The need for a paradigm shift in adherence research: The case of ADHD

Nonadherence to long-term medications attenuates optimum health outcomes. There is an abundance of research on measuring and identifying factors affecting medication adherence in a range of chronic medical conditions. However, there is a lack of standardisation in adherence research, namely in the methods and measures used. In the case of attention deficit hyperactivity disorder, this lack of standardisation makes it difficult to compare and combine findings and to draw meaningful conclusions. Standardisation should commence with a universally accepted categorisation or taxonomy of adherence which takes into consideration the dynamic nature of medication-taking. This should then be followed by the use of valid and reliable measures of adherence which can accurately quantify adherence at any of its phases, and provide useful information which can be utilised in planning targeted interventions to improve adherence throughout the patient medication-taking journey.     

Long-term adherence to nasal continuous positive airway pressure therapy by hypertensive patients with preexisting sleep apnea

Background and objectiveAlthough positive screening for and treatment of obstructive sleep apnea (OSA) have been recommended for patients with cardiovascular problems, patient adherence to nasal continuous positive airway pressure (CPAP) therapy primarily for a cardiovascular concern is unknown. Therefore, this study aimed to determine the adherence to CPAP therapy by hypertensive patients with OSA after a screening test performed regardless of OSA-related symptoms.Subjects and methodsCPAP therapy was administered to 194 of the 1365 hypertensive patients who underwent the screening. The monthly dropout from CPAP therapy and the adequate use level (4 h every night, 70% days in a month) were assessed using the Kaplan–Meier analysis over a 3-year follow-up period.ResultsOf the patients, 106 (55%) refused or abandoned the therapy by the end of the follow-up period (adherence, 45%). An adequate use level was maintained by 76 patients (39%). Most of the patients’ background characteristics, including age, sex, Epworth sleepiness scale scores, and parameters obtained on polysomnography, were not related to adherence or adequate use level. The good-compliance level on the first visit after CPAP therapy introduction was most strongly related to adherence (95% CI, 0.05–0.32; p < 0.001) and adequate use level (95% CI, 0.06–0.33; p < 0.05). Fourth quartile of apnea hypopnea index value (greater than 67/h) was also related to adherence (95% CI, 0.21–0.98; p < 0.02) and adequate use level (95% CI, 0.19–0.88; p < 0.05).ConclusionsThe adherence and use level in this population may not be satisfactory but are comparable with those in previous sleep center reports treating symptomatic OSA patients. Thus, the present results would encourage hypertensive patients to undergo positive screening for OSA, regardless of OSA-related symptoms. However, an outcomes study with the same cohort is needed.     

Adherence profiles in kidney transplant patients: Causes and consequences

Objective: Adherence is a dynamic phenomenon and a critical determinant of transplant patients outcome. The objective of this longitudinal study was to explore adherence in kidney transplant patients followed-up for up to three years after transplantation.Methods: Adherence was repeatedly estimated using the Morisky-Green-Levine 4-Item Medication Adherence Scale, in two successive cohorts of 345 (EPIGREN) and 367 (EPHEGREN) kidney transplant recipients. Mixed effect modeling with latent processes and latent classes was used to describe adherence time-profiles.Results: Two latent classes were identified. The adherent class represented 85% of the patients. Patients of the poorer-adherence class displayed a lower adherence at one month (p<10⁻³), which worsened over time. Good adherence was associated with age >50 years, fewer depression episodes (5% vs. 13%, p = 0.001) and a better mental health component of quality of life (MCS-SF36 47 ± 11 vs. 41 ± 13, p = 0.015). Survival without acute rejection episodes was longer in the adherent class (p = 0.004).Conclusions: The risk of poor adherence in renal transplant patients can be detected as early as one month post-transplantation, using appropriate and easy tools adapted to routine monitoring.Practice Implications: An early focus on vulnerable patients should allow putting into place actions in order to reduce the risk of poor outcome related to poor adherence.     

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

ObjectivesThe growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.MethodsTo describe methodological features of quantitative studies concerning older adults’ medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.Results55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.ConclusionsFuture studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.Practice implicationsTheoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.     

Effects of Dietary Self-Monitoring,Physical Activity,Liraglutide 3.0 mg,and Placebo on Weight Loss in the SCALE IBT Trial

IntroductionIndividuals who enroll in intensive behavioral therapy (IBT) programs are asked to make several lifestyle changes simultaneously. However, few studies have examined the relative effects of adherence to different treatment components on weight loss.ObjectiveThis secondary analysis of the SCALE IBT trial assessed adherence to the medication regimen, dietary self-monitoring, and physical activity recommendations and their relative contributions to weight change in individuals with obesity who were provided with IBT combined with either liraglutide 3.0 mg or placebo.MethodsSCALE IBT was a double-blinded, multicenter, randomized controlled trial comparing 56-week weight losses in individuals with obesity who received liraglutide 3.0 mg (n = 142) or placebo (n = 140), as an adjunct to IBT. Adherence to dietary self-monitoring, physical activity, and medication usage (liraglutide or placebo) were measured during the 56-week treatment period. A regression model was used to estimate the relative contribution of adherence to each treatment component to weight loss at week 56.ResultsThe proportion of individuals who adhered to each intervention component decreased over time. Compared with non-adherence, complete adherence to dietary self-monitoring and physical activity recommendations were associated with estimated weight changes of −7.2% (95% CI −10.4 to −4.0; p < 0.0001) and −2.0% (95% CI −3.2 to −0.8; p = 0.0009), respectively. Complete adherence to liraglutide predicted an additional weight loss of −6.5% (95% CI −10.2 to −2.9; p = 0.0005) relative to individuals who did not adhere to the medication regimen, while adherence to placebo did not have a statistically significant effect on weight loss (p = 0.33).ConclusionsHigh adherence to dietary self-monitoring and use of liraglutide 3.0 mg was associated with clinically relevant weight loss with IBT and adjunctive pharmacotherapy. The effect of adherence to physical activity was significant but smaller.     

Adhesion of Candida tropicalis to polystyrene and epithelial cell lines: Insights of correlation of the extent of adherent yeast cells among distinct surfaces

Candida tropicalis is an emerging fungal pathogen associated with high mortality. We aimed to compare adherence capability of C. tropicalis to polystyrene and epithelial cell lines (HeLa and Vero), and determine whether adherent blastoconidia is cell-type specific. Blastoconidia adhesion to epithelial cells and polystyrene were determined by crystal violet assay. The percentage of epithelial cells with adhered blastoconidia and the number of adhered blastoconidia per cell line were determined by light microscopy. The correlation between adhesion surfaces was assessed by Pearson's correlation coefficient. The adhesiveness of C. tropicalis to polystyrene was greater than that observed for ephitelial cells. High correlation values (r² 0.9999222, p 0.007941) were found for the adhesion capability between biotic and polystyrene surface for isolates 100.10 (obtained from blood) and 335.07 (obtained from tracheal secretion). The number of adherent blastoconidia per HeLa cell was greater in comparison to that observed for Vero cells (P < 0.05). Further, high correlation (r² 1, p 0.0001) was found for the adhesion ability between HeLa cells and Vero cells. The results suggest a correlation of C. tropicalis adhesion capability among different surfaces, and that the adhesion to epithelial cells is specific to the cell type.     

Opportunistic fungal infections in persons living with advanced HIV disease in Lagos,Nigeria; a 12-year retrospective study

IntroductionNigeria has a large estimated burden of AIDS-related mycoses. We aimed to determine the proportion of patients with AIDS-related opportunistic fungal infections (OFIs) at an urban antiretroviral treatment (ART) centre in Nigeria.MethodsA retrospective analysis of a cohort of ART-naïve, HIV-infected patients, assessed for ART eligibility and ARTexperience at the PEPFAR outpatient clinic at Lagos University Teaching Hospital over a 12-year period (April 2004-February 2016) was conducted.ResultsDuring this period, 7,034 patients visited the clinic: 4,797 (68.2%) were female; 6161 patients had a recorded baseline CD4 count, and the median CD4 count was 184 cells/µl (IQR, 84–328). A baseline HIV-1 viral load (VL) was recorded for 5,908 patients; the median VL was 51,194 RNA copies/ml (IQR, 2,316–283,508) and 6,179/7046(88%) had initiated ART. Some 2,456 (34.9%) had a documented opportunistic infections, of whom 1,306 (18.6%) had an opportunistic fungal infection. The total number of OFI episodes was 1,632: oral candidiasis (n=1,473, 90.3%), oesophageal candidiasis (n=118; 8%), superficial mycoses (n=23; 1.6%), Pneumocystis pneumonia (PJP) (n=13; 0.8%), and cryptococcal meningitis(CM) (n=5; 0.4%). 113 (1.6%) were known to have died in the cohort.ConclusionApproximately 1 in 5 HIV-infected patients in this retrospective cohort, most of whom had initiated ART, were clinically diagnosed with an OFI. Improved access to simple accurate diagnostic tests for CM and PJP should be prioritised for this setting.     

Participation and outcome in manualized self-help for bulimia nervosa and binge eating disorder — A systematic review and metaregression analysis

There is a growing body of research on manualized self-help interventions for bulimia nervosa (BN) and binge eating disorder (BED). Study and treatment dropout and adherence represent particular challenges in these studies. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes are lacking. We conducted a systematic literature review using electronic databases and hand searches of relevant journals. In metaregression analyses, we analyzed study dropout as well as more specific measures of treatment participation in manualized self-help interventions, their association with intervention characteristics (e.g. duration, guidance, intervention type [bibliotherapy, CD-ROM or Internet based intervention]) and their association with treatment outcomes. Seventy-three publications reporting on 50 different trials of manualized self-help interventions for binge eating and bulimia nervosa published through July 9th 2012 were identified. Across studies, dropout rates ranged from 1% to 88%. Study dropout rates were highest in CD-ROM interventions and lowest in Internet-based interventions. They were higher in samples of BN patients, samples of patients with higher degrees of dietary restraint at baseline, lower age, and lower body mass index. Between 6% and 88% of patients completed the intervention to which they had been assigned. None of the patient, study and intervention characteristics predicted intervention completion rates. Intervention outcomes were moderated by the provision of personal guidance by a health professional, the number of guidance sessions as well as participants' age, BMI, and eating disorder related attitudes (Restraint, Eating, Weight and Shape Concerns) at baseline (after adjusting for study dropout and intervention completion rates). Guidance particularly improved adherence and outcomes in samples of patients with bulimia nervosa; specialist guidance led to higher intervention completion rates and larger intervention effects on some outcomes than non-specialist guidance. Self-help interventions have a place in the treatment of BN and BED, especially if the features of their delivery and indications are considered carefully. To better determine who benefits most from what kind and “dosage” of self-help interventions, we recommend the use of consistent terminology as well as uniform standards for reporting adherence and participation in future self-help trials.     

Impact of adherence to surgical and non-surgical components of infective endocarditis guidelines and recommendations

BackgroundInfective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes.AimTo assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis.MethodsA single centre, retrospective cohort study.ResultsAmongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07–5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60–8.47]) were significantly associated with an adverse outcome.ConclusionsOur data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes.