Factors Associated with Patient Preferences for Disease-Modifying Therapies in Multiple Sclerosis.

BACKGROUND: Treatment adherence in patients with multiple sclerosis (MS) is essential to reduce the rate of acute neurological attacks, severity of relapses, and hospitalizations and to slow its progression. Adherence rates in MS patients have been shown to be affected by multiple factors, including physical or cognitive difficulties, perceived lack of treatment efficacy, treatment-related adverse events, injection anxiety, and frequency of administration. OBJECTIVE: To elicit the preferences of MS patients for noneconomic and economic attributes of current disease-modifying therapies (DMTs). METHODS: We used conjoint analysis to estimate preferences from a convenience sample through a web-based online survey. Patients were invited to participate in the study using web portals and newsletters for MS patients. The conjoint survey included the following 6 attributes: (1) overall efficacy based on autoimmune disease progression stabilization; (2) acute increase in disease activity (flare-up); (3) rate of respiratory tract infections; (4) rate of serious respiratory tract infections (leading to hospitalization); (5) medication use; and (6) patient monthly out-of-pocket medication costs. Using a fractional factorial design, 24 product profiles were created. Each respondent reviewed a random selection of 8 profiles. With each profile, subjects were asked to indicate their likelihood to try the hypothetical products on a scale from 0 to 100. Random effects linear regression was used to elicit preferences. RESULTS: After exclusion of respondents with incomplete information, data from 129 subjects were included in the analysis. The overall relative importance of each attribute for the ranges presented were (1) 38.4% for monthly out-of-pocket cost; (2) 21.5% for route and frequency of administration; (3) 15.9% for risk of hospitalization by infection; (4) 11.9% for risk of respiratory tract infection; (5) 7.4% for risk of flare-ups; and (6) 5.0% for disease progression stabilization. Preference weights indicated that subjects favored subcutaneous (beta coefficient [ß] = -2.26, 95% CI = -4.22 to -0.22) and oral administration (ß = 7.93, 95% CI = 5.95 to 10.2) over intramuscular (ß = -5.67, 95% CI = -8.67 to -3.56), but no significant differences were found between subcutaneous over intramuscular administration. Monthly out-of-pocket cost was the most influential attribute, with an overall relative importance of 38%. The most preferred level was $75 (ß = 12.85, 95% CI = 10.64 to 15.06) followed by $150 (ß = 3.41, 95% CI = 0.98 to 5.84) when compared between $75, $150, $300, and $450 a month. CONCLUSIONS: Conjoint analysis proved to be a convenient tool to quantify respondents' relative preferences for DMT characteristics. Respondents gave higher weight to DMT monthly out-of-pocket costs and mode of administration than to adverse effects or efficacy. These findings may assist in the development of DMT cost-sharing strategies and shared decision making at the point of care. DISCLOSURES: No outside funding supported this study. The authors declare no potential conflicts of interest. Study concept and design were contributed by Hincapie and Burns. Data were collected by Hincapie and Burns, and interpreted by all the authors. The manuscript was written by Hincapie, Penm, and Burns and revised by Penm, Hincapie, and Burns. At the time of data collection, Burns was a PhD candidate at The University of Oklahoma, College of Pharmacy.

Depression screening for prescribed medications with mental health risk: Considerations for clinical decision support, workflow redesign, and health information exchange arrangements.

OBJECTIVE: Depression screening should be increased when prevailing knowledge underscoring medication-associated mental health risk is highest. Depression screening in primary care practices when medications with mental health risk were prescribed was estimated while considering the absence and presence of clinical decision support systems. MATERIALS AND METHODS: A cross-sectional, descriptive study using the National Ambulatory Medical Care Survey (NAMCS) data from 2008 to 2010 was conducted. Primary care physician visits were classified based on whether a medication prescribed had a contraindication, severe warning, moderate warning, adverse event only, or no documented mental health risk. Adjusted odds of depression screening for each risk warning level were estimated while controlling for important sociodemographic factors and presence of computerized systems for medication warnings and guideline recommendations. RESULTS: Depression screening at primary care practice visits when medications were prescribed was 2.1% and increased to 2.8% or higher when medications had a moderate or severe mental health risk warning or medication-disease contraindication. Depression screening was increased at visits when at least one medication was prescribed that had a contraindication (AOR = 6.31, P < 0.001), severe warning (AOR = 2.04, P = 0.003), or moderate warning (AOR = 2.50, P = 0.012) for mental health risk, but not for mental health adverse event only warnings alone (AOR = 1.54, P = 0.074). DISCUSSION: Depression screening is increased when medications were prescribed with a documented mental health risk. Presence of clinical decision support systems may help discern between minor and major medication-associated mental health risks. CONCLUSIONS: Appropriately, positioned warning systems with targeted content, workflow redesign, and health information exchange may improve depression screening in at-risk patients.

Cultural competence in correctional mental health.

Cultural competence is an essential aspect of competence as a mental health professional. In this article, the framework of cultural competence developed in general psychiatry-acquiring knowledge, attitudes, and skills necessary to understand the interaction between culture and the individual-is applied to the prison setting. Race and ethnicity, extremes of age, gender, and religion are highlighted and examined as elements of the overall culture of prisons. The model of the cultural formulation from the DSM-IV is then adapted for use by clinicians in the correctional setting, with particular emphasis on the interaction between the inmate's culture of origin and the unique culture of the prison environment.

Exploring patient expectations for pharmacist-provided literacy-sensitive communication.

BACKGROUND: Limited health literacy is common and associated with adverse health care outcomes. Although pharmacies and pharmacists are accessible to most patients, research has indicated that they do not routinely report efforts to target interventions for patients with suboptimal health literacy. Moreover, little is known about the use and expectation of literacy-based communication techniques in pharmacies from the patient perspective. OBJECTIVE: The intent of this pilot study was to describe the use of health literacy-based communication techniques, expectations for their use, and satisfaction with communication as reported by patients at high risk for medication misadventures who receive care at a clinic-based community pharmacy. METHODS: A cross-sectional telephonic interview of a purposive sample of patients aged 65 years or older who were prescribed at least 8 unique medications was conducted. Patients were recruited from 1 clinic-based pharmacy that serves a predominantly urban low-income population. A telephonic interview guide was derived from previous literature and included 52 questions related to respondent characteristics, perceptions of experiences regarding verbal communications with the pharmacist, expectations for communication with the pharmacist, and satisfaction with current pharmacy communication techniques. Responses were summarized and described. RESULTS: Nineteen patients completed the telephonic interviews. Patients commonly reported that the pharmacist provided the following counseling for new prescriptions: how to take their medication (88.9%), side effects (84.2%), and indication (47.4%). In contrast, only 44.4%, 55.6%, and 33.3% of patients expected the pharmacist to engage in these same counseling behaviors. A minority of patients reported the use of various recommended clear health communication techniques by the pharmacist, and an even smaller percentage expressed expectations for their use. Despite the limited use of literacy-based communication techniques, 73.7% of patients reported being very satisfied with pharmacy counseling, and 94.7% reported good to excellent understanding of their medications. CONCLUSION: Patient-pharmacist interactions consistently met or exceeded patient expectations. However, pharmacists use of literacy-based communication techniques was low as were patient expectations. Future research and training efforts should focus on not only increasing pharmacists' use of literacy-based communication techniques but also raising patients' expectations for performing these activities.

Treatment compliance in adolescents after attempted suicide: a 2-year follow-up study.

OBJECTIVE: To describe mental health services utilization for adolescents after attempted suicide, explore factors related to treatment compliance, and determine the relation between compliance and suicidality. METHOD: Eighty-five adolescents (ages 13-18) who had attempted suicide and their families were recruited from four psychiatric hospitals and were evaluated for symptoms of psychopathology. Subsequent assessments were conducted every 6 months for 2 years to determine treatment utilization, treatment compliance (nonadherence to medication regimens or nonattendance of psychosocial treatments against provider advice), attitudes toward treatments used, and further suicide attempts and ideation. RESULTS: Adolescents with a disruptive behavior disorder diagnosis were less compliant with individual psychotherapy, as were those with a substance dependence other than alcohol or marijuana. Those with an affective/ anxiety disorder diagnosis were less compliant with psychopharmacological interventions (6 months postattempt). Parental perception of treatment as helpful was predictive of greater compliance, whereas adolescents' attitudes toward treatment were not predictive of compliance. Finally, compliance with treatment was not generally predictive of future suicidality. CONCLUSIONS: Interventions focused on increasing compliance with mental health treatment for adolescent suicide attempters should focus on specific child psychopathology, as well as parental attitudes toward treatment.

Method validation of in vitro RNA transcript analysis on the Agilent 2100 Bioanalyzer.

The Agilent 2100 Bioanalyzer can characterize in vitro RNA transcripts for their integrity, purity, concentration, and size. The results are comparable to denatured agarose electrophoresis with ethidium bromide staining and UV spectrophotometry combined. In this report, we describe our strategy for validating this method following the International Conference on Harmonization guidelines. The assay has a linear range of quantitation between 500 and 25 ng/microL. Quantitation accuracy is within +/-20% of measurements produced from spectrophotometry and sizing accuracy is within +/-7% based on theoretical sizes. Concentration and sizing measurements within a single assay produce RSDs that are <10 and <2%, respectively, indicating good precision. The method also maintains a tolerable precision when altering operator, day, and reagent kit lot. The RSD for quantitation is

Membrane depolarization is the initial action of crotoxin on isolated murine skeletal muscle.

Although much is known about the pathogenesis of crotoxin-induced muscle damage, the initial site and action of the toxin is still not clear. In this study we used an electrochromic fluorescent dye, Di-4-ANEPPS, to measure the changes in membrane potential of isolated murine omohyoid muscle to determine if depolarization could be one of the initial effects of crotoxin. Omohyoid isolates were pre-loaded with 1 microM Di-4-ANEPPS, exposed to various crotoxin treatments, and the change in fluorescence was recorded using either a dual-wavelength spectrofluorometer or digital imaging. Spectrofluorometry indicated that crotoxin depolarized isolated omohyoid muscles within 4 min as indicated by an increase in fluorescence to 122% of control values. Crotoxin also induced depolarization of extensor digitorum longus and soleus muscles as indicated by an increase in fluorescence of 140 and 110% of the control, respectively. Fluorescent images obtained from omohyoid muscle preparations exposed to crotoxin and Di-4-ANEPPS revealed localized areas of increased fluorescence, muscle contractions, derangement of myofibrils, and differing sensitivity to crotoxin of different muscle cells. Light microscopy results confirmed this variable disruption of muscle cell integrity and differing sensitivity to crotoxin. An increase in creatine kinase release rates confirmed damage to the plasma membrane. We conclude that plasma membrane depolarization is most likely the earliest indicator of cell damage from crotoxin and is quickly followed by hypercontraction of myofilaments, disruption of the plasma membrane, release of creatine kinase and necrosis.