Randomized controlled trial of a pictorial aid intervention for medication adherence among HIV-positive patients with comorbid diabetes or hypertension.

As the HIV-infected population ages and the burden of chronic comorbidities increases, adherence to medications for HIV and diabetes and hypertension is crucial to improve outcomes. We pilot-tested a pictorial aid intervention to improve medication adherence for both HIV and common chronic conditions. Adult patients with HIV and diabetes (DM) and/or hypertension (HTN) attending a clinic for underserved patients and at risk for poor health outcomes were enrolled. Patients were randomized to receive either a pictorial aid intervention (a photographic representation of their medications, the indications, and the dosing schedule) or a standard clinic visit discharge medication list. Adherence to antiretroviral therapy (ART) for HIV and therapy for DM or HTN was compared. Predictors of ART adherence at baseline were determined using logistic regression. Medication adherence was assessed using medication possession ratio (MPR) for the 6-month interval before and after the intervention. Change in adherence by treatment group was compared by ANOVA. Among the 46 participants, there was a trend towards higher adherence to medications for HIV compared with medications for hypertension/diabetes (baseline median MPR for ART 0.92; baseline median MPR for the medication for the comorbid condition 0.79, p = 0.07). The intervention was feasible to implement and satisfaction with the intervention was high. With a small sample size, the intervention did not demonstrate significant improvement in adherence to medications for HIV or comorbid conditions. Patients with HIV are often medically complex and may have multiple barriers to medication adherence. Medication adherence is a multifaceted process and adherence promotion interventions require an approach that targets patient-specific barriers.

Patient-provider communication in nephrology care for adolescents and young adults.

OBJECTIVE: To compare the relative quantity of talk between providers, caregivers, and adolescents and young adults (AYAs) with chronic kidney disease (CKD) and how communication differs by age. METHODS: During nephrology clinic visits, conversations between AYAs with CKD (N=99, ages 11-20, median=15), their caregivers, and providers (N=19) were audiotaped and coded using the Roter Interaction Analysis System. Linear mixed models tested AYA age differences in talk frequency by AYAs, caregivers, and providers. Post-hoc analyses tested differences in talk using AYA age groups. RESULTS: During clinic visits, providers spoke the most (63.7%), and caregivers spoke more (22.6%) than AYAs (13.7%). Overall talk differed by AYA age in AYAs (p<0.001) and caregivers (p<0.05), but not providers. Higher AYA age was associated with more AYA talk (biomedical information-giving, partnering, rapport-oriented) and less caregiver biomedical information-giving (ps<0.001-0.05). In post-hoc analyses, young adults talked more than adolescents; caregiver talk decreased in the middle-adolescent group. CONCLUSIONS: Increases in AYA talk occur primarily in young adulthood, whereas caregiver talk decreases in middle adolescence. This may indicate an appropriate developmental shift but raises concerns about conversational gaps during middle-adolescence. PRACTICE IMPLICATIONS: During transition-oriented treatment planning, providers should engage both AYAs and caregivers to avoid potential gaps in communication.

The HIV-infected child: parental responses and psychosocial implications.

Four dimensions of psychological adaptation of 101 parents of HIV-infected children were examined. Heightened anxiety, depression, and anticipatory grief were associated with child's age at diagnosis, parent's HIV status, and parent's relationship to the child. Parents at higher risk for psychological distress were identified, and an optimum time point for intervention is suggested.

Adherence to the 2007 cystic fibrosis pulmonary guidelines: a national survey of CF care centers.

OBJECTIVE: To examine cystic fibrosis (CF) physician adherence to the 2007 CF Foundation (CFF) Pulmonary Guidelines for Chronic Medications. Specifically adherence and barriers to prescribing level A medication recommendations (i.e., inhaled tobramycin and dornase alfa) and level B medication recommendations (i.e., macrolide antibiotics and hypertonic saline) were studied. METHODS: During Spring 2010, the CFF emailed survey invitations to directors of 136 accredited CF care centers treating 50+ CF patients. Directors were asked to forward the invitations to their physician colleagues. One hundred thirty-three surveys were included in the analyses, representing 92 centers. Barriers were conceptualized based on Cabana et al.'s framework for adherence to guidelines. Adherence was assessed via a case vignette. RESULTS: Logistic regression analysis revealed that higher outcome expectancy (OR = 1.099, CI 1.010-1.196) and fewer environmental/system barriers (OR = 1.484, CI 1.158-1.902) were significantly associated with Vignette Adherence. A trend for an association between Familiarity and Vignette Adherence (OR = 1.642, CI 0.953-2.828) was evident, while no demographic variables were significantly associated with Vignette Adherence. CONCLUSION: Targeting outcome expectancy and external barriers with multifaceted, ongoing interventions may improve guideline adherence. Pulmonologists are clearly looking for empirical evidence that these medications benefit their patients over the long-term and offset patient treatment burden with improved health.

Who participates in research on adherence to treatment in insulin-dependent diabetes mellitus? Implications and recommendations for research.

OBJECTIVE: Examine the implications of nonparticipation in studies of treatment adherence among adolescents with chronic health conditions. METHODS: Empirical data from an adherence study with adolescents with diabetes were used to demonstrate the influence of family participation on demographic and health outcome variables. Ninety-four families were categorized into one of three groups: (1) families that declined to participate in the study at recruitment (nonconsenters), (2) families that agreed to participate, but failed to return the study questionnaires (nonreturners), and (3) families that had at least one family member return the questionnaires (participants). RESULTS: Despite being similar demographically, nonreturners had significantly lower treatment adherence scores and the adolescents tested their blood sugar less frequently than participants. Participants and non-consenters did not differ on any available data. CONCLUSIONS: We discuss the implications of these group differences on the generalizability of research findings, offer suggestions about how to maximize and maintain participation in research studies, and suggest directions for future research.

A psychological behavioral screening service: use, feasibility, and impact in a primary care setting.

OBJECTIVE: To describe a psychology behavioral screening service and the use of the service in subsequent primary care provider (PCP) treatment decisions. METHODS: The goal of the behavioral screening service was to obtain standardized parent and teacher rating scale data for children identified by PCPs as having possible behavioral problems. Medical chart review data were collected on 147 children for 1 year following screening to evaluate (1) PCP follow-up of the behavioral concern, (2) prescription of psychotropic medications, (3) referral to mental health services, and (4) receipt of mental health services. RESULTS: Children screened by this psychology service had clinically significant behavioral problems, according to both parent and teacher data; PCPs appeared to use screening results to guide decisions about medication prescription but not mental health referrals. Children with more behavioral problems were more likely to be prescribed psychotropic medications and to be seen by a mental health professional. CONCLUSIONS: These data suggest that a psychology behavioral screening service is feasible and may help guide PCP treatment decisions for children with behavior problems, particularly regarding the prescription of psychotropic medication.