Targeting medication non-adherence behavior in selected autoimmune diseases: a systematic approach to digital health program development

Background 29 autoimmune diseases, including Rheumatoid Arthritis, gout, Crohn’s Disease, and Systematic Lupus Erythematosus affect 7.6-9.4% of the population. While effective therapy is available, many patients do not follow treatment or use medications as directed. Digital health and Web 2.0 interventions have demonstrated much promise in increasing medication and treatment adherence, but to date many Internet tools have proven disappointing. In fact, most digital interventions continue to suffer from high attrition in patient populations, are burdensome for healthcare professionals, and have relatively short life spans. Objective Digital health tools have traditionally centered on the transformation of existing interventions (such as diaries, trackers, stage-based or cognitive behavioral therapy programs, coupons, or symptom checklists) to electronic format. Advanced digital interventions have also incorporated attributes of Web 2.0 such as social networking, text messaging, and the use of video. Despite these efforts, there has not been little measurable impact in non-adherence for illnesses that require medical interventions, and research must look to other strategies or development methodologies. As a first step in investigating the feasibility of developing such a tool, the objective of the current study is to systematically rate factors of non-adherence that have been reported in past research studies. Methods Grounded Theory, recognized as a rigorous method that facilitates the emergence of new themes through systematic analysis, data collection and coding, was used to analyze quantitative, qualitative and mixed method studies addressing the following autoimmune diseases: Rheumatoid Arthritis, gout, Crohn’s Disease, Systematic Lupus Erythematosus, and inflammatory bowel disease. Studies were only included if they contained primary data addressing the relationship with non-adherence. Results Out of the 27 studies, four non-modifiable and 11 modifiable risk factors were discovered. Over one third of articles identified the following risk factors as common contributors to medication non-adherence (percent of studies reporting): patients not understanding treatment (44%), side effects (41%), age (37%), dose regimen (33%), and perceived medication ineffectiveness (33%). An unanticipated finding that emerged was the need for risk stratification tools (81%) with patient-centric approaches (67%). Conclusions This study systematically identifies and categorizes medication non-adherence risk factors in select autoimmune diseases. Findings indicate that patients understanding of their disease and the role of medication are paramount. An unexpected finding was that the majority of research articles called for the creation of tailored, patient-centric interventions that dispel personal misconceptions about disease, pharmacotherapy, and how the body responds to treatment. To our knowledge, these interventions do not yet exist in digital format. Rather than adopting a systems level approach, digital health programs should focus on cohorts with heterogeneous needs, and develop tailored interventions based on individual non-adherence patterns.

Generation and Evolution of Natal Pulses: Solitary Meanders in the Agulhas Current

Solitar y meanders of the Agulhas Current, so-called Natal pulses, may play an important role in the overall dynamics of this current system. Several hypotheses concer ning the triggering of these pulses are tested using sea sur face height and temperature data from satellites. The data show the for mation of pulses in the Natal Bight area at irregular inter vals ranging from 50 to 240 days. Moving downstream at speeds between 10 and 20 km day 2 1 they sometimes reach sizes of up to 300 km. They seem to play a role in the shedding of Agulhas rings that penetrate the South Atlantic. The inter mittent for mation of these solitar y meanders is argued to be most probably related to barotropic instability of the strongly baroclinic Agulhas Current in the Natal Bight. The vorticity structure of the obser ved basic flow is argued to be stable anywhere along its path. However , a proper perturbation of the jet in the Natal Bight area will allow barotropic instability , because the bottom slope there is considerably less steep than elsewhere along the South African east coast. Using satellite altimetr y these perturbations seem to be related to the inter mittent presence of offshore anticyclonic anomalies, both upstream and eastward of the Natal Bight.

Conditioning and preconditioning of the optimal state estimation problem

Optimal state estimation is a method that requires minimising a weighted, nonlinear, least-squares objective function in order to obtain the best estimate of the current state of a dynamical system. Often the minimisation is non-trivial due to the large scale of the problem, the relative sparsity of the observations and the nonlinearity of the objective function. To simplify the problem the solution is often found via a sequence of linearised objective functions. The condition number of the Hessian of the linearised problem is an important indicator of the convergence rate of the minimisation and the expected accuracy of the solution. In the standard formulation the convergence is slow, indicating an ill-conditioned objective function. A transformation to different variables is often used to ameliorate the conditioning of the Hessian by changing, or preconditioning, the Hessian. There is only sparse information in the literature for describing the causes of ill-conditioning of the optimal state estimation problem and explaining the effect of preconditioning on the condition number. This paper derives descriptive theoretical bounds on the condition number of both the unpreconditioned and preconditioned system in order to better understand the conditioning of the problem. We use these bounds to explain why the standard objective function is often ill-conditioned and why a standard preconditioning reduces the condition number. We also use the bounds on the preconditioned Hessian to understand the main factors that affect the conditioning of the system. We illustrate the results with simple numerical experiments.

Joint use of attribute importance rankings and non-attendance data in choice experiments

The joint and alternative uses of attribute non-attendance and importance ranking data within discrete choice experiments are investigated using data from Lebanon examining consumers’ preferences for safety certification in food. We find that both types of information; attribute non-attendance and importance rankings, improve estimates of respondent utility. We introduce a method of integrating both types of information simultaneously and find that this outperforms models where either importance ranking or non-attendance data are used alone. As in previous studies, stated non-attendance of attributes was not found to be consistent with respondents having zero marginal utility for those attributes