Relationships between antiparkinson medication nonadherence, regimen modifications, and healthcare utilization and expenditures

The impact and feasibility of a brief, virtual, educational intervention for home healthcare professionals on Parkinson's Disease and Related Disorders: pilot study of I SEE PD Home

BACKGROUND

Individuals with advanced Parkinson's Disease (PD) and Parkinson-related disorders (PRD) are frequently referred for home allied therapies and nursing care, yet home healthcare professionals have limited training in PD/PRD. While recognizing the need for such care, patients and families report home healthcare professionals are unfamiliar with these conditions, which may be driven by neurophobia and may contribute to suboptimal care and early termination of services. We sought to determine the feasibility and effects of a virtual, multimodal educational intervention on PD knowledge, confidence, and empathy among home health professionals.

METHODS

Home health nurses, occupational therapists, physical therapists and physical therapy assistants, and speech-language pathologists participated in a daylong, virtual symposium on advanced PD/PRD, combining focused lectures, discipline-specific breakout sessions, immersive virtual reality vignettes, and interactive panels with both patients and families, and movement disorders and home healthcare experts. Participants completed online pre- and post-symposium surveys including: demographics; PD/PRD knowledge (0-10 points possible); empathy (Interpersonal Reactivity Index); and 10-point scales of confidence with and attitudes towards individuals with PD/PRD, respectively. Pre-post intervention changes and effect sizes were evaluated with paired t-tests and Cohen's d. We performed qualitative analyses of post-symposium free-text feedback using a grounded theory approach to identify participants' intentions to change their practice.

RESULTS

Participants had a mean improvement of 3.1 points on the PD/PRD knowledge test (p < 0.001, d = 1.97), and improvement in confidence managing individuals with PD/PRD (p = 0.0003, d = .36), and no change in empathy. The interactive, virtual format was rated as effective by 95%. Common themes regarding symposium-motivated practice change included: interdisciplinary collaboration; greater involvement and weighting of the patient and caregiver voice in care plans; attention to visit scheduling in relation to patient function; recognition and practical management of the causes of sudden change in PD/PRD, including infections and orthostatic hypotension.

CONCLUSIONS

A virtual, multimodal, brief educational pilot intervention improved PD/PRD-specific knowledge and confidence among home healthcare nurses and allied health professionals. Future studies are necessary to test the short- and long-term effects of this intervention more broadly and to investigate the impact of this education on patient and caregiver outcomes.

COVID-19 social distancing: negative effects on people with Parkinson disease and their associations with confidence for self-management

BACKGROUND

The purpose of this study was to describe the effects of COVID-19 social distancing on the function, health, and well-being of people with Parkinson disease (PD), and test the association of these effects with patients' activation levels, i.e., their skills and confidence in managing their health.

METHODS

Community-dwelling individuals with PD answered an anonymous web-based survey. Part 1 included 27 multiple-choice questions regarding changes in function, health, medical care, and well-being. Part 2 consisted of the Patient Activation Measure, which enquired about skills and confidence in managing one's health.

RESULTS

Respondents (N = 142) reported decreases in various function (24.8%-37.3%), health (33.8%-43%), and well-being (26.1%-47.1%) domains. Rehabilitation ceased for 61.2%. Among those reporting a worsening of health, 67.8% associated this with the cessation of rehabilitative treatments or decrease in physical activity. Patients' activation levels were inversely correlated with increased assistance for activities of daily living, increased tiredness, worsening symptoms, and lack of support from family and friends.

CONCLUSIONS

Social distancing had a major negative impact on the health and function of people with PD.

PRACTICAL IMPLICATIONS

Supporting people with PD skills and confidence in managing health may preserve their physical and mental health during this period of dramatic changes in life's circumstances.

Emergency Room Visit Prevention for Older Patients with Parkinsonism in a Geriatric Clinic

BACKGROUND

Older persons with parkinsonism (PWP) are at high risk for hospitalization and adverse outcomes. Few effective strategies exist to prevent Emergency Department (ED) visits and hospitalization. The interdisciplinary Geriatrics Clinic for Parkinson's ("our clinic") was founded to address the complexity of parkinsonism in older patients, supported by a pharmacist-led telephone intervention (TI) service. Our primary objective was to study whether TI could avert ED visits in older PWP.

METHODS

Using a prospective, observational cohort, we collected data from all calls in 2016, including who initiated and reasons for the calls, patient demographics, number of comorbidities and medications, diagnoses, duration of disease, and intervention provided. Calls with intention to visit ED were classified as "crisis calls". Outcome of whether patients visited ED was collected within 1 week, and user satisfaction by anonymous survey within 3 weeks.

RESULTS

We received 337 calls concerning 114 patients, of which 82 (24%) were "crisis calls". Eighty-one percent of calls were initiated by caregivers. Ninety-three percent of "crisis calls" resolved without ED visit after TI. The main reasons for "crisis calls" were non-motor symptoms (NMS) (39%), adverse drug effects (ADE) (29%), and motor symptoms (18%). Ninety-seven percent of callers were satisfied with the TI.

CONCLUSION

Pharmacist-led TI in a Geriatrics Clinic for Parkinson's was effective in preventing ED visits in a population of older PWP, with high user satisfaction. Most calls were initiated by caregivers. Main reasons for crisis calls were NMS and ADE. These factors should be considered in care planning for older PWP.

The effect of a structured medication review on quality of life in Parkinson's disease: The study protocol

BACKGROUND

Treatment of Parkinson's disease (PD) is symptomatic and frequently consists of complicated medication regimes. This negatively influences therapy adherence, resulting in lower benefit of treatment, drug related problems and decreased quality of life (QoL). A potential effective intervention strategy is a structured medication review, executed by community pharmacists. However, little is known about the effects on clinical endpoints like QoL, as well as on feasibility and cost-effectiveness in PD patients.

OBJECTIVES

To assess the effect of a structured medication review on QoL in PD patients. Secondary objectives are measurements of physical disability, activities in daily life, non-motor symptoms, health state, personal carers' QoL and cost-effectiveness. Furthermore, a better insight in the process of performing medication reviews will be obtained from the perspective of community pharmacists.

METHODS

In this multicenter randomized controlled trial we aim to enroll 200 PD patients from the outpatient clinic of three Dutch hospitals. Community pharmacists will perform a structured medication review in half of the assigned patients; the other half will receive usual care. Data obtained by use of six validated questionnaires will be collected at baseline and after 3 and 6 months of follow-up. Semi-structured interviews with community pharmacists will be conducted till data saturation has been reached.

DISCUSSION

This trial targets a high-risk patient group for whom optimizing therapy by a structured medication review might be of added value. If effectiveness is proven, this could further promote the implementation of pharmaceutical care in a primary care setting.

Effect of Pharmacist-Led Interventions on (Non)Motor Symptoms, Medication-Related Problems, and Quality of Life in Parkinson Disease Patients: A Pilot Study

INTRODUCTION

Patients with Parkinson disease (PD) use multiple drugs. This pill burden with consequent poor adherence may cause worsening of motor symptoms and drug-related problems. Therefore, a multifaceted pharmacist-led intervention program was designed to improve adherence, motor-functioning, and quality of life (QoL) in PD patients.

METHODS

This prospective pilot study was performed in an outpatient PD clinic, where usual care was compared with stepwise introduction of 3 interventions: unit dose packaging (UDP), Parkinson KinetiGraph (PKG), and pharmacist-led medication review (MR).The study analyzed endpoints at 6 weeks (stage 1, usual care), 10 weeks (stage 2, UDP), 14 weeks (stage 3, UDP + PKG), and 26 weeks (UDP + PKG + MR) on motor symptoms, medication adherence, and QoL.

RESULTS

Medication adherence improved significantly after the combined UDP, PKG, and MR intervention in nonadherent patients. On time significantly increased from 56% (±30) at stage 1, to 64% (±25) at stage 3, and to 68% (±27) at stage 4, which correlated with an increase of 1.4 and 2.2 hours in stage 3 and 4, respectively. Quality of life only improved significantly after MR (Parkinson's Disease Questionnaire with 8 domains, 21.0 ± 3.5 in stage 3 vs 19.5 ± 5.3 in stage 4, P = 0.01).

CONCLUSIONS

Our data did not support the added value of UDP alone or in combination with PKG. Only the combined intervention of UDP, PKG, and MR showed significant improvements in medication adherence, on time, and QoL. This supports the effectiveness of MR by a clinical pharmacist for PD patients in an outpatient setting. Therefore, this small scale study should be followed by larger-scale trials on this topic.

Clinical aspects of adherence to pharmacotherapy in Parkinson disease: A PRISMA-compliant systematic review

BACKGROUND

Parkinson disease (PD) is the second most common neurodegenerative disease with various motor and nonmotor symptoms. Progressive course of PD requires frequent medication adjustments. Various combinations of drugs and dose regimens could be used to control symptoms. Thus, not surprisingly, adherence to pharmacotherapy is frequently suboptimal in these patients having negative effect on motor control and patient's quality of life.

METHODS

In this article, we offer up-to-date review of adherence in PD compared with other chronic conditions. In addition, we summarize factors influencing level of adherence, ways of measuring, and methods of adherence optimization. For the review of adherence in PD, a literature search was undertaken using PubMed database and relevant search terms. Articles were screened for suitability and data relevance.

RESULTS

PubMed and Scopus databases were systematically searched in 2016 and data extraction was a multistep process based on the PRISMA Guidelines.

CONCLUSION

According to the recent data, sufficient control of motor symptoms and adequate quality of life are primary goals in the treatment of PD. Adherence to pharmacotherapy play a key role in this process, thus the medication should be tailored for each patient. In order to improve level of suboptimal adherence, these patients should have got recommended various dosing devices or alarms. Good communication with the patients and their relatives or caregivers is also essential.

Effects of medication adherence on hospitalizations and healthcare costs in patients with schizophrenia in Thailand

Background:

This study was conducted to determine the impacts of medication adherence on hospitalization and direct healthcare cost in patients with schizophrenia in Thailand.

Methods:

A retrospective study was undertaken. Patients with schizophrenia aged 18–65 years who visited a University hospital and received antipsychotics from April 2011 to October 2011 were included. Propensity score–adjusted logistic regression was used to determine the impacts of medication adherence on schizophrenia-related and all-cause hospitalizations.

Results:

A total of 582 patients were included. Three out of 224 patients (1.3%) were hospitalized with schizophrenia in optimal adherence group, while 10 of 140 (7.1%) were hospitalized in under-adherence group, and 7 of 218 (3.2%) were hospitalized in over-adherence group. Based on propensity score–adjusted multivariate logistic regression, the adjusted odds ratio was 5.86 (95% confidence interval = 1.53–22.50) for schizophrenia-related hospitalization and 8.04 (95% confidence interval = 2.20–29.40) for all-cause hospitalization. The average annual direct healthcare costs in patients with optimal adherence, under-adherence, and over-adherence were US$371 ± US$836, US$386 ± US$734, and US$508 ± US$2168, respectively.

Conclusion:

An initiation of interventions to maintain optimal adherence in patients with schizophrenia would significantly impact the healthcare system.

No Difference on Adherence Between Immediate-Release Versus Extended-Release Dopamine Agonists in Uninsured Subjects with Parkinson's Disease

Background

Pharmacological management of subjects with Parkinson's disease (PD) is complex. Regardless of drug selection, adherence is one of the main concerns. Nonadherence is associated with poor symptomatic control and low quality of life. In general, adherence to once-a-day formulations is thought to be better in comparison to 3-times-daily dosing.

Methods

A cross-sectional study was carried out. Consecutive uninsured subjects diagnosed with PD were treated either with an immediate- or extended-release dopamine agonist formulation. Clinical and demographic data were collected. Subjects were assessed using the International Parkinson and Movement Disorder Society UPDRS. Adherence was evaluated using the Morisky-Green test (MGT).

Results

A total of 314 (175 males and 139 females) subjects with PD were included. In regard to treatment, 188 (59.9%) were on an immediate-release dopamine agonist and 126 (40.1%) on an extended-release dopamine agonist. According to the MGT, 21 (6.7%) subjects were classified as nonadherent, 273 (86.9%) with a low adherence, and only 20 (6.4%) were considered with high adherence. Dopamine agonist levodopa equivalent daily dose was higher in the extended-release group (296.6 ± 112.4 vs. 231.3 ± 133.4; P = 0.011); also, these subjects had more years of formal education (12.3 ± 5.2 vs. 9.5 ± 5.2; P = 0.630). No difference in adherence levels was found (P = 0.802) between subjects treated with an immediate-release dopamine agonist and those receiving an extended-release formulation.

Conclusions

Overall adherence in subjects with PD is low. Use of an extended-release over an immediate-release dopamine agonist formulation in this study population is not associated with a better adherence.

Diabetes care among elderly medicare beneficiaries with Parkinson's disease and diabetes

Background

Elderly individuals with type 2 diabetes mellitus (T2DM) suffer from several comorbidities, which affect their health outcomes, as well as process of care. This study assessed process and intermediate clinical outcomes of diabetes care among elderly individuals with T2DM and co-occurring Parkinson’s disease(PD).

Methods

This study used a retrospective cohort design with propensity score matching using Humana Medicare Advantage Part D claims database (2007-2011) and included elderly (age ≥ 65 years) Medicare beneficiaries with T2DM (identified by ICD-9-CM code of 250.x0 or 250.x2). PD was identified using ICD-9-CM code of 332.xx. After propensity score matching there were 2,703 individuals with T2DM and PD and 8,109 with T2DM and no PD. The three processes of care measures used in this study included: (i) HbA1c test; (ii) Lipid test; (iii) and Nephropathy screening. Intermediate clinical outcomes consisted of glycemic and lipid control.

Results

Multivariable conditional logistic regressions revealed that elderly individuals with T2DM and PD were 12 % (AOR: 0.88, 95 %CI: 0.79-0.97) and 18 % (AOR: 0.82, 95 %CI: 0.72-0.94) less likely to meet the annual American Diabetes Association (ADA) recommended HbA1c and lipid testing goals respectively compared to individuals with T2DM and no PD. Multinomial conditional logistic regressions showed that elderly individuals with T2DM and PD were more likely to have HbA1c and lipid (HbA1c < 8 %; LDL-C <100 mg/dl; HDL-C ≥ 50 mg/dl; triglyceride <150 mg/dl; and total cholesterol <200 mg/dl) control.

Conclusions

Among elderly individuals with T2DM, those with PD were less likely to achieve ADA recommended annual HbA1c and lipid testing compared to those without PD. However, PD individuals were more likely to achieve intermediate glycemic and lipid control.