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What does James Spader like?

James Spader likes an overview of adherence research!

Treatment adherence in chronic disease
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Problem Why has adherence not improved since the 1970s? Adherence research from the 1970s to 2010s has focused on why people are poor adherers: prevalence, predictors, how to study adherence, how to measure adherence. But if you use the strict definition of intervention study, ie, randomized control trial with both adherence and clinical outcome studied, there have only been 19 intervention studies. Half of them showed a positive effect on adherence.
Overall findings Here are the general findings about the state of adherence research:
  • Multiple measures of adherence: self-report, practioner report, physiological markers, clinical record review, pill counts, and electronic pill monitors
  • Effect sizes: interventions generally have a low-moderate effect size, not becoming greater than 0.37. Multi-focal approaches that incorporate cognitive, behavioral and affective components do better than single focal approaches, probably because of the multiple reasons for non-adherence.
  • Predictors of high adherence: self-efficacy, initial adherence, complex regimens, schedule changes or disruptions. However, predictors tend to vary depending on method of assessment
  • Non-predictors of high adherence: Demographic factors
  • Caveat: People over 75, or "old-old", have worse adherence than the "young-old", ie 60-70 year olds.
  • Risk factors: aging neurological system, multiple chronic illnesses, multiple prescriptions, and more side-effects
Variance of adherence Here is a picture of the variance in adherence of a twice-daily pill

Dunbar-Jacob figure
Recommendations for future research
  • Finding out reasons for missing doses
  • Cost-effectiveness of interventions
  • Impact on clinical outcomes
  • Adherence in chronic disorders

James Spader likes ideas for really long-term, unrealistic healthcare reform ideas to improve non-adherence!

Thinking Outside the Pillbox - Medication Adherence as a Priority for Health Care Reform
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Main message Changes in health care delivery, particularly primary care, is needed for improvement in adherence.
  1. Address financial barriers, like co-payments
  2. Data and data infrastructure that help track patient refills
  3. Payment reform: change from fee-for-service to the kind that rewards quality or something
  4. Screening patients for risk of non-adherence
Interesting citations
  1. 2005 Osterberg: Non-adherence costs $100 billion per year

James Spader likes testing a reminder device for Alzheimer people!

Medication reminder device for the elderly patients with mild cognitive impairment
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Complaints Did you know that cognitive impairment is one of the risk factors for medication nonadherence in elderly patients? So says Cooper. Even a little less cognitive function affects you alot, says Hayes. You should also check out Banning.
Summary They gave Alzheimer seniors the electronic medical devices that track when you open them and the seniors used them and liked them and their adherence got better.

James Spader likes a meta-study on the association between adherence to drug therapy and adherence!

A meta-analysis of the association between adherence to drug therapy and mortality
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Complaint Hey, the effect of adherence should be measured on objective health outcomes, like mortality. Medication adherence is associated with positive health outcomes. There is even association between good adherence to placeboes and mortality. This is called the "healthy adherer" effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behavior.
Main message Medication adherence is associated with positive health outcomes in 19 studies of 21 studies. The odds ratio is 0.55 for those with good adherence compared to poor adherence. That means the risk of mortality of good-adherencers is half of that of not-good adherers. Conversely, the risk of mortality was more than double for partipants in drug therapies that proved harmful than poor adherers.
Another cool thing There is even association between good adherence to placeboes and mortality. This is called the "healthy adherer" effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behavior. 1997 McDermott found that adherence to the placebo is associated with improved outcomes in 12 studies. DiMatteo found that risk of poor health outcome was 26% lower in good-adherers.
Recommendations to other researchers Drug surveillance: stratification by adherence groups could help as good-adherers would have higher rates of adverse drug effects. Usually drug trials will only give an overall average adherence rate.

James Spader likes how Digia did their usability for two apps!

Applying User-Centered Design to Movile Application Development
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Main point Digia is a Finnish company that makes third-party apps. They made the Nokia Genimap Navigator and the Genimap ImagePlus apps. Here is how they did the usability studies for each of them.
Navigator They did technology development before the usability experience group came in, so they did not have the chance to do a user needs study. They did a 3-day UI design workshop with the engineers and did paper prototypes. The design was not used completely because they already started implementation. They did a small pilot study with 20 users for 3 weeks, and each person kept a diary. The pilot study found out that the product did not meet their needs. For example, when asking the GPS for "taxi," it would give the administration building of the taxi building. They used this information to revise the UI of the commercial version of the Navigator. Afterwards, they did another usability test and wanted improvements, but it was too late to make it to the delivered product.
ImagePlus They did a 2-month CD study (whatever that is) with 8 developers. This was a simple image-manipulation app for the phone. They made a long feature list by compiling the editing features of the PC equivalent of editing software. They did a paper prototype and cut down their feature list to save money. To save money again, intead of making a UI prototype, they use actual software implemented for each increment. This is how they found out a joystick was not testing well with users and so they came up with a different method. They used many rounds to get the correct what-you-see-is-what-you-get experience.
Lessons learned
  • Focused CI studues: If you do not have user needs understanding, you can do a CI study (whatever that is) with 6-8 peoeple and analyze the results with affinity diagrams, sequence models and personas.
  • Realistic UI prototypes for mobile apps: Constant iterations cost money, cause delays and frustrations. It is best to find usability problems earlier, before implementation.
  • Usability testing in the mobile context: Large pilot studies are good, but also really expensive and are typically done too late.
Conclusion No feature should be added to the product only because it is easy and cheap to implement, or because you think it is a good idea.

James Spader likes how older adults respond to technology!

Early user involvement in the development of information technology-related products for older people
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Main points This is about the utopia project.
  • The mobile app industry mainly makes apps aimed at the youth market, not older adults
  • Older people have significantly different needs, priorities, and expectations than younger people
  • The typical developer or researcher will find it easier to design for someone like themselves, and not understand the day-to-day impact of age-related impairments
Older people Have to expend more effort into recruiting older adults because they:
  • Socially isolated
  • Significantly reduced mobility
  • Spend much more of their time at home than working people
Normal methods of getting data have to be modified.
  • Focus groups: they tend to treat this as social hour and get off-topic. One good way to get around this is to make a designated social time, and designated focus group time.
  • Self-reporting: cogitive deficits make this inaccurate
  • Questionaires:
    • They tend to require more certainty before making statements, and will respond "not sure" and will write in "not sure" if that option is not available.
    • They also take longer, tire more quickly, and this severely limits the length of sessions.
    • They prefer verbally asked questions. This is unrealistic for large projects though
    • Spontaneous excursions into the users own experiences, like if the topic were safety alarms, they would show off their own safety alarm
    • were often reluctant to critisize products, and asked researchers if they made the app before making a negative comment
  • Interviews: The older population is more likely to spend time at home than working people. This group would benefit a lot from home-based technologies, but are also more vulnerable to the negative effects of inappropriate home technologies. This can be mitigated by in-home interviews and observations, and seeing how people obtained their home equipment, how they learned to use it, who supported them, and reporting of good and bad experiences.
Attitudes About technology:
  • Older people think that they have no use for computers, and are more negative about the amount of effort needed to learn how to use them
  • Older people often attribute discomfort to using technology as their own fault rather than failure in design of the technology
About UI culture differences between developers and older users:
  • Language: widgets, chip, scrolling, original document vs. a copy, monitor, etc.
  • They also have a lack of trust in the system and reluctance to experiment. Even experienced older users would stick to a learned sequence of actions, even if that meant taking a huge detour. Speed was less important than "getting the job done."
Conclusion Only a third of British companies even think of older people when designing products. There is a lot of work to do.

James Spader likes how older users navigate early cell phones!

How older adults meet complexity: Aging effects on the usability of different mobile phones
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Main point Older adults are willing to use modern devices and are interested in modern technology, but they do not think that the devices meet their design and usability needs Why?
  • hard to implement all the functions in a way that provides good and universal accessibility
  • screen size is small
  • you cannot see the things in the menu until you open it, and then you have to memorize what is in the menu, create a mental map if it were
  • relatively few studies done on older adult requirements for usable mobile phones
Definition The definition of usability is "the case with which users interact with the device, achieving optimal performance with respect to effectiveness, efficiency, and users satisfaction."
Experiment They had 32 people (16 people between 20-30 years, and 16 between 50-65 years) both carry out four tasks on the Nokia 3210 and the Siemens C351. Pretty sure they just asked faculty, staff and students because everyone in the experiment was univeristy educated.
  1. Call
  2. Send text message
  3. Hide own number
  4. Edit entry in phone book
Methods Things measured:
  1. Time needed to do tasks
  2. Number of detour steps
  3. Number of returns to higher levels in the menu

  • Younger users solved 97% of the 4 tasks, whereas only 76% of the older users did
  • Younger users spent 2 min 22 sec on each tasks, whereas older users needed 4 min 32 sec
  • Younger users did 79 detour steps while older users made 113.6 detour steps
  • Younger users went back 11.4 times while older users went back 16.2 times
Efficiency measures and cognitive complexity Ziefel figure 4 and 5 Interaction diagrams of phone complexity and age Ziefel figure 7
Discussion Compared to their younger friends, older adults solved 43% fewer tasks, spent 48% more time, took 36% more detour steps, and returned to the top menu 35% more. Older adults said they were less willing to struggle through a jungle of menys, did not want to search for a function, and wanted functions in easy reach with maximum transparency. They preferred the simpler phone. They were also more cautious and reluctant when navigating, and took fewer keystrokes through time. Older adults took longer detours, so if they continued on the wrong path, they would go down it longer. They also had trouble remembering which paths they already took and which ones were new.

James Spader likes high adherence when using self-report!

"The AdHOC Study of Older Adults' Adherence to Medication in 11 Countries"
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Main point They interviewed 3,881 adults >65 years and their caregivers in various European countries. They asked the participant or caregiver what medications they took today or yesterday, and checked responses with medication available and prescriptions. The median number of mediations was 6 and on average, 87.5% percent of participants were fully adherent.
Predictors of non-adherence
  • problem drinking
  • greater cognitive impairment
  • resisting care
  • being unmarried
  • ADL (activities of daily living) impairment
  • no medicaiton review in the last 6 months
Discussion The adherence rate was pretty high, even though they combined both subjective and objective data which has good face validity and does not change behavior. Ummm, but they only picked people with caregivers and that might make the numbers higher? Weird!

James Spader likes how even mildly demenia causes you to not take your pills!

"Medication adherence in healthy elders: small cognitive changes make a big difference"
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Main point They made 38 people >65 years take a twice daily vitamin C for 5 weeks and recorded them with an electronic 7-day pill box. First week was not counted because it was a run-in period.
Results Self-report shows that the subkects were not aware of how often they were missing their vitamins. Self report overestimates, but not because of deceit. The participants are not fully aware of their inability to adhere to the regimen.
  • 93% self-reported they had "excellent adherence" ie >80%, but only 53% in reality were
  • 12% self-reported that they never missed a nose, but only 5.3% had perfect adherence
Even a very mild cognitive deficit has a big impact on medication taking. Hayes 2009 figure 3

James Spader likes another systematic review of adherence interventions!

"A review of interventions used to improve adherence to medication in older people."
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Main points
  • 18/49 RCTS show improvement in health outcomes and ES scores in 9/20
  • RCTs did not use a theoretical framework
  • Behavioral: drug aids, blister packs, drug calendars, reminder charts, pill boxes, refill containers
  • Educational: individual and group teaching, discussions, medication cards and charts
  • Health care professional involvement: domicillary visits, brown bag reviews, patient education programs
  • Health outcome specific: blood pressure, cholesterol, peak flow serum monitoring, urinary drug levels

James Spader likes mHealth apps for older adults!

"Medication noncompliance: an issue to consider in the drug selection process"
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Main tip You should tailor medication regimens to the patients usual daily schedule and lifestyle
Things we already know An overview of things we already know.
  • Bad health arises from non-adherence
  • Everyone is non-adherent, even organ transplant recipients
  • It costs a lot of money
  • Although old people have a disporportionate number of medications, they are not more or less adherent than everyone else
Mythbusters or not Positive predictors of adherence
  • Patient perception: percetion of the seriousness and susceptibility of his illness, and the efficacy of his drugs
  • Physician-patient relationship: more satisfaction the better
  • Therapeutic regimen: the simpler the better
  • Disease: Surprisingly, compliance is higher for chronic diseases like antihypertension, diabetes, and asthma than antibiotics. It is also higher for asymptomatic things like analgesics, antacids and sedative-hypnotics than things you take for symptoms
  • Family members who spend time with patient
Table 1
Feldman 1994 figure 1
Negative predictors of adherence
  • Social isolation
  • Child saftey containers
  • Treatment requiring behavior change
  • Psychiatric diagnosis
Table 2
Feldman 1994 table 2
Not predictors of adherence either way
  • Age
  • Education: surprisingly, there is not. It might be because doctors do not think they need to educate their more educated patients, or the educated ones think they are smarter than their doctors
  • Medication cost: this has been a bit more limited but still, doctors should try to prescribe the least expensive option
Table 3
Feldman 1994 table 3
Usefulness formula A suggested equation: the usefulness of a medication, which is effectiveness * compliance = usefulness. Usefulness formula made by Smith
Feldman 1994 formula
For example, epinehprine and timolol are both things you can take for glaucoma.
Epinephrine has an effectiveness of 70% and timolol has an effectiveness of 80%.
You would think they would be sort of equal, but ephinephrine has a compliance rate of 30%, so it has a usefulness of 21%.
Timolol has a compliance rate of 95%, giving it a usefulness rating of 76%.
This makes it 1.5x more useful than ephinephrine.
Usefulness formula applied by Worthen
Feldman 1994 formula application

James Spader likes mHealth apps for older adults!

"Touchscreen mobile devices and older adults: a usability study"
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Overview How do older users feel when using a touchscreen versus a button-based product?
Title Things to read:
Introduction The assumption that older adults wish to avoid using new technology is a misconception: Differences in usage among older people:
  • They tend to feel more anxious when using a new system
  • They tend to become more frustrated with themselves
  • They are more distracted by noise and "useless information" such as advertisements, decorations, animations
Methods Semistructured interviews, and then they did a series of tasks on a touchscreen phone and then a button phone. The tasks were:
  • Call home from the contact list
  • Add a number to the contact list
  • Write a text message and then send it
  • Set an alarm for 5:30 pm
Recurring themes
  • Nagivating through the menu causes confusion
  • Apprehension about their capabilities in interacting with the technologies
  • Considered themselves "too old" to be using technologies this advanced
  • One participant said he was happy with the phone, as he thoguht it would be much harder. But other people whined so it seems that developers have not really designed it so everyone can use it
Recommendations Do more research on older adult user perceptions to make sure that their desires, as well as physical and cognitive needs, are being met

James Spader likes mHealth apps for older adults!

"Treatment adherence in chronic disease"
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Title Thing 1
Title Thing 1