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Measuring improvements in adherence Jennie Connor University of Auckland, New Zealand

Measuring improvements in adherence Jennie Connor University of Auckland, New Zealand. Do fixed dose combination pills or unit-of-use packaging improve adherence?. Systematic review of randomised trials Effect on adherence and clinical outcomes

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Measuring improvements in adherence Jennie Connor University of Auckland, New Zealand

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  1. Measuring improvements in adherence Jennie Connor University of Auckland, New Zealand

  2. Do fixed dose combination pills or unit-of-use packaging improve adherence? • Systematic review of randomised trials • Effect on adherence and clinical outcomes • Only a small number of trials found, most poor quality • Some benefit but evidence is weak • What is a significant improvement? • Heterogenous adherence measures • How valid? • How reliable? • How useful in usual practice?

  3. Direct methods (look for evidence of the drug in the body) Test for drug, metabolite or tracer in: urine blood saliva Indirect methods Pill counting Medication event monitoring (MEMS) Prescribing/dispensing records Self-report Diary Adherence questionnaire Appointment keeping Therapeutic response Methods for measuring adherence

  4. How valid? = is it measuring what you intend it to? • What are you trying to measure? • Are they getting effective treatment? or • Are they following the regimen (dose and timing)? • No ‘gold standard’ with which to compare • Direct methods • only measure recent ingestion of drug • Pill counts and MEMS • Show medications/caps have been removed from the container • Pill counts over-estimate adherence • MEMS provides timing information, no doses

  5. Prescriptions/dispensing • Little validity except discontinuation • Greatly over-estimate adherence • Self-report • Response varies greatly with context, relationship, and nature of questioning • Social desirability and recency effects • Generally over-estimates adherence. Good specificity for nonadherence • Formalised in questionnaires – can include adherence-related behaviours, barriers….e.g.PMAQ. Not for repeated use. • Medication diaries – more reliable information than recall. Details of timing. • Appointment keeping: raises index of suspicion • Therapeutic response: weak indicator

  6. How reliable? Hard to know without a good reference standard • Accuracy of self report varies between settings • PMAQ and other formal instruments are designed and tested for reliability, informal interview is not. • Drug testing may vary between individuals, or over time

  7. How useful in practice? • All methods have limitations: may need to use more than one • Consider the patient and clinician burden and cost • Self-report compares well with other measures in many studies and is most readily available • Need to think about a definition of clinically significant non-adherence • To distinguish those at high risk of treatment failure, rather than e.g. “80% rule”

  8. Improving adherence measurement • In research • Defining acceptable adherence: is there a known threshold for effective treatment that needs to be reached? • Validation studies of measures – for this condition, this population • Multiple complementary measures and composite measures - standardisation • Distinguishing patterns of non-adherence – erratic, unwitting, intelligent. • What is a significant improvement in adherence for this drug or condition?

  9. Improving adherence measurement • In practice • Will usually need to use simple and cheap methods • Partnership with patient to improve adherence and its measurement by self-report • Assessment of adherence as part of routine of care – a continuous process • Context-specific combination of measures : little place for routine pill counting: identifying patterns of non-adherence as well as extent • Consider poor attenders and poor responders as higher risk

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