Jan Kavookjian

Motivational interviewing as a behavioral intervention to increase HAART adherence in patients who are HIV-positive: A systematic review of the literature

Abstract As HIV infection rates continue to rise, more and more people are faced with a complex, life-altering highly active antiretroviral therapy (HAART) regimen. With some researchers reporting as few as 50–70% of patients achieving adherence in the first six months of a HAART regimen, many behavioral interventions to increase HAART adherence have been examined. One such intervention, motivational interviewing (MI), has shown promise in previous studies and reviews as a possible successful intervention. Researchers conducted a review of the literature to identify studies analyzing the effect of a MI intervention on HAART adherence, with the objectives of examining this relationship and identifying gaps in the literature. To draw definitive conclusions about these questions and to maintain high methodological quality in the search, researchers used the Cochrane method for systematic reviews while conducting this review. Five studies were retained for review from the search and all were RCTs. Sample sizes ranged from 141 to 326 patients. Three of the five studies showed a significant increase in adherence rates, two studies reported a significant decrease in viral load, and one study showed an increase in CD4 cell count as a result of the intervention. A lack of a universally accepted definition of adherence and large gaps in the areas of humanistic and economic outcomes in the literature creates challenges in comparing improvements in HAART adherence across studies. Despite these challenges in comparison, MI appears to be a promising intervention to improve HAART adherence in HIV-positive individuals, but further studies of rigorous methodological quality are needed to fully understand the effect of this intervention.

Comparing Adherence to and Persistence with Antipsychotic Therapy Among Patients with Bipolar Disorder

Background: Medication nonadherence is a significant problem among patients with bipolar disorder. Objective: To compare adherence and persistence among patients with bipolar disorder initiated on antipsychotics in a state Medicaid system over a 12 month follow-up period. Methods: Claims data for patients with bipolar disorder from a de-identified Medicaid database were examined. Patients were classified into 4 monotherapy treatment groups (risperidone, olanzapine, quetiapine, or typical antipsychotic) based on the first prescription filled between January 1, 1999, and December 31, 2001. Adherence and persistence were analyzed over a 12 month follow-up period. Adherence was measured using the Medication Possession Ratio (MPR). Persistence was defined as the total number of days from the initiation of treatment to therapy modification (ie, discontinuation, switching, or combination with another antipsychotic). Adjustment for confounding variables was undertaken using ordinary least-squares and Cox proportional hazard regression modeling. Results: The mean MPRs were 0.68 for risperidone (n = 231), 0.68 for olanzapine (n = 283), 0.71 for quetiapine (n = 106), and 0.46 for typical antipsychotics (n = 205). Patients initiated on typical antipsychotics were 23.6% less adherent than patients initiated on risperidone (p < 0.001). Mean persistence (days) was 194.8 for risperidone, 200.9 for olanzapine, 219.8 for quetiapine, and 179.2 for typical antipsychotics. Extended Cox regression modeling indicated no significant differences between antipsychotics in hazards of therapy modification within 250 days of initiation. However, patients initiated on typical antipsychotics were 5.2 times more likely to modify therapy compared with those initiated on risperidone after 250 days of antipsychotic therapy (p < 0.001). Conclusions: Adherence and persistence were similar between atypical antipsychotic groups. The typical antipsychotic group, however, demonstrated lower adherence and a greater likelihood of patients modifying therapy compared with the risperidone cohort

Telephone-based motivational interviewing for medication adherence: a systematic review

ABSTRACTAdherence to prescribed medications continues to be a problem in the treatment of chronic disease. Motivational interviewing (MI) has been shown to be successful for eliciting patients’ motivations to change their medication-taking behaviors. Due to the constraints of the US healthcare system, patients do not always have in-person access to providers. Because of this, there is increasing use of non-traditional healthcare delivery methods such as telephonic counseling. A systematic review was conducted among published studies of telephone-based MI interventions aimed at improving the health behavior change target of medication adherence. The goals of this review were to (1) examine and describe evidence and gaps in the literature for telephonically delivered MI interventions for medication adherence and (2) discuss the implications of the findings for research and practice. The MEDLINE, CINAHL, psycINFO, psycARTICLES, Academic Search Premier, Alt HealthWatch, Health Source: Consumer Edition, and Health Source: Nursing/Academic Edition databases were searched for peer-reviewed research publications between 1991 and October 2012. A total of nine articles were retained for review. The quality of the studies and the interventions varied significantly, which precluded making definitive conclusions but findings among a majority of retained studies suggest that telephone-based MI may help improve medication adherence. The included studies provided promising results and justification for continued exploration in the provision of MI via telephone encounters. Future research is needed to address gaps in the current literature but the results suggest that MI may be an efficient option for healthcare professionals seeking an evidence-based method to reach remote or inaccessible patients to help them improve their medication adherence.

Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review.

OBJECTIVES The management of type 2 diabetes (T2D) requires complex behavior changes and treatment regimens to achieve optimal outcomes. Interventions including motivational interviewing (MI) have been explored to help patients achieve behavior change and outcomes; this study aimed to explore evidence and gaps in the literature for MI interventions and outcomes in adults with T2D. METHODS A modified Cochrane method structured the search strategy among databases including MEDLINE, CINAHL, PsycINFO, and others. Inclusion criteria included randomized controlled trials that assessed the effects of MI on behavior changeoutcomes and resultant clinical outcomes in adults with T2D. RESULTS Of the initial 159 studies identified, 14 were eligible for retention. Behavior targets in the retained studies included dietary changes, physical activity, smoking cessation, and alcohol reduction. MI had significant impact on some dietary behaviors and on weight loss. MI intervention structures were heterogeneous across studies; fidelity assessment was infrequent. CONCLUSION The effects of MI interventions on outcomes in T2D showed promising results for dietary behaviors. Clinical change outcomes from MI-based interventions were most favorable for weight management in T2D. PRACTICE IMPLICATIONS Behavior-specific MI interventions may positively influence study outcomes. Assessment of MI intervention fidelity will enhance treatment integrity and claims for validity.

Health-Related Quality of Life and Quality of Life in Type 2 Diabetes

AbstractBackground and objectives: Health-related quality of life (HR-QOL) and quality of life (QOL) are increasingly being examined as outcomes in assessments among patients with type 2 diabetes mellitus. However, there is a lack of standardization in interpreting the two outcomes and insufficient appreciation of the differences between HR-QOL and QOL. This study reports relationships between two instruments of HR-QOL and an instrument of QOL in a cross-sectional study of patients with type 2 diabetes. Methods: Patients with type 2 diabetes at the outpatient clinics of a university hospital completed measures of generic health status (12-item Short-Form Health Survey [SF-12], version 2 and EQ-5D) and diabetes-specific QOL (Audit of Diabetes Dependent Quality of Life [ADDQoL]). Patient-reported data were merged with retrospective clinical data including glycosylated hemoglobin (HbA1c), co-morbidities, diabetes complications score, body mass index (BMI), and others, obtained from electronic medical records. A path model of our hypothesized relationships between the physical and psychological components of HR-QOL, overall HR-QOL, and QOL was tested in addition to examining bivariate correlations between these constructs. The fit of the path model was assessed using multiple indexes of fit, including an overall chi-squared (χ2) test, the Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), and the Root Mean Square Error Approximation (RMSEA). The differences in the association between clinical, medical history and sociodemographic variables with HR-QOL and QOL were explored employing univariate t-tests and ANOVAs as well as multiple regression models. Results: The usable response rate was 44.3% (n = 385). The mean HbA1c of respondents was 7.2% (±1.4), mean duration of diabetes was 10.2 (±9.1) years, and 62.1% were obese (BMI ≥30kg/m2). About 49% of respondents were taking oral medications only, 31.7% were taking oral medications and insulin, and 9.4% were taking insulin only. Spearman correlations of the EQ-5Dindex were 0.640 with the SF Physical Component Score (PCS)-12, 0.534 with the SF Mental Component Score (MCS)-12, and 0.316 with the ADDQoL (all p<0.001). A path analytic model relating SF-12 scores with EQ-5Dindex and ADDQoL scores exhibited good fit (χ2 = 1.32; p = 0.250; CFI = 0.99; TLI = 0.99; RMSEA = 0.03). Insulin use and diabetes-related complications were significantly associated with poorer scores on all measures. Only ADDQoL scores were significantly better among those with the American Diabetes Association-recommended HbA1c level of <7.0% (p = 0.002). Obesity was significantly associated with impaired SF-12 and EQ-5Dindex scores but not ADDQoL scores, while depressive symptoms were significantly associated with poorer scores on all these measures. The included explanatory variables explained a greater proportion of the variance in HR-QOL (PCS-12, MCS-12, EQ-5Dindex) than in QOL (ADDQoL) scores. Conclusion: The study found that HR-QOL measures showed small correlations with the impact of diabetes on QOL. The fit statistics supported the hypothesized relationships in the path model, and provided empirical evidence that HR-QOL is a subset of QOL. In comparison to HR-QOL, QOL was less explained by the included explanatory variables, suggesting a greater influence on QOL by factors not accounted for in the present study.

A Nontraditional Faculty Development Initiative Using a Social Media Platform

Objective. To assess the outcomes from an 11-year nontraditional professional development activity implemented by female faculty members at several colleges and schools of pharmacy. Design. Within the context of an online fantasy football league, faculty members practiced community-based faculty development strategies, including peer mentoring, skills development, constructive feedback and other supportive behaviors. Assessment. Data were extracted from curriculum vitae to characterize the academic progress of participants and to quantify scholarly work collaborations among league members. Analyses were limited to members who had participated in the league for 10 or more consecutive years. Seventy-one collaborative scholarly works occurred among team managers, including presentation of 20 posters and 2 oral presentations at national or international meetings, publication of 29 peer-reviewed articles and 15 book chapters, and funding of 5 research projects. Conclusion. Social media platforms can foster nontraditional faculty development and mentoring by enhancing connectivity between pharmacy educators who share similar interests.

Interventions for adherence with oral chemotherapy in hematological malignancies: A systematic review

BACKGROUND Poor adherence to treatment for chronic diseases including some hematological malignancies impedes health outcomes and increases costs. Oral chemotherapy is an emerging trend that raises concern about nonadherence problems in these targeted patients. OBJECTIVES This systematic literature review explores evidence and gaps in the literature regarding interventions to enhance adherence with prescribed oral chemotherapy in patients with hematological malignancies. METHODS Searches of databases and abstracts from conferences were performed for 1987 to January 2013 using a modified Cochrane method. Studies measuring interventions to improve adherence alone or together with clinical, humanistic, and economic outcomes were included. Assessment of methodological quality was performed for each retained study. RESULTS The literature search generated 6 studies that met inclusion criteria. Four of these reported a statistically significant increase in the adherence outcome, compared with baseline. Tailored and educational interventions were widely used among the retained studies. Post-intervention adherence rates were 41-96.1%; intervention groups yielded higher rates than comparison groups. Two studies reported statistically significant improvement in clinical outcomes (cytogenetic response and survival time). One study reported that severity of illness was associated with survival time but not with adherence. Studies that used both tailored and educational interventions showed significant relationship between adherence and clinical outcomes; however, the study that used dosage simplification did not. None of the studies explored humanistic or economic outcomes. CONCLUSIONS Interventions to improve adherence with oral chemotherapies in hematological malignancies remain limited. Though they were heterogeneous in nature, interventions tested in the retained studies suggested a positive impact on the adherence outcome; some established a significant relationship between adherence and clinical outcomes. The results yielded limited evidences regarding characteristics of a specific intervention, but supported a general structure for methods to improve adherence and other outcomes in real-life settings. Further rigorous methodological studies are needed to fully examine impact on adherence and clinical outcomes.

Effects of pill burden on discontinuation of the initial HAART regimen in minority female patients prescribed 1 pill/day versus any other pill burden

Highly active antiretroviral therapy (HAART) is a mainstay of treatment for patients with Human Immunodeficiency Virus (HIV). Since second line HAART therapies can be costlier and less effective, it is essential to understand the duration of initial HAART therapies. The overall aim of this study was to estimate the effects of daily pill burden on the time to discontinuation of the initial HAART regimen. Patients were initially identified through the clinics CAREWARE database. A chart review was conducted for data collection, where only adult, female, HIV-positive patients initiating therapy at the study clinic between 1 January 2001 and 31 December 2011 were included. All study subjects were followed up from the initiation of HAART to treatment discontinuation. A Kaplan–Meier curve was generated to describe time to discontinuation by regimens, and a Cox proportional hazards model was developed to assess the impact of different regimen and patient demographic characteristics on the hazard of discontinuation of the initial regimen. A total of 498 charts were initially reviewed. After assessment of these patients for inclusion criteria, a cohort of 115 adult female patients who initiated HAART at the study clinic was included. Patients treated with 1 pill/day regimen had a significantly longer time to discontinuation than regimens of >1 pills/day (mean duration of initial therapy was 1062.56 days vs. 631.70 days, respectively, p = 0.003). Compared to 1 pill/day regimens, >1 pills/day regimens were associated with a higher hazard of discontinuation (hazard ratio (HR) =3.44 with 95% confidence interval (CI) = 1.25, 9.48). A higher viral load and patients without insurance were also found to be significantly associated with increased hazards of discontinuation. Overall, female HIV patients initiating therapy with the 1 pill/day HAART regimen were less likely to discontinue their treatment compared to patients initiating with >1 pills/day HAART regimen.

Impact of Visual Impairment on Health-Related Quality of Life in Multiple Sclerosis

The aim of this study was to evaluate the impact of visual impairment on health-related quality of life (HRQOL) in patients with multiple sclerosis (MS). Patients at an outpatient MS clinic were as...

The impact of motivational interviewing on adherence and symptom severity in adolescents and young adults with chronic illness: A systematic review

OBJECTIVE Given the negative consequences associated with non-adherence in adolescents and young adults (AYAs) with chronic illness, it is important to identify interventions to address this issue. Therefore, this reviews primary objective is to evaluate the impact of motivational interviewing (MI) on adherence and symptom level/severity in AYAs with chronic illness using a modified Cochrane method. METHOD Four databases (e.g., CINAHL, Medline, PsychINFO, and International Pharmaceutical Abstracts) were systematically reviewed. 121 articles were identified in the initial search. Article eligibility was assessed on two tiers using the inclusion criteria. RESULTS Twelve articles were retained for data extraction. Diabetes, asthma, and HIV were the most common chronic illness populations examined in the study. Eleven of the twelve articles provided support for either improved adherence, symptom reduction, or a combination of both after participants received MI. Quality of life was also enhanced in three studies. CONCLUSION Because adherence and symptom levels were positively impacted, it appears that MI may be a promising intervention for AYAs with chronic illness in addressing non-adherence and potentially improving quality of life. PRACTICE IMPLICATIONS Healthcare providers should consider implementing MI in their practice to establish rapport and potentially improve long-term health outcomes for AYAs with chronic illness.