Monitoring | AlignMap

Oral chemotherapy safety practices at US cancer centres

Saul N Weingart, Jonathan Flug, Daniela Brouillard, Laurinda Morway, Ann Partridge, Sylvia Bartel, Lawrence N Shulman, Maureen Connor. BMJ, doi:10.1136/bmj.39069.489757.55 (published 12 January 2007)

Adherence Monitoring

This report of a questionnaire survey of 42 responding cancer treatment centers on their protocols for administering the increasingly used oral chemotherapy agents reveals several potential problem areas.

A single finding regarding compliance however, caught my eye:

Nearly a quarter (10) of centres had no formal process for monitoring patients’ adherence.

Commentary

While monitoring adherence to protocols for such potent agents is surely indicated, I am (cynically) surprised that 75% of the Centers claim to formally monitor adherence and wonder (again, cynically) if such monitoring consists of more than a self-report by the patient.

In any case, this survey provides insight into the psychological complexities of clinicians’ perceptions of the risk of adverse side-effects. That safety protocols appear to be significantly attenuated if a medication is administered orally rather than by i.v. is revealing.

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Use of the Medication Event Monitoring System to estimate medication compliance in patients with schizophrenia E Diaz, H Levine, et al Psychiatry Neurosci. 2001 September; 26(4): 325–329.

This admirably straightforward study focuses on the feasibility of and potential hurdles in using the Medication Event Monitoring System (MEMS) to monitor medication compliance in schizophrenic patients.

MEMS data were collected for a six month post-hospitalization period for fourteen patients taking antipsychotics.

Results

Patient medication compliance data were collected from 10 (71%) of 14 patients during the first month, from 7 (58%) of 12 (2 patients dropped out) during the second and from 5 (45%) of 11 (a third patient dropped out) during months 3–6. Mean compliance rates were 63% for the first month and ranged from 56% to 45% over the next 5. First-month compliance rates were significantly lower for those who were subsequently readmitted to hospital (n = 7) than for those who were not (p < 0.01). [Quote from abstract]

Commentary

While not an insurmountable finding, it is significant that seven patients of the fourteen from whom data was collected lost one 1 or more caps, each of which cost $126. Given that two patients dropped out in the first month and another dropped out in months 3-6, this is not a trivial occurrence.

This project does support the authors’ somewhat hedged conclusion,
“For many of these severely ill patients, we were able to estimate compliance with antipsychotic medication using a MEMS electronic monitor.” It is, however, fair to note that for a significant number, this was not a workable solution. And, given the dropout rate, the recommendations for “more frequent follow-ups in the immediate period after inpatient discharge” and paying a fee for patients to return the caps, and the observation that “clinicians needed to be reminded of the importance of MEMS use so they would continue to encourage the correct use of the cap,” it is evident that implementing MEMS to monitor compliance in schizophrenic patients falls short of being a simple turnkey operation. Instead, it appears that MEMS is a potentially valuable tool but one that requires specific skills and significant effort and attention to use.

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In the preceding post, Patient Acceptance Of Monitoring , I followed a discussion of the potential benefits of electronic monitoring of compliance with the comment that “Because the article provides no details of the research referenced in this excerpt, it begs the question of what proportion of the patient population would find such monitoring acceptable under which conditions.”

With that comment in mind, I contacted Stephen Agritelley, the Director of Intel’s Health Systems Research Lab, who was quoted in the original article.¹

The pertinent portion of my message read
Because no details of that market research are given, some important questions vis-à-vis patient compliance are unanswered. (For example, what proportion of the patient population would find such monitoring acceptable under which conditions? Do different segments of the patient populations respond positively to different conditions?)

Those unanswered queries lead into my requests:
1. Is the market research referenced available and, if so, could I obtain a copy?
2. If the research is unavailable because it is proprietary, could you characterize it in broad terms (e.g., was the data derived from focus groups, interviews, surveys, etc; how many patients were involved; what were the basic criteria for determining if a patients found the monitoring acceptable; what proportion of the patient population found monitoring acceptable, … )?

Mr. Agritelley’s prompt reply follows:

We did not derive this conclusion from market research per se, but from primary investigative research we implement in the field. As we have gone into participants homes and apartments, installed sensor nets and applications built on top of sensor nets, we gauge people’s acceptance both directly from asking them questions as well as in a derivative fashion. I don’t have a report I can send you that can claims “70 out of 100 people think xyz…” I can tell you that our findings point to the fact that while folks are monitored and if they gain some direct feedback from the system that is helpful to them, they are more likely to accept the system and have less concerns about privacy.

The Future of Health Care? High-Tech is Revolutionizing Care at Practice and Home
Sarah Lueck
Originally published: Wall Street Journal June 26, 2006 [back]

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The Future of Health Care? High-Tech is Revolutionizing Care at Practice and Home
Sarah Lueck
Originally published: Wall Street Journal June 26, 2006
____________________

While this article focuses on the role of healthcare technology for the elderly in the future, the most interesting finding, vis-à-vis patient compliance, is this excerpt:

A major question for technology companies developing systems for home use is whether people will want to be monitored. Intel’s market research shows that, “in general, the answer is yes. They see value in the system,” says Stephen Agritelley, acting director of health research and innovation in the company’s digital health group. But they don’t want information simply to be collected and sent to a third party. While that might be appropriate in some cases, it’s “kind of big-brotherish,” Mr. Agritelley says. Instead, he says, older adults prefer to have more control and to get reminders to take a pill sent to them.

Commentary

The notion that patients might accept monitoring not only of disease symptoms but also of compliance with treatment if the proposition is framed appropriately is encouraging and intriguing, especially given the unreliability of patient self-report of adherence, for example, to a medication schedule. There is some evidence that such monitoring would improve compliance but even if it did not, providing the clinician with dependable adherence data would itself be invaluable. (See Cascading Costs Section of Noncompliance Costs and previous post, How To (Correctly) Not Take Medications As Prescribed )

Because the article provides no details of the research referenced in this excerpt, it begs the question of what proportion of the patient population would find such monitoring acceptable under which conditions. (Since we know that some patients attempt to sabatoge compliance monitoring, this is not a trival issue.) And other queries come to mind. Given that, in general, about half of patients comply with a given treatment plan, would positioning the monitoring to fit specific characteristics of patient groups increase the number of patients who find it acceptable? Further, do different segments of the patient populations respond positively to different conditions?

While these and similar issues must be addressed if widespread electronic monitoring is to be successful, the potential offered by electronic, passive reporting of compliance not only justifies that effort but also pursuing it now, even before the final formats of the technology are available for use by the general public.

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