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Overreporting of medication use common for children with ALL
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Young patients with acute lymphocytic leukemia and their parents often overreported adherence to 6-mercaptopurine, an oral maintenance therapy, according to published findings.
“Because this therapy is administered orally every day, we cannot supervise our patients to make sure they are taking their pills,” Smita Bhatia, MD, MPH, director of the Institute for Cancer Outcomes and Survivorship at University of Alabama at Birmingham School of Medicine and a HemOnc Today Editorial Board member, said in a press release. “Findings from this study suggest that we need better ways to monitor intake of medications as prescribed.”
Bhatia, Wendy Landier, PhD, RN, CRNP, associate professor in the division of pediatric hematology-oncology at University of Alabama at Birmingham School of Medicine, and colleagues compared self-reporting with electronic monitoring of 6-mercaptopurin (6MP) intake.
The analysis included 416 children (median age, 6 years; range, 2-20; 66.6% male) with ALL from 87 institutions who were in first remission. Among the patients, 35.6% were white, 37% were Hispanic, 13.5% were Asian and 13.9% were black. In total, 38.4% of patients had high-risk disease.
Each patient was given a prescription pill bottle for 6MP that had a microprocessor chip in the cap (MEMS TrackCap, Aardex Ltd) to track every date and time the bottle was opened.
Patients or their parents also completed self-report questionnaires and gave them to providers at monthly appointments. Researchers assessed the self-reporting data at four study time points: day 29, 57, 113 and 141.
A patient was labeled a “perfect reporter” if results of self-reporting were equal to the electronic monitoring, an “overreporter” if the self-report was higher than the electronic monitoring by more than 5 days per month for more than 50% of the 4 study months, or “other” if the patients did not meet criteria as a self-reporter or overreporter.
Overall, 412 patients completed the study, for a total of 1,344 patient-months of self-reporting and electronic monitoring data.
Self-reports showed patients took 6MP 92.6% of the total days, whereas the electronic MEMS cap showed patients took the treatment 83.7% of the total days.
The adjusted mean days per month of 6MP intake for the study were 25.8 ± 5.4 to 26.3 ± 3.7 by self-reporting compared with 22.8 ± 6.6 to 25.3 ± 4.4 for electronic monitoring (P < .0001).
Twelve percent of the patients were perfect reporters, 23.6% of patients were overreporters, 0.5% were underreporters and 63.9% were others.
Of those deemed as others, 95.1% self-reported 6MP intake that exceeded electronic monitoring by 1 or more days in 1 or more study months, indicating that 84.4% of all patients’ self-reports exceeded the electronic report at least some of the time.
Overreporting was more common among patients who did not adhere to their medicine than those who did (47% vs. 8%).
“We observed that there was an inverse relationship between overreporting and the extent of nonadherence,” Bhatia said.
Researchers used multivariable logistic regression to identify predictors of the overreporter phenotype. After adjusting for age at study entry, annual household income, NCI risk classification, 6MP dose intensity and TPMT genotype, results showed Hispanic race (OR = 2.4; 95% CI, 1.1-5.1), Asian race (OR = 3.1; 95% CI, 1.2-8.3), black race (OR = 5.4; 95% CI, 2.3-12.8), paternal education less than college (OR = 1.4; 95% CI, 1-2) and 6MP nonadherence (OR = 9.4; 95% CI, 5.1-17.5) were associated with the overreporter phenotype.
Based on one-on-one interviews with patients and their parents, researchers determined forgetfulness was the main reason for nonadherence. Therefore, the researchers subsequently conducted a trial where physicians sent personalized text messages to patients and parents at a prescribed time to remind them to take the medication. The parent and patient would text the physician back indicating the dose was taken.
“We found that partnering with a parent was very conducive to our patients’ adherence, playing a key role in combatting forgetfulness,” Landier said in the release.
“Our first study showed that nonadherence was prevalent, increasing the risk for relapse [and] then found parent vigilance was an important facilitator to adherence, while forgetting to take the medication was the most commonly reported barrier. ...We hope that this will be a real step in improving outcomes in children with leukemia,” Bhatia said. – by Melinda Stevens
Disclosures: Bhatia and Landier report no relevant financial disclosures. Two other researchers report funds from St. Jude Children’s Research Hospital from income related to patent rights for the testing of TPMT genetic polymorphisms.
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