med adherence and self efficacy
TRANSCRIPT
+
SAFTINet Cardiovascular Cohort PRO: Medication Adherence
CER Team21 May 2012
+Overview
What medication adherence domains should we measure? Medication adherence: quantified Barriers Self-efficacy
What instruments should we use?
Who would be surveyed (PEC: all patients) and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Overview
What medication adherence domains should we measure? Medication adherence: quantified Barriers Self-efficacy
What instruments should we use?
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Medication Adherence Measures
Options in SAFTINet self-report: simple to obtain in real time
other real-time methods: more cumbersome and costly pill counts, drug levels, direct observation, etc.
prescription fulfillment data in SAFTINet: only for Medicaid patients only tells whether they filled the prescription
Patient(person)
Medication adherence(behavior)
Self-efficacyBarriers
+Medication Adherence Measures Feedback from PEC
Medication adherence would be helpful to know most clinicians ask this already the simpler the better
Barriers would be useful helped refine the list of domains to cover based on
clinical experience Self-efficacy—no clear direction yet from PEC
Patient(person)
Medication adherence(behavior)
Self-efficacyBarriers
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Review of Self-Reported Medical Adherence Measures
Garfield S, et al. Suitability of measures of self-reported medication adherence for routine clinical use: A systematic review. BMC Med Res Methodol. 2011; 11: 149.
Inclusion Criteria: Studies that report development, reliability or validation of a retrospective self report adherence measure against a non-questionnaire measure
Exclusion Criteria: (excerpt) non-English no instrument available only relevant to single disease or medication med adherence questions not separable from other
questions
+Review findings
58 measures in 76 papers
Length: 1 to 21 questions
Formats: face to face interview, telephone interview, self administration and computer program
43/58 specified a time period
~half had a measure of barriers too, but these were usually not comprehensive or developed with patient feedback
54/58 had validation data
+Overview of studies by design
+Overview of studies by validation
+Narrowing down the field
Selected studies with only 1 question: 21/58
Selected studies with significant findings for validation study: 16/58
Selected studies not limited to an HIV positive or Mental Health population: 5/58 Rationale: focus on less symptomatic population
+Scale [Ref #] Scale type
Time period
Sample size
Population
Validated against
Validity Results
Adherence Self Report Questionnaire (ASRQ) [25-27] Likert
None Specified 245
Patients from GP practice taking antihypertensives MEMS
Significant association (p=0.0004)
216
Patients from GP Practices taking antihypertensives MEMS
Sensitivity= 46%; Specificity=66%
Gehi [41] Likert Previous month 1015
Outpatients with documented chronic heart disease
Develop-ment of CV events
Significant association (p=0.03) bivariate analysis, 0.06 multivariate analysis)
Inui [46]Dichotomous
Previous 2 months 241
Patients with HTN Pill count
Sensitivity = 55%; Specificity = 88%
+Scale [Ref #] Scale type
Time period
Sample size
Population
Validated against
Validity Results
Medical Outcomes Study Adherence question [57] Likert
Previous 4 weeks 139
Patients >18 with HTN, DM, hyper-cholesterolemia, hypo-thyroidism or requiring HRT
Pharmacy refill records
Spearman Rho= 0.261(p=0.05)
Visual Analogue Scale (VAS) six month version [89]
Continuous (visual analogue)
Previous 6 months 1985
Patients >18 with DM MEMS
VAS higher than MEMS adherence mean difference 15% (p value not reported)
+Adherence Self Report Questionnaire (ASRQ)
+Gehi Question
In the past month, how often did you take your medications as the doctor prescribed?
“All of the time” (100%) “Nearly all of the time” (90%) “Most of the time” (75%) “About half the time” (50%) “Less than half the time” (<50%)
+Medical Outcomes Study Adherence question
How often have you taken your prescribed medication in the past 4 weeks? (Select one) none of the time a little of the time some of the time a good bit of the time most of the time or all of the time
Similar to Gehi question
+Inui Question
Many patients find it difficult to take their medicines or stick to their diets as their doctors say they should. Over the past two months since you were last in clinic, do you think you have taken your medicine as you should, on schedule and regularly? Yes No
+Visual Analogue Scale (VAS) six month version
What percent of time over the past 6 months did you take your prescribed diabetes medication? Place an “x” on a horizontal line
anchored by 0% and100% demarcations provided for every 10th percentile
+Self-Reported Medical Adherence Measures
Recommendations on selecting a measure quantifying medication adherence? Adherence Self Report Questionnaire (ASRQ)
6 levels, more text per level Gehi Question
5 levels, brief text and percentages for each level Medical Outcomes Study Adherence question
5 levels, brief text for each level Inui Question
yes/no question Visual Analogue Scale (VAS) six month version
+Medication Adherence from Claims Fulfillment Data
Medication possession ratio (MPR) = (days of medication supplied) ÷ (# days between the first and last fills)
Proportion of days covered (PDC): the proportion of all days within a specified time period a patient had enough medication
Percentage of doses taken as prescribed: the percentage of prescribed doses taken as directed during a specified time period
Cumulative medication gap (CMG) = (# days in which a medication was not available) ÷ (# days between the first and last fills)
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Medication Adherence Measures: Barriers Measure
Starting point for which barriers to ask about what barriers have been shown to matter in research
studies what barriers do you encounter in your own practices
(known to be very context dependent) emphasize barriers that are amenable to real-world
intervention (e.g., prescribe a daily rather than twice-daily medication)
Patient(person)
Medication adherence(behavior)
Self-efficacyBarriers
+Medication Adherence Measures: Barriers Measure
Starting point for which barriers to ask about what barriers have been shown to matter in research studies RAND Corporation systematic review of barriers found to
predict measured medication adherence regimen complexity cost-sharing (e.g., prescription copayments, formulary tiers,
coinsurance, pharmacy benefit caps or monthly prescription limits, formulary restrictions, and reference pricing)
depression (found effect only as comorbidity of diabetes) beliefs about medications (perceived risks of having a side
effect and perceived impact and need for the medication)
+Medication Adherence Measures: Barriers Measure
Based on the RAND list, and eliminating depression, here is a sample barriers measure, modified by PEC
Which of the following things make it harder for you to take your medication(s) as prescribed? I am worried about the side effects of the medication(s) I do not feel like I need the medication(s) for my health I do not feel like the medication(s) make me feel any better It is hard to take medication(s) more than once a day I have so many medications to take I cannot afford to pay for the medication(s) I sometimes forget to take my medication(s)
+Medication Adherence Measures: Barriers Measure
No systematic review of barriers measures
Per PubMed, the ASK-20 and ASK-12 are commonly cited not disease specific validated
ASK-12 contains the questions most often identified as barriers by
patients taking the ASK-20 Three domains – Inconvenience/forgetfulness, Treatment
beliefs, Behavior – each with a subscale
+Medication Adherence Measures: Barriers Measure
ASK-12 total score demonstrated adequate internal consistency reliability with a Cronbach’s alpha of 0.75
ASK-12 score correlates with self-report measures and objective measures Morisky Adherence Survey (-0.74) proportion of days covered as indicated by claims (r=-0.20;
P=0.059)
Score range 12-60 higher score = greater barriers
In a clinical setting it is not necessary to score the instrument, only review the items in the dark blue boxes
+Medication Adherence Measures: ASK-12
+Medication Adherence Measures: ASK-12
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Medication Adherence Measures: Self-efficacy
Medication Adherence Self-Efficacy Scale (MASES) Ogedegbe et al 2003 Validated in African-American patients with hypertension
Please rate how sure you are that you can carry out the following tasks ALL OF THE TIME: (all answers are on a 3 point scale: Not at all sure, somewhat sure, very sure) Get refills for your medications before you run out Make taking your medications part of your routine Fill your prescriptions whatever they cost Always remember to take your blood pressure medications Take your blood pressure medications for the rest of your life
+Situations come up that make it difficult for people to take their medications as prescribed by their doctors. Below is a list of such situations. We want to know your opinion about taking your blood pressure medication(s) under each of them. Please indicate your response by checking the box that most closely represents your opinion. There are no right or wrong answers. For each of the situations listed below, please rate how sure you are that you can take your blood pressure medications ALL OF THE TIME
1. When you are busy at home
2. When you are at work
3. When there is no one to remind you
4. When you worry about taking them for the rest of your life
5. When they cause some side effects
6. When they cost a lot of money
7. When you come home late from work
8. When you do not have any symptoms
9. When you are with family members
10. When you are in a public place
11. When you are afraid of becoming dependent on them
12. When you are afraid they may affect your sexual performance
13. When the time to take them is between your meals
14. When you feel you do not need them
15. When you are travelling
16. When you take them more than once a day
17. If they sometimes make you tired
18. If they sometimes make you tired
19. When you have other medications to take
20. When you feel well
21. If they make you want to urinate while away from home
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Options for Med Adherence PRO Administration
Easier to administer to all patients than to only those with select diagnoses
Having just one screening question is more practical
Administer medication adherence measure first then administer barriers +/- self-efficacy questions only administer barriers +/- self-efficacy questions to those
with non-adherence
Administer barriers +/- self-efficacy questions first and leave the medication adherence question for last
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Research Utility
Which domains would we use? medication adherence barriers measure total score self-efficacy total score
How would we use these in an analytic model?
PCMH
Medication adherence
Self-efficacyBarriers
Disease control
+Research Utility
How would we use fulfillment data in an analytic model? Verify self-report data As an outcome or intermediate variable in the PCMH model
PCMH
Prescription fulfillment
Disease control
+Overview
What medication adherence domains should we measure?
What instruments should we use? Medication adherence: quantified Barriers Self-efficacy
Who would be surveyed and how?
How would we use the findings in our research?
How would our partners use the instruments?
+Utility to Practices
Which of the components of the proposed PRO would have clinical (and other use) utility to the practices?
What related activities are the practices already doing? Some clinicians are asking about medication adherence and
barriers but not documenting responses in a field Nurses check the list of active medications at intake, asking
which they are still taking and why they stopped those they are no longer taking
Meaningful use phase 2 will require goal-setting and a barriers format might meet these criteria
ACO activities related to identifying high-risk patients for hospitalization (next slide)
+Example of Medication Adherence Question Already In Use How many prescription medications are you currently taking
every day (H-8)?
None (0) (skip to Social Needs) 1-2 (0) 3 OR MORE (1)
In a TYPICAL WEEK how often did you forget to take or decide NOT to take one or more of your medications (H-8)?
NEVER (0) RARELY (0) SOMETIMES (1) USUALLY (1) ALWAYS (1)
How sure are you that you understand the reason you are taking your medications (H-8)?
VERY SURE (0) SOMEWHAT SURE (0) NOT VERY SURE (1)
How often do you get your medications at more than one pharmacy?
NEVER (0) RARELY (0) SOMETIMES (1) USUALLY (1) ALWAYS (1)