Niraj Mistry

Technology-mediated interventions for enhancing medication adherence.

BACKGROUND Despite effective therapies for many conditions, patients find it difficult to adhere to prescribed treatments. Technology-mediated interventions (TMIs) are increasingly being used with the hope of improving adherence. OBJECTIVE To assess the effects of TMI, intended to enhance patient adherence to prescribed medications, on both medication adherence and clinical outcomes. METHODS A secondary in-depth analysis was conducted of the subset of studies that utilized technology in at least one component of the intervention from an updated Cochrane review on all interventions for enhancing medication adherence. We included studies that clearly described an information and communication technology or medical device as the sole or major component of the adherence intervention. RESULTS Thirty-eight studies were eligible for in-depth review. Only seven had a low risk of bias for study design features, primary adherence, and clinical outcomes. Eighteen studies used a TMI for education and/or counseling, 11 studies used a TMI for self-monitoring and/or feedback, and nine studies used electronic reminders. Studies used a variety of TMIs, with telephone the most common technology in use. Studies targeted a wide distribution of diseases and used a variety of adherence and clinical outcome measures. A minority targeted children and adolescents. Fourteen studies reported significant effects in both adherence and clinical outcome measures. CONCLUSIONS This review provides evidence for the inconsistent effectiveness of TMI for medication adherence and clinical outcomes. These results must be interpreted with caution due to a lack of high-quality studies.

Text messages for influenza vaccination among pregnant women: A randomized controlled trial

OBJECTIVE To evaluate if text message reminders increase the likelihood of receiving the influenza vaccine among pregnant women. METHODS Pregnant women were randomized to either receive or not receive weekly text messages. Women were told the messages would be about health-related behavior in pregnancy. Those randomized to the intervention group received two messages weekly for four consecutive weeks reinforcing that the influenza vaccine is recommended for all pregnant women and safe during pregnancy and breastfeeding. Women were contacted six weeks postpartum to determine if they had received the vaccine. Sample size calculation determined that 108 women were required in both groups to see a 75% increase in vaccination rates over baseline in the text message group compared to the control group. RESULTS Recruitment began November 4, 2013, and 317 women were randomized. The mean gestational age at recruitment was 22weeks. There were 40/129 (31%) women in the text message group and 41/152 (27%) women in the control group who received the vaccine (p=0.51). Significant predictors of vaccine acceptance were being married compared to single (95% vs. 67%, p<0.001), having higher household income (55% vs. 39%, p=0.03) and having received the vaccine before (77% vs. 36%, p<0.001). Among women receiving text messages, the majority were satisfied, with only 15/129 (12%) reporting that they did not like receiving the messages, and 24/129 (19%) stating that the information in the messages was not helpful. CONCLUSION Weekly text messages reinforcing the recommendation for and safety of the influenza vaccine in pregnancy did not increase the likelihood of actually receiving the vaccine among pregnant women. Overall vaccination rates were low, highlighting the need for patient education and innovative techniques to improve vaccine acceptance. Registered with ClinicalTrials.gov at http://www.clinicaltrials.gov, registration number NCT 02428738.

Family fIRST, an Interactive Risk Screening Tool for Families in a School-Based Pediatric Clinic A Look at Feasibility and Pilot Data

The purpose of this study was to create a tablet-based, social history screening tool called Family fIRST and evaluate its feasibility and usability in a school-based medical clinic. A mixed methods study design was used to examine quantitative and qualitative outcomes of a survey and semi-structured interview completed by families and physicians. The majority (87%) found the survey easy to understand. Themes for improvement included more free-form space and increased sensitivity around question wording. Clinic physicians felt Family fIRST increased discussion around social history and suggested the tool should help link to suggested resources. Demographic results showed that 12 of 29 (43%) parents had income less than

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study

15 000 and 19 of 29 (65%) were unemployed. Family fIRST was a well-received and feasible tool to implement at the school-based medical clinic. Preliminary results show that families attending the clinic have increased prevalence of negative determinants of health; social history should therefore represent a key area of focus at the medical visit in order to optimize clinic support of families.

Mobile Text Messaging and Adherence of Patients to Medication Prescriptions: A txt a dA keeps da doctR awA?

BACKGROUND Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Childrens Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Childrens Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

A critical review of recent clinical practice guidelines for pediatric urinary tract infection

Low patientmedication adherence is one of the 2 largest unsolved gaps in health care, with the other being suboptimal therapyprescription. For example, oral anticoagulation (OAC) is firmlyrecommended inpatientswithatrial fibrillationathigh risk for stroke, but typically about half of the eligible patients donot receiveOAC.1Of those patients who receive OAC, approximately half will not begin therapy or will stop therapy within a year,2 and of those patients persisting with an OAC regimen, only half take their pills consistently as prescribed.3As a consequence,most patientswill not reap the full health benefits fromproven therapies such asOAC. There is rising interest inmedication adherence research,4 but these well-meaning efforts have not yet led to substantial and reliable adherence improvements when looking at the entire adherence research field. Are we perhaps missing the signal of specific interventions? In this issueof JAMAInternalMedicine, Thakkar et al5 provideafocusedandthoroughmeta-analysisof randomizedclinical trials that aimed to improve medication adherence in patients with chronic disease by the specific means of mobile telephone textmessaging (TM), amongwhom they observed adoubling of the relative odds of improving adherence. Technology-mediated interventions are logical candidates for innovations inadherenceresearch,especially if theyareaswidely used as mobile telephones. Research testing new technologies naturally lags behind the introduction and uptake of the technology,6 which is why most of the included randomized clinical trialswerepublished in thepast 5years, renderingmobile telephone TM the “new kid on the block.” The kid has shown potential, but—as Thakkar et al5 indicate—caution is warrantedwhen interpreting the results.Most studieshad fundamental methodological weaknesses that are common in medication adherence research to date,7 and several of these shortcomings are lethal to the case of whether TM interventions areworth the effort and resources required to create and conduct them. First, did the pooled studies truly show an improvement in adherence for chronic disease? Most studies used selfreport to measure adherence, but self-report typically overestimatesadherence,especially inunmaskedtrialsas theserandomized clinical trialswere.Unobtrusivemeasurements such as pharmacy claims data would be more objective and accurate. Furthermore, lasting effects are crucial for chronic disease, but these studies had amedian interventionduration of only 12 weeks, and no study reported on adherence beyond the active intervention period. Second, and even more important, measuring a clinical outcome could assess whether the adherence improvement translated into benefits important to the patient, but the randomized clinical trials in the meta-analysis by Thakkar et al5 did not measure such outcomes, nor would it have been feasible to do so in these small and short-term studies. Therefore, TM has not been subjected to the acid test of whether it makes a clinically useful difference. Third, because the meta-analysis focused on one type of intervention, the authors chose to conveniently pool the results using standardized effect sizes, but it is hard to ignore the many differences among the studies. The substantial statistical heterogeneity (I2 = 62%) across the included clinical trials reflects obvious differences in the following characteristics: (1) The clinical conditions varied, with some patients requiring chronic daily lifelong treatment (eg, for human immunodeficiency virus) vs intermittent or seasonal treatment (eg, for allergic rhinitis) vs treatments that are typically required in the long term but may be discontinued after clinical remission (eg, in the case of epilepsy). (2) The medication regimens used differed, including the timing and frequency of intake, absence of noticeable benefits (eg, blood pressure lowering), severity of adverse effects, and route of administration. (3) Different adherence outcomes were used, including self-report, pill count, medication event monitoring systems, and pharmacy dispensing data, reported as continuous measures or dichotomous measures, with cutoffs for good adherence ranging from 80% to 95%. Adding to the adherence outcome heterogeneity is the large variation in follow-up time, and the absence of (or ambiguity about using) intent-to-treat analyses in half of the studies. (4) There was variation in baseline adherence, with only 2 studies using low baseline adherence as an eligibility criterion. Failure to focus on those patients who can benefit from interventions minimizes the effect sizes that can be observed, limits the power of studies to detect differences, and wastes resources. (5) The study settings differed, with a wide variety represented—from hospitals in Africa (9 of the studies were set in developing countries) to the general population in Denmark—indicating substantive differences in cultures, languages, resources, health services, priorities, and personal finances. (6) The intervention design varied, such that different TM approaches were used, with various message frequencies, timing, content, framing, degree of personalization, ability for patients to respond, and degree of automation. These issues of heterogeneity might be mitigated by distinguishing studies based on methodological rigor and relRelated article page 340 Research Original Investigation Text Messaging for Medication Adherence in Chronic Disease

Investigating the social organization of family health work: an institutional ethnography

INTRODUCTION Concerns regarding the quality, credibility, and applicability of recently published pediatric urinary tract infection (UTI) clinical practice guidelines have been raised due to the inconsistencies of recommendations between them. We aimed to determine the quality of the recent clinical practice guidelines on pediatric UTI by using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument, and summarize the standard of care in diagnosis and management of pediatric UTI from the top three clinical practice guidelines. METHODS A systematic literature search was performed on medical literature electronic databases and international guideline repository websites. English language-based clinical practice guidelines from 2007-2016 endorsed by any international society or government organization providing recommendations for the management of pediatric UTI were considered. Eligible clinical practice guidelines were independently appraised by six reviewers using the AGREE II tool. Clinical practice guidelines were assessed for standardized domains and summarized for overall quality. Inter-rater reliability was assessed using inter-class coefficient (ICC). RESULTS Thirteen clinical practice guidelines were critically reviewed. The Spanish clinical practice guidelines, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence clinical practice guidelines consistently scored high on all AGREE domains (total averaged domain scores 90, 88, and 88, respectively). Among the six reviewers, there was a high degree of inter-rater reliability (average measure ICC 0.938; p<0.0001). There is reasonable consensus among the top three clinical practice guidelines in their major recommendations. CONCLUSIONS The clinical practice guidelines from Spain, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence, with their major recommendations being similar, have scored highly on the AGREE II indicators of quality for the clinical practice guidelines development process.

Interventions for enhancing medication adherence

Abstract This article reports findings from focus group conversations and in-depth interviews about the things that parents do to take care of their children’s health in Toronto, Canada. Our data demonstrate that within a single urban setting, parents are differently positioned to effectively find and engage existing healthcare resources. Parents’ ‘family health work’ is shaped by systemic expectations for health and institutional literacy and inter-institutional navigation skills that not all parents possess in equal measure. The intensive focus in Ontario paediatric healthcare settings on patient and parent education suggests increased interest in cultivating autonomous health information seeking and use strategies among parents. But the degree to which parents’ health-information seeking and use strategies are deemed effective depends on whether they are able to construct coherence between what they know about their child’s health and how to take care of it, and the knowledge the medical system requires to support diagnosis and treatment. Our research suggests that the healthcare system is only interested in information-seeking autonomy insofar as it supports patients’ engagement with the systems’ existing practices, frames of validity and service pathways. People who are unable to demonstrate health knowledge and work that support existing systemic processes cannot effectively use what they know and do to support their children’s health and wellness.