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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Larkin J, Foley L, Smith SM, Harrington P, Clyne B. The experience of financial burden for people with multimorbidity: A systematic review of qualitative research. Health Expect 2020; 24:282-295. [PMID: 33264478 PMCID: PMC8077119 DOI: 10.1111/hex.13166] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/08/2020] [Indexed: 12/27/2022] Open
Abstract
Background Multimorbidity prevalence is increasing globally. People with multimorbidity have higher health care costs, which can create a financial burden. Objective To synthesize qualitative research exploring experience of financial burden for people with multimorbidity. Search strategy Six databases were searched in May 2019. A grey literature search and backward and forward citation checking were also conducted. Inclusion criteria Studies were included if they used a qualitative design, conducted primary data collection, included references to financial burden and had at least one community‐dwelling adult participant with two or more chronic conditions. Data extraction and synthesis Screening and critical appraisal were conducted by two reviewers independently. One reviewer extracted data from the results section; this was checked by a second reviewer. GRADE‐CERQual was used to summarize the certainty of the evidence. Data were analysed using thematic synthesis. Main results Forty‐six studies from six continents were included. Four themes were generated: the high costs people with multimorbidity experience, the coping strategies they use to manage these costs, and the negative effect of both these on their well‐being. Health insurance and government supports determine the manageability and level of costs experienced. Discussion Financial burden has a negative effect on people with multimorbidity. Continuity of care and an awareness of the impact of financial burden of multimorbidity amongst policymakers and health care providers may partially address the issue. Patient or public contribution Results were presented to a panel of people with multimorbidity to check whether the language and themes ‘resonated’ with their experiences.
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Affiliation(s)
- James Larkin
- HRB Centre for Primary Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Louise Foley
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Barbara Clyne
- HRB Centre for Primary Care, Royal College of Surgeons in Ireland, Dublin, Ireland.,Health Information and Quality Authority, Dublin, Ireland
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Eriksen CU, Kyriakidis S, Christensen LD, Jacobsen R, Laursen J, Christensen MB, Frølich A. Medication-related experiences of patients with polypharmacy: a systematic review of qualitative studies. BMJ Open 2020; 10:e036158. [PMID: 32895268 PMCID: PMC7477975 DOI: 10.1136/bmjopen-2019-036158] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We aimed to synthesise qualitative studies exploring medication-related experiences of polypharmacy among patients with multimorbidity. METHODS We systematically searched PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature in February 2020 for primary, peer-reviewed qualitative studies about multimorbid patients' medication-related experiences with polypharmacy, defined as the use of four or more medications. Identified studies were appraised for methodological quality by applying the Critical Appraisal Skills Programme checklist for qualitative research, and data were extracted and synthesised by the meta-aggregation approach. RESULTS We included 13 qualitative studies, representing 499 patients with polypharmacy and a wide range of chronic conditions. Overall, most Critical Appraisal Skills Programme items were reported in the studies. We extracted 140 findings, synthesised these into 17 categories, and developed five interrelated syntheses: (1) patients with polypharmacy are a heterogeneous group in terms of needing and appraising medication information; (2) patients are aware of the importance of medication adherence, but it is difficult to achieve; (3) decision-making about medications is complex; (4) multiple relational factors affect communication between patients and physicians, and these factors can prevent patients from disclosing important information; and (5) polypharmacy affects patients' lives and self-perception, and challenges with polypharmacy are not limited to practical issues of medication-taking. DISCUSSION Polypharmacy poses many challenges to patients, which have a negative impact on quality of life and adherence. Thus, when dealing with polypharmacy patients, it is crucial that healthcare professionals actively solicit individual patients' perspectives on challenges related to polypharmacy. Based on the reported experiences, we recommend that healthcare professionals upscale communicative efforts and involve patients' social network on an individualised basis to facilitate shared decision-making and treatment adherence in multimorbidpatients with polypharmacy.
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Affiliation(s)
- Christian Ulrich Eriksen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Capital Region of Denmark, Frederiksberg, Denmark
| | - Stavros Kyriakidis
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Capital Region of Denmark, Frederiksberg, Denmark
| | | | - Ramune Jacobsen
- Research Group for Social and Clinical Pharmacy, Department of Pharmacy, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Jannie Laursen
- Global Business Quality Management, Falck, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Anne Frølich
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Innovation and Research Center for Multimorbidity and Chronic Conditions, Region Zealand, Slagelse, Denmark
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Appiah B, Burdine JN, Cummings S, Poudyal A, Hutchison RW, Forjuoh SN, McLeroy KR. The effect of health-related information seeking and financial strain on medication nonadherence among patients with diabetes and/or hypertension in central Texas. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2020. [DOI: 10.1111/jphs.12353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Objective
To assess self-reported financial strain and persistence in asking treatment- and medication-related questions in relation to medication nonadherence.
Method
Data were analysed from a cross-sectional study of adults with diabetes, hypertension or both in central Texas in 2013. Measures of medication nonadherence in the past 12 months, financial strain and patients' persistence in asking treatment- and medication-related questions were identified. Medication nonadherence resulting from cost, transportation or work was compared with medication nonadherence resulting from other reasons. Binary and multinomial regression models were fitted to identify factors associated with medication nonadherence among the respondents.
Key findings
In the bivariate model, medication nonadherence from any cause was significantly associated with financial strain, not asking questions about treatments or medications, and all demographic characteristics. However, in the multinomial model, medication nonadherence resulting from cost, work or transportation was only associated with not asking medication-related question about financial strain, lack of health insurance, age and gender. This was true for nonadherence resulting from other reasons except that ethnicity was significant while gender was not.
Conclusions
While removing financial strain could aid medication adherence, clinicians should also encourage patients to be persistent in asking questions about their medications until they understand the purpose for taking them. Our findings have implications for empowering patients to be more proactive in enhancing their adherence to medications.
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Affiliation(s)
- Bernard Appiah
- Research Program on Public and International Engagement for Health, Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
| | - James N Burdine
- Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Shelby Cummings
- Department of Statistics, Texas A&M University, College Station, TX, USA
| | - Anubhuti Poudyal
- Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX, USA
| | | | - Samuel N Forjuoh
- Department of Family & Community Medicine, Scott & White Santa Fe, Temple, TX, USA
| | - Kenneth R McLeroy
- Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX, USA
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Kennedy J, Tuleu I, Mackay K. Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed. J Manag Care Spec Pharm 2020; 26:935-942. [PMID: 32715958 PMCID: PMC10391240 DOI: 10.18553/jmcp.2020.26.8.935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence. OBJECTIVES To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained. METHODS The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS). RESULTS In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes. CONCLUSION Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics. DISCLOSURES This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.
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Affiliation(s)
- Jae Kennedy
- An Associate Professor in the Department of Health Policy and Administration at Washington State University
| | - Iulia Tuleu
- An Internal Medicine Resident at Beaumont Hospital in Royal Oak, Michigan
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Medication adherence in the older adults with chronic multimorbidity: a systematic review of qualitative studies on patient's experience. Eur Geriatr Med 2020; 11:369-381. [PMID: 32297271 DOI: 10.1007/s41999-020-00313-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/17/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE Medication non-adherence represents a socially relevant challenge, particularly when interlinked to multiple chronic diseases and polypharmacy. Non-adherence rates affect treatment efficacy and increase health care costs. The aim of the study was to identify factors influencing medication adherence in the older adults through a systematic review of qualitative studies on patients' experience. METHODS Two electronic databases were searched for qualitative studies on medication adherence in chronic diseases (hypertension, heart disease, COPD, asthma) involving people aged 65 + . The systematic review was performed according to the PRISMA statement guidelines, employing theoretical frameworks of the ABC Taxonomy of patient adherence and Three Factor model of determinants of behaviour. RESULTS The initial database search identified 1234 records, of which 39 studies were considered eligible. Most of the studies focused on hypertension and were conducted in English-speaking countries. According to the ABC Taxonomy, Persistence and Implementation were the most often considered phases. Considering the Three Factor model, the most often reported themes were Information and Strategies upon being adherent. Stemming from the review findings and the patients' narratives, a new integrated model was proposed. It reports the patient's decisional flowchart describing barriers and facilitators (personal, social and environmental) to adherence. CONCLUSION Medication adherence is a complex and multifaceted process. The implementation of theoretical frameworks along with a patient-centred perspective may provide clinicians with useful suggestions for clinical practice, enhancing the patient's ability to adhere.
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Cheng C, Inder K, Chan SW. Coping with multiple chronic conditions: An integrative review. Nurs Health Sci 2020; 22:486-497. [DOI: 10.1111/nhs.12695] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Cheng Cheng
- School of Nursing and Midwifery The University of Newcastle Callaghan New South Wales Australia
- Department of Nursing Bengbu Medical College Bengbu China
| | - Kerry Inder
- School of Nursing and Midwifery The University of Newcastle Callaghan New South Wales Australia
- Hunter Medical Research Institute New Lambton Heights New South Wales Australia
| | - Sally Wai‐Chi Chan
- Hunter Medical Research Institute New Lambton Heights New South Wales Australia
- The University of Newcastle Singapore Singapore Singapore
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The use of discrete choice experiments in adherence research: A new solution to an old problem. Res Social Adm Pharm 2020; 16:1487-1492. [PMID: 32111532 DOI: 10.1016/j.sapharm.2020.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/24/2022]
Abstract
Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.
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Sathanapally H, Sidhu M, Fahami R, Gillies C, Kadam U, Davies MJ, Khunti K, Seidu S. Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: a systematic mixed studies review. BMJ Open 2020; 10:e033445. [PMID: 32051314 PMCID: PMC7045037 DOI: 10.1136/bmjopen-2019-033445] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To identify studies that have investigated the health outcome and treatment priorities of patients with multimorbidity, clinicians or both, in order to assess whether the priorities of the two groups are in alignment, or whether a disparity exists between the priorities of patients with multimorbidity and clinicians. DESIGN Systematic review. DATA SOURCES MEDLINE, EMBASE, CINHAL and Cochrane databases from inception to May 2019 using a predefined search strategy, as well as reference lists containing any relevant articles, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. ELIGIBILITY CRITERIA We included studies reporting health outcome and treatment priorities of adult patients with multimorbidity, defined as suffering from two or more chronic conditions, or of clinicians in the context of multimorbidity or both. There was no restriction by study design, and studies using quantitative and/or qualitative methodologies were included. DATA SYNTHESIS We used a narrative synthesis approach to synthesise the quantitative findings, and a meta-ethnography approach to synthesise the qualitative findings. RESULTS Our search identified 24 studies for inclusion, which comprised 12 quantitative studies, 10 qualitative studies and 2 mixed-methods studies. Twelve studies reported the priorities of both patients and clinicians, 10 studies reported the priorities of patients and 2 studies reported the priorities of clinicians alone. Our findings have shown a mostly low level of agreement between the priorities of patients with multimorbidity and clinicians. We found that prioritisation by patients was mainly driven by their illness experiences, while clinicians focused on longer-term risks. Preserving functional ability emerged as a key priority for patients from across our quantitative and qualitative analyses. CONCLUSION Recognising that there may be a disparity in prioritisation and understanding the reasons for why this might occur, can facilitate clinicians in accurately eliciting the priorities that are most important to their patients and delivering patient-centred care. PROSPERO REGISTRATION NUMBER CRD42018076076.
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Affiliation(s)
| | - Manbinder Sidhu
- School of Social Policy, Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Radia Fahami
- University of Leicester Diabetes Research Centre, Leicester, UK
| | - Clare Gillies
- University of Leicester Diabetes Research Centre, Leicester, UK
| | - Umesh Kadam
- University of Leicester Diabetes Research Centre, Leicester, UK
| | | | - Kamlesh Khunti
- University of Leicester Diabetes Research Centre, Leicester, UK
| | - Samuel Seidu
- University of Leicester Diabetes Research Centre, Leicester, UK
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Muiruri C, Sico IP, Schexnayder J, Webel AR, Okeke NL, Longenecker CT, Gonzalez JM, Jones KA, Gonzales SE, Bosworth HB. Why Do People Living with HIV Adhere to Antiretroviral Therapy and Not Comorbid Cardiovascular Disease Medications? A Qualitative Inquiry. Patient Prefer Adherence 2020; 14:985-994. [PMID: 32669837 PMCID: PMC7337208 DOI: 10.2147/ppa.s254882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/19/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND After achieving viral suppression, it is critical for persons living with HIV (PLWH) to focus on prevention of non-AIDS comorbidities such as cardiovascular disease (CVD) in order to enhance their quality of life and longevity of life. Despite PLWH elevated risk of developing CVD compared to individuals without HIV, PLWH do not often meet evidence-based treatment goals for CVD prevention; the reasons for PLWH not meeting guideline recommendations are poorly understood. The objective of this study was to identify the factors associated with adherence to CVD medications for PLWH who have achieved viral suppression. METHODS Qualitative data were obtained from formative research conducted to inform the adaptation of a nurse-led intervention trial to improve cardiovascular health at three large academic medical centers in the United States. Transcripts were analyzed using content analysis guided by principles drawn from grounded theory. RESULTS Fifty-one individuals who had achieved viral suppression (<200 copies/mL) participated: 37 in 6 focus groups and 14 in individual semi-structured interviews. Mean age was 57 years (SD: 7.8); most were African Americans (n=31) and majority were male (n=34). Three main themes were observed. First, participants reported discordance between their healthcare providers' recommendations and their own preferred strategies to reduce CVD risk. Second, participants intentionally modified frequency of CVD medication taking which appeared to be related to low CVD risk perception and perceived or experienced side effects with treatment. Finally, participants discussed the impact of long-term experience with HIV care on adherence to CVD medication and motivational factors that enhanced adherence to heart healthy behaviors. CONCLUSION Findings suggest that future research should focus on developing interventions to enhance patient-provider communication in order to elicit beliefs, concerns and preferences for CVD prevention strategies. Future research should seek to leverage and adapt established evidence-based practices in HIV care to support CVD medication adherence.
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Affiliation(s)
- Charles Muiruri
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Correspondence: Charles Muiruri Email
| | - Isabelle P Sico
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Julie Schexnayder
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Juan Marcos Gonzalez
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Sarah E Gonzales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Hovland R, Bremer S, Frigaard C, Henjum S, Faksvåg PK, Saether EM, Kristiansen IS. Effect of a pharmacist-led intervention on adherence among patients with a first-time prescription for a cardiovascular medicine: a randomized controlled trial in Norwegian pharmacies. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:337-345. [PMID: 31886591 PMCID: PMC7384053 DOI: 10.1111/ijpp.12598] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/26/2019] [Indexed: 01/09/2023]
Abstract
Objective To examine whether a pharmacist‐led intervention improves medication adherence among patients who have filled a first‐time prescription for a cardiovascular medicine. Methods Design: Unblinded randomized controlled trial. Setting: 67 Norwegian pharmacies, October 2014–June 2015. Participants: 1480 adults with a first‐time prescription for a cardiovascular medicine. Intervention: Participants in the intervention group received two consultations with a pharmacist 1–2 and 3–5 weeks after filling the prescription. Participants in the control group received care according to usual practice. Main outcome measure: The primary outcome was self‐reported adherence as measured by the 8‐item Morisky Medication Adherence Scale (MMAS‐8), at 7 and 18 weeks after filling the prescription. Adherence from baseline to week 52 was estimated using data from the Norwegian Prescription Database (NPD). Key Findings Data from MMAS‐8 showed that 91.3% of the patients in the intervention group were adherent after 7 weeks versus 86.8% in the control group (4.5% difference, 95% CI 0.8–8.2, P = 0.017). The corresponding proportions were 88.7% versus 83.7% after 18 weeks (5.0% difference, 95% CI 0.8–9.2, P = 0.021). NPD data (n = 1294) showed no significant difference in adherence after 52 weeks (95% CI −2.0 to 7.8, P = 0.24). However, adherence among statin users (n = 182) was 66.5% in the intervention group versus 57.4% among new statin users in the general population (n = 1500) (difference 9.1%, 95% CI 1.5–16.0, P = 0.019). Conclusion The main outcome measure indicates that a short, structured pharmacist‐led intervention may increase medication adherence for patients starting on chronic cardiovascular medication. However, these findings could not be confirmed by the NPD data analysis.
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Affiliation(s)
- Ragnar Hovland
- Apokus, National Centre for Development of Pharmacy Practice, Oslo, Norway
| | - Sara Bremer
- Apokus, National Centre for Development of Pharmacy Practice, Oslo, Norway
| | - Christine Frigaard
- Apokus, National Centre for Development of Pharmacy Practice, Oslo, Norway
| | | | | | | | - Ivar Sønbø Kristiansen
- Oslo Economics, Oslo, Norway.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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12
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Abstract
Aim This study aimed to explore attitudes, beliefs and experiences regarding polypharmacy and discontinuing medications, or deprescribing, among community living older adults aged ≥65 years, using ≥5 medications. It also aimed to investigate if health literacy capabilities influenced attitudes and beliefs towards deprescribing. Background Polypharmacy use is common among Australian older adults. However, little is known about their attitudes towards polypharmacy use or towards stopping medications. Previous studies indicate that health literacy levels tend to be lower in older adults, resulting in poor knowledge about medications. Methods A self-administered survey was conducted using two previously validated tools; the Patients’ Attitude Towards Deprescribing (PATD) tool to measure attitudes towards polypharmacy use and deprescribing and the All Aspects of Health Literacy Scale (AAHLS) to measure functional, communicative and critical health literacy. Descriptive statistical analysis was conducted. Findings The 137 responses showed that 80% thought all their medications were necessary and were comfortable with the number taken. Wanting to reduce the number of medications taken was associated with concerns about the amount taken (P<0.001), experiencing side effects (P<0.001), or believing that one or more medications were no longer needed (P<0.000). Those who were using ten or more medications were more likely to want to reduce the number taken (P=0.019). Most (88%) respondents would be willing to stop medication/s in the context of receiving this advice from their doctor. Willingness to consider stopping correlated with higher scores on the critical health literacy subscale (P<0.021) and overall AAHLS score (P<0.009). Those with higher scores on the overall AAHLS measure were more likely to report that they understood why their medications were prescribed (P<0.000) and were more likely to participate in decision-making (P=0.027). Opportunities to proactively consider deprescribing may be missed, as one third of the respondents could not recall a recent review of their medications.
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13
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Porter T, Ong BN, Sanders T. Living with multimorbidity? The lived experience of multiple chronic conditions in later life. Health (London) 2019; 24:701-718. [PMID: 30895825 DOI: 10.1177/1363459319834997] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multimorbidity is defined biomedically as the co-existence of two or more long-term conditions in an individual. Globally, the number of people living with multiple conditions is increasing, posing stark challenges both to the clinical management of patients and the organisation of health systems. Qualitative literature has begun to address how concurrency affects the self-management of chronic conditions, and the concept of illness prioritisation predominates. In this article, we adopt a phenomenological lens to show how older people with multiple conditions experience illness. This UK study was qualitative and longitudinal in design. Sampling was purposive and drew upon an existing cohort study. In total, 15 older people living with multiple conditions took part in 27 in-depth interviews. The practical stages of analysis were guided by Constructivist Grounded Theory. We argue that the concept of multimorbidity as biomedically imagined has limited relevance to lived experience, while concurrency may also be erroneous. In response, we outline a lived experience of multiple chronic conditions in later life, which highlights differences between clinical and lay assumptions and makes the latter visible.
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14
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Cheng C, Inder K, Chan SWC. Patients' experiences of coping with multiple chronic conditions: A meta-ethnography of qualitative work. Int J Ment Health Nurs 2019; 28:54-70. [PMID: 30232822 DOI: 10.1111/inm.12544] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2018] [Indexed: 12/21/2022]
Abstract
Multiple chronic conditions (MCCs) pose a major and growing burden on the individuals' health. The ways in which people cope with their stresses related to their chronic conditions are significant to their health outcomes. This review sought to understand lived experiences of coping with MCCs by a meta-ethnography of qualitative studies. Twenty-six studies were identified in four electronic databases including PubMed, PsycINFO, EMBASE, and CINAHL that were searched from 1966 to 2017. A seven-step analytic method was used after a quality evaluation based on Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The findings illustrated that experiences of coping with MCCs were interacted with (i) appraisals of MCCs, (ii) strategies to maintain a normal life, (iii) strategies to keep the spirits up, and (iv) coping in the social context. To sum up, this review provided a collection of narratives on coping with MCCs. The findings would help to recognize the high complexity experienced by these patients, also potentially offered a foundation for the design of a feasible intervention to more optimally highlight the demands of managing MCCs.
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Affiliation(s)
- Cheng Cheng
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia.,School of Nursing, Bengbu Medical College, Bengbu, Anhui, China
| | - Kerry Inder
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sally Wai-Chi Chan
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
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15
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Cheiloudaki E, Alexopoulos EC. Adherence to Treatment in Stroke Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020196. [PMID: 30641978 PMCID: PMC6351941 DOI: 10.3390/ijerph16020196] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/30/2018] [Accepted: 01/10/2019] [Indexed: 11/16/2022]
Abstract
Background: Compliance with medication in patients who have suffered stroke is usually not-optimal. This study aims to measure the level of compliance with the treatment and to identify socio-demographic, clinical, and subjective factors related to the long-term compliance of stroke patients with their treatment. Methods: 140 patients (66.4% males) suffered an ischemic stroke at least six months old, participated in the survey. Compliance was measured using the Medication Adherence Report Scale and the quality of life by the Stroke Specific Quality of Life questionnaire. Furthermore, the Beliefs about Medicines Questionnaire and the Brief Illness Perception Questionnaire on perceptions about the disease were assessed. The doctor–patient relationship was assessed by the Common-Sense Model of Self-Regulation questionnaire and the family support was assessed by the FSS scale. Univariate and multivariate analysis was employed to identify the significant factors affecting compliance in these stroke patients. Results: In 68.6% of patients the compliance was classified as optimal, in 25.7% as partial and as poor in 5.7%; the last two categories were treated as sub-optimal compliance in multivariate analysis. The high compliance was related to patient’s mental state (OR:3.94 95% CI: 1.84–4.46), the perception medication necessity (OR:1.26 95% CI: 1.01–1.56), and the doctor–patient communication (OR:1.76 95% CI: 1.15–2.70). Men showed a lower compliance than women, as well as increased concerns about taking medication (OR: 0.83, 95% CI: 0.69–0.99). Paradoxically, the work /productivity related quality of life was inversely associated with compliance (OR (95% CI): 0.44 (0.23 to 0.82)). Conclusions: The perception of medication necessity and the doctor–patient communication are manageable factors associated with compliance in treating patients who have suffered stroke. In addition, rehabilitation and return to work programs should consider these factors when providing support to those persons.
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Affiliation(s)
| | - Evangelos C Alexopoulos
- School of Social Sciences, Hellenic Open University, 26335 Patra, Greece.
- Occupational Health Department, Metropolitan General Hospital, 15562 Athens, Greece.
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16
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Women living with multi-morbidity in the Greater Accra Region of Ghana: a qualitative study guided by the Cumulative Complexity Model. J Biosoc Sci 2018; 51:562-577. [PMID: 30472965 DOI: 10.1017/s0021932018000342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Defined as the co-occurrence of more than two chronic conditions, multi-morbidity has been described as a significant health care problem: a trend linked to a rise in non-communicable disease and an ageing population. Evidence on the experiences of living with multi-morbidity in middle-income countries (MICs) is limited. In high-income countries (HICs), multi-morbidity has a complex impact on health outcomes, including functional status, disability and quality of life, complexity of health care and burden of treatment. Previous evidence also shows that multi-morbidity is consistently higher amongst women. This study aimed to explore the perceptions and experiences of women living with multi-morbidity in the Greater Accra Region, Ghana: to understand the complexity of their health needs due to multi-morbidity, and to document how the health system has responded. Guided by the Cumulative Complexity Model, and using stratified purposive sampling, 20 in-depth interviews were conducted between May and September 2015 across three polyclinics in the Greater Accra Region. The data were analysed using the six phases of Thematic Analysis. Overall four themes emerged: 1) the influences on patients' health experience; 2) seeking care and the responsiveness of the health care system; 3) how patients manage health care demands; and 4) outcomes due to health. Spirituality and the stigmatization caused by specific conditions, such as HIV, impacted their overall health experience. Women depended on the care and treatment provided through the health care system despite inconsistent coverage and a lack of choice thereof, although their experiences varied by chronic condition. Women depended on their family and community to offset the financial burden of treatment costs, which was exacerbated by having many conditions. The implications are that integrated health and social support, such as streamlining procedures and professional training on managing complexity, would benefit and reduce the burden of multi-morbidity experienced by women with multi-morbidity in Ghana.
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17
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Olson A, Reiland S, Davies S, Koehler AR. Learning about the experience of living with chronic conditions: A framework analysis of nursing students' reflections on their conversations with older adults. GERONTOLOGY & GERIATRICS EDUCATION 2018; 39:295-315. [PMID: 27749153 DOI: 10.1080/02701960.2016.1247067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Preparing nursing students to work effectively with older adults is an important element of undergraduate nursing education. Reflective journals written as course assignments represent a source of data about students' learning. The aim of this study was to analyze nursing students' reflective journals based on conversations with older adults who are community dwelling, to identify learning in relation to experiences of living with a chronic condition. This was one element of a wider study to evaluate learning partnerships between older adults who are community dwelling and nursing students as an alternative to traditional clinical placements in long-term care settings. Nursing students worked with faculty to complete a qualitative secondary analysis of 47 journals utilizing framework analysis. Students learned about three main aspects of living with chronic conditions: beliefs about chronic conditions, managing chronic conditions, and experiencing chronic conditions, with some evidence that these themes may be interconnected. Findings suggest that learning partnerships with older adults combined with reflective journaling enable nursing students to understand the experience of chronic conditions in later life as reflected within current literature and to identify interventions for gerontological nursing practice. Enabling nursing students to recognize the highly skilled nature of working with older adults with chronic illness has the potential to influence their future career choices.
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Affiliation(s)
| | | | - Susan Davies
- c Department of Nursing, Winona State University , Minnesota , USA
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18
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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19
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Kromme NMH, Ahaus KTB, Gans ROB, van de Wiel HBM. Internists' dilemmas in their interactions with chronically ill patients; A comparison of their interaction strategies and dilemmas in two different medical contexts. PLoS One 2018; 13:e0194133. [PMID: 29847552 PMCID: PMC5976145 DOI: 10.1371/journal.pone.0194133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 02/15/2018] [Indexed: 11/21/2022] Open
Abstract
Background Internists appear to define productive interactions, key concept of the Chronic Care Model, as goal-directed, catalyzed by achieving rapport, and depending on the medical context: i.e. medically explained symptoms (MES) or medically unexplained symptoms (MUS). Objective To explore internists’ interaction strategy discourses in the context of MES and MUS. Methods We interviewed twenty internists working in a Dutch academic hospital, identified relevant text fragments in the interview transcripts and analyzed the data based on a discourse analysis approach. Results We identified four interaction strategy discourses: relating, structuring, exploring, and influencing. Each was characterized by a dilemma: relating by ‘creating nearness versus keeping distance’; structuring by ‘giving space versus taking control’; exploring by ‘asking for physical versus psychosocial causes’; and influencing by ‘taking responsibility versus accepting a patient’s choice. The balance sought in these dilemmas depended on whether the patient’s symptoms were medically explained or unexplained (MES or MUS). Towards MUS the internists tended to maintain greater distance, take more control, ask more cautiously questions related to psychosocial causes, and take less responsibility for shared decision making. Discussion and conclusions Adopting a basic distinction between MES and MUS, the internists in our study appeared to seek a different balance in each of four rather fundamental clinical dilemmas. Balancing these dilemmas seemed more difficult regarding MUS where the internists seemed more distancing and controlling, and tended to draw on their medical expertise. Moving in this direction is counterproductive and in contradiction to guidelines which emphasize that MUS patients warrant emotional support requiring a shift towards interpersonal, empathic communication.
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Affiliation(s)
- Nicolien M. H. Kromme
- University of Groningen, University Medical Center Groningen, SectorA Chronic and Vascular Disease, Groningen, The Netherlands
- * E-mail:
| | - Kees T. B. Ahaus
- University of Groningen, Faculty of Economics and Business, Centre of Expertise Healthwise, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinold O. B. Gans
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - Harry B. M. van de Wiel
- University of Groningen, University Medical Center Groningen, Wenckebach Institute, Groningen, The Netherlands
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20
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Rashid MA, Llanwarne N, Heyns N, Walter F, Mant J. What are the implications for practice that arise from studies of medication taking? A systematic review of qualitative research. PLoS One 2018; 13:e0195076. [PMID: 29768417 PMCID: PMC5955529 DOI: 10.1371/journal.pone.0195076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 02/28/2018] [Indexed: 12/03/2022] Open
Abstract
Background Despite several decades of evidence supporting the benefits of taking medications in various diseases and healthcare settings, a significant proportion of prescribed treatments are not taken. This review sought to synthesise qualitative research exploring experiences of medication taking around the world, and to determine whether there were consistent messages arising from these studies. Methods and findings 5 databases (MEDLINE, PsycINFO, EMBASE, SCOPUS, CINAHL) were systematically searched to identify published research papers using qualitative methodologies, which explored medication-taking experiences in patients, citizens, carers, relatives and clinicians. Data were extracted independently by at least two clinician reviewers. Implications for practice from individual papers were charted and coded using thematic content analysis. These were then cross-tabulated with research paper categories to explore emergent patterns with particular implications for practice. 192 papers from 34 different countries were included in the review. Implications for practice fitted into 11 categories: increase family involvement, increase clinician involvement, promote personalised management, address practical barriers, provide ongoing support, promote self-management, adopt a patient-centred approach, improve patient education, address system barriers, increase access to non-prescribing clinicians and improve clinician training. These implications for practice were generally evenly spread across research paper categories. Conclusions Implications for practice from the published qualitative literature exploring medication-taking are notably consistent across research methods, disease categories and geographical settings. More recent clinical trials of interventions to improve adherence have started to draw on these findings by focussing on improving clinical interactions and involving patients in healthcare decisions. Promoting patient education and self-management have been widely advocated, and improvements at a system level have been frequently cited in studies from developing countries and those relating to communicable diseases. Regardless of the setting, clinicians and policymakers around the world can focus efforts to improve medication-taking by considering a number of consistently emerging findings.
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Affiliation(s)
| | - Nadia Llanwarne
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, United Kingdom
| | - Natalie Heyns
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, United Kingdom
| | - Fiona Walter
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, United Kingdom
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, United Kingdom
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21
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Adams AS, Madden JM, Zhang F, Lu CY, Ross-Degnan D, Lee A, Soumerai SB, Gilden D, Chawla N, Griggs JJ. Effects of Transitioning to Medicare Part D on Access to Drugs for Medical Conditions among Dual Enrollees with Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1345-1354. [PMID: 29241894 PMCID: PMC5734096 DOI: 10.1016/j.jval.2017.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/19/2017] [Accepted: 05/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the impact of transitioning from Medicaid to Medicare Part D drug coverage on the use of noncancer treatments among dual enrollees with cancer. METHODS We leveraged a representative 5% national sample of all fee-for-service dual enrollees in the United States (2004-2007) to evaluate the impact of the removal of caps on the number of reimbursable prescriptions per month (drug caps) under Part D on 1) prevalence and 2) average days' supply dispensed for antidepressants, antihypertensives, and lipid-lowering agents overall and by race (white and black). RESULTS The removal of drug caps was associated with increased use of lipid-lowering medications (days' supply 3.63; 95% confidence interval [CI] 1.57-5.70). Among blacks in capped states, we observed increased use of lipid-lowering therapy (any use 0.08 percentage points; 95% CI 0.05-0.10; and days' supply 4.01; 95% CI 2.92-5.09) and antidepressants (days' supply 2.20; 95% CI 0.61-3.78) and increasing trends in antihypertensive use (any use 0.01 percentage points; 95% CI 0.004-0.01; and days' supply 1.83; 95% CI 1.25-2.41). The white-black gap in the use of lipid-lowering medications was immediately reduced (-0.09 percentage points; 95% CI -0.15 to -0.04). We also observed a reversal in trends toward widening white-black differences in antihypertensive use (level -0.08 percentage points; 95% CI -0.12 to -0.05; and trend -0.01 percentage points; 95% CI -0.02 to -0.01) and antidepressant use (-0.004 percentage points; 95% CI -0.01 to -0.0004). CONCLUSIONS Our findings suggest that the removal of drug caps under Part D had a modest impact on the treatment of hypercholesterolemia overall and may have reduced white-black gaps in the use of lipid-lowering and antidepressant therapies.
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Affiliation(s)
- Alyce S Adams
- Kaiser Permanente Division of Research, Oakland, CA, USA.
| | - Jeanne M Madden
- School of Pharmacy, Northeastern University, Boston, MA, USA; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Dan Gilden
- Jen Associates, Inc., Cambridge, MA, USA
| | - Neetu Chawla
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Jennifer J Griggs
- Departments of Internal Medicine, Hematology/Oncology, and Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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Goldsmith LJ, Kolhatkar A, Popowich D, Holbrook AM, Morgan SG, Law MR. Understanding the patient experience of cost-related non-adherence to prescription medications through typology development and application. Soc Sci Med 2017; 194:51-59. [PMID: 29065312 DOI: 10.1016/j.socscimed.2017.10.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 01/05/2023]
Abstract
Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA.
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Affiliation(s)
- Laurie J Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
| | - Ashra Kolhatkar
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dominic Popowich
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Anne M Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Centre for Evaluation of Medicines, Hamilton Health Science and St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Kobue B, Moch S, Watermeyer J. "It's so hard taking pills when you don't know what they're for": a qualitative study of patients' medicine taking behaviours and conceptualisation of medicines in the context of rheumatoid arthritis. BMC Health Serv Res 2017; 17:303. [PMID: 28441949 PMCID: PMC5405531 DOI: 10.1186/s12913-017-2246-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 04/19/2017] [Indexed: 12/22/2022] Open
Abstract
Background Patients with chronic illnesses are often required to take lifelong medication to alleviate symptoms and prevent disease progression. Many patients find it difficult to adhere to prescribed medication for various reasons, some of which may link to the way they conceptualise medicines and understand their illness and treatment. This study explores the medicine taking behaviours of patients presenting with Rheumatoid Arthritis (RA), a chronic inflammatory autoimmune disease. We focused particularly on patients’ conceptualisation and understanding of medicines within this disease context, against a backdrop of scarce healthcare resources. Methods We conducted semi-structured interviews with 18 female patients at a rheumatology clinic in South Africa, as well as a review of participants’ medical records. We conducted a secondary analysis of the data using thematic analysis and framework analysis principles. Results Participants reported a range of medicine taking behaviours including self-medicating, adding complementary and alternative medicines (CAM) or traditional remedies, and sometimes acquiring prescribed medicines illegally. Participants provided insights into their understanding of what constitutes a medicine and what substances can be added to a prescribed regimen, which impacted on adherence. Importantly, the majority of participants demonstrated poor understanding of their illness, medications, regimens and dosage instructions. Conclusions Medicine taking in the context of RA, within the studied demographic, is complex and appears strongly mediated by individual and contextual factors. Poor patient understanding, individual conceptualisation of medicines and medicine taking, and the availability of a range of additional medicines and remedies impact on adherence. Based on these findings, we make some suggestions for how healthcare providers can play a greater role in educating patients living with RA about medicines, CAM and traditional remedies, as well as medicine taking behaviours.
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Affiliation(s)
- Boitshoko Kobue
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa
| | - Shirra Moch
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, and Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa.
| | - Jennifer Watermeyer
- Health Communication Research Unit, School of Human and Community Development, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2050, South Africa
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Johnson LA. Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence. Clin J Oncol Nurs 2017; 19:6-30. [PMID: 26030389 DOI: 10.1188/15.s1.cjon.6-30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence. OBJECTIVES The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice. METHODS Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research. FINDINGS Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.
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Bokhof B, Junius-Walker U. Reducing Polypharmacy from the Perspectives of General Practitioners and Older Patients: A Synthesis of Qualitative Studies. Drugs Aging 2016; 33:249-66. [PMID: 26915076 DOI: 10.1007/s40266-016-0354-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Polypharmacy, common in elderly multimorbid adults, leads to increased iatrogenic health risks. Yet, no consistent approach to stopping medicines exists in primary healthcare. OBJECTIVES Our objective was to synthesize qualitative studies exploring the perspectives and experiences of general practitioners (GPs) and older patients in reducing polypharmacy and to discover approaches already being practiced. METHODS We conducted a search in the PubMed, Cochrane Library, Web of Science Core Collection, and Scopus databases to identify qualitative studies in the primary care setting addressing multimorbid older patients and polypharmacy reduction. The seven-step model of meta-ethnography allowed for cross-interpretation between studies considering their original context and developing theories. RESULTS A total of 14 studies from the perspectives of patients (n = 6) and providers (n = 8) were included, although discontinuing medicines only occurred as a sub-theme in patient studies. Emerging key concepts for patients were experimenting with medicines, attitudes and experiences towards medicines, necessity of prioritizing treatments, relationship to GP, and system-related contributors. For GPs, they covered assumptions about elderly patients, interface prescribing problems, evidence-based guidelines, failure to meet the challenge of complex decision-making, and solutions. DISCUSSION Complex medication regimens and uncertainties in decision making are challenges for both GPs and patients. For patients, symptom experiences with medicines, relationship with their prescriber, and fragmented care are at the forefront; for GPs, it is the decision-making responsibility in the context of unsuitable guidelines, time constraints, and deficient multidisciplinary co-operation. Heuristics such as prioritizing and individualizing treatments and relaxation of guidelines emerged. These strategies require professional awareness of the problem and establishing a trusting, patient-centered consultation style and supportive work conditions.
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Affiliation(s)
- Beate Bokhof
- Institute of General Practice, Hannover, Lower Saxony, Germany.
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Okuyan B, Babi B, Sancar M, Ay P, Yücel E, Yücel A, Izzettin FV. Validation of the Turkish version of medication regimen complexity index among elderly patients. J Eval Clin Pract 2016; 22:732-6. [PMID: 26987572 DOI: 10.1111/jep.12526] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to validate the Turkish version of the 'Medication Regimen Complexity Index' (MRCI). METHODS This validation study has been conducted in prescriptions of the first 100 elderly patients who had visited the pharmacy for their prescription refill to evaluate convergent and divergent validity of the Turkish version. The reliability of the Turkish version was assessed with inter-rater and test-retest analysis after its translation and cultural adaptation. RESULTS The mean age of the 100 patients (53 women) was 74.9 years (SD = 7.58, 65-95). The scale showed high inter-rater reliability and test-retest reliability for the total and subscale scores (p < 0.05). A strong and positive correlation between the number of medications in a prescription and the total Medication Regimen Complexity Index scores (r = 0.930, p < 0.001) was determined. There were no statistically significant differences between age, gender and MRCI scores (p > 0.05). CONCLUSION These results show that the Turkish version of MRCI is a reliable and valid tool in elderly patients.
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Affiliation(s)
- Betul Okuyan
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey.
| | - Bedis Babi
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
| | - Mesut Sancar
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
| | - Pınar Ay
- Department of Public Health, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Emre Yücel
- Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, Houston, TX, USA
| | - Aylin Yücel
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, USA
| | - Fikret Vehbi Izzettin
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
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Grant RW, Uratsu CS, Estacio KR, Altschuler A, Kim E, Fireman B, Adams AS, Schmittdiel JA, Heisler M. Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system. Contemp Clin Trials 2016; 47:196-201. [PMID: 26820612 DOI: 10.1016/j.cct.2016.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. METHODS We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system. RESULTS This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015-6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) navigating research vs. quality improvement requirements; (2) addressing informed consent considerations; and (3) introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for "self-learning health system" research. CONCLUSIONS By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations.
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Affiliation(s)
- Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States.
| | - Connie S Uratsu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Karen R Estacio
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Eileen Kim
- Department of Medicine, Oakland Medical Center, Kaiser Permanente Northern California, United States
| | - Bruce Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Michele Heisler
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States; Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI, United States
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Coventry PA, Small N, Panagioti M, Adeyemi I, Bee P. Living with complexity; marshalling resources: a systematic review and qualitative meta-synthesis of lived experience of mental and physical multimorbidity. BMC FAMILY PRACTICE 2015; 16:171. [PMID: 26597934 PMCID: PMC4657350 DOI: 10.1186/s12875-015-0345-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 09/22/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Multimorbidity poses a major health burden worldwide yet most healthcare is still orientated towards the management of single diseases. Literature on the experience of living with multimorbidity is accumulating but has not yet been synthesised in a manner conducive to informing the design of self-management interventions for this population. This study aimed to systematically review and synthesise findings from published, in-depth qualitative studies about the experience of multimorbidity, with a view to identifying the components and motivation for successful self-management in this population. METHODS Systematic review of and meta-synthesis of qualitative studies that evaluated patient experience of living with and/or self-managing mental and/or physical multimorbidity. MEDLINE, Embase, PsycINFO, CINAHL, and ASSIA along with reference lists of existing reviews and content pages of non-indexed specialists comorbidity journals were searched. RESULTS Nineteen studies from 23 papers were included. A line of argument synthesis was articulated around three third-order constructs: 1) Encounters with complexity; 2) Marshalling medicines, emotions, and resources; and 3) Self-preservation and prevention. Our interpretation revealed how mental and physical multimorbidity is experienced as moments of complexity rather than mere counts of illnesses. Successful self-management of physical symptoms was contingent upon the tactical use of medicines, whilst emotional health was more commonly managed by engaging in behavioural strategies, commonly with a social or spiritual component. Motivations for self-management were underpinned by a sense of moral purpose to take responsibility for their health, but also by a desire to live a purposeful life beyond an immediate context of multimorbidity. CONCLUSIONS Understanding how people experience the complexities of mental and physical multimorbidity may be crucial to designing and delivering interventions to support successful self-management in this population. Future self-management interventions should aim to support patients to exert responsibility and autonomy for medical self-management and promote agency and self-determination to lead purposeful lives via improved access to appropriate social and psychological support.
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Affiliation(s)
- Peter A Coventry
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Nicola Small
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Maria Panagioti
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Isabel Adeyemi
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Penny Bee
- School of Nursing, Midwifery and Social Work and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Lyles CR, Seligman HK, Parker MM, Moffet HH, Adler N, Schillinger D, Piette JD, Karter AJ. Financial Strain and Medication Adherence among Diabetes Patients in an Integrated Health Care Delivery System: The Diabetes Study of Northern California (DISTANCE). Health Serv Res 2015; 51:610-24. [PMID: 26256117 DOI: 10.1111/1475-6773.12346] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To examine self-reported financial strain in relation to pharmacy utilization adherence data. DATA SOURCES/STUDY SETTING Survey, administrative, and electronic medical data from Kaiser Permanente Northern California. STUDY DESIGN Retrospective cohort design (2006, n = 7,773). DATA COLLECTION/EXTRACTION METHODS We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models. PRINCIPAL FINDINGS Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84). CONCLUSIONS Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.
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Affiliation(s)
- Courtney R Lyles
- University of California San Francisco, 1001 Potrero Ave, San Francisco, CA.,Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Hilary K Seligman
- Division of General Internal Medicine at SFGH, UCSF Center for Vulnerable Populations, San Francisco, CA
| | - Melissa M Parker
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Howard H Moffet
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - Nancy Adler
- UCSF Departments of Psychiatry and Pediatrics, San Francisco, CA
| | - Dean Schillinger
- Division of General Internal Medicine at SFGH, UCSF Center for Vulnerable Populations, San Francisco, CA.,Kaiser Permanente Northern California Division of Research, Oakland, CA
| | - John D Piette
- Schools of Public Health and Medicine, VA Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor, MI
| | - Andrew J Karter
- Kaiser Permanente Northern California Division of Research, Oakland, CA
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Wimmer BC, Dent E, Bell JS, Wiese MD, Chapman I, Johnell K, Visvanathan R. Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People. Ann Pharmacother 2014; 48:1120-1128. [PMID: 24867583 DOI: 10.1177/1060028014537469] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization. OBJECTIVE To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period. METHOD The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period. RESULT Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78). CONCLUSION Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions.
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Affiliation(s)
- Barbara C Wimmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Elsa Dent
- Discipline of Medicine, University of Adelaide, Adelaide, Australia Discipline of Public Health, University of Adelaide, Adelaide, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Michael D Wiese
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Ian Chapman
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Kristina Johnell
- Discipline of Public Health, University of Adelaide, Adelaide, Australia Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Renuka Visvanathan
- Discipline of Medicine, University of Adelaide, Adelaide, Australia Aged and Extended Care Services, The Queen Elizabeth Hospital and the Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, University of Adelaide, Adelaide, Australia
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Polypharmacy and Medication Regimen Complexity as Factors Associated with Hospital Discharge Destination Among Older People: A Prospective Cohort Study. Drugs Aging 2014; 31:623-30. [DOI: 10.1007/s40266-014-0185-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Souter C, Kinnear A, Kinnear M, Mead G. Optimisation of secondary prevention of stroke: a qualitative study of stroke patients' beliefs, concerns and difficulties with their medicines. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2014; 22:424-32. [PMID: 24606322 DOI: 10.1111/ijpp.12104] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 12/16/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives of this study are to explore stroke patients' and carers' beliefs and concerns about medicines and identify the barriers to medication adherence for secondary stroke prevention. METHODS Qualitative semistructured one-on-one interviews were conducted with 30 patients with diagnosis of stroke. Interviews were analysed using the framework approach. KEY FINDINGS The study suggests that stroke patients' and carers' perceptions of their medicines may influence medicine-taking behaviour. In some cases when beliefs outweighed concerns, practical barriers prevented participants taking their medicines. Negative beliefs about a medicine were strong enough to prevent some participants starting a new medicine. Participants' actions were influenced by the perceived consequences of not taking the medicine and the impact of the adverse effect on their quality of life. Concerns lessened with time with no adverse effects. The importance of the role of the carer and of a medicine-taking routine was evident. Participants reported the inadequacy of information provision and the desire to have more written and verbal information. Some reported total lack of contact with their general practitioner or community pharmacist after hospital discharge. CONCLUSIONS Many of the difficulties stroke patients have adhering to secondary prevention strategies are potentially preventable with tailored information provision and appropriate monitoring and follow-up by primary healthcare professionals. We have designed an intervention addressing the identified barriers to medicine taking, the impact of which is currently being measured in a randomised controlled trial of a pharmacist-led home-based clinical medication review in stroke patients.
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Affiliation(s)
- Caroline Souter
- Pharmacy Department, Western General Hospital, Edinburgh, UK
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Chiou E, Venkatraman V, Larson K, Li Y, Gibson M, Lee JD. Contextual Design of a Motivated Medication Management Device. ERGONOMICS IN DESIGN 2014. [DOI: 10.1177/1064804613508950] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many older adults find that they must manage one or more chronic illnesses entailing multiple medication regimens. These regimens can be daunting, with consequences for medication adherence and health outcomes. To promote adherence to medication regimens, we used contextual design to develop paper and digital prototypes of a medication management device. The design focused on enhancing users’ motivation to adhere to medication therapy. Our design process and outcome suggest that contextual design might serve as an effective data-driven method that can account for the less tangible aspects of work activities, such as motivation.
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Johnson EC, Horwood J, Gooberman-Hill R. Patients' journeys through total joint replacement: patterns of medication use. Musculoskeletal Care 2013; 12:92-102. [PMID: 24357121 DOI: 10.1002/msc.1062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Medication is used to manage pain that results from both osteoarthritis and total joint replacement (TJR). Research has provided insight into how people living with osteoarthritis use pain relief medication. However, it is not known whether elective TJR affects existing attitudes and behaviours with regard to pain medications. Using qualitative methods, the present study explored patterns of pain relief use around the time of TJR. METHOD In-depth face-to-face qualitative interviews were carried out with 24 patients two to four weeks after they had undergone TJR for hip or knee osteoarthritis. Participants were asked to reflect on their use of pain medication pre-surgery, while in hospital and while recovering from their operation at home. Transcripts of the audio-recorded interviews were imported into Atlas.ti® and thematic analysis was used. RESULTS Attitudes to pain relief medication and their use are not static. Many participants change their use of pain medication around the time of surgery. This shift was influenced by interactions with health professionals and changing views on the acceptability, necessity and value of pain relief in helping to manage an altered pain experience. DISCUSSION Understanding reasons for medication-taking behaviour during the journey through joint replacement may be helpful to health professionals. Health professionals have a fundamental role to play in challenging or reinforcing different treatment beliefs, which is the basis for effective use of pain relief over the pre- to postoperative period.
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Affiliation(s)
- Emma C Johnson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
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Boyd M, Waring J, Barber N, Mehta R, Chuter A, Avery AJ, Salema NE, Davies J, Latif A, Tanajewski L, Elliott RA. Protocol for the New Medicine Service Study: a randomized controlled trial and economic evaluation with qualitative appraisal comparing the effectiveness and cost effectiveness of the New Medicine Service in community pharmacies in England. Trials 2013; 14:411. [PMID: 24289059 PMCID: PMC4220816 DOI: 10.1186/1745-6215-14-411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 11/13/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Medication non-adherence is considered an important cause of morbidity and mortality in primary care. This study aims to determine the effectiveness, cost effectiveness and acceptability of a complex intervention delivered by community pharmacists, the New Medicine Service (NMS), compared with current practice in reducing non-adherence to, and problems with, newly prescribed medicines for chronic conditions. METHODS/DESIGN Research subject group: patients aged 14 years and above presenting in a community pharmacy for a newly prescribed medicine for asthma/chronic obstructive pulmonary disease (COPD); hypertension; type 2 diabetes or anticoagulant/antiplatelet agents in two geographical regions in England. DESIGN parallel group patient-level pragmatic randomized controlled trial. INTERVENTIONS patients randomized to either: (i) current practice; or (ii) NMS intervention comprising pharmacist-delivered support for a newly prescribed medicine. PRIMARY OUTCOMES proportion of adherent patients at six, ten and 26 weeks from the date of presenting their prescriptions at the pharmacy; cost effectiveness of the intervention versus current practice at 10 weeks and 26 weeks; in-depth qualitative understanding of the operationalization of NMS in pharmacies. SECONDARY OUTCOMES impact of NMS on: patients' understanding of their medicines, pharmacovigilance, interprofessional and patient-professional relationships and experiences of service users and stakeholders.Economic analysis: Trial-based economic analysis (cost per extra adherent patient) and long-term modeling of costs and health effects (cost per quality-adjusted-life-year) will be conducted from the perspective of National Health Service (NHS) England, comparing NMS with current practice.Qualitative analysis: a qualitative study of NMS implementation in different community settings, how organizational influences affect NMS delivery, patterns of NMS consultations and experiences of professionals and patients participating in NMS, and patients receiving current practice. SAMPLE SIZE 250 patients in each treatment arm would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a reduction in patient-reported non-adherence from 20% to 10% in the NMS arm compared with current practice, assuming a 20% drop-out rate. DISCUSSION At the time of submission of this article, 58 community pharmacies have been recruited and the interventions are being delivered. Analysis has not yet been undertaken. TRIAL REGISTRATION Current controlled trials: ISRCTN23560818. Clinical Trials US (clinicaltrials.gov): NCT01635361.
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Affiliation(s)
- Matthew Boyd
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - Justin Waring
- Center for Health Innovation, Leadership & Learning, Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham NG8 2BB, UK
| | - Nick Barber
- Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Rajnikant Mehta
- Trent Research Design Service, Division of Primary Care, Tower Building, University Park, Nottingham NG7 2RD, UK
| | - Antony Chuter
- 68 Brighton Cottages, Copyhold Lane, Lindfield, Haywards Heath RH16 1XT, UK
| | - Anthony J Avery
- Division of Primary Care, The Medical School, Queen’s Medical Center, Nottingham NG7 2UH, UK
| | - Nde-Eshimuni Salema
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - James Davies
- Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Asam Latif
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - Lukasz Tanajewski
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - Rachel A Elliott
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
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Manteuffel M, Williams S, Chen W, Verbrugge RR, Pittman DG, Steinkellner A. Influence of patient sex and gender on medication use, adherence, and prescribing alignment with guidelines. J Womens Health (Larchmt) 2013; 23:112-9. [PMID: 24206025 DOI: 10.1089/jwh.2012.3972] [Citation(s) in RCA: 236] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This study evaluates the differences between women and men in medication use, medication adherence, and prescribing alignment with clinical guidelines. METHODS We conducted an analysis of pharmacy and medical claims for 29.5 million adults with prescription benefits administered by a pharmacy benefits manager in the United States, age 18 and older, between January 1, 2010, and December 31, 2010. Prevalence and intensity of medication use were evaluated by sex, age group, and medication type (acute vs. chronic). Medication adherence was measured by the percentage of patients with a medication possession ratio (MPR) ≥80%. The percentage of patients receiving guideline-based treatment was measured for diabetes and select cardiovascular conditions. RESULTS The study population comprised 16.0 million women and 13.5 million men with continuous pharmacy benefit eligibility. Women were significantly more likely than men to use one or more medications during the analysis period (68% vs. 59%, respectively, p<0.001), and women used more unique medications, on average, than men (5.0 vs. 3.7 medications per year, respectively, p<0.001). Differences in drug utilization were observed for all age groups and medication types. For all clinical metrics evaluated, women were less likely than men to be adherent in their use of chronic medications, and they were less likely to receive the medication treatment and monitoring recommended by clinical guidelines. CONCLUSIONS There are significant disparities between women and men in their intensity of medication use, their adherence to medications, and their likelihood of receiving guideline-based drug therapy. These differences may indicate a need for more personalized drug selection and therapeutic management to improve clinical outcomes.
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Krska J, Morecroft CW, Poole H, Rowe PH. Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study. Int J Clin Pharm 2013; 35:1161-9. [PMID: 23990332 DOI: 10.1007/s11096-013-9841-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 08/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Polypharmacy is increasing and managing large number of medicines may create a burden for patients. Many patients have negative views of medicines and their use can adversely affect quality of life. No studies have specifically explored the impact of general long-term medicines use on quality of life. OBJECTIVE To determine the issues which patients taking long-term medicines consider affect their day-to-day lives, including quality of life. SETTING Four primary care general practices in North West England. METHODS Face-to-face interviews with adults living at home, prescribed four or more regular medicines for at least 1 year. Interviewees were identified from primary care medical records and purposively selected to ensure different types of medicines use. Interviews were recorded, transcribed and analysed thematically. RESULTS Twenty-one interviews were conducted and analysed. Patients used an average of 7.8 medicines, 51 % were preventive, 40 % for symptom relief and 9 % treatment. Eight themes emerged: relationships with health professionals, practicalities, information, efficacy, side effects, attitudes, impact and control. Ability to discuss medicines with health professionals varied and many views were coloured by negative experiences, mainly with doctors. All interviewees had developed routines for using multiple medicines, some requiring considerable effort. Few felt able to exert control over medicines routines specified by health professionals. Over half sought additional information about medicines whereas others avoided this, trusting in doctors to guide their medicines use. Patients recognised their inability to assess efficacy for many medicines, notably those used for prophylaxis. All were concerned about possible side effects and some had poor experiences of discussing concerns with doctors. Medicines led to restrictions on social activities and personal life to the extent that, for some, life can revolve around medicines. CONCLUSION There is a multiplicity and complexity of issues surrounding medicines use, which impact on day-to-day lives for patients with long-term conditions. While most patients adapt to long-term medicines use, others did so at some cost to their quality of life.
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Affiliation(s)
- Janet Krska
- School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK,
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Weir MR, Shojaee A, Maa JF. Efficacy of amlodipine/olmesartan medoxomil ± hydrochlorothiazide in patients aged ≥ 65 or < 65 years with uncontrolled hypertension on prior monotherapy. Postgrad Med 2013; 125:124-34. [PMID: 23816778 DOI: 10.3810/pgm.2013.03.2646] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Our subanalysis evaluated the efficacy of an amlodipine/olmesartan medoxomil (AML/OM)-based titration regimen to achieve blood pressure (BP) goals among patients aged ≥ 65 years. In this dose-titration study, 999 patients (228 of whom were aged ≥ 65 years) with uncontrolled BP after ≥ 1 month of monotherapy were switched to fixed-dose AML/OM 5/20 mg and uptitrated every 4 weeks to AML/OM 5/40 and 10/40 mg to achieve BP < 120/70 mm Hg. Patients were subsequently uptitrated every 4 weeks to AML/OM 10/40 mg + hydrochlorothiazide (HCTZ) 12.5 mg and AML/OM 10/40 mg + HCTZ 25 mg to achieve BP < 125/75 mm Hg. The primary efficacy endpoint (ie, the cumulative percentage of patients achieving the seated cuff systolic BP goal of < 140 mm Hg [or < 130 mm Hg for patients with type 2 diabetes mellitus] during first 12 weeks of treatment) was achieved by 76.7% and 75.6% of patients aged ≥ 65 (ie, 65-80) years and < 65 (ie, 18-64) years, respectively. For patients aged ≥ 65 and < 65 years, mean seated cuff BP changes from baseline during the titration periods ranged from -14.5/-7.8 mm Hg and -14.1/-7.7 mm Hg, respectively, for AML/OM 5/20 mg, to -28.5/-12.4 and -24.5/-14.0 mm Hg for AML/OM 10/40 mg + HCTZ 25 mg (all P < 0.0001). By week 20, the cumulative BP threshold of < 140/90 mm Hg was achieved by 86.8% and 84.2% of patients aged ≥ 65 and < 65 years, respectively. Among patients aged ≥ 65 years who underwent ambulatory BP monitoring, mean 24-hour, daytime, and nighttime ambulatory BP all decreased from baseline at weeks 12 and 20 (all P < 0.0001). At weeks 12 and 20, the mean 24-hour American Heart Association-recommended ambulatory BP target of < 130/80 mm Hg was achieved in 80.4% and 97.4% of patients aged ≥ 65 years, respectively, and in 71.3% and 88.8% of patients aged < 65 years, respectively. The majority of adverse events were mild to moderate in intensity and the incidence of treatment-emergent adverse events determined by clinical laboratory evaluation was low. The incidence of drug-related hypotension and orthostatic hypotension in patients aged ≥ 65 years was 2.2% and 0.0%, respectively, and in patients aged < 65 years, was 2.3% and 0.3%, respectively. Fixed-dose AML/OM ± HCTZ combination therapy effectively lowered BP and achieved BP goals in patients aged ≥ 65 and < 65 years with hypertension previously uncontrolled on monotherapy. The treatment regimen was well tolerated irrespective of patient age.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Pereira MDG, Pedras S, Machado JC. Validação do questionário crenças acerca da medicação em pacientes diabéticos tipo 2. PSICOLOGIA: TEORIA E PESQUISA 2013. [DOI: 10.1590/s0102-37722013000200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
O presente trabalho teve como objectivo validar o Questionário Crenças sobre a Medicação, que avalia Crenças Gerais e Crenças Específicas, estudando suas propriedades psicométricas em uma amostra de 387 pacientes diabéticos tipo 2. O estudo de validade para as Crenças Gerais revelou uma solução de um factor, com um alfa de 0,76, e para as Crenças Específicas, dois factores - Necessidades e Preocupações -, com um alfa de 0,77 e 0,69 respectivamente. Quanto à validade de constructo, verificou-se uma relação entre as Crenças Gerais e a subescala Necessidades das Crenças Específicas com Adesão à Medicação, avaliada pela Escala de Avaliação de Aderência Médica. O instrumento apresenta boas qualidades psicométricas para ser utilizado em pacientes diabéticos tipo 2.
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Is 50 cent the price of the optimal copayment? - a qualitative study of patient opinions and attitudes in response to a 50 cent charge on prescription drugs in a publicly funded health system in Ireland. BMC Health Serv Res 2013; 13:16. [PMID: 23305316 PMCID: PMC3549780 DOI: 10.1186/1472-6963-13-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/28/2012] [Indexed: 11/25/2022] Open
Abstract
Background A 50 cent prescription levy was introduced in 2010 on the General Medical Services (GMS) scheme (Irish public health insurance). This study sought to examine patient attitudes and opinions surrounding the 50 cent copayment. Given the small momentary value of the prescription fee, these results are of interest to policymakers internationally who wish to reduce copayments rather than abolish them. Methods A qualitative research design was used; semi structured interviews were carried out. Twenty four GMS eligible participants were interviewed in 23 interviews. Fifteen females and 9 males took part. Ages varied from 31- >70 years. Patients were invited to be interviewed in both independent and chain community pharmacies in three types of setting; 1) a socially deprived urban area, 2) a suburban affluent area and 3) a rural area. The Framework method was used for data management and analysis using QSR International’s NVivo 9.2 qualitative data analysis software. The “Francis method” was used to test for data saturation. Results Results are of interest to the Irish context and also at a broader international level. Patients were mostly accepting of the prescription levy with some reservations concerning an increased price and the way in which generated revenue would be used by government. Participants identified waste of prescription drugs at the hand of patients (moral hazard), but there was discordant opinion on whether the 50 cent copayment would halt this moral hazard. Interviewees felt the levy was affordable, albeit some may suffer a financial impact more than others. Conclusions This qualitative study gives important insights into the experiences of GMS patients with regard to the prescription levy. Information regarding the appropriateness of a 50 cent copayment as a symbolic copayment needs to be confirmed by quantitative analysis. Further insight is required from a younger population.
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Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc 2012; 60:E1-E25. [PMID: 22994865 DOI: 10.1111/j.1532-5415.2012.04188.x] [Citation(s) in RCA: 452] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Laba TL, Brien JA, Jan S. Understanding rational non-adherence to medications. A discrete choice experiment in a community sample in Australia. BMC FAMILY PRACTICE 2012; 13:61. [PMID: 22715853 PMCID: PMC3511288 DOI: 10.1186/1471-2296-13-61] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 06/04/2012] [Indexed: 11/18/2022]
Abstract
Background In spite of the potential impact upon population health and expenditure, interventions promoting medication adherence have been found to be of moderate effectiveness and cost effectiveness. Understanding the relative influence of factors affecting patient medication adherence decisions and the characteristics of individuals associated with variation in adherence will lead to a better understanding of how future interventions should be designed and targeted. This study aims to explore medication-taking decisions that may underpin intentional medication non-adherence behaviour amongst a community sample and the relative importance of medication specific factors and patient background characteristics contributing to those decisions. Methods A discrete choice experiment conducted through a web-enabled online survey was used to estimate the relative importance of eight medication factors (immediate and long-term medication harms and benefits, cost, regimen, symptom severity, alcohol restrictions) on the preference to continue taking a medication. To reflect more closely what usually occurs in practice, non-disease specific medication and health terms were used to mimic decisions across multiple medications and conditions.161 general community participants, matching the national Australian census data (age, gender) were recruited through an online panel provider (participation rate: 10%) in 2010. Results Six of the eight factors (i.e. immediate and long-term medication harms and benefits, cost, and regimen) had a significant influence on medication choice. Patient background characteristics did not improve the model. Respondents with private health insurance appeared less sensitive to cost then those without private health insurance. In general, health outcomes, framed as a side-effect, were found to have a greater influence over adherence than outcomes framed as therapeutic benefits. Conclusions Medication-taking decisions are the subject of rational choices, influenced by the attributes of treatments and potentially amenable to intervention through education, strategic pricing and the altering of dosing characteristics. Understanding individual treatment preferences is thus an important step to improving adherence support provision in practice. Re-framing future interventions and policies to support rational and informed individual patient choices, is the way forward to realising the full potential health and economic benefits from the efficacious use of medications.
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Affiliation(s)
- Tracey-Lea Laba
- Faculty of Pharmacy, University of Sydney, Camperdown, Sydney, Australia.
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Gadkari AS, McHorney CA. Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res 2012; 12:98. [PMID: 22510235 PMCID: PMC3375198 DOI: 10.1186/1472-6963-12-98] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 04/17/2012] [Indexed: 12/17/2022] Open
Abstract
Background Unintentional non-adherence has been characterized as passively inconsistent medication-taking behavior (forgetfulness or carelessness). Our objectives were to: (1) study the prevalence and predictors of unintentional non-adherence; and (2) explore the interrelationship between intentional and unintentional non-adherence in relation to patients’ medication beliefs. Methods We conducted a cross-sectional survey of adults with asthma, hypertension, diabetes, hyperlipidemia, osteoporosis, or depression from the Harris Interactive Chronic Illness Panel. The analytic sample for this study included 24,017 adults who self-identified themselves as persistent to prescription medications for their index disease. They answered three questions on unintentional non-adherence (forgot, ran out, being careless), 11 questions on intentional non-adherence, and three multi-item scales assessing perceived need for medication (k = 10), perceived medication concerns (k = 6), and perceived medication affordability (k = 4). Logistic regression was used to model predictors of each unintentional non-adherence behavior. Baron and Kenny’s regression approach was used to test the mediational effect of unintentional non-adherence on the relationship between medication beliefs and intentional non-adherence. Bootstrapping was employed to confirm the statistical significance of these results. Results For the index disease, 62% forgot to take a medication, 37% had run out of the medication, and 23% were careless about taking the medication. Common multivariate predictors (p < .001) of the three behaviors were: (1) lower perceived need for medications; (2) more medication affordability problems; (3) worse self-rated health; (4) diabetes or osteoporosis (relative to hypertension); and (5) younger age. Unique statistically-significant predictors of the three behaviors were: (a) ‘forgot to take medications’ - greater concerns about the index medication and male gender; (b) ‘run out of medications’ - non-white race, asthma, and higher number of total prescription medications; (c) ‘being careless’ - greater medication concerns. Mediational tests confirmed the hypothesis that the effect of medication beliefs (perceived need, concerns, and affordability) on intentional non-adherence is mediated through unintentional non-adherence. Conclusions For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients’ suboptimal medication beliefs before they choose to discontinue therapy all together.
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Affiliation(s)
- Abhijit S Gadkari
- U,S, Outcomes Research, Merck & Co,, Inc, 351 North Sumneytown Pike, North Wales, PA 19454, USA.
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Gadkari AS, McHorney CA. Unintentional non-adherence to chronic prescription medications: how unintentional is it really? BMC Health Serv Res 2012. [PMID: 22510235 DOI: 10.1186/1472-6963-12-98.] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unintentional non-adherence has been characterized as passively inconsistent medication-taking behavior (forgetfulness or carelessness). Our objectives were to: (1) study the prevalence and predictors of unintentional non-adherence; and (2) explore the interrelationship between intentional and unintentional non-adherence in relation to patients' medication beliefs. METHODS We conducted a cross-sectional survey of adults with asthma, hypertension, diabetes, hyperlipidemia, osteoporosis, or depression from the Harris Interactive Chronic Illness Panel. The analytic sample for this study included 24,017 adults who self-identified themselves as persistent to prescription medications for their index disease. They answered three questions on unintentional non-adherence (forgot, ran out, being careless), 11 questions on intentional non-adherence, and three multi-item scales assessing perceived need for medication (k = 10), perceived medication concerns (k = 6), and perceived medication affordability (k = 4). Logistic regression was used to model predictors of each unintentional non-adherence behavior. Baron and Kenny's regression approach was used to test the mediational effect of unintentional non-adherence on the relationship between medication beliefs and intentional non-adherence. Bootstrapping was employed to confirm the statistical significance of these results. RESULTS For the index disease, 62% forgot to take a medication, 37% had run out of the medication, and 23% were careless about taking the medication. Common multivariate predictors (p < .001) of the three behaviors were: (1) lower perceived need for medications; (2) more medication affordability problems; (3) worse self-rated health; (4) diabetes or osteoporosis (relative to hypertension); and (5) younger age. Unique statistically-significant predictors of the three behaviors were: (a) 'forgot to take medications' - greater concerns about the index medication and male gender; (b) 'run out of medications' - non-white race, asthma, and higher number of total prescription medications; (c) 'being careless' - greater medication concerns. Mediational tests confirmed the hypothesis that the effect of medication beliefs (perceived need, concerns, and affordability) on intentional non-adherence is mediated through unintentional non-adherence. CONCLUSIONS For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients' suboptimal medication beliefs before they choose to discontinue therapy all together.
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Affiliation(s)
- Abhijit S Gadkari
- U,S, Outcomes Research, Merck & Co,, Inc, 351 North Sumneytown Pike, North Wales, PA 19454, USA.
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Mehta HB, Rajan SS, Aparasu RR, Johnson ML. Application of the nonlinear Blinder-Oaxaca decomposition to study racial/ethnic disparities in antiobesity medication use in the United States. Res Social Adm Pharm 2012; 9:13-26. [PMID: 22554395 DOI: 10.1016/j.sapharm.2012.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 02/21/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The nonlinear Blinder-Oaxaca (BO) decomposition method is gaining popularity in health services research because of its ability to explain disparity issues. The present study demonstrates the use of this method for categorical variables by addressing antiobesity medication use disparity. OBJECTIVE To examine racial/ethnic disparity in antiobesity medication use and to quantify the observed factor contribution behind the disparity using the nonlinear BO decomposition. METHODS Medical Expenditure Panel Survey data, 2002-2007, were used in this retrospective cross-sectional study. Adults with body mass index (BMI) >30, or BMI ≥27 and comorbidities such as hypertension, cardiovascular diseases, diabetes, or hyperlipidemia were included in the cohort (N=65,886,625). Multivariable logistic regression was performed to examine racial/ethnic disparity in antiobesity medication use controlling for predisposing, enabling, and need factors. The nonlinear BO decomposition was used to identify the contribution of each predisposing, enabling, and need factors in explaining the racial/ethnic disparity and to estimate the residual unexplained disparity. RESULTS Non-Hispanic Blacks were 46% (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.35-0.83) less likely to use antiobesity drugs compared with non-Hispanic Whites, whereas no difference was observed between Hispanics and non-Hispanic Whites. A 0.22 percentage point of disparity existed between non-Hispanic Whites and Blacks. The nonlinear BO decomposition estimated a decomposition coefficient of -0.0013 indicating that the observed disparity would have been 58% higher (-0.0013/0.0022) if non-Hispanic Blacks had similar observed characteristics as non-Hispanic Whites. Age, gender, marital status, region, and BMI were significant factors in the decomposition model; only marital status explained the racial/ethnic disparity among all observed characteristics. CONCLUSIONS The study revealed that differences in the predisposing, enabling, and need characteristics (except marital status) did not successfully explain the racial/ethnic disparity in antiobesity medication use. Further studies examining racial/ethnic differences in individual beliefs, behavioral patterns, and provider prescription patterns are vital to understand these disparities.
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Affiliation(s)
- Hemalkumar B Mehta
- Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, 1441 Moursund St, Houston, TX 77030, USA
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Schulman-Green D, Jaser S, Martin F, Alonzo A, Grey M, McCorkle R, Redeker NS, Reynolds N, Whittemore R. Processes of self-management in chronic illness. J Nurs Scholarsh 2012; 44:136-44. [PMID: 22551013 DOI: 10.1111/j.1547-5069.2012.01444.x] [Citation(s) in RCA: 401] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Self-management is a dynamic process in which individuals actively manage a chronic illness. Self-management models are limited in their specification of the processes of self-management. The purpose of this article is to delineate processes of self-management in order to help direct interventions and improve health outcomes for individuals with a chronic illness. DESIGN Qualitative metasynthesis techniques were used to analyze 101 studies published between January 2000 and April 2011 that described processes of self-management in chronic illness. METHODS Self-management processes were extracted from each article and were coded. Similar codes were clustered into categories. The analysis continued until a final categorization was reached. FINDINGS Three categories of self-management processes were identified: focusing on illness needs; activating resources; and living with a chronic illness. Tasks and skills were delineated for each category. CONCLUSIONS This metasynthesis expands on current descriptions of self-management processes by specifying a more complete spectrum of self-management processes. CLINICAL RELEVANCE Healthcare providers can best facilitate self-management by coordinating self-management activities, by recognizing that different self-management processes vary in importance to patients over time, and by having ongoing communication with patients and providers to create appropriate self-management plans.
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Abstract
The increasing numbers of people seeking care for chronic disease has placed unparalleled demands on nurses who journey with them as they grasp the meaning of their altered health status. The complexity of the newly diagnosed chronic disease can be overwhelming. Newly diagnosed elder patients need a refuge in which to explore the uncertainties and challenges in managing a chronic illness. Reactions to a new diagnosis are uniquely shaped by the elder person's culture, age, life circumstances, and previous coping strategies. Six dichotomous response pairs are posed: relief versus devastation, courage versus cowardice, disease obsession versus disease aversion, rational thinking versus intuition, reawakening versus stuck, and self-reliance versus dependence. Nurses can create a sanctuary for elderly patients with protected space, presence, partnership, past to future orientation, and perspective on life. Nurses who embrace this mission may find themselves returning to the reasons they sought a nursing career, to support and strengthen elderly people in the most vulnerable moments of their lives.
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Abstract
Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.
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Affiliation(s)
- Roschelle Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt Pleasant, Michigan 48859, USA.
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Wang V, Liu CF, Bryson CL, Sharp ND, Maciejewski ML. Does medication adherence following a copayment increase differ by disease burden? Health Serv Res 2011; 46:1963-85. [PMID: 21689097 DOI: 10.1111/j.1475-6773.2011.01286.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To compare changes in medication adherence between patients with high- or low-comorbidity burden after a copayment increase. METHODS We conducted a retrospective observational study at four Veterans Affairs (VA) medical centers by comparing veterans with hypertension or diabetes required to pay copayments with propensity score-matched veterans exempt from copayments. Disease cohorts were stratified by Diagnostic Cost Group risk score: low- (<1) and high-comorbidity (>1) burden. Medication adherence from February 2001 to December 2003, constructed from VA pharmacy claims data based on the ReComp algorithm, were assessed using generalized estimating equations. RESULTS Veterans with lower comorbidity were more responsive to a U.S.$5 copayment increase than higher comorbidity veterans. In the lower comorbidity groups, veterans with diabetes had a greater reduction in adherence than veterans with hypertension. Adherence trends were similar for copayment-exempt and nonexempt veterans with higher comorbidity. CONCLUSION Medication copayment increases are associated with different impacts for low- and high-risk patients. High-risk patients incur greater out-of-pocket costs from continued adherence, while low-risk patients put themselves at increased risk for adverse health events due to greater nonadherence.
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Affiliation(s)
- Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
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Unni E, Farris KB. Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach. PATIENT EDUCATION AND COUNSELING 2011; 83:382-390. [PMID: 21454030 DOI: 10.1016/j.pec.2011.02.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 02/17/2011] [Accepted: 02/19/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach. METHODS Study design was online cross sectional survey. A conceptual framework was developed using Andersen's Behavioral Model and Leventhal's Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence. RESULTS The models based on Andersen's Behavioral Model and Leventhal's Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications. CONCLUSION Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence. PRACTICE IMPLICATIONS Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.
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Affiliation(s)
- Elizabeth Unni
- Department of Pharmaceutical Sciences, University of Southern Nevada College of Pharmacy, South Jordan, NV, USA.
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