Leah L. Zullig

Ingredients of Successful Interventions to Improve Medication Adherence

Nonadherence to prescription medication is common and costly.1 On average, 50% of medications for chronic diseases are not taken as prescribed.2 Medication nonadherence is widespread, and accountability for this issue is shared by patients, their caregivers, clinicians, and the health care system as a whole. Furthermore, there is an increasing business case for addressing medication nonadherence; as payment and delivery system models evolve to place health care organizations and clinicians at risk for patientoutcomesanddownstreamcosts(eg,bundledpayments and accountable care organizations), interest in coordinationofcareandinventionofdurabletreatmentscontinues to increase. Because the problem of nonadherence is often multifactorial, effective programs to improve medication adherence need to adopt comprehensive approaches, often involving several proven strategies. Several evidence reviews have identified interventions effective in promoting both overall and condition-specific medication adherence.3-5 Although no universal formula will improve medication adherence in all settings, several ingredients areessentialforanywell-designedinterventionforimproving medication adherence. These ingredients include improving patients’ understanding of their treatments; providing counseling and accountability; ensuring that there are tools and strategies to assist patient self-monitoring; and increasing access to affordable medications.

Patient-Oncologist Cost Communication, Financial Distress, and Medication Adherence

BACKGROUND Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care. METHODS We surveyed insured adults receiving anticancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication nonadherence was defined as skipping doses or taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions because of cost. Multivariable analysis assessed the association between nonadherence and cost discussions. RESULTS Among 300 respondents (86% response), 16% (n = 49) reported high or overwhelming financial distress. Nineteen percent (n = 56) reported talking to their oncologist about cost. Twenty-seven percent (n = 77) reported medication nonadherence. To make a prescription last longer, 14% (n = 42) skipped medication doses, and 11% (n = 33) took less medication than prescribed; 22% (n = 66) did not fill a prescription because of cost. Five percent (n = 14) reported chemotherapy nonadherence. To make a prescription last longer, 1% (n = 3) skipped chemotherapy doses, and 2% (n = 5) took less chemotherapy; 3% (n = 10) did not fill a chemotherapy prescription because of cost. In adjusted analyses, cost discussion (odds ratio [OR] = 2.58; 95% CI, 1.14 to 5.85; P = .02), financial distress (OR = 1.64, 95% CI, 1.38 to 1.96; P < .001) and higher financial burden than expected (OR = 2.89; 95% CI, 1.41 to 5.89; P < .01) were associated with increased odds of nonadherence. CONCLUSION Patient-oncologist cost communication and financial distress were associated with medication nonadherence, suggesting that cost discussions are important for patients forced to make cost-related behavior alterations. Future research should examine the timing, content, and quality of cost-discussions.

Stigma, perceived blame, self‐blame, and depressive symptoms in men with colorectal cancer

We measured the prevalence of stigma, self‐blame, and perceived blame from others for their illness among men with colorectal cancer (CRC) and examined whether these factors were associated with depressive symptoms, independent of clinical and sociodemographic factors.

Developing and Sustaining Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative

ObjectiveThe Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care.MethodsIn the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance–the Colorectal Cancer Care Collaborative (C4).ResultsWe describe the process and thinking that led to two parallel quality improvement “collaboratives” that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions.ConclusionWe conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Quality of Nonmetastatic Colorectal Cancer Care in the Department of Veterans Affairs

PURPOSE The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators). PATIENTS AND METHODS A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated. RESULTS More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.8 [corrected] days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.2 [corrected] days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease). CONCLUSION Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

Improving Colorectal Cancer Screening and Care in the Veterans Affairs Healthcare System

The Veterans Health Administration (VHA) has recently launched several nationwide initiatives to improve the quality of its colorectal cancer (CRC) screening and care. The timeliness of follow-up diagnostic tests in patients who have positive noncolonoscopic CRC screening tests is one of the target areas of these initiatives. Multiple aspects of colon cancer care are being monitored, and the degree of adherence to accepted quality measures is being assessed. The purpose of this review is to describe the background leading to these initiatives and their expected impact on CRC screening and management in the VHA.

Comparison of adverse events during 5‐fluorouracil versus 5‐fluorouracil/oxaliplatin adjuvant chemotherapy for stage III colon cancer

In clinical trials, combined 5‐fluorouracil (5FU) plus oxaliplatin improves the survival of patients who have resected, stage III colon cancer with manageable toxicity. However, the tolerability of this in the general population of patients with colon cancer is uncertain.

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems

BackgroundStage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis.MethodsTwo distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003–2007. We assessed metastatic CRC patients treated from 2003–2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression.Results342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58–1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82–1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race.ConclusionHigher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer

The authors found that cost-related medication nonadherence was prevalent among patients with cancer who sought financial assistance.

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.