IV. DETERMINING THE ADHERENCE OF PATIENTS
A) Predictions or Judgments of Adherence
It is well documented that provider estimates, patient self-report, measures of appointments kept, pill counts, and assays for the presence of drugs are relatively insensitive measures of adherence. (Sumartojo, 1993) While one study showed a positive correlation between predictions of adherence and actual adherence to outpatient therapy, the nurses and physicians who made the predictions had treated the patients in hospitals for months prior to outpatient therapy. (Moulding 1979A) Furthermore, they were not able to predict all poorly adherent patients. Multiple studies have shown that no one or no combination of factors can consistently determine or predict which patients are or will be adherent. (Miller et al. 2002)
B) Assessing Adherence with Medication Monitors
Non-electronic devices, which record when medication is removed from a container, (medication monitors) were proposed in 1962 (Moulding1962), and subsequently modified (Moulding et al. 1967; Moulding 1979B). Since then electronic medication monitors have been developed. Three 'trace sheet monitors' that record when each pill is removed by breaking lines of conductive ink over cavities in blister cards have been marketed. (Cypak Inc. 2007; Certus International Inc. 2007; Information Mediary Inc. 2007) Three cap removal monitors that indicate when a cap is removed from a medication container are available. (Aardex ltd. 2007; Information Mediary Inc. 2007; Simpill Inc. 2007) While these latter devices do not record how many pills are taken out when the cap is removed, devices based on this concept, like the cover opening monitor shown on this website (Moulding and Ellis 2007) may prove to be the most practical means of assessing adherence, since it is the least expensive to manufacture and easy to refill. (See: Cover and Cap Opening Monitors, scroll to figures one and two.) Multiple alternative monitor designs, which determine when each dose is removed, have been placed on an this website, to allow investigators and funding sources to chose the optimal device for their needs and encourage inventors to develop improvements. (Moulding and Ellis 2007)
Although none of these medication monitors prove ingestion of the doses removed, they provide far greater supervision of SAT than any other measure of adherence. (Moulding 1979A) The frequency of 'on schedule' medication removal without ingestion needs to be determined and weighed against the limitations of giving DOT to all patients.
C) Built in Displays to Retrieve the Adherence Record and Assist the Patient
To make medication monitors useful in all settings, a variety of built in displays to retrieve the adherence record without computers or personal digital assistants (PDAs) could be used. The least expensive is a single multi-color light emitting diode (LED), which costs <$ 0.15. (See: Cover and Cap Opening Monitors, scroll up to the written material entitled 'Use of the Display by the Caregiver '.) The LED could present the percentage of medication taken since the last time the device was refilled with a green flash for >90% adherence, yellow for 75-90% and red for <75%. Additional red flashes could be displayed for greater degrees of poor adherence. Furthermore, the LED could display the adherence record for each month since the start of therapy, valuable data that could be used to plan additional therapy if the chart were lost or the patient moved to another health facility.
The LED could also answer a common questions asked by many patients, "Did I or did I not take medication today?" With the push of a button the LED would flash green if the patient should take medication and a red if he should not.
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SUMMARY
I. INTRODUCTION
II. THE SUCCESS AND PROBLEMS WITH DOT
III. RELIABLE PATIENTS - A POTENTIAL RESOURCE FOR REDUCING THE ADHERENCE PROBLEM
IV. DETERMINING THE ADHERENCE OF PATIENTS
V. EXPERIENCE WITH SELF ADMINISTERED TREATMENT GIVEN IN MEDICATION MONITORS (MONITORED SAT)
VI. PROPOSED SUPERVISION OF TREATMENT BASED ON MONITORED SAT AND DOT GIVEN SELECTIVELY
VII. USE OF MONITORED SAT TO IMPROVE TREATMENT OUTCOMES AND EXPAND SERVICES IN VARIOUS SETTINGS
VIII. CAN MEDICATION MONITORS HELP PREVENT DRUG RESISTANT DISEASE
IX) USE OF MEDICATION MONITORS WHEN MANAGING HIV/AIDS and HIV/AIDS/TB
X) EXPENSE AND PRACTICALITY OF USING MEDICATION MONITORS
XI. EVALUATION
XII. IN SUM
REFERENCES:
ELECTRONIC MEDICATION MONITORS HOME