Improving Medication Knowledge Among Older Adults With Heart Failure: A Patient-Centered Approach to Instruction Design

Mechanisms underlying comprehension of health information in adulthood: the roles of prior knowledge and working memory capacity

Prior knowledge, working memory capacity (WMC), and conceptual integration (attention allocated to integrating concepts in text) are critical within many contexts; however, their impact on the acquisition of health information (i.e. learning) is relatively unexplored.We examined how these factors impact learning about nutrition within a cross-sectional study of adults ages 18 to 81. Results showed that conceptual integration mediated the effects of knowledge and WMC on learning, confirming that attention to concepts while reading is important for learning about health. We also found that when knowledge was controlled, age declines in learning increased, suggesting that knowledge mitigates the effects of age on learning about nutrition.

Application of support vector machine for prediction of medication adherence in heart failure patients

Objectives

Heart failure (HF) is a progressive syndrome that marks the end-stage of heart diseases, and it has a high mortality rate and significant cost burden. In particular, non-adherence of medication in HF patients may result in serious consequences such as hospital readmission and death. This study aims to identify predictors of medication adherence in HF patients. In this work, we applied a Support Vector Machine (SVM), a machine-learning method useful for data classification.

Methods

Data about medication adherence were collected from patients at a university hospital through self-reported questionnaire. The data included 11 variables of 76 patients with HF. Mathematical simulations were conducted in order to develop a SVM model for the identification of variables that would best predict medication adherence. To evaluate the robustness of the estimates made with the SVM models, leave-one-out cross-validation (LOOCV) was conducted on the data set.

Results

The two models that best classified medication adherence in the HF patients were: one with five predictors (gender, daily frequency of medication, medication knowledge, New York Heart Association [NYHA] functional class, spouse) and the other with seven predictors (age, education, monthly income, ejection fraction, Mini-Mental Status Examination-Korean [MMSE-K], medication knowledge, NYHA functional class). The highest detection accuracy was 77.63%.

Conclusions

SVM modeling is a promising classification approach for predicting medication adherence in HF patients. This predictive model helps stratify the patients so that evidence-based decisions can be made and patients managed appropriately. Further, this approach should be further explored in other complex diseases using other common variables.

Effects of communication skills training and a Question Prompt Sheet to improve communication with older cancer patients: a randomized controlled trial

A randomized pre- and post-test control group design was conducted in 12 oncology wards to investigate the effectiveness of an intervention, existing of a communication skills training with web-enabled video feedback and a Question Prompt Sheet (QPS), which aimed to improve patient education to older cancer patients (≥65 years). The effects were studied by analyzing questionnaires and video recordings of patient education sessions preceding chemotherapy with 210 different patients. Patients' recall of information was the primary outcome of the study. Recall was checked against the actual communication in the video-recordings. Moreover, communication skills were assessed by observing the extent to which nurses implemented 67 communication aspects, categorized in seven dimensions, using the QUOTE(chemo). Experimental nurses demonstrated a significant intervention effect on communicating realistic expectations. Within-group improvements were measured in the experimental group for tailored communication, affective communication and interpersonal communication. Although the use of a QPS significantly increased question asking, only limited results were found on older patients' recall scores. The overall proportion recall of recommendations showed a marginally significant pre-/post-change in proportion recall in favour of the experimental group and there was a significant pre-/post-change in two out of six sub-categories. The results indicate that nurses' communication skills can be improved by communication skills training. More research is needed to understand the difficult relationship between patient-provider communication and recall of information.

Psychosocial correlates of health literacy among older patients with coronary heart disease

This study examined psychosocial correlates of health literacy (HL) scores among older patients with coronary heart disease (CHD). A cross-sectional survey assessed psychosocial factors relating to the following: self-efficacy (i.e., perception of ability to perform a specified behavior) for diet, exercise, medication, and for a future attempt to quit smoking; social support; social stigma; appointment attendance; knowledge of heart problems; and understanding of health information. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM). Of 321 patients, 70 had a REALM score in the low HL range (<60). When adjusting for demographics, a lower REALM score was significantly associated with reports of increased difficulty understanding health information (p < .001), less knowledge of heart problems (p = .002), increased discomfort about asking for explanations of health information (p = .014), less support with discussing health problems (p = .020). Patients with CHD and low HL are likely to face psychosocial challenges when managing their health problems. In order to encourage these individuals to seek help, health professionals need to be aware of the psychosocial characteristics of patients with low HL. These individuals may need behavioral support to increase both their self-efficacy and their understanding of their medical condition.

Geriatric drug therapy: neglecting the inevitable majority

Demographic evolution will considerably increase the number of people aged 65 years and beyond in the coming decades. The elderly not only represent the most heterogeneous population, but also are a major user group for prescribed medicines, a predominance that will continue to further increase. Medicines and medication management are much more complex and challenging in the elderly and can only be addressed through a multidisciplinary approach. There is strong evidence that the elderly are able to properly manage their medication; however, their medications require different features than the standard medications used by adults. The elderly are exposed to several chronic disease conditions and their treatments, as well as experience age-related changes and limitations that need to be reflected in their medication management strategies. Geriatric drug therapy remains a multidisciplinary task. The health care industry, physicians, pharmacists, nurses and care givers provide and guide the patient's therapy according to individual needs, while the health care system and regulatory authorities build the necessary framework of support and resources.Any realistic and significant enhancement to the elderly patients' medicines and medication management needs to be addressed by all disciplines and stakeholders involved since the absence of any of the stakeholders in the overall process negatively impacts the achievable enhancement in geriatric drug therapy.

Improving the usability of patient information leaflets

OBJECTIVE

This study assesses the usability of three patient information leaflets and attempts to improve them while complying with the current EU regulations.

METHODS

Three original leaflets were tested among 154 potential users. Every participant answered 15 scenario questions for one of the leaflets. The leaflets were subsequently redesigned based on the test results and evidence-based Document Design principles. The revised texts were tested among 164 participants.

RESULTS

All three original leaflets suffered from usability problems, especially problems related to finding relevant information. On average, only 75% of the topics could be located. Comprehension of the information, once found, was around 90%. The revisions led to better performance. Information was found faster and more successful. Comprehension scores were higher as well. A follow-up study shows that these findings can be generalized over paper formats.

CONCLUSION

Although the current EU regulations for patient information leaflets do not guarantee leaflet usability, the leaflets can be improved somewhat within the regulations. However, further research should evaluate the text structure currently imposed on leaflets.

PRACTICAL IMPLICATIONS

Information leaflets must be written, or rewritten, according to Document Design principles. Furthermore, they must be user tested in a rigorous way.

Case management for heart failure in the emergency department

Heart failure affects approximately 5 million individuals in the United States and is the most common discharge diagnosis among the elderly. The number of individuals diagnosed with heart failure will continue to rise as the population of the United States ages. The natural course of the disease is characterized by periods of stability interrupted by periods of symptom exacerbation. These periods of exacerbation often require emergency intervention or hospitalization for management. Once an individual is hospitalized, they are at a greater risk for rehospitalization. The causes of rehospitalizations are multifactorial and many are preventable. Case managers are in a position to have a positive impact on the readmission rate. Interventions include adherence to medication guidelines, increasing patients' knowledge of self-care measures, assessing discharge readiness and needs, and increasing the frequency of symptom monitoring for early intervention. Case management begins in the emergency department and facilitates care throughout the patient's stay by fostering communication among all caregivers and the patient and family. Case managers also affect the quality of care patients receive by instituting processes that streamline care and ensure that quality care is provided to the patients. They also serve as mentors and resources for other members of the healthcare team. Most of the information about case management comes from inpatient and outpatient programs; however, the emergency department nurse can adapt these models to support their role. More research is needed as to what specific portions of the case manager's role are most appropriate for the emergency department.

Clinical pathways: adherence issues in complex older female patients with heart failure (HF)

HF is a leading health care concern, often under-recognized and under-treated in older women. Management of this complex condition frequently requires a multidisciplinary approach and a clinical pathway can be used to deliver coordinated care. This report is based on the intervention/treatment arm (n = 45) of a randomized controlled trial in older women who participated in a multidisciplinary clinic. We describe the development of a clinical pathway for HF and the variance reporting including factors affecting adherence with the pathway. Variances are patient or staff actions that did not meet the expected outcomes. Of the 45 intervention arm female patients, 5 were able to fully complete the program, meaning that all of the intended 12 visits were completed successfully. Thirteen women missed more than three clinic visits, and the rest attended most visits. Variance tracking identified that visits were interrupted most often by patient-related health issues, such as fatigue and pain, which may not be surprising given the expected multiple co-morbidities in this population. Transportation problems were identified as a barrier to attendance. Our study demonstrates that a clinical pathway can be implemented in an older, female population with HF. This report identifies some of the challenges and provides future recommendations for prospective pathway development.

Working memory and the design of health materials: a cognitive factors perspective

OBJECTIVE

Working memory and other supportive cognitive processes involved in learning are reviewed in the context of developing patient education materials. We specifically focus on the impact of certain design factors such as text format and syntax, the inclusion of images, and the choice of modality on individuals' ability to understand and remember health information.

METHODS

A selective review of relevant cognitive and learning theories is discussed with regard to their potential impact on the optimal design of health materials.

RESULTS

Working memory is measured as an individual's capacity to hold and manipulate information in active consciousness. It is limited by necessity, and well-designed health materials can effectively minimize extraneous cognitive demands placed on individuals, making working memory resources more available to better process content-related information.

CONCLUSIONS

Further research is needed to evaluate specific design principles and identify ideal uses of print versus video-based forms of communication for conveying information.

PRACTICE IMPLICATIONS

The process of developing health materials should account for the cognitive demands that extrinsic factors such as modality place on patients.

Does age really matter? Recall of information presented to newly referred patients with cancer

PURPOSE

To examine age- and age-related differences in recall of information provided during oncology consultations.

PATIENTS AND METHODS

Two hundred sixty patients with cancer diagnosed with heterogeneous cancers, seeing a medical or radiation oncologist for the first time, participated in the study. Patients completed questionnaires assessing information needs and anxiety. Recall of information provided was measured using a structured telephone interview in which patients were prompted to remember details physicians gave about diagnosis, prognosis, and treatment. Recall was checked against the actual communication in audio-recordings of the consultations.

RESULTS

Recall decreased significantly with age, but only when total amount of information presented was taken into account. This indicates that if more information is discussed, older patients have more trouble remembering the information than younger ones. In addition, recall was selectively influenced by prognosis. First, patients with a poorer prognosis recalled less. Next, the more information was provided about prognosis, the less information patients recalled, regardless of their actual prognosis.

CONCLUSION

Recall is not simply a function of patient age. Age only predicts recall when controlling for amount of information presented. Both prognosis and information about prognosis are better predictors of recall than age. These results provide important insights into intervention strategies to improve information recall in patients with cancer.

Recall in older cancer patients: measuring memory for medical information

PURPOSE

Remembering medical treatment information may be particularly taxing for older cancer patients, but to our knowledge this ability has never been assessed in this specific age group only. Our purpose in this study was to investigate older cancer patients' recall of information after patient education preceding chemotherapy.

DESIGN AND METHODS

We constructed a recall questionnaire consisting of multiple-choice questions, completion items, and open-ended questions related to information about treatment and recommendations on how to handle side effects. Immediately after a nursing consultation preceding chemotherapy treatment, 69 older patients (M = 71.8 years, SD = 4.1) completed the questionnaire. We checked recall against the actual communication in video recordings of the consultations.

RESULTS

On average, 82.2 items were discussed during the consultations. The mean percentage of information recalled correctly was 23.2% for open-ended questions, 68.0% for completion items, and 80.2% for multiple-choice questions.

IMPLICATIONS

Older cancer patients are confronted with a lot of information. Recall of information strongly depended on question format; especially active reproduction appeared to be poor. To improve treatment outcomes, it is important that cancer patients are able to actively retrieve knowledge about how to prevent and recognize adverse side effects and that this is checked by the health professional. We make suggestions on how to make information more memorable for older cancer patients.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.

Patients' health literacy and experience with instructions: influence preferences for heart failure medication instructions

OBJECTIVE

We developed a pharmacist-based patient education intervention to improve older adults' adherence to chronic heart failure (CHF) medications, which included written patient-centered instructions. The study evaluated these instructions by examining whether patients preferred them to standard pharmacy instructions.

METHOD

Elders diagnosed with CHF participated in the randomized controlled trial (83 in the intervention; 153 in usual care control group). Instruction preferences were collected after 6 months of participation.

RESULTS

Patient-centered instructions were preferred for learning about adherence information (e.g., schedule) and standard instructions for learning about drug interactions. Preference for the patient-centered instructions was greater for intervention versus control participants and for participants with lower health literacy. Literacy no longer predicted preferences with patients' cognitive abilities controlled, suggesting literacy reflected more fundamental cognitive mechanisms.

DISCUSSION

The finding that preferences varied with patients' experience using the instructions and cognitive abilities suggests instructions should accommodate diverse patient needs and abilities.

Correlates of health literacy in patients with chronic heart failure

PURPOSE

Many older adults have inadequate health-related literacy, which is associated with poor health outcomes. Thus, it is important to identify determinants of health literacy. We investigated relationships between health literacy and general cognitive and sensory abilities, as well as education, health, and demographic variables, in a community sample of middle-aged and older adults.

DESIGN AND METHODS

Participants were 314 community-dwelling adults (67% female, 48% African American) diagnosed with chronic heart failure recruited for a pharmacist-based intervention study to improve adherence to chronic heart failure medications. We adminstered demographic, health, education, cognitive (e.g., processing speed, working memory), and sensory measures, and the Short Test of Functional Health Literacy in Adults (STOFHLA), as part of the baseline condition of this study.

RESULTS

STOFHLA scores were lower for participants who were older, less educated, male, African American, had more comorbidities, or scored lower on all cognitive ability measures. Hierarchical linear regression analyses showed that education and cognitive ability were independently associated with the STOFHLA measure and explained age differences in health literacy.

IMPLICATIONS

The association of cognitive abilities and literacy has important implications for health literacy models and for interventions to reduce the impact of low health literacy on health outcomes. For example, medication instructions should be designed to reduce comprehension demands on general cognitive abilities as well as literacy skills.

Use of pictorial aids in medication instructions: a review of the literature

PURPOSE

The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.

SUMMARY

Many patients depend on medication labels and patient information leaflets for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients' satisfaction with medication instructions.

CONCLUSION

The use of pictorial aids enhances patients' understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.