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Ellumiante Test

Wendy Test

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Ellumiante Test

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  1. Adherence to Oral Chemotherapy in Childhood Acute Lymphoblastic LeukemiaConcept Analysis & Review of the Literature Wendy Landier, Doctoral Student University of Hawai‘i School of Nursing

  2. Background: Childhood A.L.L. • Most common childhood malignancy • 1 in 4 children diagnosed with cancer at age less than 15 yrs Jemal et al., 2009

  3. Background:Relapse in Childhood A.L.L. • 1 in 5 children with A.L.L. relapse despite contemporary therapy • Relapsed A.L.L. • Constitutes large proportion of children with cancer • More common than: • Newly diagnosed A.M.L. • Most other solid tumors of childhood • Long-term prognosis generally poor after relapse • Significant contributor to childhood cancer mortality Nguyen et al., 2008

  4. Background:Prognostic Features in Childhood A.L.L. Pui, 2006 Abbreviation: WBC = White blood cell count

  5. Background:Phases of Therapy for A.L.L. Intensification Induction Consolidation Interim Maintenance Maintenance 1.5 to 2.5 years 6 to 12 months Therapy Begins Therapy Ends 2 to 3 years Landier & Wallace, 2003

  6. Background:Oral Chemotherapy for A.L.L. • Oral antimetabolite chemotherapy • Daily 6-mercaptopurine (6-MP) • Weekly methotrexate (MTx) • Required during “maintenance” phase of A.L.L. therapy Koren et al., 1990; Schmiegelow et al., 1995

  7. Background:Oral Chemotherapy for A.L.L. • Positive correlation between RBC antimetabolite concentrations and survival • Methotrexate polyglutamates (MTxPG) • 6MP - Thioguanine nucleotides (6TGN) • Role of systemic exposure to 6MP in sustained remission better defined than that of methotrexate Koren et al., 1990; Lennard et al., 1995; Relling et al., 1999; Schmiegelow et al., 1996

  8. Background:Oral 6MP in A.L.L. Therapy • Lower systemic exposure to 6-MP linked with increased risk of relapse • Variability in exposure may be due to differences in: • Pharmacogenetics • Bioavailability (e.g., ingestion of food, milk) • Adherence ADHERENCE Koren et al., 1990; Lilleyman & Leonard 1994; Relling et al.., 1999 Aplenc & Lange, 2004; de Lemos et al., 2007; Lau et al., 1998

  9. Adherence to Oral Chemotherapy in Childhood A.L.L.:An Evolutionary Concept Analysis PAPER #1

  10. Concept Analysis:Objectives • To clarify the concept of adherence to oral chemotherapy in childhood A.L.L. • To examine the implications for nursing practice • To provide a foundation for further research and knowledge development

  11. Concept Analysis:Methodology • Rodgers’ Evolutionary Method • Concepts considered: • Dynamic • Ever-changing over time • Context-bound • Goal: • Provide clarity of concept • Serve as strong heuristic for further concept development and inquiry Rodgers, 2000

  12. Concept Analysis:Evolutionary Method • Multidisciplinary literature review • Rigorous qualitative data analysis • Identification of: • Attributes • Antecedents • Consequences • Associated expressions/surrogate terms • Interdisciplinary/sociocultural contextual variations/references Rodgers, 2000

  13. Method – Step 1Concept Identification • Identification of: • Concept • Associated expressions/surrogate terms ADHERENCE Rodgers, 2000

  14. Adherence:Identification of Associated Terms • Closely related to compliance • Terms sometimes used interchangeably COMPLIANCE: Often associated with paternalism, authoritarianism, and lack of patient autonomy ADHERENCE: More commonly associated with shared decision-making between patient and healthcare provider Evangelista, 1999; Duncan, Cloutier & Bailey, 2007

  15. Adherence:Identification of Associated Terms • Mutuality • Therapeutic alliance • Maintenance • Concordance • Cooperation • Self-care Duncan et al., 2007; Kyngas, Duffy & Kroll, 2000; Pritchard et al, 2006; Shay, 2008

  16. Method – Step 2Setting and Sample • Multidisciplinary literature search via Ovid SP: • Nursing (CINAHL): 104 citations • Psychology (PsyINFO): 115 citations • Medicine (MEDLINE): 349 citations • Additional search: • ERIC (separate search): 24 citations • Cancer/leukemia enriched subset (MEDLINE): 17 citations Rodgers, 2000

  17. Method – Step 2Setting and Sample • Search parameters: • English language • 1978-2008 • Subject heading • Patient compliance • Medication compliance • Treatment compliance • Key words • Adherence • Child • Adolescent • Chronic disease • Total citations identified = 609 • Abstracts evaluated for relevance • 79 representative papers selected for final sample Rodgers, 2000

  18. Method – Step 3Data Analysis • Data abstraction • Citation, publication year • Discipline (departmental affiliation/credentials of first author) • Required components for Evolutionary Method • Thematic analysis • Attributes • Antecedents • Consequences • Identification of Themes • Inductive process • Compared across disciplines Rodgers, 2000

  19. Method – Step 3:Data Abstraction Form Required components of Evolutionary Method

  20. Results:Definitions from the Literature • “Adherence” and “compliance” used interchangeably • Represent different attributes of this multifaceted and complex concept ADHERENCE: More commonly used in recent literature, in some cases is used in place of compliance COMPLIANCE: More dominant term in 1970’s and 1980’s

  21. Results: Definitions from the Literature COMPLIANCE • Ability to complete or perform what is due • Flexibility • Adaptability • Malleability • Subordinate behaviors Evangelista, 1999

  22. Results:Definitions from the Literature COMPLIANCE • “The extent to which a patient’s behavior coincides with advice and therapy prescribed by a medical provider” • “The extent to which an individual chooses behaviors that coincide with a clinical prescription” • “The patient’s active, intentional and responsible process of self-care, in which the patient works to maintain his or her health in close collaboration with healthcare staff” Festa, Tamaroff, Chasalow, & Lanzkowsky, 1992, p. 808 Dracup & Meleis, 1982, p. 31 Kyngas et al., 2000, p. 7

  23. Results:Definitions from the Literature NON-COMPLIANCE • “Behaviors that vary from the consensual regimen” • “On a continuum from the occasional lapse to total refusal” • “A person’s informed decision not to adhere to a therapeutic recommendation” Dracup & Meleis, 1982, p. 31 Lilleyman & Lennard, 1996, p. 1220 Kim & Moritz (NANDA), 1982, p. 299

  24. Results:Definitions from the Literature “The complexity of non-compliance cannot be reduced to and adequately reflected in the labeling of the individual as being either compliant or non-compliant” Kyngas et al, 2000, p.11

  25. Results:Definitions from the Literature ADHERENCE • “Willingness on the part of the patient to participate with the prescribed regimen” • “One’s ability to maintain the behaviors associated with a plan of care. This often involves taking medications, keeping appointments, or changing health behaviors.” Dracup & Meleis, 1982, p. 31 Shay, 2008, p. 42

  26. Results:Definitions from the Literature NON-ADHERENCE • “When failure to comply is sufficient to interfere appreciably with achieving the therapeutic goal” • “Can range from a complete failure to take the prescribed medication to the patient's altering of either dose or duration of therapy” O’Hanrahan & O’Malley, 1981, p. 291 Festa et al., 1992, pp. 808-809

  27. Results:Antecedents of Adherence in A.L.L. ANTECEDENTS • Diagnosis of childhood A.L.L. requiring treatment with oral antimetabolite chemotherapy • Patient/family factors: • Knowledge/understanding of diagnosis/treatment • Adaptation to illness • Ability or willingness to learn medication-taking skills • Patient age/developmental stage • Family functioning • Social support • Health beliefs • Socioeconomic indicators

  28. Results:Antecedents of Adherence in A.L.L. ANTECEDENTS • Healthcare system factors: • Complexity, duration and side effects of treatment • Clear healthcare provider communication and supportive presence • Healthcare access and costs • Perceived value of adherence: • Disease control • Long-term survival/cure

  29. Results:Attributes of Adherence in A.L.L. ATTRIBUTES • Willingness or motivation to stick to the prescribed treatment • Persistence over a prolonged, defined period • In collaboration with and according to the specific instructions of the healthcare provider • Chemotherapy dose requirements • Restrictions (in regard to timing, food and milk products)

  30. Results:Attributes of Adherence in A.L.L. ATTRIBUTES • Cognitive and mental capacity to follow instructions • Flexibility to adapt and conform to ongoing regimen changes • Active participation in the process of oral chemotherapy administration • Identification of key participants in adherence process: • Person with overall responsibility for home administration • Healthcare provider who provides close supervision

  31. Results:Consequences of Adherence in A.L.L. CONSEQUENCES • Potential for: • Maintaining optimal levels of chemotherapy metabolites • Improved disease outcome • Increased patient/caregiver self-esteem, pride, accomplishment (related to active participation in care)

  32. Results:Contextual Variations Interdisciplinary • All Disciplines: • Importance of: • Taking medication exactly as prescribed • According to instructions of healthcare provider • Over a prolonged, defined period Davies & Lilleyman, 1995; Kyngas et al., 2000; Pritchard et al., 2006

  33. Results:Contextual Variations Interdisciplinary • Medicine & Psychology: • Correct dosing and administration • Specific restrictions regarding time of day, food intake • Nursing: • Adaptability and active participation • Epidemiology: • Child’s age/developmental stage • Family’s cultural and health beliefs Lau et al., 1998; Lennard et al., 1995 Goode et al., 2004; Kyngas et al, 2000 Hovell et al., 2003; Rogers et al., 2001)

  34. Results:Contextual Variations Sociocultural • Lower SES associated with decreased adherence, particularly in regard to: • Income • Access to care • Nutritional status • Language barriers noted as potential sources of impaired adherence de Oliveira et al., 2004 Tebbi et al., 1986

  35. Results:Contextual Variations References • Children and adolescents with A.L.L. in the maintenance phase of treatment • Children and adolescents with other chronic illnesses: • Asthma • Hodgkin lymphoma and other cancers • Diabetes • Human immunodeficiency virus infection • Rheumatoid arthritis • Tuberculosis Davies et al., 1993; Festa et al., 1992 Knight, 2005; Festa et al, 1992; Tamaroff, Festa, Adesman, & Walco, 1992; Kyngas, 1999; Palardy, Greening, Ott, Holderby, & Atchison, 1998; Singh et al., 1999; Kyngas & Rissanen, 2001; Hovell et al., 2003

  36. Clarifying/Defining the Concept:Suggested Definition Adherence in Childhood A.L.L. The concept of adherence to oral chemotherapy in childhood A.L.L. is: • Complex • Multi-dimensional • Context-bound

  37. Clarifying/Defining the Concept:Suggested Definition Adherence in Childhood A.L.L. The active self-care behavior of taking (or having the responsibility for administering) daily oral chemotherapy, in collaboration with and according to the instructions of a healthcare provider over a defined, prolonged treatment period.

  38. Clarifying/Defining the Concept:Suggested Definition Inherent Themes • Ability or willingness to stick to or follow a plan • Intention, capacity, responsibility, and collaboration • Ability to adapt to change • Willingness to carefully follow the instructions of the healthcare provider • Active participation in the process of daily oral chemotherapy administration Shay, 2008; Kyngas et al., 2000; Evangelista, 1999; de Oliveira et al., 2004; Malbasa, Kodish, & Santacroce, 2007

  39. Strengths/Limitations EVOLUTIONARY METHOD • Strengths: • Breadth of literature review • Systematic and rigorous approach • Emphasis on current use of concept • Limitations: • Sampling design (did not include complete analysis of all literature retrieved) • Analysis would be strengthened by field work to identify exemplars

  40. Implications ADHERENCE IN CHILDHOOD A.L.L. • Clinical implications for healthcare providers: • Importance of clear communication • Reinforcement of adherence-related behaviors • Development of disease management plans with emphasis on: • Skills for medication-taking (e.g., pill-swallowing) • Managing daily medication administration (e.g., reminder systems)

  41. Implications ADHERENCE IN CHILDHOOD A.L.L. • Research needed to determine: • Health behaviors that predict adherence • Role of healthcare providers in fostering adherence • Barriers and facilitators to adherence as perceived by patients/families • Goal: To inform future interventions to improve adherence in vulnerable groups

  42. Adherence to Oral Chemotherapy in Childhood A.L.L.:A Review of the Literature PAPER #2

  43. Purpose • To summarize current literature relevant to adherence to oral chemotherapy in children with A.L.L. • To identify the factors that may affect adherence in this population

  44. Significance • Understanding factors that influence adherence is important in order to: • Guide healthcare providers in delivering care that will promote adherence • Potentially increase likelihood of relapse-free survival in these children

  45. Methodology • Online database search: • Years: 1975-2008 • Databases: MEDLINE, CINAHL, CANCERLIT • Key words: Adherence, patient compliance, child, adolescent, parent/caregiver, oral chemotherapy, 6-mercaptopurine, antimetabolites, antineoplastic agents, leukemia, acute lymphoblastic leukemia, childhood leukemia, cancer, neoplasm, chronic illness, family, diabetes, asthma, HIV, nurse’s role, patient participation, family participation, parent/caregiver participation, professional-family relations • Additional relevant papers identified from reference lists of retrieved articles

  46. Methodology:Inclusion Criteria • Major focus on one or more of these topics: • Adherence to therapy in childhood/chronic illness • Adherence to oral chemotherapy in childhood/ adolescent cancer • Adherence to 6-mercaptopurine or prednisone in childhood/adolescent A.L.L. • Family aspects of management of childhood/ adolescent illness • Interventions to improve adherence in chronic illness (pediatric or adult due to limited literature)

  47. Methodology • 101 papers identified • 52 met inclusion criteria and were reviewed • Data abstracted into matrix according to method of Garrard Garrard, 2007

  48. ResultsMeasuring Adherence • Adherence can be measured by: • Serum assays (previous day) • RBC metabolite levels (previous 30 days) • Surrogate measures (WBC, ANC) • Behavioral measures (pill counts, MEMS caps) • Self-report (questionnaires, interviews, diaries) Pritchard, Butow, Stevens, & Duley, 2006

  49. Results:Range of Adherence Behaviors Suboptimal adherence is clinically prevalent

  50. Factors Potentially Influencing Adherence:Patient/Family Factors • Sociodemographic Factors: • Older age (particularly adolescence) • Male gender • Larger family size • Maternal employment outside the home • Lower levels of parental education • Lower socioeconomic status Baker et al., 1993; Festa et al., 1992, Tamaroff et al., 1992; Lennard et al., 1995; Macdougall et al., 1992; Smith et al., 1979; Lancaster et al., 1997; Tebbi et al., 1986; de Oliveira et al., 2004

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