Health services use and prescription access among uninsured patients managing chronic diseases

Individual, interpersonal, and community factors associated with health outcomes in patients with type 2 diabetes mellitus treated at federally qualified health centers

Purpose

To examine factors of influence in diabetes management and their association with self-reported health outcomes in patients with type 2 diabetes treated at Federally Qualified Health Centers (FQHCs).

Methods

This cross-sectional study examined data from the 2014 Health Center Patient Survey (HCPS). Predictor variables were categorized across three levels of the National Institute on Minority Health and Health Disparities research framework. Outcome variables retrieved from HCPS included self-reports of blood glucose levels, and diabetes-related emergency department (ED)/hospital visits during past year.

Results

A total of 936 patients with diabetes were included. Most (65%) participants received a diabetes self-management plan. During the previous year, 72% received > = 2 A1C checks, 52% reported high blood glucose levels, and 12% visited an ED/hospital. Multivariable results showed that insulin use and receiving a self-management plan were associated with high blood glucose levels and ED/hospital visits. Community factors of being unable to get medications and receiving a specialist foot exam were respectively associated with high blood glucose levels and ED/hospital visits.

Conclusion

Different factors were associated with health outcomes in patients with diabetes treated at FQHCs. Identifying these factors can help with targeted screening and follow-up and assessing potential interventions to improve health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01388-5.

Socioeconomic and Health-Related Factors Affecting Congestive Heart Failure Readmissions

Congestive heart failure (CHF) readmissions are frequent and costly but preventable. The purpose of this study was to analyze socioeconomic and health-related factors of CHF readmissions by examining the relationship between 30-day readmissions of individuals with CHF and their payer status, race, ethnicity, primary language spoken, living arrangement, and comorbidities. This retrospective case-control study used secondary data from 450 CHF patients admitted to a not-for-profit Northern Virginia hospital from July 2014 to December 2017. Data were analyzed using χ 2 and logistic regression. Living arrangements and comorbid chronic renal failure (CRF) were statistically significant predictors of CHF readmissions; all other factors were nonsignificant. Patients who lived with family and those in assisted living facilities were less likely to be readmitted than those who lived alone (odds ratio [OR] = 0.2 and 0.5, respectively). Patients without CRF were less likely to be readmitted than those who had CRF (OR = 0.6). This study contributes data to inform community-based health programs tailored toward frequently readmitted individuals due to CHF exacerbation.

Access and Utilization of Asthma Medications Among Patients Who Receive Care in Federally Qualified Health Centers

OBJECTIVES

To describe access to and use of prescription asthma medications, and to assess factors associated with asthma exacerbation, healthcare utilization, and health status among asthma patients treated at Federally Qualified Health Centers.

METHODS

This is a retrospective cross-sectional study. We analyzed data from the 2014 National Health Center Patient Survey. This data is publicly available from the Health Resources and Services Administration. Data was collected from patients receiving face-to-face care from health centers funded under Section 330 of the Public Health Service Act. Data from patients was collected between October 8, 2014, and April 17, 2015. We included adult participants who reported having a diagnosis of asthma and confirmed that they still have asthma. Association between explanatory variables (access to prescription medications and use of asthma controller medications) and outcome variables (asthma exacerbations, asthma hospitalizations or emergency department visits, and self-rated health) was assessed using multivariable regression analyses while adjusting for demographics.

RESULTS

A total of 919 participants with asthma were included. Approximately 32% of the participants experienced delays in getting prescription medications, 26% were unable to get them, 60% experienced an asthma exacerbation last year, 48% rated their health as fair/poor, and 19% visited a hospital or an emergency department last year. Multivariable results showed that participants who were currently taking controller medications were more likely to have experienced an asthma exacerbation (OR = 4.02; 95% CI 1.91 to 8.45; P < .01), or visited a hospital or an emergency department (OR = 3.07; 95% CI 1.39 to 6.73; P < .01) in the last year compared with those who had never taken controller medications. Experiencing difficulties in accessing asthma medications was associated with lower self-rated health (β  = -.51; 95% CI -0.94 to -0.08; P = .02).

CONCLUSIONS

Future interventions should seek to improve asthma patient care and health outcomes using innovative strategies that act at multiple levels of the healthcare system (eg, individual, interpersonal, community levels).

Towards an understanding of the burdens of medication management affecting older people: the MEMORABLE realist synthesis

BACKGROUND

More older people are living in the community with multiple diagnoses and medications. Managing multiple medications produces issues of unrivalled complexity for those involved. Despite increasing literature on the subject, gaps remain in understanding how, why and for whom complex medication management works, and therefore how best to improve practice and outcomes. MEMORABLE, MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation, aimed to address these gaps.

METHODS

MEMORABLE used realism to understand causal paths within medication management. Informed by RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines, MEMORABLE involved three overlapping work packages: 1) Realist Review of the literature (24 articles on medication management exploring causality); 2) Realist Evaluation (50 realist-informed interviews with older people, family carers and health and care practitioners, explaining their experiences); and 3) data synthesis and theorising from 1) and 2).

RESULTS

Medication management was viewed from the perspective of 'implementation' and structured into five stages: identifying a problem (Stage 1), getting a diagnosis and/or medications (Stage 2), starting, changing or stopping medications (Stage 3), continuing to take medications (Stage 4), and reviewing/reconciling medications (Stage 5). Three individual stages (1, 3 and 4) are conducted by the older person sometimes with family carer support when they balance routines, coping and risk. Stages 2 and 5 are interpersonal where the older person works with a practitioner-prescriber-reviewer, perhaps with carer involvement. Applying Normalisation Process Theory, four steps were identified within each stage: 1) sense making: information, clarification; 2) action: shared-decision-making; 3) reflection/monitoring; and 4) enduring relationships, based on collaboration and mutual trust. In a detailed analysis of Stage 5: Reviewing/reconciling medications, adopting the lens of 'burden', MEMORABLE identified five burdens amenable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Two initial improvement propositions were identified for further research: a risk screening tool and individualised information.

CONCLUSIONS

Older people and family carers often find medication management challenging and burdensome particularly for complex regimens. Practitioners need to be aware of this potential challenge, and work with older people and their carers to minimise the burden associated with medication management.

TRIAL REGISTRATION

PROSPERO 2016:CRD42016043506.

Medication management in older people: the MEMORABLE realist synthesis

Background

The number and proportion of older people in the UK are increasing, as are multimorbidity (potentially reducing quality of life) and polypharmacy (increasing the risk of adverse drug events). Together, these complex factors are challenging for older people, informal carers, and health and care practitioners.

Objectives

MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) aimed to understand how medication management works and propose improvements.

Design

A realist approach informed three work packages, combining a realist review of secondary data with a realist evaluation of primary interview data, in a theory-driven, causal analysis.

Setting

The setting was in the community.

Participants

Older people, informal carers, and health and care practitioners.

Interventions

Studies relating to medication management and to reviewing and reconciling medications; and realist-informed interviews.

Main outcome measures

Not applicable.

Data sources

MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and EMBASE were searched (all searched from January 2009 to July 2017; searched on 1 August 2017). Supplementary articles were identified by the Research Team. Data were also obtained through interviews.

Review methods

Searches of electronic databases were supplemented by citation-tracking for explanatory contributions, as well as accessing topic-relevant grey literature. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, articles were screened and iteratively analysed with interview data, to generate theory-informed (normalisation process theory) explanations.

Results

Developing a framework to explain medication management as a complex intervention across five stages: identifying problem (Stage 1), starting, changing or stopping medications (Stage 3) and continuing to take medications (Stage 4), where older people, sometimes with informal carers, make individual decisions and follow routines that fit medication management into their day-to-day lives, engendering a sense of control. In getting diagnosis and/or medications (Stage 2) and reviewing/reconciling medications (Stage 5), older people and practitioners share decision-making in time-limited contacts: involving four steps – sense-making, relationships, action and reflection/monitoring (normalisation process theory); and conceptualising burden – through a detailed analysis of Stage 5, generating a theoretical framework and identifying five burden types amendable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Proposing interventions: risk identification – a simple way of identifying older people and informal carers who are not coping, at risk and who need appropriate help and support; and individualised information – a short, personalised record and reference point, co-produced and shared by older people, informal carers and practitioners that addresses the experience of living with multimorbidities and polypharmacy.

Limitations

Few studies directly address the complexity of medication management as a process and how it works. Limitations included, having identified the overall complexity, the need to focus the analysis on reviewing/reconciling medications (Stage 5), the exclusion of non-English-language literature, the focus on non-institutionalised populations and the broad definition of older people.

Conclusions

MEMORABLE explored the complexity of medication management. It highlighted the way interpersonal stages in the medication management process, notably reviewing/reconciling medications, contribute to the mitigation of burdens that are often hidden.

Future work

Co-produced studies to scope and trial the two proposed interventions; studies to extend the detailed understanding of medication management, linked to burden mitigation; and a study to clarify the medication management outcomes wanted by older people, informal carers and practitioners.

Study registration

This study is registered as PROSPERO CRD42016043506.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 26. See the NIHR Journals Library website for further project information.

Low-Income Residents' Perceptions of Medication Availability

Access to medications is a critical determinant of health which often mediates the effects of diseases and leads to healthier lifestyles. With limited access to pharmacies, neighborhoods become pharmacy deserts. The purpose of this study was to explore the medication needs and perceptions of low-income community residents. A purposive sample of 40 low-income community residents participated in focus groups. Content analysis revealed four themes: transitioning to the present, stereotyping, feelings of disconnectedness, and ideal pharmacy. These findings reiterate the difficulties of living in pharmacy deserts, and decrease the gaps of limited qualitative research in this area.

The impracticality of biomedical rejuvenation therapies: translational and pharmacological barriers

The notion that it is possible to eradicate age-related degeneration and live a life with a negligible rate of senescence solely by using a physical "repair-oriented" approach is flawed on a number of fronts. Here, I will argue that there are so many unknown variables embedded in this line of thinking that make the final result impossible to predict. Two relatively easy-to-research areas are the search for successful cross-link breakers and an effective lysosomal degradation therapy. A more complex and speculative strategy is whole-body interdiction of lengthening of telomeres (WILT). Highlighting these as examples, I argue that it is unlikely that such rejuvenation biotechnologies will be used meaningfully by the general public. The discussion assumes that although such therapies may in theory one day be developed in the laboratory, and even possibly be formulated as physical clinical therapies, these will be unusable in practical terms when applied upon humans at large. Due to inherent characteristics of our biological, evolutionary, and psychological heritage, it is implausible that curing aging will occur by using physical interventions alone.