Can a Multifaceted Intervention Including Motivational Interviewing Improve Medication Adherence, Quality of Life, and Mortality Rates in Older Patients Undergoing Coronary Artery Bypass Surgery? A Multicenter, Randomized Controlled Trial with 18-Month Follow-Up

Home-based transitional cardiac telerehabilitation in older adults post coronary artery bypass grafting: A randomized controlled trial

This randomized controlled trial evaluated the effectiveness of a 12-week home-based transitional cardiac telerehabilitation (Hb-T-CTR) program on health-related quality-of-life and therapeutic self-care in older adults' post-Coronary Artery Bypass Grafting (CABG). The intervention group (n = 57) underwent Hb-T-CTR, incorporating preoperative counseling, postoperative education, a culturally adapted video, home visits, and telephone counseling, while the control group (n = 61) received standard care. Using the Coronary Revascularization Outcome Questionnaire and the Sidani Doran Therapeutic Self-Care Measure, data were collected at three time points. Results showed significant improvements in overall scores for both health-related quality of life (t1=3.386, P = 0.001; t2=4.224, P < 0.001) and therapeutic self-care (t1=7.104, P < 0.001; t2=4.242, P < 0.001) in the intervention group compared to controls. This telehealth approach provides convenient and accessible rehabilitation services for older adults' post-CABG and highlights the importance of integrating Hb-T-CTR into routine care for personalized rehabilitation. This study underscores the potential of telehealth tools in overcoming barriers and enhancing patient-centered interventions.

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

Effectiveness of cardiac rehabilitation programs on medication adherence in patients with cardiovascular disease: A systematic review and meta-analysis

Background

Education to improve medication adherence is one of the core components of cardiac rehabilitation (CR) programs. However, the evidence on the effectiveness of CR programs on medication adherence is conflicting. Therefore, we aimed to summarize the effectiveness of CR programs versus standard care on medication adherence in patients with cardiovascular disease.

Methods

A systematic review and meta-analysis was conducted. Seven databases and clinical trial registries were searched for published and unpublished articles from database inception to 09 Feb 2022. Only randomised controlled trials and quasi-experimental studies were included. Two independent reviewers conducted the screening, extraction, and appraisal. The JBI methodology for effectiveness reviews and PRISMA 2020 guidelines were followed. A statistical meta-analysis of included studies was pooled using RevMan version 5.4.1.

Results

In total 33 studies were included with 16,677 participants. CR programs increased medication adherence by 14 % (RR = 1.14; 95 % CI: 1.07 to 1.22; p = 0.0002) with low degree of evidence certainty. CR also lowered the risk of dying by 17 % (RR = 0.83; 95 % CI: 0.69 to 1.00; p = 0.05); primary care and emergency department visit by mean difference of 0.19 (SMD = -0.19; 95 % CI: -0.30 to -0.08; p = 0.0008); and improved quality of life by 0.93 (SMD = 0.93; 95 % CI: 0.38 to 1.49; p = 0.0010). But no significant difference was observed in lipid profiles, except with total cholesterol (SMD = -0.26; 95 % CI: -0.44 to -0.07; p = 0.006) and blood pressure levels.

Conclusions

CR improves medication adherence with a low degree of evidence certainty and non-significant changes in lipid and blood pressure levels. This result requires further investigation.

A machine-learning assisted review of the use of habit formation in medication adherence interventions for long-term conditions

Adherence to medication in long-term conditions is around 50%. The key components of successful interventions to improve medication adherence remain unclear, particularly when examined over prolonged follow-up periods. Behaviour change theories are increasingly interested in the utility of habit formation for the maintenance of health behaviour change, but there is no documentation on how habit has been conceptualised in the medication adherence intervention literature, or what effect the key technique identified in habit formation theory (context dependent repetition) has in these studies. To examine this, a machine-learning assisted review was conducted. Searches of MEDLINE, EMBASE and PSYCInfo and the reference list of a comprehensive systematic review of medication adherence interventions yielded 5973 articles. Machine learning-assisted title and abstract screening identified 15 independent RCTs published between 1976 and 2021, including 18 intervention comparisons of interest. Key findings indicate that conceptualisations of habit in the medication adherence literature are varied and behaviour change technique coding identified only six studies which explicitly described using habit formation. Future work should aim to develop this evidence base, drawing on contemporary habit theory and with explicit demonstration of what techniques have been used to promote habit formation.

A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation

BACKGROUND

Cardiovascular disease (CVD) is a predominant cause of mortality. Pharmacists play an important role in secondary prevention of CVD, however, their role in cardiac rehabilitation is under-reported and services are under-utilised.

AIM

To explore the role of pharmacists in cardiac rehabilitation, the impact of their interventions on patient outcomes, and prospects of future role development.

METHOD

Databases searched were PubMed, Embase, Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from January 2006 to October 2021. Randomised and non-randomised controlled trials were selected if they assessed the role of pharmacists in cardiac rehabilitation. Cochrane risk of bias tool, Joanna Briggs Institute (JBI) Critical Appraisal Tool for Quasi-Experimental Studies and the National Heart, Lung and Blood Institute (NIH) quality assessment tool, were used to assess quality and a narrative synthesis was conducted.

RESULTS

The search yielded 786 studies, only five met the inclusion criteria. The pharmacist-led interventions included patient education, medication review and reconciliation, and medication adherence encouragement. Four out of the five studies showed that pharmacist-led interventions in cardiac rehabilitation significantly improved patient clinical and non-clinical outcomes. One study showed a statistically significant reduction in low density lipoprotein-cholesterol (LDL-C) levels to optimal target of < 70 mg/dL (80% vs 60%, p = 0.0084). Two studies reported better medication adherence, and two studies showed greater improvement in all domains of health-related quality of life observed in the intervention group.

CONCLUSION

Pharmacist-led interventions in cardiac rehabilitation could lower CVD risk factors and hence recurrence. Although these findings support pharmacists' involvement in cardiac rehabilitation, larger intervention studies are needed to evaluate the feasibility of pharmacist-led interventions and their impact on hospital admissions and mortality risk.

Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials

OBJECTIVES

To systematically review published randomized controlled trials (RCTs) assessing the efficacy of MI to support medication adherence in adults with chronic conditions.

METHODS

A systematic review (PROSPERO-CRD42020025374) was performed by searching in Pubmed/MEDLINE, PsycINFO, The Cochrane Library and Web of Science. Studies were included for the following: RCTs assessing the impact of MI on medication adherence among adults with chronic diseases. Two reviewers conducted independent screening of records and full-text articles published until July 2020. Quality was assessed with the Risk of Bias 2 tool for RCTs.

RESULTS

From 1262 records identified, 54 RCTs were included. The MI interventions were delivered alone or in combination with other interventions, and varied in mode of delivery (e.g. face-to-face, phone), exposure level (duration, number of sessions), and provider characteristics (profession, training). Most interventions were developed in infectious diseases (n = 16), cardiology (n = 14), psychiatry (n = 8), and endocrinology (n = 7). Medication adherence showed significant improvement in 23 RCTs, and other clinical outcomes were improved in 19 RCTs (e.g. risky behaviors, disease symptoms).

CONCLUSIONS

MI is an approach to medication adherence support with an increasing evidence base in several clinical domains and further potential for adaptation to different settings.

PRACTICE IMPLICATIONS

In further studies, particular attention should focus on methodological issues such as the populations of patients to include - patients with suboptimal adherence, the evaluation of fidelity to the MI spirit and components, and a sound measurement of medication adherence and clinical outcomes.

Effects of eHealth Interventions on Quality of Life and Psychological Outcomes in Cardiac Surgery Patients: Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing heart surgery may experience a range of physiological changes, and the postoperative recovery time is long. Patients and their families often have concerns about quality of life (QoL) after discharge. eHealth interventions may improve patient participation, ensure positive and effective health management, improve the quality of at-home care and the patient's quality of life, and reduce rates of depression.

OBJECTIVE

The purpose of this study was to evaluate the effects of eHealth interventions on the physiology, psychology, and compliance of adult patients after cardiac surgery to provide a theoretical basis for clinical practice.

METHODS

We conducted systematic searches of the following 4 electronic databases: PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Mean (SD) values were used to calculate the pooled effect sizes for all consecutive data, including QoL, anxiety, and depression. Where the same results were obtained using different instruments, we chose the standardized mean difference with a 95% CI to represent the combined effect size; otherwise, the mean difference (MD) with a 95% CI was used. Odds ratios were used to calculate the combined effect size for all dichotomous data. The Cohen Q test for chi-square distribution and an inconsistency index (I²) were used to test for heterogeneity among the studies. We chose a fixed-effects model to estimate the effect size if there was no significant heterogeneity in the data (I²≤50%); otherwise, a random-effects model was used. The quality of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2).

RESULTS

The search identified 3632 papers, of which 19 met the inclusion criteria. In terms of physical outcomes, the score of the control group was lower than that of the intervention group (MD 0.15, 95% CI 0.03-0.27, I²=0%, P=.02). There was no significant difference in the mental outcomes between the intervention and control groups (MD 0.10, 95% CI -0.03 to 0.24, I²=46.4%, P=.14). The control group's score was lower than that of the intervention group for the depression outcomes (MD -0.53, 95% CI -0.89 to -0.17, I²=57.1%, P=.004). Compliance outcomes improved in most intervention groups. The results of the sensitivity analysis were robust. Nearly half of the included studies (9/19, 47%) had a moderate to high risk of bias. The quality of the evidence was medium to low.

CONCLUSIONS

eHealth improved the physical component of quality of life and depression after cardiac surgery; however, there was no statistical difference in the mental component of quality of life. The effectiveness of eHealth on patient compliance has been debated. Further high-quality studies on digital health are required.

TRIAL REGISTRATION

PROSPERO CRD42022327305; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327305.

The Effect of Cardiac Rehabilitation on Lipid Levels in Patients with Coronary Heart Disease. A Systematic Review and Meta-Analysis

Background

Cardiac rehabilitation (CR) is a multidisciplinary medical program. Most studies have emphasized the effect of exercise-based CR in lowering lipid levels; however, the effect of CR as a comprehensive program on lipid levels remains unclear.

Methods

Electronic database were searched up to 2022. Randomized controlled trials with lipid profile indicators were included. Standardized mean differences (SMDs) and 95% CIs were used to evaluate the effect size. Begg's funnel plot and Egger's linear regression test were used to assess publication bias.

Results

CR remarkably reduced low-density lipoprotein cholesterol (LDL-C) levels (SMD = -0.23; 95%CI: [-0.38, -0.08]; P < 0.001), triglyceride (TG) levels (SMD = -0.17; 95%CI: [-0.28, -0.06]; P < 0.001), and total cholesterol (TC) levels (SMD = -0.30; 95%CI: [-0.43, -0.16]; P < 0.001) and increased high-density lipoprotein cholesterol (HDL-C) levels (SMD = 0.19; 95%CI: [0.10, 0.29]; P < 0.001).

Conclusions

CR reduce TC, TG, and LDL-C levels while improving HDL-C levels. CR should be promoted and more trials should be conducted for long-term CR.

Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease: the MIMeRiC randomized controlled trial

Background

In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence.

Methods

This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient’s clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use.

Results

316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin–angiotensin–aldosterone system inhibitors.

Conclusions

Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health.

Trial registration: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02178-0.

The Impact of Pharmaceutical Care in Multidisciplinary Teams on Health Outcomes: Systematic Review and Meta-Analysis

OBJECTIVES

Pharmacists' care has an essential role in multidisciplinary teams in charge of chronic patients. However, data available on the clinical outcomes of these activities appear inconclusive. This study aimed to systematically investigate the effect of multidisciplinary teams that include coordinated pharmaceutical care on clinical outcomes.

DESIGN

Systematic review and meta-analysis. Relevant studies identified from MEDLINE, Cochrane, Web of Science, Scopus and CINAHL databases were analyzed. The search included randomized clinical trials published in 2000-2018. Included studies were all published studies in English that compared the effectiveness of multidisciplinary teams including pharmacist care to usual care. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.

SETTING AND PARTICIPANTS

29 studies involving 4186 adult patients were included.

MEASURES

Follow-up time varied from 30 to 180 days. The most common primary endpoint was the frequency of hospitalizations or readmissions, followed by variation in clinical parameter variables related to quality of prescription, treatment adherence and costs.

RESULTS

Twelve (41.3%) of the included studies scored low risk of bias according to the AMSTAR-2 scale, the remaining 17 (58.7%) being classified as intermediate risk. The intervention of a multidisciplinary team reduced the probability of readmission by 32% [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.62-0.89]. Six of the 29 (20.7%) studies included met the inclusion criteria of the meta-analysis on quality-of-life outcomes. The intervention of the multidisciplinary team represented a significant increase in patients' quality of life (OR 0.58, 95% CI 0.47-0.69). Analysis of heterogeneity showed a significant difference between the studies. No evidence of publication bias was identified.

CONCLUSIONS AND IMPLICATIONS

Multidisciplinary programs that include pharmaceutical care reduce the risk of visiting hospitals and improve patients' quality of life. This review supports the importance of the pharmacists as part of multidisciplinary teams.

The impact of community pharmacists on older adults in Turkey

OBJECTIVE

This study aimed to evaluate the impact of theory-based, structured, standardized pharmaceutical care services led by community pharmacists (CPs) on patient-related outcomes in older Turkish adults.

PRACTICE DESCRIPTION

This prospective, quasi-experimental pilot study was conducted at the national level at community pharmacies in Turkey. After virtual training of CPs, pharmaceutical care services including medicine bag check-up, medication review, patient medicine card, patient education, and counseling services (including motivational interviewing) were delivered to promote medication adherence in older adults.

PRACTICE INNOVATION

Theory-based, structured, standardized pharmaceutical care services addressing medication adherence problems in older Turkish adults with noncommunicable diseases.

EVALUATION METHODS

Descriptive data (including demographic and clinical data, medication-related problems by using the DOCUMENT classification, potential inappropriate prescribing by using the Ghent Older People's Prescriptions Community Pharmacy Screening- (GheOP³S) tool, and pharmacy service satisfaction) were presented. Pre- and post-evaluation were compared by using the Wilcoxon test (for continuous variables) and McNemar's or McNemar-Bowker chi-square test (for categorical variables).

RESULTS

One hundred and thirty-eight medication-related problems were identified among 52 older adults. The medication adherence rate was significantly increased from 51.9% to 75%, and the mean of total quality of life (QoL) score rose significantly from 51.7 to 53.4 (P < 0.05). There was a statistically significant change in the median of necessity-concern differential (baseline: 7 [2.2-10.0] vs. final: 8.0 [5-11]; P < 0.05). At baseline, all patients had at least 1 potential inappropriate prescribing according to the GheOP³S tool, and the rate was 73.1% at the final assessment.

CONCLUSION

Community pharmacist-led pharmaceutical care services significantly improved patient-related outcomes (such as medication adherence, beliefs about medication, and QoL) in older adults with noncommunicable diseases. No statistically significant change was detected in their lifestyle behaviors (such as physical activity and diet program) or health awareness.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BACKGROUND

Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.

METHODS AND FINDINGS

We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.

CONCLUSIONS

In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

Testing an app-based intervention to improve insomnia in patients with epilepsy: A randomized controlled trial

PURPOSE

Insomnia has adverse effects on people with epilepsy. We aimed to test a novel cognitive behavioral therapy for insomnia (CBT-I) app-based intervention on insomnia symptoms and social psychological factors in people with epilepsy and to examine the possible mechanisms among the factors.

METHODS

Participants were recruited from neurology clinics in Iran and comprised individuals diagnosed with epilepsy and having moderate to severe insomnia. A two-arm randomized controlled trial design was used, consisting of a treatment group (CBT-I; n = 160) and control group (patient education; n = 160). Primary outcomes were self-reported sleep quality, insomnia severity, and sleep hygiene behavior and objective sleep characteristics measured by actigraphy. Secondary outcomes were attitude, perceived behavioral control, intention, action planning, coping planning, behavioral automaticity, self-monitoring, anxiety, depression, and quality of life (QoL). All outcomes were measured at baseline, and at one, three, and six months postintervention, except objective sleep, which was assessed at baseline, and one and six months postintervention. Data were analyzed using linear mixed models.

RESULTS

Current findings showed that sleep quality, insomnia severity, sleep hygiene behavior, and sleep onset latency were significantly improved in the CBT-I group compared with the patient education group at all measurement points. Also, the CBT-I group had significantly improved anxiety, depression, and QoL compared with the patient education group. Mediation analyses showed that attitude, intention, coping planning, self-monitoring, and behavioral automaticity significantly mediated the effect of the intervention on sleep outcomes.

CONCLUSION

Results support the use of the CBT-I app to improve sleep outcomes among people with epilepsy.

Effect of pragmatic versus explanatory interventions on medication adherence in people with cardiometabolic conditions: a systematic review and meta-analysis

OBJECTIVE

To synthesise findings from randomised controlled trials (RCTs) of interventions aimed at increasing medication adherence in individuals with type 2 diabetes (T2DM) and/or cardiovascular disease (CVD). And, in a novel approach, to compare the intervention effect of studies which were categorised as being more pragmatic or more explanatory using the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) tool, to identify whether study design affects outcomes. As explanatory trials are typically held under controlled conditions, findings from such trials may not be relatable to real-world clinical practice. In comparison, pragmatic trials are designed to replicate real-world conditions and therefore findings are more likely to represent those found if the intervention were to be implemented in routine care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid Medline, Ovid Embase, Web of Science and CINAHL from 1 January 2013 to 31 December 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RCTs lasting ≥3 months (90 days), involving ≥200 patients in the analysis, with either established CVD and/or T2DM and which measured medication adherence. From 4403 citations, 103 proceeded to full text review. Studies published in any language other than English and conference abstracts were excluded.

MAIN OUTCOME MEASURE

Change in medication adherence.

RESULTS

Of 4403 records identified, 34 studies were considered eligible, of which 28, including 30 861 participants, contained comparable outcome data for inclusion in the meta-analysis. Overall interventions were associated with an increase in medication adherence (OR 1.57 (95% CI: 1.33 to 1.84), p<0.001; standardised mean difference 0.24 (95% CI: -0.10 to 0.59) p=0.101). The effectiveness of interventions did not differ significantly between studies considered pragmatic versus explanatory (p=0.598), but did differ by intervention type, with studies that included a multifaceted rather than a single-faceted intervention having a more significant effect (p=0.010). The analysis used random effect models and used the revised Cochrane Risk of Bias Tool to assess study quality.

CONCLUSIONS

In this meta-analysis, interventions were associated with a significant increase in medication adherence. Overall multifaceted interventions which included an element of education alongside regular patient contact or follow-up showed the most promise. Effectiveness of interventions between pragmatic and explanatory trials was comparable, suggesting that findings can be transferred from idealised to real-word conditions.

PROSPERO REGISTRATION NUMBER

CRD42017059460.

A theory-based intervention to promote medication adherence in patients with rheumatoid arthritis: A randomized controlled trial

Introduction/objectives

Adherence to prescribed medication regimens is fundamental to the improvement and maintenance of the health of patients with rheumatoid arthritis. It is therefore important that interventions are developed to address this important health behavior issue. The aim of the present study was to design and evaluate a theory-based intervention to improve the medication adherence (primary outcome) among rheumatoid arthritis patients.

Methods

The study adopted a pre-registered randomized controlled trial design. Rheumatoid arthritis patients were recruited from two University teaching hospitals in Qazvin, Iran from June 2018 to May 2019 and randomly assigned to either an intervention group (n = 100) or a treatment-as-usual group (n = 100). The intervention group received a theory-based intervention designed based on the theoretical underpinnings of the health action process approach (HAPA). More specifically, action planning (making detailed plans to follow medication regimen), coping planning (constructing plans to overcome potential obstacles that may arise in medication adherence), and self-monitoring (using a calendar to record medication adherence) of the HAPA has been used for the treatment. The treatment-as-usual group received standard care.

Results

Data analysis was conducted based on the principle of intention to treat. Using a linear mixed-effects model (adjusted for age, sex, medication prescribed, and body mass index), the results showed improved medication adherence scores in the intervention group (loss to follow-up = 16) compared to the treatment-as-usual group (loss to follow-up = 12) at the 3-month (coefficient = 3.9; SE = 0.8) and 6-month (coefficient = 4.5; SE = 0.8) follow-up. Intervention effects on medication adherence scores were found to be mediated by some of the theory-based HAPA variables that guided the study.

Conclusion

The results of the present study support the use of a theory-based intervention for improving medication adherence among rheumatoid arthritis patients, a group at-risk of not adhering to medication regimens.

Trial registration (in Iranian Registry of Clinical Trials)

irct.ir, IRCT20180108038271N1

Key Points • Theoretical underpinnings of the health action process approach are useful to improve medication adherence for RA patients.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05224-y) contains supplementary material, which is available to authorized users.

The effects of usual Care in Psychosocial Intervention Trials of patients with coronary artery disease: a systematic review

BACKGROUND

Many intervention studies of coronary artery disease (CAD) have found health benefits for patients in the "treatment as usual" (TAU) group like in the specific psychotherapy group. In this pilot study, we wanted to examine and discuss the role and reasons for TAU effects.

METHODS

By means of a systematic review, we examined the control conditions from psychotherapeutic RCTs with CAD patients related to depressive symptoms, mortality and recurrence rate of events. The review question was limited to factors influencing the TAU effectiveness in such psychotherapeutic outcome studies.

RESULTS

We found a decrease in depressive symptoms in TAU patients (mean ES: 0.65) and very differing mortality and recurrence rates of events. The effects were dependant on the year the study was published (1986-2016), the follow-up time of the study (0.25-7.8 years) and the treatment arms. A small dose of additional counselling, medical attention, and teaching of therapeutic techniques with clinical competence may reinforce the therapeutic alliance. These factors would be possible moderators of control group efficacy related to the reduction in depressive symptoms and a decrease in mortality and events.

CONCLUSION

In the reviewed studies, we found that the control condition was beneficial for CAD patients, but this benefit was highly variable. Specified psychotherapeutic interventions showed an additional independent effect of treatment on depression and effects on morbidity and mortality. There is a need to identify patients at risk of remaining depressed or under severe stress during usual care. These patients may require additional psychosocial intervention.

The effect of aromatherapy with rose and lavender on anxiety, surgical site pain, and extubation time after open-heart surgery: A double-center randomized controlled trial

To determine the effect of aromatherapy with rose and lavender on the patient outcomes after open-heart surgery (OHS). In the clinical trial, patients were randomized to four groups. One group received routine care, the placebo group received a cotton swab soaked in water and the other two groups received either a cotton swab containing three drops of rose or lavender essence (0.2 ml). A total of 160 patients were randomized into four groups. Intergroup anxiety was not significantly different; however, the reciprocal time-group effect was significant among the four groups. The extubation time was significant among the four groups which related to rose essence group compared with the control group (p < .001) and placebo group (p = .029). The surgical site pain was significant in the rose essence and lavender groups compared to the control group. Aromatherapy can reduce extubation time, surgical site pain severity, and anxiety in patients undergoing OHS.

Efficacy of a Theory-Based Cognitive Behavioral Technique App-Based Intervention for Patients With Insomnia: Randomized Controlled Trial

Background

Sleep hygiene is important for maintaining good sleep and reducing insomnia.

Objective

This study examined the long-term efficacy of a theory-based app (including cognitive behavioral therapy [CBT], theory of planned behavior [TPB], health action process approach [HAPA], and control theory [CT]) on sleep hygiene among insomnia patients.

Methods

The study was a 2-arm single-blind parallel-group randomized controlled trial (RCT). Insomnia patients were randomly assigned to a treatment group that used an app for 6 weeks (ie, CBT for insomnia [CBT-I], n=156) or a control group that received only patient education (PE, n=156) through the app. Outcomes were assessed at baseline and 1 month, 3 months, and 6 months postintervention. Primary outcomes were sleep hygiene, insomnia, and sleep quality. Secondary outcomes included attitudes toward sleep hygiene behavior, perceived behavioral control, behavioral intention, action and coping planning, self-monitoring, behavioral automaticity, and anxiety and depression. Linear mixed models were used to evaluate the magnitude of changes in outcomes between the two groups and across time.

Results

Sleep hygiene was improved in the CBT-I group compared with the PE group (P=.02 at 1 month, P=.04 at 3 months, and P=.02 at 6 months) as were sleep quality and severity of insomnia. Mediation analyses suggested that perceived behavioral control on sleep hygiene as specified by TPB along with self-regulatory processes from HAPA and CT mediated the effect of the intervention on outcomes.

Conclusions

Health care providers might consider using a CBT-I app to improve sleep among insomnia patients.

Trial Registration

ClinicalTrials.gov NCT03605732; https://clinicaltrials.gov/ct2/show/NCT03605732

Effectiveness of mobile phone-based self-management interventions for medication adherence and change in blood pressure in patients with coronary heart disease: A systematic review and meta-analysis

AIMS

The aim of this study was to synthesise and evaluate the effectiveness of mobile phone-based self-management interventions for medication adherence and change in blood pressure in patients with coronary heart disease.

METHODS

Relevant randomised controlled trials evaluating mobile phone-based self-management interventions for medication adherence and/or change in blood pressure in coronary heart disease patients were identified by searching six electronic databases (PubMed, Cochrane, CINAHL, ProQuest, Scopus and EMBASE) from January 2008 to January 2019. The trials were screened, data were extracted and quality was assessed by two independent reviewers. Meta-analyses were performed for different outcomes while narrative syntheses were conducted for studies that could not be pooled or when there was the presence of high heterogeneity.

RESULTS

Fifteen trials were included in this review, of which 11 of these trials were meta-analysed. Mobile phone-based self-management interventions were associated with a statistically significant reduction in diastolic blood pressure (combined mean difference of -1.99 (95% confidence interval (CI) -3.20 to -0.78; P=0.0001)). However, the combined effect on medication adherence (medium size effect of d=0.72 (95% CI -0.32 to 1.75; P=0.17)) and change in systolic blood pressure (combined mean difference of -1.08 (95% CI -5.51 to 3.35; P=0.63)) was not statistically significant. There was significant heterogeneity among the trials reviewed.

CONCLUSION

Mobile phone-based self-management interventions have the potential to improve self-management and adherence in patients with coronary heart disease but better designed, conducted and reported trials are needed to demonstrate this.

Validation of the 5-Item Medication Adherence Report Scale in Older Stroke Patients in Iran

BACKGROUND

There is a lack of feasible and validated measures to self-assess medication adherence for older patients with stroke. In addition, the potential determinants of medication adherence for older patients with stroke remain unclear.

OBJECTIVES

The aims of this study were to (1) examine the psychometric properties of a 5-item questionnaire on medication adherence, specifically the 5-item Medication Adherence Report Scale (MARS-5), and (2) explore the determinants of medication adherence.

METHODS

Stroke patients older than 65 years (N = 523) filled out the MARS-5 and the Hospital Anxiety and Depression Scale. The medication possession rate (MPR) was calculated to measure the objective medication adherence. Several clinical characteristics (stroke types, blood pressure, comorbidity, HbA1c, quantity of prescribed drugs, fasting blood glucose, and total cholesterol) and background information were collected. We used Rasch analysis with a differential item functioning test to examine psychometric properties.

RESULTS

All 5 items in the MARS-5 fit in the same construct (ie, medication adherence), no differential item functioning items were displayed in the MARS-5 across gender, and the MARS-5 total score was strongly correlated with the MPR (r = 0.7). Multiple regression models showed that the MARS-5 and the MPR shared several similar determinants. In addition, the variance of the MARS-5 (R = 0.567) was more than that of the MPR (R = 0.300).

CONCLUSIONS

The MARS-5 is a feasible and valid self-assessed medication adherence for older patients with stroke. In addition, several determinants were found to be related to medication adherence for older patients with stroke. Healthcare providers may want to take heed of these determinants to improve medication adherence for this population.

Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis

A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.

Using extended theory of planned behavior to understand aspirin adherence in pregnant women

OBJECTIVE

To use the Theory of Planned Behavior (TPB) combined with action and coping planning plus global relationship with husband to explain the aspirin adherence in a sample of women with high-risk pregnancy.

METHODS

A total of 535 Iranian women (mean age = 32.29 ± 4.98; year of marriage = 6.89 ± 3.61) completed the study. Each participant filled out several questionnaires on TPB (i.e., a widely applied theory describing how behaviors are influenced by beliefs, attitudes, perceived behavioral control and behavioral intentions), action planning, coping planning and relationship with husband at baseline. Eight weeks later, each participant completed the Five-item Medication Adherence Rating Scale (MARS-5) and underwent the blood test on aspirin serum level to provide the subjective and objective aspirin adherence information, respectively. Structural equation modeling (SEM) was applied to test three proposed models on aspirin adherence.

RESULTS

The TPB with planning plus relationship with husband was supported (comparative fit index = 0.969; Tucker-Lewis index = 0.950). Behavioral intention was the mediator in the associations of aspirin adherence and the following variables: attitude, perceived behavioral control, and relationship with husband. Action and coping planning mediated the associations of aspirin adherence and the two variables of behavioral intention and perceived behavioral control. Relationship with husband mediated the association of subjective norm and aspirin adherence.

CONCLUSIONS

The TPB model with (action and coping) planning plus relationship with husband serves a potential mechanism to explain the aspirin adherence for women with high risk of pregnancy. Possible implications are discussed based on our results.

Preoperative Scale to Determine All-Cause Readmission After Coronary Artery Bypass Operations

BACKGROUND

Coronary artery bypass graft (CABG) operations are associated with all-cause readmission rates of approximately 15%. In attempts to reduce readmission rates, the Hospital Readmission Reduction Program expanded to include CABG operations in 2015. The aim of this study was therefore to develop a predictive readmission scale that would identify patients at higher risk of readmission after CABG using commonly available administrative data.

METHODS

Data of 126,519 patients from California and New York (derivation cohort) and 94,318 patients from Florida and Washington (validation cohort) were abstracted from the State Inpatient Database (2006 to 2011). The readmission after CABG scale was developed to predict 30-day readmission risk and was validated against a separate cohort.

RESULTS

Thirty-day CABG readmission rates were 23% in the derivation cohort and 21% in the validation cohort. Predictive factors included older age, female gender (odds ratio [OR], 1.34), African American ethnicity (OR, 1.13), Medicare or Medicaid insurance, and comorbidities, including renal failure (OR, 1.56) and congestive heart failure (OR, 2.82). These were independently predictive of increased readmission rates (p < 0.01). The readmission scale was then created with these preoperative factors. When applied to the validation cohort, it explained 98% of the readmission variability.

CONCLUSIONS

The readmission after CABG scale reliably predicts a patient's 30-day CABG readmission risk. By identifying patients at high-risk for readmission before their procedure, risk reduction strategies can be implemented to reduce readmissions and healthcare expenditures.