This study assessed the efficacy of using SMS reminders to improve adherence to a 6-dose antimalarial treatment in Zambia. The study involved 96 participants who were randomized into an intervention group that received SMS reminders or a control group. Adherence was measured using electronic monitors on medication bottles. The results found no significant difference in adherence rates between the groups, with both showing adherence over 65%. The study identifies limitations and implications for further research on using mHealth to improve malaria treatment adherence.
This document describes a study conducted at a resident clinic to reduce inappropriate Pap testing. The researchers implemented an intervention where they created a dedicated "Pap clinic" with a specific EMR template highlighting cervical cancer screening guidelines. In a pilot study before the intervention, 17% of Pap tests were inappropriate. After the intervention, the rate of inappropriate Pap tests significantly decreased to 1.7%. The intervention was effective at improving adherence to Pap testing guidelines. However, the study had limitations like a small sample size. Overall, the results suggest creating dedicated clinics and EMR templates can help reduce over-screening in primary care settings.
Innovations in Community-based Diagnosis and Treatment of Acute Malnutrition ...CORE Group
This document summarizes a research study conducted in Aweil South County, South Sudan to assess whether community health workers with low literacy could effectively treat severe acute malnutrition (SAM) using simplified tools and protocols. The study found that the health workers were able to implement the protocol and treat 310 malnourished children in the community with 75.6% cured and treatment outcomes meeting international standards. This demonstrates that with appropriate training and adapted tools, low-literacy community health workers can successfully treat uncomplicated SAM cases in their communities.
Key Data Sources for Public Health - Local Perspective - Irina HollandSouth West Observatory
National data has advantages like comparability between areas and standard indicators/targets, but local data provides more granular, timely, and useful information for public health. Local data sources in Somerset include population statistics, lifestyle surveys, screening and vaccination rates, deprivation indices, and disease registers from general practices. Examples shown how local cervical cancer and childhood vaccination data can identify poorly performing areas for intervention, and how smoking and deprivation data were used to target communities for smoking cessation programs.
This study surveyed pharmacists in Minnesota to identify gaps between the information resources taught in school and those available in practice. The survey assessed which resources pharmacists have access to and use most frequently in their workplace. Results showed pharmacists have the most access to and use Drug Facts and Comparisons, Micromedex, Pharmacists Letter, and UpToDate most frequently. Factors like reputation, accuracy, ease of use, and cost influence which resources pharmacists choose. Rural pharmacists had less access than urban pharmacists, suggesting interventions are needed to broaden rural pharmacists' access to evidence-based resources.
A Diverse Autism Registry for Etiologic and Effectiveness Studies Prevalance ...HMO Research Network
This document describes the creation of a large autism registry using data from multiple health care organizations to study the prevalence, characteristics, treatments, and causes of autism spectrum disorders. The registry will utilize existing electronic health records, surveys, and biosamples to establish a diverse population for investigating autism interventions and genetic/causal factors through rapid identification and enrollment in large studies. Initial results found an overall autism prevalence of 1.2% with variations across sites and more males than females diagnosed.
Moving Toward Improved Measurement of Malaria Mortality at the Population LevelMEASURE Evaluation
This review summarizes the key limitations of using verbal autopsies to measure malaria mortality at the population level. The main limitations identified are the low sensitivity and specificity of existing verbal autopsy tools in determining malaria as the cause of death. There is also a lack of standardization in how verbal autopsies are implemented and analyzed across studies. Additional challenges include small sample sizes and potential for recall bias. The review concludes there is an urgent need to improve verbal autopsy methods to provide more accurate estimates of malaria mortality and track progress of malaria control goals.
Redesigning a care model for better health. CareOregon's MEDS (My Easy Drug System), Health Resilience program, and human-centered design programs are leading the way.
This document describes a study conducted at a resident clinic to reduce inappropriate Pap testing. The researchers implemented an intervention where they created a dedicated "Pap clinic" with a specific EMR template highlighting cervical cancer screening guidelines. In a pilot study before the intervention, 17% of Pap tests were inappropriate. After the intervention, the rate of inappropriate Pap tests significantly decreased to 1.7%. The intervention was effective at improving adherence to Pap testing guidelines. However, the study had limitations like a small sample size. Overall, the results suggest creating dedicated clinics and EMR templates can help reduce over-screening in primary care settings.
Innovations in Community-based Diagnosis and Treatment of Acute Malnutrition ...CORE Group
This document summarizes a research study conducted in Aweil South County, South Sudan to assess whether community health workers with low literacy could effectively treat severe acute malnutrition (SAM) using simplified tools and protocols. The study found that the health workers were able to implement the protocol and treat 310 malnourished children in the community with 75.6% cured and treatment outcomes meeting international standards. This demonstrates that with appropriate training and adapted tools, low-literacy community health workers can successfully treat uncomplicated SAM cases in their communities.
Key Data Sources for Public Health - Local Perspective - Irina HollandSouth West Observatory
National data has advantages like comparability between areas and standard indicators/targets, but local data provides more granular, timely, and useful information for public health. Local data sources in Somerset include population statistics, lifestyle surveys, screening and vaccination rates, deprivation indices, and disease registers from general practices. Examples shown how local cervical cancer and childhood vaccination data can identify poorly performing areas for intervention, and how smoking and deprivation data were used to target communities for smoking cessation programs.
This study surveyed pharmacists in Minnesota to identify gaps between the information resources taught in school and those available in practice. The survey assessed which resources pharmacists have access to and use most frequently in their workplace. Results showed pharmacists have the most access to and use Drug Facts and Comparisons, Micromedex, Pharmacists Letter, and UpToDate most frequently. Factors like reputation, accuracy, ease of use, and cost influence which resources pharmacists choose. Rural pharmacists had less access than urban pharmacists, suggesting interventions are needed to broaden rural pharmacists' access to evidence-based resources.
A Diverse Autism Registry for Etiologic and Effectiveness Studies Prevalance ...HMO Research Network
This document describes the creation of a large autism registry using data from multiple health care organizations to study the prevalence, characteristics, treatments, and causes of autism spectrum disorders. The registry will utilize existing electronic health records, surveys, and biosamples to establish a diverse population for investigating autism interventions and genetic/causal factors through rapid identification and enrollment in large studies. Initial results found an overall autism prevalence of 1.2% with variations across sites and more males than females diagnosed.
Moving Toward Improved Measurement of Malaria Mortality at the Population LevelMEASURE Evaluation
This review summarizes the key limitations of using verbal autopsies to measure malaria mortality at the population level. The main limitations identified are the low sensitivity and specificity of existing verbal autopsy tools in determining malaria as the cause of death. There is also a lack of standardization in how verbal autopsies are implemented and analyzed across studies. Additional challenges include small sample sizes and potential for recall bias. The review concludes there is an urgent need to improve verbal autopsy methods to provide more accurate estimates of malaria mortality and track progress of malaria control goals.
Redesigning a care model for better health. CareOregon's MEDS (My Easy Drug System), Health Resilience program, and human-centered design programs are leading the way.
This study analyzed data from 10 randomized controlled trials testing post-discharge care management programs for heart failure patients. It found that programs using multidisciplinary teams and in-person communication significantly reduced hospital readmissions and readmission days compared to routine care. However, programs relying only on telephone follow-up did not significantly reduce hospital use. The study concludes that payers should incentivize hospitals to adopt chronic care management programs shown to effectively reduce hospital utilization, which could lower costs for programs like Medicare that cover many patients with chronic illnesses.
Randomized Controlled Pilot Study Testing Use of Smartphone Technology for Ob...Writers Per Hour
This document summarizes a randomized controlled pilot study that tested the use of smartphone technology for obesity treatment. The study involved 68 participants, with some using a smartphone app and others not. The results showed that over 50% had a positive reaction to the app, and 58% found the app's functionality helpful for physical activity and self-monitoring. However, the large dropout rate also indicated a need for more controlled trials and retention strategies like counseling to improve effectiveness. In conclusion, while smartphone technology shows potential, more research is still needed to fully analyze its impact on obesity treatment and prevention.
This document summarizes Parkland Center for Clinical Innovation's breast cancer health equity initiative. The initiative aims to understand and address socioeconomic inequities leading to breast cancer disparities. Analysis found late-stage diagnoses were more common for patients without recent mammograms or Parkland touchpoints. Focus groups revealed barriers like cost, transportation, and need for more education. Next steps include expanding data analysis, using data to drive operational and policy changes, and measuring improvements through mobile mammography unit deployment and partnerships.
Evaluating the Impact of Literature Searching Services on Patient Care Throug...Jeff Mason
Hospital libraries must demonstrate the value and impact they have within their organizations. We created a short survey to assess the impact literature searches conducted by librarians have on patient care. This presentation was given at the 2014 Medical Library Association Annual Meeting in Chicago. Preliminary results are discussed.
We want you to use our survey to assess your own value! To view a copy please visit:
http://fluidsurveys.com/s/literature-searching-impact-survey-site/
Innovations conference 2014 building a quality cancer system concurrent sessi...Cancer Institute NSW
The document summarizes findings from a survey of GPs in NSW, Australia that was part of an international cancer benchmarking study. Key findings included:
- GPs expressed strong support for timely cancer diagnosis but less so for lung cancer. Nearly half saw gatekeeping as important.
- There were differences in access to diagnostic tests and specialists between urban and rural GPs, and between public and private systems.
- Waiting times heavily influenced referral pathways.
- The findings can help improve coordination between primary and specialist cancer care and provide a baseline for monitoring changes over time.
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
While clinical trials represent leading cancer research, less than 5% of cancer patients enroll due to a lack of awareness and resources. Physicians have little time to enroll patients, and patients and doctors have misconceptions about clinical trials. Molecular targeted trials, based on genetic markers, require less patients than traditional trials to produce meaningful results. Unlike traditional trials, targeted trials do not use placebos and allow switching to tested drugs if beneficial. While complex genetic profiling is required for targeted trials, they provide more personalized treatment with fewer side effects than chemotherapy. Focusing clinical trial searches on predefined molecular markers can help patients find more suitable targeted trials.
Professor Mike Pringle presented on the impact of the Quality and Outcomes Framework (QoF) in the UK. He addressed whether QoF improved health outcomes, reduced inequality gaps, and was cost-effective. While some metrics like blood pressure monitoring rates increased after QoF, improvements pre-dated it. QoF risks included box-ticking and reduced professionalism. Initially, inequality gaps widened but narrowed over time as deprived areas improved. While QoF cost £1 billion annually, its effects were smaller than socioeconomic factors. It remains unclear if QoF is truly cost-effective.
This study analyzed data from 658 insured pregnant women in a Midwestern county to compare risks and outcomes between those who did and did not utilize the emergency department (ED) during their peripartum period. The study found that 218 women (33%) visited the ED at least once during this time. ED users were more likely to experience psychosocial risks like postpartum depression and smoking, have poorer birth outcomes like prematurity, and have inadequate prenatal care. After adjusting for demographic factors, ED use was associated with a higher likelihood of postpartum depression, smoking during pregnancy, unstable housing, delayed prenatal care initiation, and missing a postpartum visit.
The SHARE project aimed to improve care and research collaborations for pediatric rheumatology in Europe from 2012-2015. Key results included:
1. Surveys identifying needs in European countries and best practices for diagnosis, treatment, and obtaining consent.
2. Development of consensus treatment guidelines for conditions like JDM and childhood SLE through literature reviews and expert consensus.
3. An updated pediatric rheumatology website and patient information translated into multiple languages.
4. Papers identifying barriers to international data and sample sharing between countries due to differences in ethical approval processes.
The project provided guidance to improve uniformity of care for pediatric rheumatic diseases across Europe and opportunities to facilitate research collaboration and influence European policies.
Innovations conference 2014 erica wales does an online anti-cancer medicati...Cancer Institute NSW
This document summarizes Erica Wales' research evaluating an online oral anti-cancer medication education program for community pharmacists. It found that the program significantly improved pharmacists' knowledge and confidence in dispensing oral anti-cancer medications. Before the program, pharmacists on average answered 60% of knowledge questions correctly and most reported little confidence. After completing the online education, pharmacists answered on average 92% of questions correctly and reported being moderately or very confident in their knowledge. The education program was effective in improving community pharmacists' knowledge and confidence for counseling patients on oral anti-cancer medications.
The study found that 17% of Pap tests ordered in their resident clinic were inappropriate based on USPSTF guidelines. They created an intervention called the "Pap Clinic" which used an EMR template to guide decision making and patient discussions about cervical cancer screening guidelines. After implementing this clinic, they found a statistically significant decrease in inappropriate Pap tests, from 17% pre-intervention to 1.7% post-intervention. While the results were promising, the study had limitations including a small sample size and potential for selection bias. The intervention showed that templates in EMRs have potential to improve adherence to screening guidelines.
Hugh Gravelle: The impact of care quality on patient choiceNuffield Trust
Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
This study aimed to identify predictors of 30-day readmission in patients undergoing surgery for gynecologic malignancies. The overall 30-day readmission rate was 7.4%. Variables predicting readmission included experiencing a complication prior to discharge, having widespread cancer, and undergoing a non-laparoscopic surgery. A readmission prediction score was developed based on these factors and validated, identifying patients at high (>15%) risk of readmission. The study concludes this scoring system can help target high-risk patients for interventions to prevent readmissions and reduce healthcare costs.
Practice-Level Correlates of Patient-Centered Medical Home Characteristics: A...Marion Sills
For more on SAFTINet please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
Research Objective: Evidence suggests the patient centered medical home (PCMH) model should improve delivery of preventive care services, lower cost, and enhance quality of care. Widespread but varied PCMH implementation offers the opportunity to conduct observational comparative effectiveness research in real-world settings on the impact of specific PCMH functions on clinical outcomes. We examined a series of practice-level characteristics (hypothesized common causes of both PCMH characteristics and clinical outcomes) as possible correlates of PCMH characteristics and confounders of the PCMH- outcomes relationship.
Study Design: Self-report practice-level surveys were administered in 51 primary care practices in the Scalable Architecture for Federated Translational Inquiries Network (SAFTINet), Practice leadership completed (1) the SAFTINet Delivery of Coordinated Care Survey (DoCCS), a measure of multiple PCMH domains including team-based care, panel management, and enhanced access; and (2) a survey of general practice characteristics, including organizational features, patient population, provider/staff characteristics, and health information technology infrastructure. We examined variability in DoCCS total and domain scores and correlations between DoCCS scores and select practice characteristics in 47 practices with complete data.
Population Studied: Participating practices are primarily federally qualified health centers with electronic health records, representing ~260,000 patients (30% covered by Medicaid), 500 primary care providers, and four safety net healthcare organizations in Colorado and Tennessee.
Principal Findings: Total DoCCS scores were moderate to high (M = 3.70, SD = 0.54) on a scale of 1 to 5, with no significant mean differences among the four organizations. Domain scores were as follows: Personal clinician (M = 4.43, SD = 0.59), Team-based care (M = 3.34, SD = 1.43), Access (M = 3.82, SD = 0.53), Patient centeredness (M = 3.77, SD = 0.72), Coordinated/Integrated care (M = 3.82, SD = 0.51), Quality Improvement (M = 3.56, SD = 0.58), Evidence-Based Medicine (M = 3.42, SD = 0.91), Engaged Leadership (M = 3.40, SD = 0.89), and Registries (M = 3.98, SD = 1.04). Characteristics of patient population that were positively related to total score include proportion of Caucasian patients and proportion of patients for whom English is their first language. Domain-specific results will also be presented.
Conclusions: Of practices in SAFTINet, there was variability across practices in DoCCS scores, suggesting that the DoCCS can detect variation in PCMH characteristics. Practices caring for more minority and non-English- speakers.
Answering key questions on malaria drug delivery: 8 years of researchACT Consortium
Presentation by David Schellenberg
Director, ACT Consortium
Professor of Malaria & International Health at London School of Hygiene & Tropical Medicine
The experience of survival following Blood and Marrow Transplant in NSW, Aust...Cancer Institute NSW
Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many experience significant late morbidity and mortality.
The study evaluated a 4-month physical activity intervention using a virtual advisor named Carmen for inactive, low-income Latino older adults. Participants in the intervention reported a 30 minute per day increase in walking and a daily step count of around 6,800 compared to modest changes in the control group. Participants engaged well with Carmen, felt close to her, and continued accessing her for months after the formal study ended, suggesting virtual advisors may effectively promote physical activity in underserved communities.
This document summarizes an assessment of early warning indicators (EWIs) of HIV drug resistance in Namibia in 2015. Key findings include:
- Less than half of ART sites met targets for on-time pill pickup and patient retention. Pharmacy stockouts were also issues.
- Viral load suppression rates could not be fully assessed due to low rates of viral load completion among eligible patients.
- Namibia has successfully integrated EWI monitoring into its ART program. Improvement areas include patient adherence, retention, medication availability, and viral load monitoring. Corrective actions are being implemented.
Presented by Melissa McLaws, Theo Knight Jones, Chris Bartels at the open session of the standing technical and research committees of the European Commission for the control of foot and mouth disease, Cavtat, Croatia, 29-31 October 2014.
This study analyzed data from 10 randomized controlled trials testing post-discharge care management programs for heart failure patients. It found that programs using multidisciplinary teams and in-person communication significantly reduced hospital readmissions and readmission days compared to routine care. However, programs relying only on telephone follow-up did not significantly reduce hospital use. The study concludes that payers should incentivize hospitals to adopt chronic care management programs shown to effectively reduce hospital utilization, which could lower costs for programs like Medicare that cover many patients with chronic illnesses.
Randomized Controlled Pilot Study Testing Use of Smartphone Technology for Ob...Writers Per Hour
This document summarizes a randomized controlled pilot study that tested the use of smartphone technology for obesity treatment. The study involved 68 participants, with some using a smartphone app and others not. The results showed that over 50% had a positive reaction to the app, and 58% found the app's functionality helpful for physical activity and self-monitoring. However, the large dropout rate also indicated a need for more controlled trials and retention strategies like counseling to improve effectiveness. In conclusion, while smartphone technology shows potential, more research is still needed to fully analyze its impact on obesity treatment and prevention.
This document summarizes Parkland Center for Clinical Innovation's breast cancer health equity initiative. The initiative aims to understand and address socioeconomic inequities leading to breast cancer disparities. Analysis found late-stage diagnoses were more common for patients without recent mammograms or Parkland touchpoints. Focus groups revealed barriers like cost, transportation, and need for more education. Next steps include expanding data analysis, using data to drive operational and policy changes, and measuring improvements through mobile mammography unit deployment and partnerships.
Evaluating the Impact of Literature Searching Services on Patient Care Throug...Jeff Mason
Hospital libraries must demonstrate the value and impact they have within their organizations. We created a short survey to assess the impact literature searches conducted by librarians have on patient care. This presentation was given at the 2014 Medical Library Association Annual Meeting in Chicago. Preliminary results are discussed.
We want you to use our survey to assess your own value! To view a copy please visit:
http://fluidsurveys.com/s/literature-searching-impact-survey-site/
Innovations conference 2014 building a quality cancer system concurrent sessi...Cancer Institute NSW
The document summarizes findings from a survey of GPs in NSW, Australia that was part of an international cancer benchmarking study. Key findings included:
- GPs expressed strong support for timely cancer diagnosis but less so for lung cancer. Nearly half saw gatekeeping as important.
- There were differences in access to diagnostic tests and specialists between urban and rural GPs, and between public and private systems.
- Waiting times heavily influenced referral pathways.
- The findings can help improve coordination between primary and specialist cancer care and provide a baseline for monitoring changes over time.
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
While clinical trials represent leading cancer research, less than 5% of cancer patients enroll due to a lack of awareness and resources. Physicians have little time to enroll patients, and patients and doctors have misconceptions about clinical trials. Molecular targeted trials, based on genetic markers, require less patients than traditional trials to produce meaningful results. Unlike traditional trials, targeted trials do not use placebos and allow switching to tested drugs if beneficial. While complex genetic profiling is required for targeted trials, they provide more personalized treatment with fewer side effects than chemotherapy. Focusing clinical trial searches on predefined molecular markers can help patients find more suitable targeted trials.
Professor Mike Pringle presented on the impact of the Quality and Outcomes Framework (QoF) in the UK. He addressed whether QoF improved health outcomes, reduced inequality gaps, and was cost-effective. While some metrics like blood pressure monitoring rates increased after QoF, improvements pre-dated it. QoF risks included box-ticking and reduced professionalism. Initially, inequality gaps widened but narrowed over time as deprived areas improved. While QoF cost £1 billion annually, its effects were smaller than socioeconomic factors. It remains unclear if QoF is truly cost-effective.
This study analyzed data from 658 insured pregnant women in a Midwestern county to compare risks and outcomes between those who did and did not utilize the emergency department (ED) during their peripartum period. The study found that 218 women (33%) visited the ED at least once during this time. ED users were more likely to experience psychosocial risks like postpartum depression and smoking, have poorer birth outcomes like prematurity, and have inadequate prenatal care. After adjusting for demographic factors, ED use was associated with a higher likelihood of postpartum depression, smoking during pregnancy, unstable housing, delayed prenatal care initiation, and missing a postpartum visit.
The SHARE project aimed to improve care and research collaborations for pediatric rheumatology in Europe from 2012-2015. Key results included:
1. Surveys identifying needs in European countries and best practices for diagnosis, treatment, and obtaining consent.
2. Development of consensus treatment guidelines for conditions like JDM and childhood SLE through literature reviews and expert consensus.
3. An updated pediatric rheumatology website and patient information translated into multiple languages.
4. Papers identifying barriers to international data and sample sharing between countries due to differences in ethical approval processes.
The project provided guidance to improve uniformity of care for pediatric rheumatic diseases across Europe and opportunities to facilitate research collaboration and influence European policies.
Innovations conference 2014 erica wales does an online anti-cancer medicati...Cancer Institute NSW
This document summarizes Erica Wales' research evaluating an online oral anti-cancer medication education program for community pharmacists. It found that the program significantly improved pharmacists' knowledge and confidence in dispensing oral anti-cancer medications. Before the program, pharmacists on average answered 60% of knowledge questions correctly and most reported little confidence. After completing the online education, pharmacists answered on average 92% of questions correctly and reported being moderately or very confident in their knowledge. The education program was effective in improving community pharmacists' knowledge and confidence for counseling patients on oral anti-cancer medications.
The study found that 17% of Pap tests ordered in their resident clinic were inappropriate based on USPSTF guidelines. They created an intervention called the "Pap Clinic" which used an EMR template to guide decision making and patient discussions about cervical cancer screening guidelines. After implementing this clinic, they found a statistically significant decrease in inappropriate Pap tests, from 17% pre-intervention to 1.7% post-intervention. While the results were promising, the study had limitations including a small sample size and potential for selection bias. The intervention showed that templates in EMRs have potential to improve adherence to screening guidelines.
Hugh Gravelle: The impact of care quality on patient choiceNuffield Trust
Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
This study aimed to identify predictors of 30-day readmission in patients undergoing surgery for gynecologic malignancies. The overall 30-day readmission rate was 7.4%. Variables predicting readmission included experiencing a complication prior to discharge, having widespread cancer, and undergoing a non-laparoscopic surgery. A readmission prediction score was developed based on these factors and validated, identifying patients at high (>15%) risk of readmission. The study concludes this scoring system can help target high-risk patients for interventions to prevent readmissions and reduce healthcare costs.
Practice-Level Correlates of Patient-Centered Medical Home Characteristics: A...Marion Sills
For more on SAFTINet please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
Research Objective: Evidence suggests the patient centered medical home (PCMH) model should improve delivery of preventive care services, lower cost, and enhance quality of care. Widespread but varied PCMH implementation offers the opportunity to conduct observational comparative effectiveness research in real-world settings on the impact of specific PCMH functions on clinical outcomes. We examined a series of practice-level characteristics (hypothesized common causes of both PCMH characteristics and clinical outcomes) as possible correlates of PCMH characteristics and confounders of the PCMH- outcomes relationship.
Study Design: Self-report practice-level surveys were administered in 51 primary care practices in the Scalable Architecture for Federated Translational Inquiries Network (SAFTINet), Practice leadership completed (1) the SAFTINet Delivery of Coordinated Care Survey (DoCCS), a measure of multiple PCMH domains including team-based care, panel management, and enhanced access; and (2) a survey of general practice characteristics, including organizational features, patient population, provider/staff characteristics, and health information technology infrastructure. We examined variability in DoCCS total and domain scores and correlations between DoCCS scores and select practice characteristics in 47 practices with complete data.
Population Studied: Participating practices are primarily federally qualified health centers with electronic health records, representing ~260,000 patients (30% covered by Medicaid), 500 primary care providers, and four safety net healthcare organizations in Colorado and Tennessee.
Principal Findings: Total DoCCS scores were moderate to high (M = 3.70, SD = 0.54) on a scale of 1 to 5, with no significant mean differences among the four organizations. Domain scores were as follows: Personal clinician (M = 4.43, SD = 0.59), Team-based care (M = 3.34, SD = 1.43), Access (M = 3.82, SD = 0.53), Patient centeredness (M = 3.77, SD = 0.72), Coordinated/Integrated care (M = 3.82, SD = 0.51), Quality Improvement (M = 3.56, SD = 0.58), Evidence-Based Medicine (M = 3.42, SD = 0.91), Engaged Leadership (M = 3.40, SD = 0.89), and Registries (M = 3.98, SD = 1.04). Characteristics of patient population that were positively related to total score include proportion of Caucasian patients and proportion of patients for whom English is their first language. Domain-specific results will also be presented.
Conclusions: Of practices in SAFTINet, there was variability across practices in DoCCS scores, suggesting that the DoCCS can detect variation in PCMH characteristics. Practices caring for more minority and non-English- speakers.
Answering key questions on malaria drug delivery: 8 years of researchACT Consortium
Presentation by David Schellenberg
Director, ACT Consortium
Professor of Malaria & International Health at London School of Hygiene & Tropical Medicine
The experience of survival following Blood and Marrow Transplant in NSW, Aust...Cancer Institute NSW
Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many experience significant late morbidity and mortality.
The study evaluated a 4-month physical activity intervention using a virtual advisor named Carmen for inactive, low-income Latino older adults. Participants in the intervention reported a 30 minute per day increase in walking and a daily step count of around 6,800 compared to modest changes in the control group. Participants engaged well with Carmen, felt close to her, and continued accessing her for months after the formal study ended, suggesting virtual advisors may effectively promote physical activity in underserved communities.
This document summarizes an assessment of early warning indicators (EWIs) of HIV drug resistance in Namibia in 2015. Key findings include:
- Less than half of ART sites met targets for on-time pill pickup and patient retention. Pharmacy stockouts were also issues.
- Viral load suppression rates could not be fully assessed due to low rates of viral load completion among eligible patients.
- Namibia has successfully integrated EWI monitoring into its ART program. Improvement areas include patient adherence, retention, medication availability, and viral load monitoring. Corrective actions are being implemented.
Presented by Melissa McLaws, Theo Knight Jones, Chris Bartels at the open session of the standing technical and research committees of the European Commission for the control of foot and mouth disease, Cavtat, Croatia, 29-31 October 2014.
Burden of HIV and Research Gaps Among Key Populations in Sub-Saharan AfricaHopkinsCFAR
Key populations including sex workers, men who have sex with men, and people who inject drugs experience disproportionately high HIV burdens in sub-Saharan Africa due to various biological, behavioral, and structural factors. HIV prevalence among female sex workers ranges from 10.9% in Eastern Europe to 36.9% in sub-Saharan Africa, where sex workers are 12 times more likely to be infected than other women. Men who have sex with men also experience high HIV prevalence, though data remains limited in sub-Saharan Africa. Combination prevention approaches including behavioral, biomedical, and structural interventions are needed to address the outsized impact of HIV on key populations.
At baseline, two of 986 sex workers were HIV positive in Madagascar. 77.5% of sex workers in Antananarivo and 73.5% in Tamatave had at least one curable sexually transmitted infection (STI). Two months after treatment and counseling, 64.9% of sex workers in Antananarivo and 57.4% in Tamatave had at least one STI. The researchers developed evidence-based STI treatment guidelines for sex workers in Madagascar in collaboration with sex workers and health professionals. The guidelines included speculum exams, syphilis screening and treatment, and presumptive treatment for other STIs during initial and follow-up visits.
This document summarizes research on population-wide drug-based strategies for malaria elimination in three African countries. Key findings include:
1) Mass drug administration (MDA) reduced malaria infection prevalence in Zambia when added to standard care, showing potential to accelerate elimination.
2) Mass test and treat (MTAT) had modest impact on incidence due to limits of current diagnostics.
3) High population coverage was achieved for MDA, focal MDA, and MTAT strategies.
4) Preliminary data found MDA and focal MDA costs were comparable to MTAT and could decrease without research components.
5) Population-wide strategies may be useful in some settings as part of a comprehensive
Measuring the Impact of National-Scale Malaria Interventions Using the Plausi...MEASURE Evaluation
This document summarizes a presentation on measuring the impact of national-scale malaria interventions in Uganda using a plausibility approach. It describes using multiple data sources like household surveys, health management information systems, and routine data to assess trends in malaria indicators and plausibly attribute changes to intervention scale-up. While each data source has limitations, triangulating different sources can help establish a causal story. Routine data provides frequent data points to precisely link changes in coverage and outcomes but has quality issues. Creative analytical methods and a prospective country evaluation design combining data sources may help provide a robust impact evaluation.
Cancer Screening in a Middle Income Country: Malaysia's experienceArunah Chandran
This document summarizes Malaysia's experience with cancer screening and control efforts. It notes that non-communicable diseases like cancer account for over 70% of deaths in Malaysia. The National Strategic Plan for Non-Communicable Diseases aims to reduce cancer morbidity, mortality, and improve quality of life through various prevention, screening, treatment, and palliative care initiatives. Specific programs are in place for cervical cancer screening via Pap smears and HPV vaccination, as well as other cancers. Challenges remain in increasing screening and treatment coverage, addressing barriers, and ensuring access. Continued efforts are needed to work towards cervical cancer elimination targets in Malaysia.
Innovations in Community-based Diagnosis and Treatment of Acute Malnutrition ...CORE Group
This study compared the efficacy of mothers versus community health workers (CHWs) screening children for severe acute malnutrition (SAM) in Niger. Over 12,000 mothers and 36 CHWs were trained to use mid-upper arm circumference (MUAC) color-coded bracelets. Results showed similar coverage rates, but mothers detected cases earlier with higher MUAC agreement rates and fewer children requiring inpatient care. Training mothers was lower cost but achieved better outcomes than using CHWs. The study demonstrates that empowering mothers to screen for malnutrition can improve programs and relieve pressure on health systems.
Teleradiology has been used in Africa to provide radiology services to remote areas. A retrospective study reviewed teleradiology cases in Africa and found that 37% had significant health diseases based on the radiology findings. The study also found that 8% of the pediatric cases were at high risk for disease if ignored. The conclusions were that teleradiology can enable early detection and accurate diagnosis, improve patient outcomes, decrease the spread of infection, and reduce overall healthcare costs.
Improving malaria treatment and control through enhanced diagnostic practiceACT Consortium
Professor David Schellenberg, director of the ACT Consortium, presents at the European Congress on Tropical Medicine and International Health in Basel, Switzerland on 7 September 2015.
This document summarizes a seminar on the epidemiology of cervical cancer in Nepal. It discusses that cervical cancer is the 4th most common cancer globally and is largely preventable through screening and HPV vaccination. In Nepal, 2332 women are diagnosed with cervical cancer annually, with 80.9% of cases diagnosed at late stages. Public health strategies in Nepal to address this include developing screening guidelines, vaccinating girls aged 9-13, providing treatment, and establishing a cancer registry. Screening programs and HPV vaccination are effective interventions, but screening rates in Nepal remain low at only 2.4% due to various barriers.
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3. Problem and Purpose
• Problem: Poor pharmacoadherence remains a
significant barrier to malaria control and
elimination.
• Purpose: To assess the efficacy of a program to
increase the pharmacoadherence rate of the six-
dose ACT treatment of P. falciparum malaria in
the Copperbelt province of Zambia using SMS
reminders through the mobile phone.
4. Question
Are SMS reminders to patients associated with
adherence rates to a six-dose ACT antimalarial
treatment in the Copperbelt Province, Zambia?
5. Literature Review
• Terms: (“cell phone” or “mobile phone” or “mHealth”)
AND (“adherence” or “compliance,”) AND (“health” or
“medication”) AND (“Africa” or “sub-Sahara” or
“Zambia” or “community health workers” or “malaria”)
• Results: (25 Total results included)
6 systematic reviews 10 experimental
7 observ./analytic 1 observ./descriptive
1 non-research article
6. Literature Review Results
• ACT pharmacoadherence
• Mobile health
• Mobile phones to improve adherence
– Non-malaria
– Malaria
7. Theoretical Framework:
Theory of Planned Behavior
Barriers preventing
perceived behavioral
control from becoming
actual behavioral control
SMS Intervention
8. Sample and Setting
• Sample: Convenience sample of 96 participants
(88 participants required for effect size of .30,
α=0.05, power of 0.80)
• Setting: Government Clinic, Fisenge, Zambia
• Target Population: Rural Zambians over 18
years of age who were at least minimally
literate in English, and who were diagnosed
with uncomplicated P. falciparum malaria
9. Intervention and Instruments
• Intervention
– SMS to participants
• Instruments
– Diagnostic: ParaHIT f RDT
– Measurement: MEMS Cap ver. 6
11. Results: Adherence
Intervention (SMS)
# (%)
Control (No SMS)
# (%)
Total
# (%)
Probably adherent 31 (64.6%) 33 (68.8%) 64 (66.7%)
Probably non-
adherent
17 (35.4% 15 (31.2%) 32 (33.3%)
Total 48 48 96
χ2
=0.19, df=1, p=0.67
12. Results: Other
• Demographics
– 52.1% male & 47.9% female
– Age range: 18-64
• Groups
• Pilot study
• Logistic regression
– No variables associated with probable adherence
– Three variables associated with probable perfect
adherence
15. • Implications
– Nursing practice
– Policy
• Further research
– RCT’s
– Synergy with other initiatives
– mHealth
• Summary
Implications & Further Research
Editor's Notes
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Malaria - The estimated global toll of malaria in 2012 was 207 million cases associated with 627,000 deaths.
Eighty-six percent of presumed and confirmed malaria cases in the world occurred in Africa with the majority of these in sub-Saharan Africa.
Zambia, located in the heart of sub-Saharan Africa is plagued by malaria, particularly the Plasmodium falciparum (P. falciparum) species.
The annual number of diagnosed and confirmed cases in Zambia in 2012 was 4.7 million, 2.3% of the total global cases, with an estimated 11,000 deaths.
Of individuals diagnosed with P. falciparum malaria, 90.5% will die if left untreated.
In addition to the significant impact on morbidity and mortality, this parasitic infection is estimated to cost African countries more than $12 billion annually through diagnosis, treatment, and lost productivity, equaling 2-3% of the adjusted Gross National Product of the continent.
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Detection - Accurate malaria detection is critical for combatting the disease. While microscopy is the gold standard for diagnosis of malaria, the cost and lack of availability of trained lab technicians prevent widespread use in resource-limited settings. Currently, Zambian clinics utilize the rapid diagnostic test (RDT) as the accepted diagnostic test
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Treatment - The current pharmacological treatment for uncomplicated P. falciparum malaria, recommended by the WHO, is an artemisinin-based combination therapy. The ACT medication regimen, which has not been modified since 2006, consists of six doses to be taken twice daily over three days, with the 2nd dose 8 hours after the initial dose which is administered at the clinic and subsequent days’ doses 12 hours apart. The extent to which one follows the prescribed regimen is referred to as adherence or pharmacoadherence. This regimen is critical and has been found to be more than 97% effective when strictly adhered to, resolving clinical symptoms even before the regimen is complete.
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Pharmacoadherence - Current statistics for malaria treatment pharmacoadherence rates in sub-Saharan Africa vary widely in their methods and definitions resulting in a range between 36.5% and 91% (M = 61.2; SD = 20.0). Specific attempts to improve pharmacoadherence have included observation, the blister pack, and electronic pillboxes such as the Medication Event Monitoring System (MEMS)
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Mobile phones - Recent advancements in mobile phone technology and availability hold promise for health research application in sub-Saharan Africa. Over two-thirds of the population in Africa is covered by a mobile network, which has resulted in individuals who previously had no access to landlines now having access to low-cost handheld devices with SMS capabilities. Eighty-seven percent of urban Zambian households and 52% of rural households had access to at least one mobile phone in 2008, with expectations for a continued rapid rise as the wave of technology floods the continent.
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Problem: Poor pharmacoadherence remains a significant barrier to malaria control and elimination.
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Purpose: To assess the efficacy of a program to increase the pharmacoadherence rate of the six-dose ACT treatment of P. falciparum malaria in the Copperbelt province of Zambia using SMS reminders through the mobile phone.
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Question: Are SMS reminders to patients associated with adherence rates to a six-dose ACT antimalarial treatment in the Copperbelt Province, Zambia?
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Literature Review
Databases searched: CINAHL, MedLine, and Cochrane Database of Systematic Reviews
Dates: 2005-2013 with 30 results. Incl/Excl criteria applied
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Terms: (“cell phone” or “mobile phone” or “mHealth”) AND (“adherence” or “compliance,”) AND (“health” or “medication”) AND (“Africa” or “sub-Sahara” or “Zambia” or “community health workers” or “malaria”)
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Results: (25 Total results included)
6 systematic reviews10 experimental
7 observ./analytic1 observ./descriptive
1 non-research article
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ACT pharmacoadherence
The pharmacoadherence rates to ACT in two independent studies in sub-Saharan Africa demonstrate surprising similarity to each other with a moderate probable adherence ranging from 64% to 66%. In contrast, other studies found that probable adherence fell in the 38-48% range. The variance is likely associated with a stricter definition of probably adherent in the latter three studies, which considered not only the consumption of all pills, but the timing of consumption as well.
Health researchers have attempted to identify factors associated with adherence to malarial treatment, in order to better identify interventions to improve adherence, and have had widely varying results. While some researchers have focused on finding factors associated with adherence, others have identified barriers preventing or impeding better rates which can lead to possible interventions to improve it.
Adherence to malarial treatment continues to present a multi-faceted challenge. The plurality of factors and results from adherence studies indicates a strong need for further study and standardization. The rapid expansion of technology offers great opportunity for innovative research to address some of these areas.
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Mobile health
The recent rise in technology and mobile phone use in Africa offers an unlimited number of resources for multiple healthcare applications to a wide range of diseases. mHealth, the common name given to mobile technology used for healthcare, is expanding as quickly as the technology it utilizes. Studies exploring the patterns of mobile phone use in sub-Saharan Africa have found the response to the use of cellphones in healthcare to be very positive and cost-effective.
Studies represent a broad use of mobile phones and a broad range of results. Overall results indicate that mHealth is emerging as a potential gold-mine of innovations, containing limitless applications and opportunity for further research including interventions to improve pharmacoadherence in general and ACT in particular.
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Mobile phones to improve adherence
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Non-malaria
The majority of the research on mobile phone use for adherence in sub-Saharan Africa focuses on ART adherence in South Africa, a country that is arguably the most technologically advanced in this geographic context. Much of the non-malaria research utilizing mobile phones for adherence has implemented similar techniques using SMS direct to patients for reminders and many of them offer hope for achievable wide-spread results. Studies have not produced statistical significance across the board, but many suggest promise for new implementations and continued research.
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Malaria
Only six studies were found using SMS for malaria control in Africa with five of these focusing on upstream uses such as disease surveillance or commodity monitoring (Zurovac et al., 2012). The only RCT discovered using downstream SMS reminders for malaria treatment in sub-Saharan Africa is that of Zurovac et al. (2011) in which SMS are sent to CHWs. No studies were discovered that utilized SMS directly to patients for ACT pharmacoadherence in sub-Saharan Africa indicating a significant gap in the literature and research. The current study offers an attempt to address this gap and change adherence behavior.
TPB Model
The theoretical framework underlying the suggested intervention is the Theory of Planned Behavior. The Theory of Planned Behavior (TPB) is a social cognitive model credited to Icek Ajzen as an extension of his and Fishbein’s theory of reasoned action, and incorporates aspects of Bandura’s theory of self-efficacy.
The TPB postulates that there are three constructs that guide behavior. The first construct is that of behavioral beliefs, involving the individual’s beliefs about the expected outcomes of a particular behavior. The collective behavioral beliefs result in a particular favorable or unfavorable attitude towards the behavior. The second, normative beliefs, focuses on the perceived expectations of significant others and one’s motivation to meet those expectations. The collective normative beliefs comprise a subjective norm or social pressure to behave or not to behave in a certain manner. The third and final construct, control beliefs, measures the perception of factors that may facilitate or inhibit this behavior, and the perceived power inherent in those factors. Collective beliefs about control result in a perception of the amount of control one has over one’s own behavior. The sum of these three outcomes – behavioral attitudes, subjective norms and perceived control - results in a level of intention, which, if sufficiently significant, generally results in the desired behavior. Increasing any one of these constructs increases the level of intention, which in turn increases the likelihood of the individual carrying out the behavior
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Barriers preventing perceived behavioral control from becoming actual behavioral control
While perceived control is a critical element in the TPB, there can be barriers to the execution of a behavior, making actual control less than perceived control. These barriers may interrupt one’s intention, preventing the individual from carrying out the behavior. This limit on volitional control indicates that the actual control that one has over a behavior, rather than merely the perceived control, is what determines the resultant action. Some of the barriers to regimen adherence that are identified in the literature review are: Forgetfulness, the medication having a bad taste, the negative side effects (e.g. nausea, vomiting) caused by the medication, and tendency to quit taking the medication when symptoms subside.
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SMS intervention
The intervention of SMS used in this study sought to overcome some of the barriers to adherence by providing both a reminder to address forgetfulness and encouragement to complete the regimen. In addition, the study included a short questionnaire collecting information that may prove helpful in the more difficult task of initiating long-term change in beliefs that can bring about deep-seated, long-term change in behavior.
Sample: Convenience sample of 96 participants (88 participants required for effect size of .30, α=0.05, power of 0.80)
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Setting: Government Clinic, Fisenge, Zambia
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Target Population: Rural Zambians over 18 years of age who were at least minimally literate in English, and who were diagnosed with uncomplicated P. falciparum malaria
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Intervention
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SMS to participants
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Instruments
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Diagnostic: ParaHIT f RDT
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Measurement: MEMS Cap ver. 6
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Recruitment
The clinic nurse identified a potential participant through observational use of inclusion criteria, and referred him or her to the assistant. The assistant then established the eligibility of the individual as a participant using inclusion/exclusion criteria, described details of participation, including the voluntary nature of the study and the incentive offered, and inquired regarding their willingness to participate. If the individual was willing to take part in the study, the assistant obtained permission to record the conversation, educated the participant regarding the regimen, and obtained consent through signature on an Invitation to Participate which was printed in English
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Random assignment
Each participant was randomly assigned to either the intervention group or the control group by block randomization through an envelope system
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Participant instructions
The research assistant verbally instructed all participants on the treatment regimen. Patients were educated regarding the need to take medication with food, and, if vomiting occurs within one hour of the ingestion, to take the next dose and obtain a replacement dose from the clinic. The healthcare provider administered the first dose of the medication in the clinic with the research assistant observing. The assistant reviewed pictorial instructions and provided the remaining nurse-prepared medications per clinic protocol in perforated foil blister packs containing a 4-pill dose each. These were inserted into an electronic pill bottle with a MEMS cap, along with written instructions regarding the regimen. The MEMS cap on the pillbox containing the ACT electronically recorded the time of each opening of the medication bottle beginning with the first dose. The participant was instructed to return between three days and one week from the distribution date with the electronic pillbox for a health re-evaluation. A pre-paid phone card with 20 kwacha (approximately $3.50) of talk time was presented in appreciation for participation when the bottle was returned.
If the participant was in the control group, the assistant released him/her.
If the participant was in the intervention group, the SMS communication was described and reviewed if necessary. The assistant then released him/her and initiated the SMS intervention sequence.
Intervention
Control
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SMS intervention sequence
The PI generated an SMS reminder to the participant at the prescribed time each dose of the medication was to be taken - 8 hours after the initial dose and at the prescribed times of 8 a.m. and 8 p.m. for the subsequent 2 days of the regimen.
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Pharmacoadherence measurement
Pharmacoadherence was measured by comparing electronic pillbox openings to the prescribed times of the treatment regimen. Adherence was defined as having an electronically recorded bottle opening within one hour of the prescribed time for the second dose (8 hours after initial dose), and a recorded bottle opening within two hours of the prescribed time for the next two days’ doses (8 a.m. and 8 p.m. on each day) based on dosage recommendations. The completion of the regimen was verified by a final pill count (target = 0). If the recorded bottle opening times fell within the designated ranges and the pill count was 0, the patient was considered probably adherent. If either requirement is not satisfied, they were classified probably non-adherent.
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The pharmacoadherence data were analyzed by Pearson’s Chi-square test of association and the result was not found to be significant (χ2=1.01, df=1, p=0.32).
REVIEW TABLE
Probable perfect adherence was defined by digitally-recorded MEMS bottle openings occurring only during the timeframes of adherence and only the required six openings with one in each timeframe but was also NOT found to be associated with the SMS intervention (χ2=1.01, df=1, p=0.32).
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Results
MEMS cap and demographic data were collected over a 2-month period and analyzed using IBM SPSS for Mac version 22.0. All records used in the sample were complete with no missing data.
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Demographics
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52.1% male & 47.9% female
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Age range: 18-64
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Groups – Chi-square test of homogeneity showed no difference (All p>0.05)
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Pilot study – The first ten patients recruited comprised a pilot study to determine whether adjustments to the study were needed and to refine procedures before completing the study. Adjustments were made as necessary, and those in the pilot study who needed no adjustments are included in the full and final sample.
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Logistic regression was conducted to determine if other variables were associated with adherence.
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- No variables associated with probable adherence
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- Three variables associated with probable perfect adherence
1. Lower age (OR 0.099, 95% CI [0.024, 0.41], p<0.01), 2. owning a radio (OR 0.096, [0.019, 0.47], p<0.01), and3. residing in a village rather than rural (OR 0.116, [0.026, 0.51], p<0.01).
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Discussion
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Higher than comparable ACT adherence rates
While the association between the SMS and adherence were not significant, the rates of adherence for both control (68.8%) and intervention groups (64.6%) were higher than other comparable measures of ACT adherence in sub-Saharan Africa. When the definition of adherence included consideration of the medication timing in the literature, probable adherence ranged from 38.7% to 48.3%. The higher rate of adherence may be attributed to the use of the MEMS bottle, which has been found to improve adherence .
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Variables associated with probable perfect adherence
The lower age may be associated due to the young being more open to treatment by medication since they did not live through much of the traditional treatment history that preceded modernity. Owning a radio may indicate a higher socio-economic status and/or being exposed to mass media anti-malarial campaigns. Village life would bring more exposure to the experience of others who have benefited from medical treatment compared to those living in rural areas. The likelihood of electricity in the village also brings an added level of technology, and with it, education.
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- Methodological assumptions & limitations
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Design
Contamination: Since none of those responding to the end-of-study questionnaire indicated knowledge of the other group, contamination was considered negligible.
Verification of SMS receipt: Receipt and timing of SMS messages were not confirmed
Other issues that could negatively impact the timeliness of the receipt of the SMS include participants leaving the coverage area, not being in the vicinity of their phone, or having depleted mobile phone batteries without immediate access to electricity to recharge them.
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Sampling
Using a convenience sample as opposed to a probability sample can result in selection bias. Due to the sampling being taken from a single village location, patient demographic characteristics may differ from those in other regions of the country. While all visible observations indicate that Fisenge is a typical rural Zambian village in the Copperbelt Province, statistics were not available to justify this assumption, limiting generalizability without further statistical substantiation.
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Measurement
Defining and measuring actual adherence
MEMS cap helps, but it records only the opening and closing of the pill bottle, not ingestion of medication
The assumption was that if a MEMS cap recorded an opening during the adherence time window probable adherence was assumed, even if the bottle was opened at other times between adherence windows
Consistency in the definition and measurement of adherence is critical as related studies are conducted.
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Statistical
One assumption of the Chi-square test is that no cells have a count of five or less. Our analysis and sample size met that assumption, validating the use of Chi-square.
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Other Challenges
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Communication barrier
Though the assistant was fluent in English, miscommunication still occurred. The explanation of randomization, for example, took significant explaining multiple times before the assistant understood the process. This communication barrier even with those fluent in English could potentially impact the study.
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Cultural differences
For example, a significant number of community members reported that malaria can be contracted by eating an unripe mango, or even from being caught out in the rain. Curses and spells are believed to be one of the primary causes of illness in the Copperbelt. Based on these misunderstandings, it seems that better education and knowledge may improve not only adherence, but also prevention of the disease.
Traditional African belief often attributes the causes of diseases to ancestors or witchcraft.
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Mobile phones
The cost of mobile phones and the poverty in sub-Saharan Africa often lead to fixed shared-access mobile phones. Though the participant may still have access as required for this study, the phone may be in use by another member of the household at the time the SMS is sent.
Challenge is knowing to which phone number to send the SMS.
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MEMS caps
Another challenge was the need to reuse MEMS caps for multiple patients, a practice that is discouraged by the manufacturer, Aardex (2013). The primary reason for the discouragement of this practice is the possibility of cross-contamination, however since malaria in a non-contagious disease, and because the pills were in blister packs within the bottles, this objection was not considered substantive
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Implications
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Nursing practice
The study indicates few implications to nursing practice due to the lack of association between SMS and adherence other than to add to the current body of knowledge. However, there are some implications for nursing research. Pharmacoadherence is a multi-faceted concept that will not be easily solved with any individual intervention. The SMS reminder, if found to be associated with adherence in further research, can be used to supplement other adherence strategies in the hope to improve pharmacoadherence not only for ACT and malaria, but also for other long-term illnesses, where forgetfulness may be more prevalent.
The many challenges that the PI faced with communicating clearly to those of another language and culture reinforced the necessity of adequate training and understanding for those involved in research. The more one learns about the culture prior to research, the less likely miscommunication and misunderstanding is to occur.
The lack of adherence differences discovered and the higher level of adherence may be due to a combination of these best practices and the incentive provided.
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Policy
The National Malaria Control Programme of Zambia falls under the Directorate of Public Health and Research in the Ministry of Health and has established the Zambian National Health Strategic Plan 2011-2015. One of the main objectives of this plan is to reduce the annual incidence of malaria to 75 per 1,000 by 2015 exceeding the RBM goal (RBM, 2010). Two strategies in the plan, a focus on health service delivery by promoting support for health management, and targeting malaria treatment interventions offer opportunities for technology to be used to improve pharmacoadherence. However, any such use is affected by mobile network coverage and marginalized areas must be targeted by national policies to ensure the effectiveness of such interventions.
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Further research
RCT’s
Synergy with other malaria initiatives
mHealth - Mobile phone applications & attachments
SUMMARY - Though we found no association between SMS and adherence, there is much further research to be done. Harnessing the wave of technological innovation could lead to a more healthy humanity as we continue to allow our imaginations to guide us. Dare we dream of eliminating this dreadful disease?