Technical and Behavioral Interventions for Medication Adherence through Mobile Health

In this research, we present a novel intervention, Carrot and Stick, to improve the outcome of one of the self-management tasks, medication adherence (MA), among patients with chronic disease(s). Our design incorporates the growing importance of mobile health (m-health) in Health Information Technology (HIT) with the users’ dependency on mobile phones to facilitate valuable behavioral changes. Drawing on Social Cognitive Theory, Social Exchange Theory, Goal-setting Theory, and people’s dependence on smartphones, we develop the functionalities in our intervention, including positive and negative reinforcement, goal-setting, and social connections. The iterative process of our development follows the Design Science Approach. In the evaluation and validation of our intervention, we not only examine the intervention’s impacts on patients through analytical models and simulation but also demonstrate the possible active support of the intervention from healthcare providers based on the current pay-for-performance (P4P) scheme. Our results suggest that (1) with the help of electronic medication container, appropriate reminder design can reduce the patients’ chances of forgetting doses, overdosing, and intaking doses at the wrong time, (2) positive reinforcement can help increase the probability of the patient achieving expected MA, while negative reinforcement has a further impact that is added to the increment, (3) our intervention can assist the patient in saving more than $600 per year, and (4) under the current P4P scheme, physicians with the exceptional performance or with bad performance are likely to invest in the intervention to change their patients’ behaviors, while physicians with good performance are less likely to participate. Our research is the first to utilize negative reinforcement in intervention design to enhance MA; it is also the first to provide corresponding interventional solutions that are customized according to elements derived from theories. Besides, the focus and understanding of healthcare providers’ involvement in the incentive program can facilitate the adoption, prescription, and implementation of the proposed intervention

Pharmacy value-based incentive programs: an evaluation of health plan strategies, pharmacist attitudes, and financial impact on retail stores

Since the Affordable Care Act (ACA) in 2012 health plans serving Medicare beneficiaries have begun receiving sizeable incentives (\u3e$1B) for demonstrating high ratings to quality performance scores in CMS’s Medicare star ratings program. Several of the quality measures can be directly impacted by retail pharmacists (e.g. medication adherence measures) resulting in health plans implementing programs designed to incentive retail pharmacies to work toward improving their own performance related to quality measures. While awareness of these value-based incentive (VBI) programs is growing there is still a significant lack of research which elucidates the nature of these programs and the potential impact they are having on the field of retail pharmacy. This dissertation attempts to provide a better understanding of the impact of VBI programs on retail pharmacy through three parts. The first paper provides a categorization of the three primary strategies which are being employed through current VBI programs. Furthermore the paper summarizes and provides anecdotal evidence of five distinct programs which are being considered or implemented. The second paper explores retail pharmacy’s perception of the impact of quality measures and VBI programs through quality research with retail pharmacy managers. The third paper evaluates the financial impact to retail pharmacies of three potential VBI programs. The results of this dissertation provide a step forward in exploring how retail pharmacy is being affected by healthcare’s shift toward achieving quality performance ratings

Intolerance of uncertainty and impulsivity in opioid dependency

Opioid abuse has reached epidemic status in the United States, and opioids are the leading cause of drug-related deaths in Australia and worldwide. One factor that has not received attention in the addiction literature is intolerance of uncertainty (IU). IU is personality trait characterised by exaggerated negative beliefs about uncertainty and its consequences. This thesis investigates the links between IU and impulsive decision-making in the context of opioid-dependency. Four experimental studies examined impulsive decision-making from multiple perspectives, and assessed for the first time how impulsivity interacts with IU in opioid-dependent individuals. Across all four studies, opioid-dependent adults reported markedly higher levels of IU compared to a healthy control group. This consistent result provides strong evidence that IU is a personality trait that is related to drug addiction, whether it may be a pre-morbid risk factor, a result of chronic drug use or a co-occurring phenomenon based on shared neural correlates. A common thread between studies was that IU and impulsivity were meaningfully related in opioid-dependent individuals, but not in control groups. Specifically, IU was correlated with self-reported impulsive personality traits, poor attentional control, risk taking for monetary losses and risk-aversion for health improvements. No meaningful correlations were found between IU and impulsivity in control participants. These findings have important implications for addiction prevention and therapy. It is commonly accepted that pharmaceutical opioids are a driving factor for the upsurge in heroin abuse, and IU may be helpful to screen for at-risk individuals. Furthermore, addiction treatment could benefit by addressing IU in order to improve faulty beliefs about and reactions to uncertainty

Efeito de uma intervenção combinada no controlo da hipertensão arterial, em doentes dos cuidados de saúde primários, em Lisboa

Tese de mestrado, Epidemiologia, Faculdade de Medicina, Universidade de Lisboa, 2015Introduction: Although effective antihypertensive treatments have been developed in the last decades, 57.5% of the patients have uncontrolled blood pressure (BP), enforcing the need to develop better control strategies. Study Objectives: The objective of the present study is to evaluate whether a combined intervention, which includes a tailored educational and behavioral component, improves BP control and medication adherence, compared to usual care. Methods: This was a two-arm, randomized controlled trial, with three-month follow-up. Eligible patients had a diagnosis of hypertension, with a mean systolic blood pressure (SBP) ≥ 140 or diastolic blood pressure (DBP) ≥ 90 mmHg for the BP measurements from the previous 12-month period (SBP ≥ 130 or DBP ≥ 80 mmHg for patients with diabetes mellitus) and were taking no more than four antihypertensives. Eligible patients were randomly assigned to receive the education and behavioral intervention or usual care. The intervention was based on a tailored educational session and on a paper diary, developed to facilitate the registry of their BP levels and daily antihypertensive medication. Patients were advised to bring their diaries to each clinical visit, to be reviewed with the physician. The primary outcome was the change in the BP control from baseline to follow-up. We examined changes in SBP and DBP and in medication adherence as secondary outcomes. Results: Of the 248 enrolled patients (Intervention=83; control=165), 198 patients completed the follow-up visit. At baseline, 33.7% of participants had controlled BP and 80.8% were adherent to antihypertensive medication. The control group contained more patients with diabetes (p=0.007) and a higher proportion of smokers (p=0.003). There were no differences in BP control after three months between the control and the intervention group (adjusted odds ratio (OR) 0.64; confidence interval (CI): 0.3-1.5; p=0.288). Mean BP decreased 6.45/4.73 and 5.47/2.7 mmHg in the control and intervention groups, respectively, with no differences between groups [p=0.679 (SBP) and p=0.166 (DBP)]. More intervention patients improved medication adherence, but no group differences were observed at follow-up (adjusted OR 0.83; CI: 0.3-2.2; p=0.688). For patients with uncontrolled BP at baseline, the control group had a significantly greater reduction of SBP (-3.87mmHg, p=0.041) and DBP (-4.83mmHg, p=0.002) and a significantly higher improvement in BP control (adjusted OR 0.19; CI: 0.1-0.7; p=0.008) compared to the intervention group. In the sensitivity analysis, similar results to the primary analysis were observed. Conclusions: This intervention did not lead to improvements in BP control or medication adherence. The high adherence and BP control rates at baseline, and the significantly higher proportion of patients with treatment changes in the control group, may explain why no intervention effect was observed.Introdução: A hipertensão arterial é um dos mais importantes fatores de risco para as doenças cardiovasculares e apresenta uma elevada prevalência em Portugal. Apesar de, nas últimas décadas, terem sido desenvolvidas terapêuticas antihipertensoras eficazes, 57,5% dos hipertensos medicados não têm a sua hipertensão controlada, reforçando a necessidade de desenvolver estratégias para melhorar o controlo da pressão arterial em Portugal. Diversas intervenções para melhorar a adesão em doentes hipertensos têm sido desenvolvidas e estudadas. O recurso a diários para preenchimento pelo doente hipertenso é uma ferramenta de autocontrolo utilizada para melhorar a adesão à terapêutica, promovendo um maior envolvimento e motivação do doente, além do facto de ser um meio de recordar a toma da medicação. A automonitorização da pressão arterial (em casa) pode ser efetiva na modificação da perceção do hipertenso face à sua pressão arterial, podendo, assim, incentivá-lo a cumprir melhor as modificações de estilo de vida e a toma da medicação. A combinação destas intervenções foi avaliada no projeto HyDia quanto à melhoria no controlo da pressão arterial, através da melhoria da adesão à terapêutica e conhecimento sobre a hipertensão e medicação antihipertensora e da facilitação da comunicação médico-doente quanto a esta patologia. Objetivos: Inserido no projeto HyDia, o presente trabalho pretende analisar o efeito de uma intervenção combinada, que inclui uma componente educacional e comportamental, na melhoria do controlo da pressão arterial e da adesão à terapêutica, face aos cuidados de saúde habituais. Métodos: O estudo HyDia é um ensaio clínico aleatorizado e controlado, sem ocultação e com três meses de seguimento dos participantes. Os participantes foram selecionados de centros de saúde/unidades de saúde familiar da região de Lisboa. Foram considerados como elegíveis, doentes hipertensos, com pressão arterial sistólica (PAS) ≥ 140 mmHg ou pressão arterial sistólica (PAD) ≥ 90 mmHg (PAS ≥ 130 mmHg ou PAD ≥ 80 mmHg para doentes com diabetes mellitus) nos 12 meses anteriores e a tomarem não mais do que quatro medicamentos antihipertensores. Foram excluídos do estudo indivíduos dependentes de terceiros para a toma da medicação, com problemas cognitivos, angina instável, doença renal ou hepática grave, insuficiência cardíaca grave, enfarte de miocárdio ou acidente vascular cerebral nos seis meses anteriores e grávidas. Os doentes elegíveis foram aleatoriamente designados para receber a intervenção educacional e comportamental ou cuidados habituais, na proporção de 1:2, respetivamente. A intervenção baseou-se numa sessão educacional adaptada ao perfil do doente e num diário em papel – Diário da Hipertensão – desenvolvido de forma a facilitar o registo das medições de pressão arterial e da medicação antihipertensora por parte dos doentes, de acordo com um protocolo predefinido. Os participantes do grupo intervenção receberam também um monitor Omrom® 6M e foi-lhes pedido que medissem a pressão arterial duas vezes por dia em dois dias da semana e que registassem os valores no diário. Os participantes foram aconselhados a levar os seus diários às consultas médicas, possibilitando a consulta e preenchimento pelo médico. Um mês e dois meses depois da sessão de intervenção, foram realizados telefonemas aos participantes com o objetivo de os encorajar a manter as alterações comportamentais e garantir que a intervenção estava a ser seguida de acordo com o protocolo. O outcome primário foi a alteração do controlo da pressão arterial. As alterações da PAS e PAD e da adesão à medicação foram analisadas como outcomes secundários. Resultados: Entre janeiro de 2012 e março de 2013, foram selecionados um total de 554 indivíduos potencialmente elegíveis para o estudo dos seis centros de saúde/unidades de saúde familiar participantes. Destes, 86 (15,5%) estavam incontactáveis, 65 (11,7%) não preenchiam os critérios de inclusão e 148 (26,7%) recusaram participar. Dos 255 participantes incluídos no estudo, 85 foram colocados no grupo de intervenção e 170 no grupo controlo (cuidados habituais). Após a entrevista inicial, sete participantes foram excluídos (três não estavam a tomar medicação antihipertensora e quatro participantes estavam a tomar mais do que quatro medicamentos antihipertensores diferentes). Do total de 248 participantes com avaliação inicial, 198 participantes completaram a entrevista de seguimento. Na entrevista inicial, não foram observadas diferenças significativas entre os grupos, exceto em relação à proporção de participantes com diabetes e à proporção de participantes fumadores, que foi significativamente superior no grupo controlo. Um total de 64 (33,7%) participantes tinham a sua pressão arterial controlada e 160 (80,8%) eram aderentes à terapêutica antihipertensora. Aos três meses verificou-se que a proporção de doentes com a pressão arterial controlada aumentou significativamente em ambos os grupos. Contudo, esse aumento não diferiu entre os grupos intervenção e controlo, mesmo após o ajuste para a covariáveis (OR 0.64; intervalo de confiança (IC): 0.3-1.5; p=0.288). Entre a entrevista inicial e a entrevista de seguimento, a PAS foi reduzida em 6,5 mmHg no grupo controlo (p <0,001), e 5,5 mmHg no grupo de intervenção (p = 0,004). As correspondentes reduções na PAD foram 4,7 mmHg (p <0,001), e 2,7 mmHg (p = 0,020), no grupo controlo e intervenção, respetivamente. Contudo, não se observaram diferenças significativas na redução da PAS e da PAD entre os grupos, mesmo após ajuste para as covariáveis [p=0.679 (PAS); p=0.166 (PAD)]. Verificou-se um maior aumento da proporção de aderentes no grupo de intervenção entre os momentos de avaliação, contudo não foram observadas diferenças significativas entre os grupos (OR ajustado 0.83; IC: 0.3-2.2; p=0.688). Porque o objetivo do estudo era aplicar a intervenção em doentes com hipertensão não controlada, as análises foram repetidas no subgrupo dos participantes com pressão arterial não controlada na avaliação inicial (66.3%). Para este subgrupo verificou-se que a pressão arterial passou a estar controlada num número significativamente superior de participantes do grupo controlo comparativamente ao grupo de intervenção, com um OR de 0.19 (IC 0,1-0,7) após ajuste para as covariáveis. Também para este subgrupo se verificaram reduções na PAS e PAD em ambos os grupos. Contudo, após ajuste para as covariáveis, a redução no grupo controlo foi significativamente superior ao do grupo intervenção tanto para a PAS (p=0.041) como para a PAD (p=0.002). À semelhança do que se observou para a amostra total, verificou-se uma tendência para o aumento da adesão à terapêutica antihipertensora no grupo intervenção. Contudo, a proporção de aderentes à terapêutica não foi significativamente superior no grupo de intervenção comparativamente ao grupo controlo aos três meses (OR ajustado 0.88; IC: 0.3-2.6; p=0.814). Para avaliar a robustez dos resultados, através de uma análise de sensibilidade, o efeito da intervenção no outcome primário (controlo da pressão arterial) foi re-estimado de acordo com quatro cenários: (1) análise por “intenção de tratar”; (2) considerando todos os participantes perdidos para follow-up como não controlados na entrevista de seguimento; (3) excluindo os participantes com mais de 4,5 meses entre a entrevista inicial e a entrevista de seguimento; e (4) considerando as novas recomendações da Sociedade Europeia de Hipertensão e Sociedade Europeia de Cardiologia para o controlo da hipertensão nos hipertensos com diabetes mellitus (PAS <140 mmHg e PAD <85 mmHg). Na análise se sensibilidade foram observados resultados semelhantes à análise primária, confirmando assim a robustez dos resultados. Conclusão: Esta intervenção educacional e comportamental não conseguiu aumentar o controlo da pressão arterial e da adesão à terapêutica no grupo de intervenção comparativamente ao grupo controlo. Apesar da pressão arterial ter sido significativamente reduzida entre os dois momentos, tanto aqueles que receberam a intervenção como os que não receberam, beneficiaram do estudo. A elevada proporção de aderentes e de controlados na avaliação inicial, bem como a proporção significativamente superior de participantes com alterações da medicação no grupo controlo, pode explicar porque é que não foram observados efeitos da intervenção

From Computation to Clinic

Theory-driven and data-driven computational approaches to psychiatry have enormous potential for elucidating mechanism of disease and providing translational linkages between basic science findings and the clinic. These approaches have already demonstrated utility in providing clinically relevant understanding, primarily via back translation from clinic to computation, revealing how specific disorders or symptoms map onto specific computational processes. Nonetheless, forward translation, from computation to clinic, remains rare. In addition, consensus regarding specific barriers to forward translation—and on the best strategies to overcome these barriers—is limited. This perspective review brings together expert basic and computationally trained researchers and clinicians to 1) identify challenges specific to preclinical model systems and clinical translation of computational models of cognition and affect, and 2) discuss practical approaches to overcoming these challenges. In doing so, we highlight recent evidence for the ability of computational approaches to predict treatment responses in psychiatric disorders and discuss considerations for maximizing the clinical relevance of such models (e.g., via longitudinal testing) and the likelihood of stakeholder adoption (e.g., via cost-effectiveness analyses)

A supervised cooperative learning system for early detection of language disorders

The Quality of Life of a person may depend on early attention to his neurodevel-opment disorders in childhood. Identification of language disorders under the age of six years old can speed up required diagnosis and/or treatment processes. This paper details the enhancement of a Clinical Decision Support System (CDSS) aimed to assist pediatricians and language therapists at early identification and re-ferral of language disorders. The system helps to fine tune the Knowledge Base of Language Delays (KBLD) that was already developed and validated in clinical routine with 146 children. Medical experts supported the construction of Gades CDSS by getting scientific consensus from literature and fifteen years of regis-tered use cases of children with language disorders. The current research focuses on an innovative cooperative model that allows the evolution of the KBLD of Gades through the supervised evaluation of the CDSS learnings with experts¿ feedback. The deployment of the resulting system is being assessed under a mul-tidisciplinary team of seven experts from the fields of speech therapist, neonatol-ogy, pediatrics, and neurology

JUST CULTURE IN HEALTHCARE ERROR MANAGEMENT: NURSE-IN-TRAINING VIEW OF JUST CULTURE AND OUTCOMES OF EVENT INVOLVEMENT

This experimental study will assess the behavioral and psychosocial effects of just culture error management strategies for medical errors in a healthcare setting, and the outcomes of such strategies on work-related perceptions, attitudes, and behaviors. A total of 247 nurses-in-training were randomly assigned to one of 6 experimental conditions. In each condition, participants read a vignette that described an at-risk medical error and the error management strategy employed by a hypothetical organization. The medical error was written to implicate both the individual involved, and the larger organizational system. Vignettes differed with regard to error management strategy employed by the organization (punitive, blameless, just culture) and the degree of event severity (no harm, harm). Participants rated the organizational justice and trustworthiness of the hypothetical organization described in the vignette; then, reported their own willingness to engage in safety compliance and error reporting behaviors and their degree of organizational commitment and attraction. Results suggest that error management strategies based in just culture were associated with increase perceptions of organizational justice and trustworthiness, increased intention to engage in safety compliance, and stronger attraction and commitment to the organization. Furthermore, perceptions about the organizational justice and organizational trust mediated the relationship between error management strategy and these outcomes. Event severity did not moderate the association between error management and organizational perceptions. Furthermore, error management strategy was unrelated to error reporting intention. Control variables of familiarity with concepts of just culture, experience with medical errors (as provider or patient), and demographic variables of gender and age were not associated with organizational commitment, organizational attraction, or safety compliance. However, error reporting intention was positively associated with familiarity with concepts of just culture was positively and negatively associated with experience with medical errors as a provider

Co-designing an eHealth Intervention to Support the Self-Management of Fibromyalgia

Fibromyalgia is a rheumatic pathology that causes a wide range of symptoms that can appear individually, or in sets, such as fatigue, sleep disorders, attention, and concentration deficit, also having connection with musculoskeletal, psychological, cardiovascular, gastrointestinal disorders. This pathology has a greater predominance in women and, in Portugal, for every man there are six women with the diagnosis and a total of approximately two hundred thousand people (2.1% of the population). The non-pharmaceutical way to mitigate these symptoms is through physical therapy. Considering the pandemic moment in which we live, there have been many difficulties in having physical therapy sessions because of the fear of infection through contact with their physical therapists. There are also people who live in more isolated areas and with little access to healthcare, who often must travel to larger urban centers to get the care they need. Moreover, these people have difficulties in self-managing their illness, where depending on the day their symptoms can get worse, and they do not know how to deal with them. Currently, there is no specialized solution for people with this diagnosis that solves these problems, so this dissertation aims to study and design a solution that allows people diagnosed with fibromyalgia to self-manage their pathology, as well as have a closer contact with their physical therapist, by being able to perform their sessions in a hybrid way, i.e., in person or remotely. This solution was designed using a Co-Design approach, following the Design Thinking methodology, where the community (people with the diagnosis, physiotherapists, researchers and academics) were involved in all stages of the process, from problem identification and idealization of their solutions, to prototyping and its validation. This solution involved the development of a mobile application, having several important components, such as self management, telerehabilitation, motivation, community and communication. In order to evaluate the whole process and the usability of the solution, tests were performed with end users who had not yet participated in the design of the solution

A practitioner behaviour change intervention for deprescribing in the hospital setting

Background Half of older people in hospital have a pre-admission medicine prescribed that is potentially inappropriate. Deprescribing research has historically focused on the primary care setting. The aim of this thesis was to develop a practitioner behaviour change intervention for enhancing deprescribing in the hospital setting. Methods Underpinned by behavioural science, the research programme comprised four empirical studies: evaluation of existing hospital deprescribing activity; survey of patients’ and carers’ attitudes towards deprescribing; focus groups with geriatricians and pharmacists to identify key barriers and enablers to address in an intervention; expert panel consensus study to select Behaviour Change techniques (BCTs) for the intervention. Results Deprescribing in hospital occurred for 0.6% of pre-admission medicines, of which 84.1% was reactive in response to harm and 15.9% proactive to prevent harm. Deprescribing in hospital was acceptable to patients and carers: 97.4% and 76.3% respectively were willing to accept a doctor’s deprescribing proposition. Geriatricians and pharmacists described several existing deprescribing enablers in hospital including alignment with their generalist role/knowledge and routine patient monitoring. Key barriers to deprescribing were a misconception of patients’ and carers’ resistance to deprescribing, pharmacists’ perception that deprescribing is riskier than continuing to prescribe, pharmacists’ working patterns limiting capacity to support deprescribing and it being a low hospital priority. Introduction of incentives to deprescribe was an enabler. Six BCTs were selected and characterised to address the key barriers and enabler: social comparison (two distinct characterisations); salience of consequences; pros and cons; restructure the physical environment; action planning. Conclusion There is significant scope to increase deprescribing in hospital and this is acceptable to patients and carers. The behavioural intervention to enhance geriatrician and pharmacist led deprescribing requires modelling to determine the optimal configuration of BCTs. Subsequent testing of the intervention is necessary to determine efficacy at enhancing deprescribing and impact on patient outcomes