Examining determinants of self management behaviors in patients with diabetes: an application of the Theoretical Model of Effortful Decision Making and Enactment

OBJECTIVE

This study examined determinants of self-monitoring of blood glucose (SMBG) in patients with diabetes based on a theoretical model. The model focuses on two equally important components of the decision process within a single framework: (1) making a decision and (2) enacting the decision.

METHODS

Diabetes patients with HbA1c >7% and requiring insulin therapy were recruited from a southeastern Michigan healthcare system. Responses were elicited using a mail-in questionnaire. SMBG was measured using a two-week diary and two recall measures. The applicability of the theoretical model as it relates to SMBG was tested using structural equation modeling (SEM).

RESULTS

The SEM analysis demonstrated that goal desire is an antecedent to goal intentions and that implementation desire and implementation intentions mediate the path between goal intentions and SMBG. Further, implementation intentions are a significant predictor of SMBG.

CONCLUSION

Consistent with the theoretical model, results indicated that implementation desire and implementation intentions mediate the relationship between strength of goal intention and performing specific behaviors to achieve the goal.

PRACTICE IMPLICATIONS

It is evident that in order to be more effective, educational programs or interventions should consider incorporating implementation and action plans to help patients translate decisions and intentions into behavior.

Prevalence and predictors of utilization of community pharmacy generic drug discount programs

BACKGROUND

Since 2006, select pharmacies in the United States have been offering programs where prescriptions for certain generic medications can be filled at very low cost (e.g., a 30-day supply for $4). However, limited knowledge exists on the characteristics of patients who have used these services.

OBJECTIVE

To examine the prevalence of use of community pharmacy generic drug discount programs and the characteristics of patients using these programs.

METHODS

Two cross-sectional surveys of patients in a university-affiliated health system general medicine clinic were conducted over an approximately 4-week period in the summers of 2008 and 2010. The survey measured self-reported information in 3 parts: a listing of current medications, questions about program use, and patient demographics. The survey was administered to patients as they were waiting to see their physicians with a research assistant on-site for assistance and to collect the completed surveys. Medications listed by patients were classified as acute or chronic by pharmacists on the research team. Descriptive statistics (Pearson chi-square or Student's t-tests) were used to compare subjects across years and between groups of discount program users and nonusers. Logistic regression models were constructed to identify significant predictors of program use, testing demographic factors, prescription drug coverage, number of medications, monthly out-of-pocket payments, and year of the survey.

RESULTS

The convenience sample included 414 individuals overall, 203 in 2008 and 211 in 2010. After excluding respondents who did not answer all survey questions, the sample size was 311 (n = 148 in 2008 and 163 in 2010). The sample was mostly Caucasian; most patients had prescription coverage; and a large majority of medications filled were for chronic use. Patient characteristics were similar in the 2 groups except for a higher mean number of self-reported medications in 2010 than 2008 (4.2 vs. 3.4, respectively, P = 0.01). Use of a discount medication program was reported by 52 (31.9%) of those surveyed in 2010 compared with 7 (4.7%) in 2008 (P less than 0.001). When both groups were combined, factors associated with use of generic drug discount programs included filling prescriptions for a higher number of medications (odds ratio [OR] =1.13, 95% CI =1.01-1.27, P =0.036) and the year of the survey (OR for 2010 =9.02, 95% CI =3.8221.29). Differences in program use were also observed among categories of age and income.

CONCLUSIONS

Over a 2-year period, there was an increase in the use of discount generic medication programs in this university clinic population. Patients who take more prescription medications are more likely to choose such plans, and differences in program use were observed between ranges of age and income. More extensive analysis is needed to better predict patient use of such services.

Cardiovascular risk among university students from developed and developing nations

BACKGROUND

A key aspect in halting global increase in cardiovascular events is prevention and especially prevention at an early age. Unfortunately, global data regarding cardiovascular risk factors in the young are limited. Therefore the objectives of this study were to identify the most common cardiovascular risk factors among young adults in a university setting in both developed and developing countries.

METHODS

Lifestyle and cardiovascular risk factors (smoking status, rates of physical activity, alcohol use, family history, blood pressure, fasting lipid panel, fasting blood glucose) were prospectively evaluated in young adults at three different university settings [University of Michigan (Ann Arbor, USA), University of Kalamoon (Deratiah, Syria), and Kakatiya University (Warangal, India)].

RESULTS

A total of 296 subjects (mean age and standard deviation 22 ± 3 years) were evaluated. Rates of current smoking were markedly higher (p < 0.001) in Syria (43%) compared with the USA (6.2%) and India (1.7%). Subjects in India were significantly (p < 0.001) less likely to engage in physical activity (20.2%) compared with the USA (90.7%) and Syria (68.8%). Fasting blood glucose levels and body mass index were significantly higher (p < 0.001) in Syria as compared to other countries. Significant differences were also noted in LDL, HDL, and triglycerides among the three sites.

CONCLUSIONS

Cardiovascular risk factors among young adults in a university setting vary depending on global setting. Based upon the results of this study, targeted interventional programs based on risk findings from individual countries may be a reasonable future strategy to help reduce long term cardiovascular morbidity and mortality.

Chlorthalidone Reduces Cardiovascular Events Compared With Hydrochlorothiazide

There is significant controversy around whether chlorthalidone (CTD) is superior to hydrochlorothiazide (HCTZ) in hypertension management. The objective of this analysis was to evaluate the effects of CTD compared with HCTZ on cardiovascular event (CVE) rates. We performed a retrospective observational cohort study from the Multiple Risk Factor Intervention Trial data set from the National Heart, Lung, and Blood Institute. The Multiple Risk Factor Intervention Trial was a cardiovascular primary prevention trial where participants were men 35 to 57 years of age enrolled and followed beginning in 1973. CVEs were measured yearly, and time to event was assessed by Cox regression. Systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, potassium, glucose, and uric acid were measured yearly. The difference between groups was evaluated by repeated-measures mixed modeling, and each model was adjusted for predictors of each variable. CVEs were significantly lower in those on CTD (adjusted hazard ratio: 0.51 [95% CI: 0.43 to 0.61]; P <0.0001) and on HCTZ (adjusted hazard ratio: 0.65 [95% CI: 0.55 to 0.75]; P <0.0001) compared with those who took neither drug. When comparing the 2 drugs, CTD had significantly fewer CVEs compared with HCTZ ( P =0.0016). CTD displayed significantly lower SBP ( P <0.0001), lower total cholesterol ( P <0.0001), lower low-density lipoprotein cholesterol ( P =0.0009), lower potassium ( P =0.0003), and higher uric acid ( P <0.0001) over time compared with HCTZ. In conclusion, both HCTZ and CTD reduce CVEs compared with neither drug. When comparing both drugs, CTD reduces CVEs more than HCTZ, suggesting that CTD may be the preferred thiazide-type diuretic for hypertension in patients at high risk of CVEs.

Concurrent validity of kidney transplant questionnaire in US renal transplant recipients

BACKGROUND

Valid instrumentation in the assessment of health-related quality of life (HQoL) in renal transplant recipients is critical to identifying particular nuances and determinants of HQoL in this population. Therefore, the validity of disease-specific instruments to measure HQoL in renal transplant recipients, such as the Kidney Transplant Questionnaire (KTQ), needs further investigation. The objective of this study was to assess the concurrent validity of the KTQ in adult US renal transplant recipients using the well established SF-12 Health Survey version 2 (SF-12v2) as the comparison instrument.

METHODS

One hundred and fourteen renal transplant recipients met the following inclusion criteria for this study, ie, were at least 21 years of age, more than two years post-transplant, and receiving immunosuppressant therapy. Subjects were asked to complete a series of HQoL instruments, ie, the KTQ and the SF-12v2 (physical component summary [PCS-12] and mental component summary [MCS-12]). Descriptive statistics were calculated, and correlational analyses were conducted to examine the concurrent validity of the HQoL instruments.

RESULTS

Among 100 participants (87.7% response rate), the majority of participants were male (52%), had deceased donor transplants (63%), and received Medicare benefits (84%). PCS-12 was positively correlated with three of five KTQ subscales (P < 0.05), ie, KTQ-physical (r = 0.43), KTQ-fatigue (r = 0.42), and KTQ-uncertainty/fear (r = 0.2). MCS-12 was positively correlated with all KTQ subscales (P < 0.01), ie, KTQ-physical (r = 0.26), KTQ-fatigue (r = 0.48), KTQ-uncertainty/fear (r = 0.33), KTQ-emotional (r = 0.47), and KTQ-appearance (r = 0.28).

CONCLUSION

The findings support the concurrent validity of the KTQ in US renal transplant recipients. Future studies should continue exploring the validity of the KTQ, as well as its practical and research utility in HQoL measurement in the renal transplant population.

A new comorbidity index: the health-related quality of life comorbidity index

OBJECTIVE

To derive and validate the health-related quality of life comorbidity index (HRQL-CI).

STUDY DESIGN AND SETTING

Of 261 clinical classification codes (CCCs) in the 2003 Medical Expenditure Panel Survey (MEPS), 44 were identified as adult, gender-neutral, chronic conditions. The least absolute shrinkage and selection operator (LASSO) procedure identified CCCs significantly associated with the Short Form-12 physical component summary (PCS) and mental component summary (MCS) scores. Regression models were fitted with the selected CCCs, resulting in two subsets corresponding to PCS and MCS, collectively called the HRQL-CI. Internal validation was assessed using 10-fold cross-validation, whereas external validation in terms of prediction accuracy was assessed in the 2005 MEPS database. Prediction errors and model R² were compared between HRQL-CI models and models using the Charlson-CI.

RESULTS

LASSO identified 20 CCCs significantly associated with PCS and 15 with MCS. The R² for the models, including the HRQL-CI (0.28 for PCS and 0.16 for MCS) were greater than those using the Charlson-CI (0.13 for PCS and 0.01 for MCS). The same pattern of higher R² for models using the HRQL-CI was observed in the validation tests.

CONCLUSION

The HRQL-CI is a valid risk adjustment index, outperforming the Charlson-CI. Further work is needed to test its performance in other patient populations and measures of HRQL.

A simple and promising tool to improve self-monitoring of blood glucose in patients with diabetes

AIM

To examine patient formation of implementation plans, a volitional strategy, and its influence on self-monitoring of blood glucose (SMBG).

METHODS

A randomized experimental-control design over a 2-week time period was used. The study population was diabetes patients with HbA1c >7% and requiring insulin therapy. Patients were recruited from a southeastern Michigan healthcare system. A self-administered intervention was designed to assist patients to formulate plans to perform SMBG. The primary outcome measure was SMBG rates. Three control groups were used to control for testing effects. Hypotheses were tested using ANOVA at a significance level of 0.05. SMBG was measured using a 2-week diary and two recall measures.

RESULTS

There were 402 patients with diabetes recruited for the study. Analyses indicated that making implementation plans increased SMBG rates as assessed by a diary and two recall measures. The patients in the experimental group checked their blood sugar up to 7.77 times more than the control groups (sig<0.05) over a 2-week time period as measured by the diary.

CONCLUSIONS

Patient behavior can be impacted by using an implementation planning tool. This technique can help improve patient self-monitoring behavior.

Validation of the Special Projects of National Significance adherence tool in HIV/AIDS patients

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) is crucial for success. Therefore, having validated tools to help assess adherence is necessary. The Health Resources and Services Administration assessed adherence as a Special Project of National Significance (SPNS). As a result of their study, a 3-question survey was developed as a simple tool to assess adherence in patients with HIV/AIDS.

OBJECTIVE

To validate the SPNS adherence survey as an accurate and effective way to assess adherence and to determine whether any other independent variables correlate with a significant reduction in viral load.

METHODS

The study was a retrospective chart review of 300 patients actively enrolled in an HIV/AIDS clinic from January 2007 to September 2007. Patients were eligible for the study if they had been on HAART for at least 6 months, were > or =18 years old, and had completed at least 2 surveys.

RESULTS

A total of 74 patients met the criteria; the majority were male (75.3%) and African American (91.9%). Twenty-six (35.1%) patients had scores < or =10, indicating poorer adherence, and 48 (64.9%) patients had scores > or =11. The mean number of antiviral plus other medications was 4.4. Dosing of HAART drugs was once (5 nonadherent, 23 adherent pts.) and twice (21, 25 pts., respectively) daily, and mean number of different antiretroviral tablets/capsules being taken was 1.7 and 1.5, respectively. The nonadherent patients' average viral load was 15,202.3 copies/mL, while the adherent patients' average viral load was 163.8 copies/mL (p = 0.001) The SPNS score was significantly associated with HIV-RNA viral load (-0.482, p < 0.001). There also was a significant association between a higher HIV-RNA viral load and the total number of medications a patient was taking, as well as the number of different antiretroviral tablets/capsules being taken (0.299, p = 0.01; 0.249, p = 0.03). There was no significant difference in HIV-RNA viral load when comparing age, sex, race, income, and frequency of HIV drug dosing.

CONCLUSIONS

The SPNS survey is a valid and simple tool in measuring adherence that can aid health-care professionals in assessing adherence to HAART.

Severity of anxiety and work-related outcomes of patients with anxiety disorders

BACKGROUND

This study examined associations between anxiety and work-related outcomes in an anxiety disorders clinic population, examining both pretreatment links and the impact of anxiety change over 12 weeks of treatment on work outcomes. Four validated instruments were used to also allow examination of their psychometric properties, with the goal of improving measurement of work-related quality of life in this population.

METHODS

Newly enrolled adult patients seeking treatment in a university-based anxiety clinic were administered four work performance measures: Work Limitations Questionnaire (WLQ), Work Productivity and Activity Impairment Questionnaire (WPAI), Endicott Work Productivity Scale (EWPS), and Functional Status Questionnaire Work Performance Scale (WPS). Anxiety severity was determined using the Beck Anxiety Inventory (BAI). The Clinical Global Impressions, Global Improvement Scale (CGI-I) was completed by patients to evaluate symptom change at a 12-week follow-up. Two severity groups (minimal/mild vs. moderate/severe, based on baseline BAI score) were compared to each other on work measures.

RESULTS

Eighty-one patients provided complete baseline data. Anxiety severity groups did not differ in job type, time on job, job satisfaction, or job choice. Patients with greater anxiety generally showed lower work performance on all instruments. Job advancement was impaired for the moderate/severe group. The multi-item performance scales demonstrated better validity and internal consistency. The WLQ and the WPAI detected change with symptom improvement.

CONCLUSION

Level of work performance was generally associated with severity of anxiety. Of the instruments tested, the WLQ and the WPAI questionnaire demonstrated acceptable validity and internal reliability.

Satisfaction with current health status in patients with a history of acute coronary syndrome

OBJECTIVE

To describe satisfaction with current health status in patients with a recent history of an acute coronary syndrome (ACS) event and to determine the association between satisfaction and patient-specific variables.

RESEARCH DESIGN AND METHODS

Patients from an ACS registry who were discharged from a university affiliated hospital over a 3-year period were mailed the study questionnaire.

MAIN OUTCOMES MEASURES

Data included demographics, cardiac-specific measures, and general health status (SF-8 PCS, MCS and the EQ-5D VAS) and health status preference weight (EQ-5D Health Index). Satisfaction with current health status was assessed by a single question derived for this study with a 5-point Likert scale from 'not satisfied at all' to 'highly satisfied.' ANOVA determined the association between levels of satisfaction and health status scores. A multivariate linear regression model determined the association of patient, disease, and treatment variables with satisfaction. Independent variables were determined to be significant if the p-value in the model was <0.05.

RESULTS

Respondents (490, 40.3% response rate) averaged 65.2 +/- 11.3 years of age; 71% male; 92% Caucasian; 64% with MI history; and 17% had their most recent cardiac event within 6 months. 63% of respondents were either mostly satisfied or highly satisfied with there current health status. Based on level of satisfaction, the mean PCS ranged from 36.9 +/- 8.9 to 63.0 +/- 6.2; mean MCS from 38.3 +/- 13.1 to 55.7 +/- 5.7; mean EQ-5D VAS from 37.0 +/- 21.7 to 90.8 +/- 20.7, and mean EQ-5D Health Index from 0.38 +/- 0.3 to 0.93 +/- 0.14, all ANOVA models p < 0.001. Statistically significant independent variables in the multivariate linear regression model included the number of symptoms, DASI cardiac function score, perceived severity of disease, and age. Satisfaction with current health state was associated with older age, fewer symptoms, better DASI cardiac function scores, and lower perceived severity of illness.

CONCLUSION

Health-related quality of life, or health status, and satisfaction with health status have a direct, positive association. Greater burden of illness and younger age were significantly associated with dissatisfaction with health status. Extrapolation of results is limited to determining association but not causation due to the cross sectional study design.

Patient characteristics associated with the use of antidepressants among people diagnosed with DSM-IV mood disorders: results from the National Comorbidity Survey Replication

BACKGROUND

Depression is one of the most common mental illnesses in the United States. However, research on antidepressant usage patterns in a large nationally representative sample is limited.

OBJECTIVES

The aims of this study were (1) to examine factors associated with the use of antidepressants in patients with DSM-IV mood disorders, and (2) to determine reasons for inadequate and non-persistent medication taking behaviors.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted using the National Comorbidity Survey Replication (NCS-R) dataset in the U.S. People within the dataset with DSM-IV mood disorders were qualified as the sample population (n = 1798). Selected factors based on the Andersen's Behavioral Model of Health Services Use were assessed among antidepressant users (n = 473) and nonusers (n = 1322). The logistic regression analysis was used to examine the association between the dependent variable, the use of antidepressants, and the independent variables, predisposing, enabling and need factors. Descriptive statistics were used to determine reasons of inadequate and non-persistent medication taking behaviors.

RESULTS

Antidepressant use was more prevalent in patients who were middle age (30-59) (p < 0.01), non-Hispanic white (p < 0.001), unemployed (p < 0.001), living in the South (p < 0.01), having a regular source of care (p < 0.001), and having high severity of emotional distress (p < 0.001). About 41% of patients reported that they forgot to take or took less medication in the study period. Reasons for stopping medication included: "The medication was not helping" (30.8%), followed by "Side effects" (13.8%) and "Couldn't afford to pay for the medicine" (13.0%).

LIMITATIONS

A small sample size in racial/ethnic minority groups; a small sample size in the reasons of stopping taking medications due to the missing values in consecutive questions.

CONCLUSIONS

The factors associated with use of antidepressants and reasons of inadequate and non-persistent medication taking behaviors in patients with mood disorders are many and varied. Health care providers need to understand these factors as they work with their patients to improve the likelihood of patients' successfully to complete their course of treatment.

Effects of cerivastatin withdrawal on statin persistence

BACKGROUND

Medication-taking behavior is influenced by many factors, as described by the Health Belief Model. Information on withdrawals of drugs from the market may be an example of negative external stimuli that might influence patients' decisions to persist with long-term drug therapy.

OBJECTIVE

To evaluate the association between the withdrawal of cerivastatin from the market and persistence in taking all other statins in patients who recently experienced acute coronary syndrome (ACS).

METHODS

Patients from a large ACS registry who responded to questions about medication use during a postdischarge telephone survey between November 2000 and February 2002 were categorized into 3 groups: pre- (November 1, 2000-April 30, 2001), peri- (May 1, 2001-August 31, 2001), and post- (September 1, 2001-February 28, 2002) cerivastatin withdrawal periods. Patients were considered persistent if, at the time of the survey, they continued to take study medication that had been prescribed at discharge. Persistence with angiotensin-converting enzyme inhibitors, aspirin, and beta-blockers was also assessed to determine whether changes in statin persistence were unique to the class or related to other medication issues that affected all classes. The Kruskal-Wallis test, with post hoc Mann-Whitney U test, was used to analyze the differences in persistence between the groups. All comparisons were considered statistically significant at p less than 0.05.

RESULTS

There were no significant differences in patient characteristics between study groups. Persistence with statins decreased during the periwithdrawal period (88.4% pre vs 76.7% peri) and rebounded in the postwithdrawal period (90.8%; p = 0.007). There were no significant differences in persistence with the other drug classes.

CONCLUSIONS

The temporary decline in statin persistence appeared to be associated with the withdrawal of cerivastatin, while persistence with the other study medications remained constant. Clinicians need to understand the potential effect of factors such as media attention surrounding a drug's withdrawal on patients' medication-taking behavior.

Medication adherence following coronary artery bypass graft surgery: assessment of beliefs and attitudes

BACKGROUND

The medication management of patients following coronary artery bypass graft (CABG) surgery may include antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors, and statins. However, poor adherence is common, and patient attitudes and beliefs play a role in adherence.

OBJECTIVE

To evaluate the association between self-reported adherence and the beliefs patients have about cardiovascular medicines used after CABG.

METHODS

Adults were surveyed 6-24 months following CABG. The validated Beliefs about Medicines Questionnaire (BMQ) assessed attitudes concerning the Specific Necessity, Specific Concerns, General Harm, and General Overuse of medicines. The validated medication adherence scale assessed self-reported adherence. Analysis included univariate comparison (BMQ scales) and multivariate logistic regression (identification of adherence predictor variables).

RESULTS

Of 387 patients surveyed, 132 (34%) completed the questionnaire. Nonparticipants were more likely to be female and have undergone 1- or 2-vessel CABG procedures compared with 3- or 4-vessel procedures. Subjects were primarily English-speaking, white, and male. Adherent behavior was reported in 73 of 132 patients (55%). The average period between CABG and the survey was 16 months. Nonadherent patients were in stronger agreement on the General Overuse (p = 0.01) and General Harm (p = 0.04) scales. The adjusted odds of adherent behavior were significantly lower, with an increasing General Overuse score (OR 0.83; 95% CI 0.72 to 0.95; p = 0.007); an annual income of $50,000 to $100,000 relative to less than $20,000 (OR 0.36; 95% CI 0.14 to 0.91; p = 0.031), and a living status of "alone" compared with "with adults and no children" (OR 0.20; 95% CI 0.06 to 0.65; p = 0.007). The odds ratio of self-reported adherence was higher with increasing age (OR 1.05; 95% CI 1.01 to 1.09; p = 0.023).

CONCLUSIONS

In summary, patient beliefs and attitudes regarding medications, along with other social, economic, and demographic factors, help explain differences in self-reported adherence to standard drug therapy following CABG.

Influence of an interactive computer-based inhaler technique tutorial on patient knowledge and inhaler technique

BACKGROUND

Patient knowledge of correct inhaler technique is essential in the treatment of pulmonary disease. Computer delivery of educational content may augment existing teaching efforts.

OBJECTIVE

To determine whether a computer-based tutorial on inhaler technique could improve patients' knowledge and ability to correctly demonstrate inhaler technique.

METHODS

A total of 34 adults with pulmonary disease and experience using inhalers were randomized into the control or intervention groups. The intervention group viewed the tutorial, after which they demonstrated their inhaler technique and completed an Inhaler Technique Knowledge Test. Control group patients, who did not view the tutorial, were also evaluated on their demonstrated inhaler technique and technique knowledge. Additional information obtained included demographics, illness and treatment history, and patients' use of computers. Lastly, all patients who viewed the tutorial completed a brief questionnaire eliciting tutorial feedback. Control group patients were invited to view the tutorial after other data collection was complete. The 2 principal outcomes were the observed inhaler technique score and the inhaler technique knowledge test score. Comparisons between groups were conducted using Student's t-test and chi(2) test, with a p value less than 0.05 considered statistically significant.

RESULTS

Eighteen subjects were enrolled in the computer group; 16 were in the control group. The intervention group demonstrated significantly better inhaler technique, with a mean Observed Inhaler Technique Score of 88.3 +/- 12.3 compared with 67.4 +/- 19.2 for the control group (p = 0.001). The intervention group also scored significantly higher on the Inhaler Technique Knowledge Test, with a score of 80.9 +/- 17.0 versus 67.4 +/- 11.8 for the control group (p = 0.01). Overall, the program appeared acceptable to patients.

CONCLUSIONS

Patients in the tutorial group demonstrated better inhaler technique and scored higher on the Inhaler Technique Knowledge Test compared with those in a control group. This tutorial may be a useful educational tool to enhance patient education regarding inhaler technique.

Knowledge of appropriate acetaminophen doses and potential toxicities in an adult clinic population

OBJECTIVE

To evaluate the knowledge of appropriate doses and potential toxicities of acetaminophen and assess the ability to recognize products containing acetaminophen in an adult outpatient setting.

DESIGN

Cross-sectional, prospective study.

SETTING

University adult general internal medicine (AGIM) clinic.

PATIENTS

104 adult patients presenting to the clinic over consecutive weekdays in December 2003.

INTERVENTIONS

Three-page, written questionnaire.

MAIN OUTCOME MEASURES

Ability of patients to identify maximum daily doses and potential toxicities of acetaminophen and recognize products that contain acetaminophen.

RESULTS

A large percentage of participants (68.3%) reported pain on a daily or weekly basis, and 78.9% reported use of acetaminophen in the past 6 months. Only 2 patients correctly identified the maximum daily dose of regular acetaminophen, and just 3 correctly identified the maximum dose of extra-strength acetaminophen. Furthermore, 28 patients were unsure of the maximum dose of either product. Approximately 63% of participants either had not received or were unsure whether information on the possible danger of high doses of acetaminophen had been previously provided to them. When asked to identify potential problems associated with high doses of acetaminophen, 43.3% of patients noted the liver would be affected. The majority of the patients (71.2%) recognized Tylenol as containing acetaminophen, but fewer than 15% correctly identified Vicodin, Darvocet, Tylox, Percocet, and Lorcet as containing acetaminophen.

CONCLUSION

Although nearly 80% of this AGIM population reported recent acetaminophen use, their knowledge of the maximum daily acetaminophen doses and potential toxicities associated with higher doses was poor and appeared to be independent of education level, age, and race. This indicates a need for educational efforts to all patients receiving acetaminophen-containing products, especially since the ability to recognize multi-ingredient products containing acetaminophen was likewise poor.

Self-reported adherence in patients with asthma

BACKGROUND

Not all patients with asthma adhere to their prescribed drug regimens. The Behavioral Model of Health Services Utilization, organized as predisposing, enabling, and need variables, may be useful in identifying variables related to adherent medication-taking behavior.

OBJECTIVE

To examine the relationship between predisposing, enabling, and need variables and self-reported adherence with asthma controller drugs.

METHODS

A secondary analysis was conducted from a cross-sectional study using survey and claims data obtained from adults with asthma enrolled in a managed care organization. Independent variables included predisposing (age, gender, race, years with asthma, number of comorbidities, health beliefs), enabling (income, number of metered-dose inhaler [MDI] instructors, inhaler technique, perceived physician access), and need (patient-perceived severity, symptom-derived severity, health-related quality of life). Adherence was measured using a 4 item questionnaire scored as the mean of the responses, with 5 denoting highest adherence. Multivariate regression analysis was used to identify variables with statistically significant relationships to self-reported adherence. Stepwise backward elimination was used, with the final model consisting of variables considered significant at p less than 0.05.

RESULTS

The 573 respondents (1270 packets sent; 45% response rate) were primarily white (89.5%) and female (71.0%), with an average age of 40.5 +/- 12.4 years (mean +/- SD) and average asthma duration of 18.3 +/- 14.2 years. The mean adherence scale score was 3.7 +/- 1.1, with 84.6% indicating some level of nonadherence (score <5). The final model had an adjusted R(2) of 0.26 and included 6 independent variables. Better adherence was associated with stronger beliefs in the benefits of treatment and trigger avoidance, greater perceived asthma severity, longer asthma duration, more MDI instructors, and higher scores on the Short-Form 36 mental component summary.

CONCLUSIONS

Complex beliefs, perceptions, and experiences constitute the variables associated with adherent medication-taking behavior. Future longitudinal studies should include these variables to determine the predictive strength of the model.

Gender and perceived severity of cardiac disease: evidence that women are "tougher"

PURPOSE

Patients' beliefs about their disease may affect their willingness to engage in preventive health behaviors. We sought to determine whether men and women with acute coronary syndrome differ in their perceptions of the severity of cardiac-related illness while controlling for the clinical severity of their condition.

METHODS

All patients with acute coronary syndrome discharged from a university hospital during a 3-year period were mailed a questionnaire, and medical records were abstracted. The questionnaire assessed perceived severity of cardiac-related illness (5-point scale from "very mild" to "very severe"), symptom frequency, type of acute coronary syndrome event, number of medications, Duke Activity Status Index (DASI), time since most recent cardiac event, Charlson Comorbidity Index, and demographic information. A logistic regression model was constructed with perceived severity of heart disease as the dependent variable. Gender was the key independent variable while controlling for the other patient and disease variables.

RESULTS

The 490 respondents (1217 surveys sent, 40.3% response rate) included 348 men and 142 women who were similar with regard to race and type of acute coronary syndrome event experienced. Women were older, less educated, had a lower DASI score, had more symptoms, and were taking more medications. However, they perceived their cardiac disease as being no more severe than the men. The significant predictors in the regression model of perceived severity included gender, DASI, number of symptoms, type of acute coronary syndrome event, and comorbidity. Female gender was associated with lower perceived severity (odds ratio 0.30-0.80).

CONCLUSIONS

Women rate their cardiac disease as less severe than do men when controlling for other measures of cardiac disease severity.

Adherence to medications by patients after acute coronary syndromes

BACKGROUND

Nonadherence to medication may lead to poor medical outcomes.

OBJECTIVE

To describe medication-taking behavior of patients with a history of acute coronary syndromes (ACS) for 4 classes of drugs and determine the relationship between self-reported adherence and patient characteristics.

METHODS

Consenting patients with the diagnosis of ACS were interviewed by telephone approximately 10 months after discharge. The survey elicited data characterizing the patient, current medication regimens, beliefs about drug therapy, reasons for discontinuing medications, and adherence. The survey included the Beliefs About Medicine Questionnaire providing 4 scales: Specific Necessity, Specific Concerns, General Harm, and General Overuse, and the Medication Adherence Scale (MAS). Multivariate regression was used to determine the independent variables with the strongest association to the MAS. A p value < or = 0.05 was considered significant for all analyses.

RESULTS

Two hundred eight patients were interviewed. Mean +/- SD age was 64.9 +/- 13.0 years, with 60.6% male, 95.7% white, 57.3% with a college education, 87.9% living with > or =1 other person, and 42% indicating excellent or very good health. The percentage of patients continuing on medication at the time of the survey category ranged from 87.4% (aspirin) to 66.0% (angiotensin-converting enzyme inhibitors). Reasons for stopping medication included physician discontinuation or adverse effects. Of patients still on drug therapy, the mean MAS was 1.3 +/- 0.4, with 53.8% indicating nonadherence (score >1). The final regression model showed R(2) = 0.132 and included heart-related health status and Specific Necessity as significant predictor variables.

CONCLUSIONS

After ACS, not all patients continue their drugs or take them exactly as prescribed. Determining beliefs about illness and medication may be helpful in developing interventions aimed at improving adherence.

Perceived work performance of patients who experienced an acute coronary syndrome event

The objectives of this study were to describe the perceived work performance of patients previously diagnosed with acute coronary syndrome (ACS) and to determine the relationship between patient-specific variables and perceived work performance. This cross-sectional study utilized a mailed survey to all patients discharged from a university affiliated hospital with the diagnosis of ACS during a 3-year period. Perceived work performance was measured using the Work Performance Scale (WPS). Independent variables included health status (SF-8, PCS-8, MCS-8 and EQ-5D visual analog scale), cardiac functional status (Duke activity status index), symptom count, comorbidity index, patient-perceived cardiac disease severity, medication count and compliance, job satisfaction, current employment duration, patient demographics and ACS type. Step-wise multivariate linear regression models determined the independent variables with significant association (p < 0.05) to WPS. Of 1,217 patients surveyed, 490 (40%) responded, including 158 currently working (study sample). The regression model with the highest explanatory ability (r(2) = 0.29) included number of symptoms, age, perceived cardiac severity and PCS-8, with more symptoms, higher perceived severity, higher age and lower PCS-8 scores associated with lower WPS. Currently employed ACS patients report a high level of work performance. Symptom burden, perceived disease severity, age and physical function appear to be associated with perceived work performance.