major points Use simple, everyday language Use written information or pamphlets and verbal education at all encounters Involve family and friends in the discussion when appropriate Provide quality web sites for patients wishing to access health education information from the Internet Suggest computerized self-instruction for complex chronic conditions Provide concrete advice for how to cope with medication costs Reinforce all discussions often, especially for low-literacy patients M a€“ Modify patient beliefs and human behavior. The test was performed in accordance with the directions provided in the accompanying manual. Accessing perceived susceptibility, severity, benefit, and barriers is necessary in all patient encounters since knowledge alone is insufficient to enhance adherence, especially those that involve complex behavioral change [13].Empower patients to self-manage their condition [25] Ask patients about their needs. That we have been able to demonstrate how our AT has impacted on BP is important and particularly pleasing because few, if any, previous adherence studies have been able to establish this. The test result was negative when no colour change was observed after 5 minutes, positive when the colour changed to dark purple and equivocal when the colour turned green.
Create an open dialogue with each patient and ask about his or her expectations, needs, and experiences in taking medication.
Ask patients what might help them become and remain adherent [24] Ensure that patients understand they will be at risk if they dona€™t take their medication Ask patients to describe the consequences of not taking their medication Have patients restate the positive benefits of taking their medication Address fears and concerns (perceived barriers) of taking the medication Consider the use of contingency contracting. Our study had a short period of follow-up (1 month) which may have reduced the likelihood of us detecting differences in the rates of medication adjustment between the two groups. A contingency contract is an agreement between a patient and provider, which states behavioral goals for the patient and reinforces or rewards that the patient will receive contingent upon achievement of these goals.
Ogedegbe40 reported that the effect of motivational interviewing intervention led to steady maintenance of adherence in hypertensive African Americans, over 12 months follow-up compared with a significant reduction in adherence noted in the usual care group. Provide rewards for adherence Reward self-efficacy with praise Incent with coupons, certificates, points programs, or food, candy, or other small items such as pocket size hand sanitizer, reduced visit frequency, or partial payment for medical equipment P a€“ Provide communication and trust. This effect was also associated with greater frequency of adjustments in medication in the usual care group.
Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials.
Thus with a longer follow-up period we may have observed similar changes.One factor that is known to reduce adherence is to take more than one drug.
A physiciana€™s communication style is one of the strongest predictors of a patienta€™s trust in his or her physician. A practice-based trial of motivational interviewing and adherence in hypertensive African Americans. Providers can improve in all areas of data gathering, patient education and counseling, rapport building, facilitation and patient activation. Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease. Active listening is an interactive process with the intent to listen for meaning and requires careful attention to what a patient is saying. It includes techniques such as: Confirming the patienta€™s message has been heard (feedback, questions, prompts for clarity, and other signs of having received the message) Accurately paraphrasing patient remarks Using verbal and nonverbal cues to show understanding and empathy Giving feedback to the patient during a discussion Furthering the dialogue to gain more information Providing the needed responses and watching for patient acceptance or reluctance Provide emotional support.
Although the use of a single therapist limits the generalisability of this intervention, we believe that this was mitigated as FA was trained according to the standard manual to deliver AT and the fidelity of her delivery was confirmed. Our adapted version consisted of three multiple choice items corresponding to sections B (social support), C (possible reasons for non-adherence) and D (adherence behaviour) of the original baseline questionnaire. We scored any answer other than "never" to the questions in sections C and D or less than "somewhat satisfied" to the questions in section B as positive.
Offer physical touch to show caring, deliver compassion, respond to emotional needs, and maintain hope and a positive attitude. However, we recognise that because of the relationship the patients in the AT group developed with FA during therapy, they might have not wanted to let her down, and been particularly adherent during the assessment period.
Funded by a doctoral studentship grant from Philadelphia University, Jordan and the University of East Anglia, UK.
This effect may have been enhanced by the short follow-up period (4 weeks).We used pill counting after 1 month to estimate the level of adherence, but we recognize that the absence of pills does not necessarily mean that the patient has correctly taken their medications. A provider should remember to speak in simple language at the patienta€™s linguistic level.


Pill counting cannot identify other types of non-adherence, such as inappropriate timing or dosage.Implications for future researchAll of the AT was delivered by a single person (FA) in this study. Patients who delayed at least once for a medication refill visit and those who had an incorrect number of tablets remaining at least once were classified as non-adherent. This reduces our ability to state that its effect could be as easily achieved by other clinicians. Future studies should also follow more participants over a longer period to increase our understanding of the durability of the effect in a larger and potentially more diverse population. Adherence to medication is complex and future trials may wish to determine whether drug doses were taken in the correct amount and at the correct time. Future studies should also collect data to enable a cost effectiveness analysis to be conducted.
An important question when applying AT in clinical practice is whether a short-term intervention (one session per week over 7 weeks) is sufficient to maintain BP-lowering effect over time. Means are presented with standard deviation (SD) and medians with interquartile range (IQR). Some patients want complete authority in deciding their therapy while others do not wish to be involved at all.
Other aspects of AT need to be tested to determine the robustness and generalisability of this therapy.
Aspects to be tested could include frequency and intensity of the therapy, the location of its delivery, the mode of delivery (for example, by telephone), the numbers to whom it is delivered (for example, one-to-one or group sessions), the character of the person delivering the AT (for example, lay advisors), and whether the duration of effect could be enhanced by the use of top-up sessions.Implications for practiceFrom our findings it can be concluded that a relatively short dose of AT is sufficient to reduce BP and improve adherence to medication for at least 1 month. The sensitivity, specificity, positive and negative predictive values and accuracy of single and combined adherence measures were calculated by using MEMS as the gold standard. It is possible that these results reflected changes in patient's behaviour, attitudes and beliefs that would lead to regular drug intake eventually becoming a habitual behaviour.
This is an unmet competency for many physicians that can easily be overcome by using the Degner scale (See Resources) [26]. Decision-Making LexiconInformed Decision a€“ one where a reasonable choice is made by a reasonable individual using relevant information about the advantages and disadvantages of all the possible courses of action, in accordance with the individuala€™s beliefsShared Decision a€“ one where the provider and patient share all stages of the decision making process simultaneously. In the purest form both provider and patient reveal treatment preferences and both agree on the decision to implement.Allow adequate time for patients to ask questions.
Increase a patienta€™s comfort level with asking questions by Creating a safe environment where patients feel comfortable talking openly Using plain language instead of technical language or medical jargon Sitting down (instead of standing) to achieve eye level with a patient Using pictograms (See Resources) Allowing patients to write down instructions Asking patients to "teach backa€? the instructions given to them Build trust.
A provider may rate themselves (or ask patients to rate them) on a scale of 1 to 5 (1=strongly disagree; 5=strongly agree) on the five statements below. Although all patients were on community-based DOT, seven had no formal treatment supporter. Three patients defaulted and four patients dropped out of the study (three were transferred to another region and one developed jaundice and his treatment had to be interrupted).
Trust in physicians and blood pressure control in blacks and whites being treated for hypertension in the REGARDS study.
Patient trust-in-physician and race are predictors of adherence to medical management in inflammatory bowel disease. 1, the proportions of non-adherent patients identified by the different measures varied widely. Table 3 shows the sensitivity, specificity, positive and negative predictive value and accuracy of the adherence measures in terms of their ability to differentiate between adherent and non-adherent patients. The ACTG adherence questionnaire and urine colour test had the highest sensitivities but lowest specificities. The Morisky scale and refill visits had the highest specificities but lowest sensitivities. A cut-off value of 80% could not be applied because none of the patients who completed treatment was less than 80% adherent. Its sensitivity and negative predictive value for the identification of patients who were less than 95% adherent improved by adding any of the other adherence measures except the Morisky scale (Table 3). Impacts of the physician's emotional intelligence on the trust, patient-physician relationship, and satisfaction.
Twenty-five patients (68%) stated that the white, bulky appearance of the MEMS bottle reminded them to take the medication.
However, the other patients said that the use of MEMS had not influenced their adherence behaviour. Activities Healthcare Provider Office Staff Can Use to Enhance Adherence [27]Improve the convenience of scheduling appointments, referrals, refills Remind patients to refill early Install interactive voice response systems Manage compliance-linked financial incentives Provide at home self-management programs Provide counseling, repeated monitoring and feedback Use automated telephone or computer-assisted patient monitoring Use manual telephone follow-up Deliver appointment and prescription refill reminders Send patient mailings that reinforce medication taking Teach behavioral strategiesL a€“ Leave the bias.
A large body of evidence concludes that ethnic, minority, and socioeconomic disparities related to health outcomes exist across all disease conditions and types of care, including preventive care.
Patients in this population experience lower levels of patient-centered communication and greater verbal passivity with physicians than Caucasian patients and patients with higher levels of education [2]. This usually occurred when patients did not want to take the bottle along on travel occasions. Almost 80% of the patients were more than 95% adherent and only one patient was less than 80% adherent. Ask about adherence behavior at every encounter Ferret out adherence barriers and lack of receptivity to medical information If self-report still leaves questions about adherence try pill counting or measuring serum or urine drug levels Periodically review patienta€™s medication containers, noting renewal dates Visit the web site below for a Medication Nonadherence Risk Assessment tool that includes a 1-page step-by-step instruction sheet and a 2-page patient assessment form. However, the adherence rates of our patients could have been biased by their participation in the study.
Although we tried to deviate as little as possible from routine practice, the repeated adherence questionnaires and urine tests certainly made participants aware of our interest in their adherence behaviour.
Two thirds of the patients felt that their adherence behaviour had been influenced by the use of MEMS, but their average adherence rate did not differ from those observed among patients who stated that MEMS had not influenced their behaviour.
If a patient is having difficulty following his or her regimen, a simple solution is generally the best. S a€“ Simplifying the Regimen"I believe that switching you to a once a day medication will be easier to manage. Unfortunately, it will cost a bit more but will provide better control and will provide you with added convenience. The high adherence rates in the study population forced us to apply high adherence rate cut-off values to calculate the validity and reliability of the adherence measures. Is this an option that you would be willing to consider?a€? (Let the patient decide on cost benefit) "In order for this medication to work effectively, you will need to take this medication twice a day. Can you take it at breakfast and dinner to help you remember or is there a more convenient time?a€? (Match pill taking to activities of daily living) "Tell me about all the pills you take and leta€™s determine together if you could take them all in the morning.a€? (Simplify the time of day the patient must focus on medication taking) "You need two different medications to control your condition.
The sensitivity and negative predictive value of the routinely used combination of pill counts and clinic attendance for medication refills improved substantially by adding a simple and cheap measure such as the ACTG adherence questionnaire, particularly at an adherence rate cut-off value of 95%.
Which option would best suit your needs?a€? (Let the patient decide if cost or convenience is more important) "Go ahead and fill all three of these prescriptions. Since the orange urine colouration caused by rifampicin is of short duration and may be absent altogether,28 it is likely that the urine colour test misclassified some patients with yellow urine as non-adherent. Such misclassifications are difficult to confirm in a study population with high adherence rates. Then add in the next two when you feel comfortable but not later than 3 weeks from today.a€? (Gradually step a patient into a complex regimen) I a€“ Imparting Knowledge"Here is your prescription and here are written directions.
In starting this new regimen, how will you incorporate these medications into your daily routine?" (Allow the patient to repeat back instructions in their own words) "The pharmacy will put directions on the pill bottle, but here are some pictures [pictograms] you can use as a reminder. Differences in wording in the questionnaires may account for this.8 hile patients had to answer either "yes" or "no" to the questions in the Morisky scale, they could answer "often", "sometimes", "rarely", or "never" to comparable questions in the ACTG adherence questionnaire. Attach this to a calendar and mark off when you take each pill.a€? (Relay information at the patientsa€™ level) "Here is a booklet that describes your condition. The ACTG adherence questionnaire (and to a lesser extent the BMQ) has the added advantage of disclosing factors that cause non-adherence in the individual patient. Is it possible to ask your wife to help you remember to take this medication?a€? (Involve family members) "Ita€™s important to take this medication every day. We therefore suggest using the triple combination consisting of the ACTG adherence questionnaire, refill visits and pill counts to monitor treatment adherence by Tanzanian patients on community-based DOT. However, if the cost imposes a financial hardship on you, please let me know right away and we can look at other options.a€? (Help optimize adherence by addressing cost) M a€“ Modifying Beliefs"Have you ever taken a medication every day and do you think you will have any problems with this?a€? (Ask about your patienta€™s needs) "After this surgery, you will need to take 3 additional pills.
If the results are interpreted carefully, the combination seems valid and its use in routine practice appears feasible.
What can I do to help you with this change?a€? (Tailor conversations to specific patient needs) "Can you tell me what you think will happen if you stop taking your medication?a€? (Ensure patients know their risks) "Do you have any fears or concerns about the medication I have prescribed?a€? (Identify perceived barriers) "Most of my patients on long-term therapy make a contract with me to always take their medication because it can often be difficult to remember to take medication(s) each day.
In order to create a partnership between myself and my patients, I offer rewards for participating in the contract.
Ia€™m glad you tried it and also glad you brought this to my attention because we can find another medication without this side effect.a€? (Give feedback to the patient) "Hmm, I hear you, but I want to know more.
To monitor adherence among patients on community-based DOT in resourcelimited settings where electronic monitoring is not feasible, combinations of simple and affordable adherence measures can be used.
Can you describe yesterdaya€™s symptoms?a€? (Further the dialogue) "It appears like you are uncomfortable with my suggestion. What part of this plan doesna€™t work for you?a€? (Watch for patient acceptance; involve patient in decision making) L a€“ Leaving the Bias"Buenos Dias and good morning.
Further studies in larger patient populations are needed to assess the adherence rates of patients on community-based DOT and to confirm the validity of simple and affordable adherence measures.
Leta€™s sit down and have a chat.a€? (Relate to patienta€™s demographic) "Ia€™m happy to see you Mrs. Will you be able to read this story this week?a€? (Tailor education to patienta€™s level of understanding) E a€“ Evaluating Adherence [13]"Do you ever forget to take your medications?a€? (Ask direct questions) "Do you ever find yourself not as careful about taking your medications?a€? (Ask about adherence often) "When you feel better, do you sometimes stop taking medication?a€? (Recognize lack of receptivity) "Sometimes, when you feel worse, do you stop taking your medicine?" (Identify adherence barriers) Not taking medication as prescribeda€”taking either too little, or too much, for too short, or too long a period, at the wrong time or in an ineffective waya€”can have negative consequences for patients, healthcare, and the economy.
Nonadherence is a multidimensional problem and providers have a role in improving the statistics.
By following the SIMPLE approach providers can modify their practices and practice patterns to enhance patient compliance.
This approach includes Simplifying the regimen, Imparting knowledge, Modifying patient beliefs, Providing communication and building trust, Leaving bias behind, and Evaluating adherence. Provider training in adherence strategies is needed and should focus on communication skills, cultural sensitivity, and patient-centered interviewing as competencies that will improve patientsa€™ adherence. Research shows that provider efforts can only go so far in improving medication adherence in the clinical setting [12]. Nevertheless, this should not deter prescribers from working with their patients to achieve maximum understanding and implementation of optimal health recommendations. To accomplish maximum adherence, those who use adherence-increasing strategies have a responsibility to ensure the patienta€™s safety and comprehension.
Taking medication as directed to prevent misuse and abuse is addressed in other ACPM Time Tools.
Read more about Use, Abuse, Misuse and Disposal of Prescription Pain Medication and Over-the-Counter Medication Use, Misuse and Abuse (coming soon). Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi. I prefer to make the final selection of my treatment after seriously considering my doctora€™s opinion. Photonovelas (or fotonovelas) are like comic books, but they are compiled using photographs and captions.
They are a highly visual and creative form of getting a message across to a diverse population. Based on the revolutionary Brazilian educator Paulo Frierea€™s concepts of participatory education, the process of creating the photonovelas allows learners to define the content and outcome of their own learning by creating a story line about an important topic or theme and then acting it out; using pictures as a means to express a story and message. Essentially, the genre of the photonovela challenges a more traditional educational approach because it has the learner as the main subject in the pedagogical process. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Patients' self-reported adherence to cardiovascular medication using electronic monitors as comparators.
A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Primary medication adherence in a rural population: the role of the patient-physician relationship and satisfaction with care.
Examining assumptions regarding valid electronic monitoring of medication therapy: development of a validation framework and its application on a European sample of kidney transplant patients. Medication adherence and older renal transplant patients' perceptions of electronic medication monitoring.
Medication adherence in patients with HIV infection: a comparison of two measurement methods.
The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Assessment of adherence to HIV protease inhibitors: comparison and combination of various methods, including MEMS (electronic monitoring), patient and nurse report, and therapeutic drug monitoring. Electronic monitoring of adherence to treatment in the preventive chemotherapy of tuberculosis. A novel approach to monitoring adherence to preventive therapy for tuberculosis in adolescence. Current issues in patient adherence and persistence: focus on anticoagulants for the treatment and prevention of thromboembolism. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence.
Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG).
A framework for planning and critiquing medication compliance and persistence using prospective study designs. Use of electronic monitoring devices to measure antiretroviral adherence: practical considerations. Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes. Furthering patient adherence: a position paper of the international expert forum on patient adherence based on an Internet forum discussion.
Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction.



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Comments

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    29.05.2015

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    29.05.2015