Evaluating Cost Gavin Steel, Jude Nwokike, Mohan P. Joshi & Mupela Ntengu Development and...
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Transcript of Evaluating Cost Gavin Steel, Jude Nwokike, Mohan P. Joshi & Mupela Ntengu Development and...
Evaluating Cost
Gavin Steel, Jude Nwokike, Mohan P. Joshi & Mupela Ntengu
Development and Implementation of a Multi-
Method Medication Adherence Assessment Tool Suitable for
Antiretroviral Therapy Facilities in Resource-Constrained
Settings
Project Plan
Phase I – Feasibility of the tool Phase II – Validation Phase III – Dissemination of results Phase IV - Training
2
Phase I — Feasibility - Design
The four measures included in the multi method pilot tool were —
Self-report Visual Analogue Scale (VAS) Pill identification test (PIT) Pill count
The adherence tool developed was administered to patients presenting for routine follow-up ART care
After each patient contact, the administering health care worker was asked to rank his or her experience with the tool
Phase I — Feasibility - Results
4
N = 440
Phase I — Feasibility – Results (2)
The interview took an average of 5 minutes
In the self-report, “YES/NO” style responses were recommended above rank order because:o 20% of interviewers described rank order as “difficult”
to administer. o Difficulty was linked to patient’s level of education. o Ranking numbers had a weaker correlation with
MEMS {r = 0.42 vs r = 0.53}.o Ranking process was time consuming to administer.
Phase II — Validation – Final tool
Self report
Visual Analogue Scale
Pills Identification test
Pill Count
Multi Method assessment
Phase II — Validation - Design
To provide objective data to validate the tool, the following data was collected in a smaller group
o Medication Event Monitoring System (MEMS)o Viral load and CD4 counto A blinded pill count where patients were randomly
assigned to receive an undisclosed quantity of medication
MEMS
Phase II — Validation – Results (1)
Multi method score (r = 0.73; 95% CI 0.5 – 0.85)
• Correlation of measures with MEMS
Phase II — Validation – Results (2)
• Pill dumping occurred in 8% of blinded patients• Pill count over estimates adherence
• Pill Count• 60% of the 440 patients were blinded to quantity
Phase II — Validation – Results (3)
Overall validation findings:
• No single method was superior• Each method overestimated adherence• Individual methods identified different types of
adherence difficulties• The multi method adherence rating was
conservative.
Phase III – Dissemination of results
Findings were presented to the South African:
o Policy makerso Professional societies.o HIV clinical scientific community
Adherence tool formally adopted in 2008
o Essential Drug List –Primary Health Care edition.
o ARV treatment guidelines.
Phase IV - Training Users manual and training tools were
developed.
24 workshops where 635 health care providers were trained on the use of the tool.
2010 Medicine Utilization Evaluation MUE comparing two hospitals ARV prescribing:o 71% adoption of the tool by personnel trained
2 years previously o 18% where no training had been received
Conclusion (1)
Multi method adherence assessment provided the best correlation with MEMS data.
Simple Yes/No responses were preferable to rank order in self reporting.
Pill counts were susceptible to pill dumping and hence overestimated adherence.
A multi method approach identifies more patients in need of adherence support.
Conclusion (2)
Researchers developing RMU tools need to take into consideration the implementation plan.
Educational interventions improve the uptake of tools disseminated via guidelines.
Acknowledgments
Gillian Collet & Mark Patterson SPS South Africa Senior Program Associates USAID & PEPFAR