An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial

Older adults' experiences with a tablet-based self-management intervention for diabetes mellitus type II: A qualitative study

Technological interventions to support self-management can potentially help older adults manage their health, live active lives, and maintain their independence. The objective of this study was to assess individuals' experiences and perceptions of using a tablet-based application for 30 days as a component of routine diabetes self-management care in older adults with type 2 diabetes mellitus (T2DM) in the context of daily living. A qualitative research design using semi-structured interviews was used. The participants found the tablet-based application to be a beneficial and valuable component of their routine self-management activities. Five themes emerged from the interviews, namely self-dependence, awareness, positive impact on attitude and behavior, support, and balance. Findings from the individual interviews indicate that technological applications have a unique potential to support the foundations for attitude and behavioral changes toward self-management behaviors and activities, thus improving clinical outcomes.

Assessment of diabetic patients' adherence to insulin injections on basal-bolus regimen in diabetic care center in Saudi Arabia 2018: Cross sectional survey

BACKGROUND

Since insulin became a focal point of diabetes management, several studies have been carried out to monitor and improve patient outcomes. Adherence insulin therapy is an important part of diabetes management.

AIM

This study reviews the responses of patients being managed in a diabetic care setting in monitoring their adherence to basal bolus insulin therapy.

METHOD

A pre-validated questionnaire containing 18 questions was administered to patients in the diabetic care unit of the Security Forces Hospital, Riyadh, Saudi Arabia.

RESULTS

The levels of adherence with basal bolus insulin therapy was 61.9%. There is no considerable difference in adherence levels of male and female respondents with 31.62% and 31.58% respectively. The younger age groups (14-29) had the highest adherence levels at 65.75%. Higher levels of patient literacy and the location also have a positive relationship with adherence.

CONCLUSION

To improve adherence levels, dosing should be made with consideration for patient convenience, and patients should be encouraged to build positive psychological relationships. Further studies should look to studying outcomes of therapy, and markers should be developed to monitor patient progress on therapy regimen regularly. The aspect of short clinic visits is another major consideration that needs to be look into properly to understand and monitor patients' proper adherence toward the basal bolus insulin.

Smart Diabetic Screening and Managing Software, A Novel Decision Support System

BACKGROUND

Diabetes is a serious chronic disease, and its increasing prevalence is a global concern. If diabetes mellitus is left untreated, poor control of blood glucose may cause long-term complications. A big challenge encountered by clinicians is the clinical management of diabetes. Many IT-based interventions such ad CDSS have been made to improve the adherence to the standard care for chronic diseases.

OBJECTIVE

The aim of this study is to establish a decision support system of diabetes management based on diabetes care guidelines in order to reduce medical errors and increase adherence to guidelines.

MATERIALS AND METHODS

To start the process, at first the existing guidelines in the field of diabetes mellitus such as ADA 2017 and AACE guideline 2017 were reviewed, and accordingly, flowcharts and algorithms for screening and managing of diabetes were designed. Then, it was passed on to the information technology team to design software.

RESULTS

The most significant outcome of this research was to establish a smart diabetic screening and managing software, which is an important stride to promote patients' health status, control diabetes and save patients' information as an important and reliable source.

CONCLUSION

Health care technologies have the potential to improve the quality of diabetes care through IT-based intervention, such as clinical decision support systems. In a chronic disease like diabetes, the critical component is the disease management. The advantages of this web-based system are on-time registration, reports of diabetic prevalence, uncontrolled diabetes, diabetic complications and reducing the rate of mismanagement of diabetes, so that it helps the physicians in order to manage the patients in a better way.

Medication adherence: staying within the boundaries of safety

An important domain of patient safety is the management of medications in home and community settings by patients and their caregiving network. This study applied human factors/ergonomics theories and methods to data about medication adherence collected from 61 patients with heart failure accompanied by 31 informal caregivers living in the US. Seventy non-adherence events were identified, described, and analysed for performance shaping factors. Half were classified as errors and half as violations. Performance shaping factors included elements of the person or team (e.g. patient limitations), task (e.g. complexity), tools and technologies (e.g. tool quality) and organisational, physical, and social context (e.g. resources, support, social influence). Study findings resulted in a dynamic systems model of medication safety applicable to patient medication adherence and the medication management process. Findings and the resulting model offer implications for future research on medication adherence, medication safety interventions, and resilience in home and community settings. Practitioner Summary: We describe situational and habitual errors and violations in medication use among older patients and their family members. Multiple factors pushed performance towards risk and harm. These factors can be the target for redesign or various forms of support, such as education, changes to the plan of care, and technology design.

The relationship between patients' knowledge of diabetes therapeutic goals and self-management behaviour, including adherence

Background The Middle East region has one the highest prevalence rates of diabetes in the world. Little is known about the determinants of adherence and the role of knowledge in diabetes self-management within these populations. Objective To investigate the relationship between patients knowledge of diabetes therapeutic targets with adherence to self-care measures in a sample of patients with type 2 diabetes in Kuwait. Setting Primary care chronic care clinics within the Ministry of Health of Kuwait. Methods A cross sectional survey was carried out with 238 patients from six clinics. A multistage stratified clustered sampling method was used to first randomly select the clinics and the patients.

MAIN OUTCOME MEASURE

Self-reported adherence to three behaviours: medication taking, diet and physical activity. Results Respondents were able to correctly report a mean (SD) of 1.6 (1.3) out of 5 of the pre-specified treatment targets. Optimal adherence to physical activity, diet and medications was reported in 25, 33 and 47 % of the study cohort, respectively. A structural equation model analysis showed better knowledge of therapeutic goals and own current levels translated into better adherence to medications, diet and physical activity. Conclusion Knowledge of therapeutic goals and own recent levels is associated with adherence to medications, diet, or physical activity in this Kuwaiti cohort of patients with diabetes. Low adherence to self-care management and poor overall knowledge of diabetes is a big challenge to successful diabetes care in Kuwait.

Medication understanding, non-adherence, and clinical outcomes among adult kidney transplant recipients

We sought to evaluate the prevalence of medication understanding and non-adherence of entire drug regimens among kidney transplantation (KT) recipients and to examine associations of these exposures with clinical outcomes. Structured, in-person interviews were conducted with 99 adult KT recipients between 2011 and 2012 at two transplant centers in Chicago, IL; and Atlanta, GA. Nearly, one-quarter (24%) of participants had limited literacy as measured by the Rapid Estimate of Adult Literacy in Medicine test; patients took a mean of 10 (SD=4) medications and 32% had a medication change within the last month. On average, patients knew what 91% of their medications were for (self-report) and demonstrated proper dosing (via observed demonstration) for 83% of medications. Overall, 35% were non-adherent based on either self-report or tacrolimus level. In multivariable analyses, fewer months since transplant and limited literacy were associated with non-adherence (all P<.05). Patients with minority race, a higher number of medications, and mild cognitive impairment had significantly lower treatment knowledge scores. Non-white race and lower income were associated with higher rates of hospitalization within a year following the interview. The identification of factors that predispose KT recipients to medication misunderstanding, non-adherence, and hospitalization could help target appropriate self-care interventions.

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial

Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

A primary care, electronic health record-based strategy to promote safe drug use: study protocol for a randomized controlled trial

Background

The Northwestern University Center for Education and Research on Therapeutics (CERT), funded by the Agency for Healthcare Research and Quality, is one of seven such centers in the USA. The thematic focus of the Northwestern CERT is ‘Tools for Optimizing Medication Safety.’ Ensuring drug safety is essential, as many adults struggle to take medications, with estimates indicating that only half of adults take drugs as prescribed. This report describes the methods and rationale for one innovative project within the CERT: the ‘Primary Care, Electronic Health Record-Based Strategy to Promote Safe and Appropriate Drug Use’.

Methods/Design

The overall objective of this 5-year study is to evaluate a health literacy-informed, electronic health record-based strategy for promoting safe and effective prescription medication use in a primary care setting. A total of 600 English and Spanish-speaking patients with diabetes will be consecutively recruited to participate in the study. Patients will be randomized to receive either usual care or the intervention; those in the intervention arm will receive a set of print materials designed to support medication use and prompt provider counseling and medication reconciliation. Participants will be interviewed in person after their index clinic visit and again one month later. Process outcomes related to intervention delivery will be recorded. A medical chart review will be performed at 6 months. Patient outcome measures include medication understanding, adherence and clinical measures (hemoglobin A₁c, blood pressure, and cholesterol; exploratory outcomes only).

Discussion

Through this study, we will be able to examine the impact of a health literacy-informed, electronic health record-based strategy on medication understanding and adherence among diabetic primary care patients. The measurement of process outcomes will help inform how the strategy might ultimately be refined and disseminated to other sites. Strategies such as these are needed to address the multifaceted challenges related to medication self-management among patients with chronic conditions.

Trial registration

Clinicaltrials.gov NCT01669473.

Does improving patient-practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence

OBJECTIVE

To conduct a systematic literature review appraising the effects of interventions to improve patient-practitioner communication on cardiovascular-related clinical outcomes.

METHODS

Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age.

RESULTS

Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients' information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills.

CONCLUSION

Few interventions targeting patient-practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient-practitioner communication to improve cardiovascular-related clinical outcomes.

PRACTICE IMPLICATIONS

Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.

Adherence to therapies in patients with type 2 diabetes

Adherence to therapy is defined as the extent to which a person's behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient-healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.