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

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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

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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