Fake it til you make it

I have not been disciplined in my work today. It is 1:22pm and I haven't started what I am supposed to be working on. I got sucked into shinier things that are much more appealing. I don't want to work on what I'm supposed to be working on.

I know, once I get started momentum will kick in. So that's what I'm doing here. I'm procrastinating, kind of, but in a fake it til I make it kind of way by talking about the bitsĀ of the work I find interesting. I'm hoping I trick myself into getting fired up about doing the work. Here goes...

I'm writing a literature review looking at the empiric research on patient-directed medication management services that have been implemented in cancer populations. One of the things that struck me (which is becoming a bit of a recurring theme) is how segmented the literature is. Research isĀ reported as adherence interventions, symptom management interventions (e.g. pain), or pharmacist-led interventions and systematic reviews typically look at one segment in isolation. This seems a bit silly to me. If you only look at interventions claiming to be 'adherence' interventions, then you'll likely miss the more comprehensive services that address adherence as well as everything else, like medication review. If you only look at pharmacist-led interventions, then you'll miss all the interventions delivered by nurses, or designated research assistants. Sure, they might be more simple, but they're probably also less resource intensive and may suffice for some people depending on their level of need. If you want to know about what interventions improve medication outcomes, surely you need to look at the whole lot, don't you?

Another thing that I find interesting short sighted, is how often we exclude the very people who would have the most to benefit from the intervention. I mean, if you're investigating an intervention that is designed to positively impact the medication taking behaviour of a person who is self-administering medication, then it shouldn't matter if they speak another language, or they have some cognitive impairment, or psychiatric illness. They're probably the ones who need the most help, no? Sure, it'll be harder to implement the intervention, but it might give more meaningful results that are actually relevant to the real world. Wouldn't it be better to explicitly state that self-administration of medicines is an inclusion criteria, than to list things like cognitive impairment and psychiatric illness as exclusions? I'm pretty sure people with stable psychiatric illness are relied upon to self-administer medicines all the time. And if someone's got such cognitive impairment that you can't obtain informed consent, then they probably shouldn't be administering their own medication.

And one more thing, while I'm thinking out loud. Is it really accurate to call something an adherence intervention if the decision to prescribe has already been made? I don't want to get all pedantic about the semantics, but they are distinctly different terms. If an intervention is about how much a person's medication taking behaviour matches what was prescribed, then it's really talking about compliance. Adherence implies there was some sort of agreement between patient and the prescriber about what the plan should be. I suppose you could argue that if an intervention identified that the patient had an issue with the prescribed medication and then took steps to resolve the problem with the prescriber to something that was mutually agreeable, then that could be considered an adherence intervention.

This is why I don't like writing literature reviews. It's too bloody hard to do it well. It's so easy to gloss over stuff and generalise, and not pay attention to the details like the terms they're using etc. But the details matter. If you lump a whole bunch of interventions together because they all measure 'how many doses were taken' as an outcome, then it's pretty much guaranteed that you're not going to get any meaningful results. Studies will be too heterogeneous and of low quality to draw any meaningful conclusions. What's the point of that? How does that add value to the existing knowledge base? I don't want to do that. So better get back to it I guess.


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