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PubMedDate not supplied

Adherence to the therapeutic regimen in heart, lung, and heart-lung transplant recipients.

Optimal outcome after heart, lung, and heart-lung transplantation can only be obtained if patients are supported in adhering to a lifelong therapeutic regimen. The transplant patient's therapeutic regimen consists of a lifelong medication regimen, including immunosuppressive drugs; monitoring for signs and symptoms related to complications; avoidance of risk factors for cardiovascular disease and cancer (ie, diet and exercise prescriptions, nonsmoking); avoidance of abuse/dependence of alcohol or illegal drugs, as well as attending regular clinical checkups. Nonadherence to all aspects of this regimen is substantial. Nonadherence has been related to negative clinical outcome in view of acute rejections, graft vasculopathy, higher costs, and mortality. This review focuses on the prevalence, correlates, and consequences of nonadherence to the therapeutic regimen in heart, lung, and heart-lung transplantation. The current state of the-art on adherence-enhancing interventions is reported. Priorities for future research are outlined.

Aftercare↗
PubMed2006

Prospective analysis of nonadherence in autoimmune hepatitis: a common problem.

OBJECTIVES: To prospectively assess nonadherence to medications, the relationship between nonadherence and medical outcome and the relationship between a psychiatric risk factor (posttraumatic stress) and nonadherence in patients with a diagnosis of autoimmune hepatitis. PATIENTS AND METHODS: Data were obtained in children with autoimmune hepatitis, who had consented to prospective monitoring of adherence, during 1 year of follow-up in our pediatric liver program. An electronic monitoring device as well as posttransplant trough blood levels of tacrolimus was used to evaluate adherence. A validated self-report questionnaire was used to assess posttraumatic stress. The medical outcome measure was the maximal alanine transaminase (ALT) for each monitored patient. RESULTS: Of 37 pediatric patients, 34 (15 posttransplant) enrolled. Fourteen (41%) used the monitoring device as directed. Monitor readings ranged between 28% and 94% of optimal adherence (100%). No patient took the medications exactly as prescribed. Electronic monitoring device readings correlated inversely with maximal ALT (P = 0.03, r = -0.59), and were also correlated with the tacrolimus level variability as a measure of adherence (P = 0.04, r = -0.72). Posttraumatic stress disorder questionnaire scores were correlated with both measures of adherence (for electronic monitoring, P = 0.02, r = -0.70, for tacrolimus levels, P = 0.03, r = 0.62). CONCLUSIONS: Nonadherence to immunosuppressants was common in this cohort, and it correlated with higher maximal ALT. Nonadherence is therefore an important risk factor for poor outcome in patients with autoimmune hepatitis. Posttraumatic stress symptoms, which were correlated with nonadherence, may serve as a focus for adherence-improving interventions.

Adolescent↗
PubMed2006

Visual analog scale of ART adherence: association with 3-day self-report and adherence barriers.

BACKGROUND: Brief self-reports of antiretroviral therapy adherence that place minimal burden on patients and clinic staff are promising alternatives to more elaborate adherence assessments currently in use. This research assessed the association between self-reported adherence on visual analog scale (VASs) and an existing, more complex self-reported measure of adherence, the AACTG, and the degree to which each method distinguished optimally and suboptimally adherent patients in terms of reported barriers to adherence. METHODS: HIV-infected patients (N = 147) at a southeastern US clinic completed a computerized assessment including an antiretroviral therapy adherence VAS, a modified version of the AACTG, and a measure of adherence. RESULTS: Adherence rates were comparable across the AACTG (81%) and VAS (87%); they significantly correlated (r = 0.585) and produced identical classification of optimal (>90%) or suboptimal (<90%) adherence for 66% of patients. In general, VAS scores tended to be higher than AACTG scores. Suboptimally adherent patients reported more adherence barriers than those classified as optimally adherent, and those so classified by the VAS reported considerably more barriers to adherence than those so classified by the AACTG. CONCLUSIONS: Results generally support the construct validity of the VAS and its use as an easily administered assessment tool that can identify patients with barriers to adherence who might benefit from adherence support interventions.

Anti-HIV Agents↗
PubMed2005

Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults.

OBJECTIVES: To determine whether an intense tai chi exercise program could reduce fear of falling better than a wellness education (WE) program in older adults who had fallen previously and meet criteria for transitioning to frailty. DESIGN: Cluster-randomized, controlled trial of 48 weeks' duration. SETTING: Ten matched pairs of congregate living facilities in the greater Atlanta area. PARTICIPANTS: Sample of 291 women and 20 men, aged 70 to 97. MEASUREMENTS: Activity-related fear of falling using the Activities-Specific Balance Confidence Scale (ABC) and the Fall Efficacy Scale at baseline and every 4 months for 1 year. Demographics, time to first fall and all subsequent falls, functional measures, Centers for Epidemiologic Studies Depression Scale, medication use, level of physical activity, comorbidities, and adherence to interventions. RESULTS: Mean ABC was similar in both cohort groups at the time of randomization but became significantly higher (decreased fear) in the tai chi cohort at 8 months (57.9 vs 49.0, P<.001) and at study end (59.2 vs 47.9, P<.001). After adjusting for covariates, the mean ABC after 12 months of intervention was significantly greater in the tai chi group than in the WE group, with the differences increasing with time (mean difference at 12 months=9.5 points, 95% confidence interval=4.8-14.2, P<.001). CONCLUSION: Tai chi led to a significantly greater reduction in fear of falling than a WE program in transitionally frail older adults. The mean percentage change in ABC scores widened between tai chi and WE participants over the trial period. Tai chi should be considered in any program designed to reduce falling and fear of falling in transitionally frail older adults.

Accidental Falls↗
PubMed2005

Nonadherence with diet and fluid restrictions among adults having hemodialysis.

PURPOSE: To describe the prevalence of nonadherence with the prescribed diet and fluid restrictions among patients receiving hemodialysis. METHODS: A multicenter cross-sectional design with 916 patients recruited from 18 dialysis centers in Germany and Belgium. The Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) was used to measure patients' nonadherence. FINDINGS: The results showed that many patients had difficulty following diet (81.4%) and fluid (74.6%) restrictions. Younger male patients and smokers were at highest risk for non-adherence. Higher levels of interdialysis weight gain were associated with nonadherence. CONCLUSIONS: The findings indicate the need to continue to monitor and study hemodialysis patients' adherence behavior longitudinally and to design interventions to enhance adherence.

Adult↗
PubMed2006

Prevalence and risk factors of non-adherence with immunosuppressive medication in kidney transplant patients.

Non-adherence with immunosuppressive regimen is a major risk factor for poor outcome after kidney transplantation. Identifying patients at risk for non-adherence requires understanding the risk factors for non-adherence. This prospective study included a convenience sample of 249 adult kidney transplant patients >1 year post-transplant. Non-adherence was monitored electronically using MEMS(R). Selected socio-economic, therapy-, patient-, condition- and healthcare team-related risk factors for non-adherence were assessed. Period prevalences were expressed as the percent of prescribed doses taken (taking adherence), the percent of correctly dosed days (dosing adherence), the percentage of inter-dose intervals not exceeding 25% of the prescribed interval (timing adherence), and the number of drug holidays per 100 days (no intake for > 48 h if once daily or for > 24 h if twice daily intake). Testing occurred by simple mixed logistic regression analysis. Factors significant after correction for multiple testing were entered into a multiple logistic regression model. Mean taking, dosing, timing adherence, and drug holidays were 98%, 96%, 93%, and 1.1 days, respectively. Non-adherence was associated with lower self-efficacy, higher self-reported non-adherence, no pillbox usage, and male gender. Adherence declined between Monday and Sunday. This study provides a framework for identifying patients at risk for non-adherence and for developing adherence-enhancing interventions.

Adult↗
PubMed2006

Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program.

BACKGROUND: Patient falls in hospitals are common and may lead to negative outcomes such as injuries, prolonged hospitalization and legal liability. Consequently, various hospital falls prevention programs have been implemented in the last decades. However, most of the programs had no sustained effects on falls reduction over extended periods of time. METHODS: This study used a serial survey design to examine in-patient fall rates and consequent injuries before and after the implementation of an interdisciplinary falls prevention program (IFP) in a 300-bed urban public hospital. The population under study included adult patients, hospitalized in the departments of internal medicine, geriatrics, and surgery. Administrative patient data and fall incident report data from 1999 to 2003 were examined and summarized using frequencies, proportions, means and standard deviations and were analyzed accordingly. RESULTS: A total of 34,972 hospitalized patients (mean age: 67.3, SD +/- 19.3 years; female 53.6%, mean length of stay: 11.9 +/- 13.2 days, mean nursing care time per day: 3.5 +/- 1.4 hours) were observed during the study period. Overall, a total of 3,842 falls affected 2,512 (7.2%) of the hospitalized patients. From these falls, 2,552 (66.4%) were without injuries, while 1,142 (29.7%) falls resulted in minor injuries, and 148 (3.9%) falls resulted in major injuries. The overall fall rate in the hospitals' patient population was 8.9 falls per 1,000 patient days. The fall rates fluctuated slightly from 9.1 falls in 1999 to 8.6 falls in 2003. After the implementation of the IFP, in 2001 a slight decrease to 7.8 falls per 1,000 patient days was observed (p = 0.086). The annual proportion of minor and major injuries did not decrease after the implementation of the IFP. From 1999 to 2003, patient characteristics changed in terms of slight increases (female gender, age, consumed nursing care time) or decreases (length of hospital stay), as well as the prevalence of fall risk factors increased up to 46.8% in those patients who fell. CONCLUSION: Following the implementation of an interdisciplinary falls prevention program, neither the frequencies of falls nor consequent injuries decreased substantially. Future studies need to incorporate strategies to maximize and evaluate ongoing adherence to interventions in hospital falls prevention programs.

Accidental Falls↗
PubMedDate not supplied

Usefulness of therapeutic drug monitoring of antiretrovirals in routine clinical practice.

BACKGROUND: Clinical trials have shown that therapeutic drug monitoring (TDM) of antiretrovirals (ARV) improves patient care. However, little is known about the usefulness of TDM in routine practice. METHOD: We reviewed all the trough concentrations of protease inhibitors and nonnucleoside reverse transcriptase inhibitors that were performed for therapeutic failure, suspected drug toxicity, or routine purposes. RESULTS: Between 1998 and 2001, 146 TDMs were done in 109 HIV patients. Of the 48 patients with therapeutic failure, 62% had resistance to ARV with adequate ARV concentrations, 16% had insufficient drug exposure without any ARV resistance mutations, and 16% combined both resistance and suboptimal drug concentrations. Subsequent therapeutic interventions (increasing adherence and/or changing HAART) resulted in an undetectable viral load in 37.5% of the patients (14/48). Five (24%) of 21 patients with suspected drug toxicity had high drug concentrations associated with side effects. In all the cases, adverse events regressed after reduction of drug dosage. Of the 77 TDMs done for routine purposes, 26% were outside the therapeutic range. CONCLUSION: The data show that TDM of ARVs in the clinical setting provides important information that can be used to improve the management of HIV patients receiving antiretroviral therapy.

Diagnostic Tests, Routine↗
PubMed2001

Myocardial infarction in young adults with low-density lipoprotein cholesterol levels < or = 100 mg/dL: clinical profile and 1-year outcomes.

STUDY OBJECTIVES: To define the clinical profile of young adults with optimal low-density lipoprotein (LDL) cholesterol levels who present with acute myocardial infarctions (MIs); to compare and contrast differences in the clinical profiles of young adults admitted to the hospital with MIs who have LDL cholesterol levels < or = 100 mg/dL and those with LDL cholesterol values > or = 160 mg/dL; and to evaluate the clinical outcomes for the two groups at 1 year. DESIGN: A retrospective chart review was conducted on all young men (55 years) and women (65 years) admitted to the hospital for MIs within a 2-year period (n = 232). A history of cardiovascular risk factors and 1-year outcomes were obtained. SETTING: Rural community medical center serving a tri-state area in the midwestern United States. PATIENTS: Patients were included in this analysis if (1) a lipid profile was drawn within 24 h of hospital admission and (2) the patient was not receiving a statin medication on hospital admission. MEASUREMENTS AND RESULTS: Of the 183 patients who met the inclusion criteria, as many as 68% (124 patients) had LDL cholesterol levels of < or = 130 mg/dL, 29% (53 patients) had LDL cholesterol level of < or = 100 mg/dL, and only 14% (26 patients) had LDL cholesterol levels of > or = 160 mg/dL. Patients were categorized into group 1 if their LDL cholesterol level was < or = 100 mg/dL and were categorized into group 2 if their LDL cholesterol level was > or = 160 mg/dL. In group 2, 92% of patients were placed on a statin medication. By 1 year, the mean LDL cholesterol level had decreased from 188 to 106 mg/dL. The rate of coronary artery bypass graft and percutaneous coronary intervention procedures was similar between groups. Hospital readmission rates (43.4% vs 50%, respectively) and 1-year mortality rates (9% vs 8%, respectively) were not different between groups group 1 and 2. CONCLUSIONS: Young adults experiencing acute MIs typically have acceptable cholesterol levels (ie, < or = 130 mg/dL) or optimal values (ie, < or = 100 mg/dL). In those patients with abnormal cholesterol levels, a combined strategy of aggressive intervention and adherence to secondary prevention protocols including lipid control is successful in improving outcomes.

Adult↗
PubMed2002

Predictors of undetectable plasma viral load in HIV-positive adults receiving antiretroviral therapy in Southern Brazil.

Factors associated with undetectable viral load (<80 copies/ml) were investigated among non-pregnant adults in antiretroviral treatment in a specialized service for HIV/AIDS in Southern Brazil. Use of antiretrovirals was investigated in two interviews (one month interval). Clinical data were collected from the clinical records; viral load previous to adherence measurement was defined the viral load previous to the first interview; the final viral load, the viral load subsequent to the second interview (interval between measures approximately 6 months). Undetectable final viral load occurred in 48% of the patients and was positively associated with levels of treatment adherence (p<0.001), being 19% for less than 60% of adherence and about 60% for adherence greater than 80%. In the multivariate model, the odds of undetectable final viral load was four times greater for 80-94% and > or =95% of adherence (CI 95% 1,80-13,28; CI 95% 1,73-9,53), compared with less than 60% adherence; it was greater for less than 6 months in treatment (OR = 3.37; CI 95% 1.09-10.46); and smaller for viral load previous to adherence measurement 5.2 log10 (OR = 0.19; CI95% 0.06-0.58), adjusted for these variables and sex, age, clinical status, current immune status, group of drugs and interval between the two measurements of viral load. The crude odds were lower for age 16-24 years and use of Nucleoside Analog Reverse Transcriptase Inhibitors only, but these effects were not significant in the multivariate model. There was no evidence of effect of sex, clinical status, current immune status, and changes in treatment regimen. Treatment adherence gave the largest effect. Motivational interventions directed at adherence may improve treatment effectiveness.

Adolescent↗
PubMed1996

Psychiatric morbidity, illicit drug use and adherence to zidovudine (AZT) among injection drug users with HIV disease.

This study describes the relationship between the need for psychiatric consultation, illicit drug use, and zidovudine (AZT) adherence in HIV-infected injection drug users (IDUs) in methadone maintenance treatment (MMT). The treatment records of 57 IDUs in MMT who had been prescribed AZT between May and August of 1991 were reviewed. Those who required psychiatric consultation (P+, N = 46, 81%) were compared with those who did not require psychiatric consultation (P-, N = 11, 19%) on adherence to AZT treatment (using the mean corpuscular volume [MCV] as a biological marker), on recent illicit drug use, and on CD4 lymphocyte (T cell) count changes from the beginning to the end of AZT treatment. The P+ subjects were less likely than P- subjects to adhere to AZT treatment: fewer in the P+ group had an MCV outside of the normal range, and P+ subjects had a lower average monthly increase in MCV since the beginning of AZT treatment. Recent illicit drug use and CD4 lymphocyte count changes from the beginning to the end of AZT treatment did not show group differences. Psychiatric morbidity among HIV-infected IDUs in MMT is common, and may contribute to poor adherence to AZT treatment. Psychiatric screening and adherence-enhancing interventions should be targeted to IDUs entering drug treatment programs.

Adult↗
PubMedDate not supplied

Adherence to mental health treatment in a primary care clinic.

BACKGROUND: Patient nonadherence is common for the standard mental health treatments in primary care: antidepressants and referrals to specialty mental health treatment. This is one of few studies to prospectively identify predictors of nonadherence. METHODS: We observed 95 veterans attending an internal medicine clinic prescribed antidepressant medication or referred to mental health treatment. We collected information on sociodemographic factors, health beliefs, preferences about treatment, past experiences, and treatment knowledge. RESULTS: At 1 month, medication adherence was greater when patients experienced previous pharmacy trouble and traveled for less than 30 minutes to reach the clinic. Appointment attendance improved when patients were ready for treatment, perceived benefits, and saw their physician as collaborative. At 6 months, medication adherence was greater when patients reported a preference for medicine treatment, traveled for less than 30 minutes, and perceived greater benefits. Fewer negative effects from previous mental health treatment improved adherence to appointments. In multivariate analyses examining adherence to all treatments, greater readiness for treatment predicted 1-month adherence, whereas being unmarried and seeing the physician as more collaborative improved 6-month adherence. CONCLUSIONS: Adherence to antidepressant medications and to mental health referrals should be examined separately. A brief initial assessment for nonadherence risk factors may identify persons for targeted adherence promoting interventions.

Adult↗
PubMed2006

Antipsychotic adherence over time among patients receiving treatment for schizophrenia: a retrospective review.

OBJECTIVE: Approximately 40% of patients with schizophrenia are poorly adherent to their antipsychotics at any given time. However, little is known about patients' adherence over time, although this has important services implications. We examined antipsychotic adherence over 4 years at the aggregate and the individual level among a large cohort of patients. METHOD: We identified 34,128 Veterans Affairs patients who received a schizophrenia diagnosis and an antipsychotic fill in fiscal year (FY) 1999, completed schizophrenia visits in each of the next 4 years (FY2000, FY2001, FY2002, FY2003), and had valid medication possession ratios (MPRs) in each of these years. We examined whether patients had consistently good adherence (MPRs >or= 0.8 in all 4 years), consistently poor adherence (MPRs < 0.8 in all years), or inconsistent adherence. We examined predictors of consistently poor or inconsistent adherence. RESULTS: The cross-sectional prevalence of poor adherence among the patient population remained stable over time; 36%-37% were poorly adherent in each year. However, 61% of patients had adherence difficulties at some point over the 4-year period. Approximately 18% had consistently poor adherence, 43% were inconsistently adherent, and 39% had consistently good adherence. Patients who were younger and nonwhite, with a substance use diagnosis, a psychiatric hospitalization, or predominant treatment with first-generation antipsychotics, were more likely to have consistently poor adherence. CONCLUSIONS: Antipsychotic adherence is not a stable trait; most patients have difficulties with adherence over time. Health organizations and clinicians must emphasize adherence-enhancing interventions that can be provided on a longer term basis to the majority of patients.

Age Factors↗
PubMed2000

Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease.

New treatments for HIV can improve immune functioning and decrease mortality. However, lapses in adherence may render these complex regimens ineffective. Sixty-three men and 9 women on highly active antiretroviral therapy completed measures of medication adherence, psychological characteristics, and barriers to adherence. HIV viral load, a health outcome measure of virus amount present in blood, was also obtained. The sample was 36% African American and 56% Caucasian, with 35% reporting disability. Nearly one third of patients had missed medication doses in the past 5 days, and 18% had missed doses weekly over the past 3 months. Frequency of missed doses was strongly related to detectable HIV viral loads. Depression, side-effect severity, self-efficacy, and social support distinguished patients with good and poor adherence. Barriers also varied with adherence level. Implications for interventions promoting HIV treatment adherence are discussed.

Adult↗
PubMed1993

Psychosocial impact of cancer screening.

Cancer screening programs, including tests for early detection and programs aimed at identifying people with carcinogenic occupational exposure, may have psychological and behavioral sequelae. An abnormal screening result can lead to distress and anxiety that may continue even after further workup rules out cancer. Such psychological distress can affect subsequent health behavior. When testing or counseling indicates risk factors for cancer, the individual generally tries to adhere to the recommended preventive guidelines. A moderate amount of anxiety about the results may even be a motivating factor in getting subsequent check-ups. However, in some cases such knowledge leads to extreme levels of distress that can actually interfere with adherence behavior. Intervention studies now suggest that simple strategies can successfully reduce screening-related anxiety. Such interventions are particularly important to assure that people with positive tests do not drop out of the system for future screening.

Anxiety↗
PubMed2000

Enhancing adherence to combination antiretroviral therapy in non-adherent HIV-positive men.

This paper describes a preliminary study aimed at testing the efficacy of a brief medication counselling and behavioural intervention in improving adherence to combination antiretroviral medication therapy and prophylactic treatment among non-adherent men living with HIV. Twenty-one non-adherent HIV-positive men obtaining primary care clinical services at a Veterans Affairs Medical Center were recruited by health care providers. Intervention participants were primarily African-Americans with histories of intravenous drug use. During a period of five months, participants were provided with monthly medication counselling and a weekly medication pill organizer. Participants were compared with 21 non-adherent matched controls receiving standard pharmacy care including review of medications. Intervention and control subjects were compared on several variables: medication refill timeliness, appointment attendance, hospitalizations and opportunistic infections. Medical information was obtained from hospital and pharmacy records at baseline and post-intervention. Pre- to post-intervention rates of adherence to medication refills and clinic appointments increased significantly among intervention participants. Relative to matched controls, intervention participants also significantly increased drop-in visits and showed fewer hospitalizations. Intervention participants also showed significant decreases in the number of opportunistic infections. Results suggest that exposure to medication counselling and behavioural interventions increase adherence, with associated reductions in negative clinical outcomes.

Acquired Immunodeficiency Syndrome↗