RESEARCH
Predicting Treatment Discontinuation Among Patients with Multiple Sclerosis: Application of the Transtheoretical Model of Change

https://doi.org/10.1331/1544345041475607Get rights and content

ABSTRACT

Objective

To delineate factors associated with discontinued use of the multiple sclerosis (MS) medication Avonex (interferon beta-1a—Biogen) as part of an effort to develop an intervention to promote treatment persistency.

Design

In-depth telephone interviews followed by a 12-page written questionnaire delivered by mail.

Setting

United States.

Participants

Of 946 patients with MS who were contacted, 531 (56%) completed questionnaires; 79% of respondents were currently using Avonex for treatment of MS.

Main Outcome Measure

Discontinuation of Avonex treatment, with analysis based on the theoretical framework of the Transtheoretical Model of Change.

Results

Four key variables (pros of Avonex use, cons of Avonex use, highest level of education completed, and level of disability) accurately identified 82% of patients who discontinued Avonex use, while also correctly identifying 81% of patients who stayed on the drug.

Conclusion

Constructs from the Transtheoretical Model of Change were effective in differentiating patients who had discontinued their Avonex treatment versus patients who continued treatment. This behavioral model likely would be an effective framework for a medication persistency intervention.

Section snippets

Objectives

This manuscript reports on Phase I of a two-phase study. Both phases focused on patient discontinuation from the use of Avonex. Previous studies by Biogen and the present study demonstrated that “adherence” (i.e., taking the drug on schedule, as prescribed) is not a problem for patients using Avonex; patients who remain on drug generally adhere to the prescribed regimen until they discontinue the regimen completely. Objectives of the Phase I study were to develop and administer a survey

Methods

Phase I consisted of two key components: (1) telephone interviews with patients who were either current Avonex users, previous Avonex users, or never (naive) Avonex users, along with a comprehensive literature review; and (2) a mail-administered questionnaire to a random sample of patients with MS who had previously enrolled in Biogen's Alliance program and who had given Biogen permission to contact them for future studies. All patients were part of Biogen's Alliance program even if they had

Response Rate and Characteristics of Participants

A total of 531 completed questionnaires (56%) were returned. One respondent, who was under the age of 18, was excluded. This yielded an analyzable sample of 530 participants.

Sociodemographic characteristics of the study population are summarized in Table 1. The average age of the respondents was 45.9 years old (range, 19–77; standard deviation [SD] = 9.98); most were white women with some college education. Some 37% were employed full time, while 34% were not employed because of their MS. Just

Other Factors as Functions of Stage

Table 4 examines stage and patient's perception of the importance of continuing to use Avonex in the next 6 months and how confident patients were about their future use of Avonex. Those patients who were not thinking about quitting (stage 1) rated the importance of continuing to use Avonex in the next 6 months as 9.66 out of 10 (1 = not all important to 10 = extremely important). This rating decreased by stage (8.61 for stage 2, 6.58 for stage 3). Moreover, confidence in using Avonex in 3, 6,

Regression Analyses: A Model to Predict Avonex Discontinuation

Bivariate relationships between the individual predictor variables and discontinuation of treatment are depicted in Table 7. Odds ratio estimates that are significantly greater than 1.0 are risk factors for discontinuation of Avonex, and estimates that are significantly less than 1.0 are protective of discontinuation of Avonex. Variables that were considered in the regression modeling were related to dropout at P-level of less than .20: age, level of education, lives with spouse or significant

Discussion

The Transtheoretical Model of Change appears to be an effective framework for differentiating patients based on use of Avonex. The newly developed pros, cons, and self-efficacy scales are strongly associated with the outcome variable, discontinuation of drug. A series of four key variables accurately identifies 82% of patients who discontinue drug use while also correctly identifying 81% of patients who stay on the drug. These variables are pros, cons, education, and level of disability.

Our

Limitations

This study involved only patients with MS who had previously enrolled in Biogen's Alliance program. These patients had agreed to be contacted by Biogen to provide new information or for future research. Therefore, the study may not be generalizable to other patients with MS using Avonex or other medications to treat MS.

Conclusion

This study identified variables that could be used, along with the Transtheoretical Model of Change to predict patient persistence (dropout) with Avonex. Four key variables (pros of Avonex use, cons of Avonex use, highest level of education completed, and level of disability) accurately identified 82% of patients who discontinued Avonex use, while also correctly identifying 81% of patients who stayed on the drug. As a result, a persistency program may now be developed that will have a high

References (25)

  • W.F. Velicer

    An expert system intervention for smoking cessation

    Patient Educ Couns.

    (1999)
  • J.O. Prochaska et al.

    Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation

    Addictive Behaviors.

    (2001)
  • D.C. Mohr et al.

    Multiple sclerosis: empirical literature for the clinical health psychologist

    J Clin Psychol.

    (2001)
  • Biogen. MS Resource Center: Understanding MS. Accessed at: www.avonex.com/application/avonex?sess=O4SLtwywAneger9FqHX...
  • Biogen. [WWW Document]. Accessed at www.biogen.com/site/content/products/on_the_market.asp, August 23,...
  • F.A. Whitlock et al.

    Depression as a major symptom of multiple sclerosis

    J Neurol Neurosurg Psychiatry.

    (1980)
  • D.C. Mohr et al.

    Therapeutic expectations of patients with multiple sclerosis upon initiating interferon beta-1b: relationship to adherence to treatment

    Multiple Sclerosis.

    (1996)
  • D.C. Mohr et al.

    Treatment of depression improves adherence to interferon beta-1b therapy for multiple sclerosis

    Arch Neurol.

    (1997)
  • D.C. Mohr et al.

    Injectable medication for the treatment of multiple sclerosis: the influence of self-efficacy expectations and injection anxiety on adherence and ability to self-inject

    Ann Behav Med.

    (2001)
  • D.C. Mohr et al.

    Telephone-administered cognitive-behavioral therapy for the treatment of depressive symptoms in multiple sclerosis

    J Consult Clin Psychol.

    (2000)
  • F.D. Lublin et al.

    Management of patients receiving interferon beta-1b for multiple sclerosis: report of a consensus conference

    Neurology.

    (1996)
  • D.C. Mohr et al.

    Treatment adherence and patient retention in the first year of a phase-III clinical trial for the treatment of multiple sclerosis

    Multiple Sclerosis.

    (1999)
  • Cited by (26)

    • Teaching motivational interviewing in a blended learning environment

      2020, Currents in Pharmacy Teaching and Learning
      Citation Excerpt :

      Motivational interviewing allows both parties to bring their expertise to the conversation in order to determine the most appropriate course of action.6 MI has made a significant impact on patient care including aspects of pharmacotherapy.1,7–11 Consistent use of MI in practice can identify barriers and reemphasize a medication's role in overall health to thereby improve adherence.12

    • The Use of Measurements and Health Behavioral Models to Improve Medication Adherence

      2018, Social and Administrative Aspects of Pharmacy in Low-and Middle-Income Countries: Present Challenges and Future Solutions
    • Measuring adherence and persistence to disease-modifying agents among patients with relapsing remitting multiple sclerosis

      2008, Journal of the American Pharmacists Association
      Citation Excerpt :

      Among those who do use a disease-modifying agent, medication adherence, as measured by MPR between the first and last dispensing, was quite high, averaging 84%. Such findings of relatively high rates of medication adherence among patients with MS are consistent with previous findings.8–10,17–19 Findings of such high mean adherence, however, should not cloud the fact that 28% of patients would be labeled as nonadherent using an 80% cut point and that the mean adherence rate decreases to 68% (with 54% being labeled as nonadherent) when the entire 24-month period is considered.

    View all citing articles on Scopus

    Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

    Funding: Supported by a research contract from Biogen, Inc.

    View full text