Intervention strategies to improve adherence among hypertensives: review and recommendations

Validation of knowledge and adherence assessment tools among patients on warfarin therapy in a Saudi hospital anticoagulant clinic

Background Although it can result in serious complications due to its narrow therapeutic index, warfarin is widely used in the treatment and prevention of thromboembolic disorders. However, patients' adherence and knowledge are determinants of therapeutic success. Objective We sought to validate instruments to provide a reliable means of identifying gaps in patient understanding and nonadherence to inform targeted pharmacists' interventions to improve these measures. Methods A cross-sectional survey was conducted. Patients' knowledge about warfarin was rated using an Arabic-language tool. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). The international normalized ratio (INR) control was quantified by the Rosendaal Method. Setting At the Security Forces hospital anticoagulant clinic (ACC), Riyadh. Main outcome measure Validity of a Knowledge and adherence tool. Results Totally, 101 patients completed the questionnaires. Interestingly, the knowledge tool demonstrated good internal consistency (total Cronbach's alpha = 0.75) and significant concurrent validity with adherence levels. Fifty-two patients were classified as having unsatisfactory knowledge. Deficiency in knowledge was most obvious with respect to the consequences of missing a dose and when to seek immediate medical attention. The MMAS-8 had moderate reliability (Cronbach's alpha = 0.65); however, its concurrent validity with good INR control was not demonstrated. Conclusions This study revealed high prevalence of nonadherence and poor knowledge in the population visiting the ACC. Given that available knowledge and adherence tools seemed to have little validity in predicting clinical outcomes, structured tools should be designed, considering progression in clinical outcomes with future pharmacists' interventions.

[Efficacy of an intervention to improve treatment compliance in hyperlipidemias]

OBJECTIVE

To analyse the efficacy of the intervention through a telephone call about patients' compliance with lipaemia therapy.

DESIGN

Controlled, randomised clinical trial.

SETTING

Ten clinics at 6 primary care centres.

PARTICIPANTS

126 people diagnosed with hypercholesterolaemia according to Spanish Consensus criteria were chosen.

INTERVENTION

Two groups were formed. The control group (CG) of 63 patients, who received the doctor's normal treatment; and the Intervention group (IG) of 63 patients, who received in addition a telephone call at 2 weeks, 2 months and 4 months.

MAIN MEASUREMENTS

Pills were counted and cholesterol, triglycerides, HDL-C and LDL-C determined at the start, and at the third and sixth months. Percentages of patients complying (80%-110%), the mean compliance percentage and the degree of control were compared. The reduction of absolute and relative risk (RAR and RRR) and the mean number of people that required an intervention in order to avoid non-compliance (NI) were calculated.

RESULTS

115 people (91.26%) completed the survey, 56 in the IG and 59 in the CG. 77.1% complied with the therapy (CI, 68.4-85.8), (CG=64.4%, CI, 55.3-73.5; IG=93.5%, CI, 88.8-98 [P<.001]). Mean compliance ran at 88.7 +/- 10.2 overall, at 84.4 +/- 12.8 in the CG and at 93 +/- 8.2 in the IG (P<.001). The RAR was 29.1%, the RRR 81%, and the NI was 3.43 patients. The patients controlled ran at 43.9% in the IG (CI, 34.9-52.9) and 23.1% in the CG (CI, 15.4-30.8) (P<.005).

CONCLUSIONS

The telephone intervention is an efficacious way of improving the percentage of patients complying with lipaemia treatment.

Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement

OBJECTIVE

To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality-improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self-management support, decision support, delivery system design, information systems, and organization of care.

DATA SOURCES

(1) Pre-post, self-report ACIC data from organizational teams enrolled in 13-month quality-improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative.

STUDY DESIGN

Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t-tests were used to evaluate the sensitivity. of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained.

RESULTS

Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self-management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52.

CONCLUSION

These results and feedback from teams suggest that the ACIC is responsive to health care quality-improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.

[Treatment compliance in arterial hypertension. A 2-year intervention trial through health education]

OBJECTIVE

To analyse the efficacy of health education (HE) through a group session with two years of intervention by postal back-up on compliance with therapy for light-to-moderate essential hypertension.

DESIGN

Controlled, randomised clinical trial.

SETTING

La Orden Health Centre.

PARTICIPANTS

110 hypertense patients diagnosed with de novo or unmonitored hypertension.

INTERVENTION

1. Control group (CG): 55 patients who received HE from their doctor. 2. Intervention group (IG): 55 patients who also received a controlled intervention. a) Group HE session, b) Postal back-up to the home every three months for two years.

MEASUREMENTS AND RESULTS

After two years, on two surprise home visits made at a month's interval, blood pressure was measured and pressure-lowering pills counted. The person whose consumption was at 80-110% of the amount prescribed was defined as compliant. The percentages of compliant patients and mean compliance were compared for the two visits. The reduction of absolute risk (RAR), of relative risk (RRR) and the number of patients needed to avoid non-compliance (NNT) were calculated. 92 people finished the trial. The two groups (n: CG = 45, IG = 47) did not differ for age, sex, time of evolution, number of illnesses or dosages of medicines prescribed. 78.26% were compliant (CI: 61.5-94.9), CG = 55.6% and IG = 95.7% (p < 0.0001). Mean overall compliance was 90.9 +/- 14, CG = 88.1 +/- 12 and IG = 93.86 +/- 11 (p = 0.01). RAR was 40.1%, RRR 90.3 and NNT 2.49% respectively.

CONCLUSIONS

HE intervention is an effective measure to improve therapeutic compliance in essential hypertension and lasts for up to two years.

Arterial hypertension: lessons from patient education

The face of hypertension has been changing rapidly over the last few decades, from a serious disease to a cardiovascular risk factor. Patient education has been instrumental in bringing about tremendous improvements in hypertension-related mortality, morbidity, life expectancy, and life quality. Patient education has evolved from an adjunct to medical therapy to an intervention in its own right. In this process patient education tasks and techniques themselves have undergone remarkable developments, driven by evolving patient needs due to medical progress. The same is true for the roles of patients and health care providers. Dealing with hypertension is a behavior change process which demands serious learning efforts from all parties involved, patients, health practitioners and health care administrators alike. This paper focuses therefore on patient education for preventive behavior change and risk factor management. Special emphasis will be placed on processes and tools for effective patient education.

Contributions of public health to patient compliance

This paper discusses the contributions of public health to compliance in five areas: clinical trials, smoking cessation, dietary compliance, breast cancer screening and hypertension control. Public health programs have been based on a number of theoretical foundations, most notably, social learning theory and the health belief model. Social marketing, community organization, and, more recently, consumer information processing models also are important. The strongest public health programs embody an ecological approach, with interventions directed not only at individuals, but also at groups, communities and changing institutional norms. Among the most important contributions of public health interventions are: multiple levels of intervention and evaluation, tailoring to target audiences, use of social support and community organization for behavior change. Together, community health and clinical compliance-enhancing strategies can exert a synergistic impact on health behavior change.

Patient and public education for cholesterol reduction: a review of strategies and issues

Elevated blood cholesterol is a major risk factor for coronary heart disease and a significant public health problem, affecting as many as 50% of all adults in the U.S. Public, professional and patient education are central to current widespread efforts to increase awareness and effective management of high cholesterol. Screening/case-finding, follow-up and nutrition education are the most widely applicable strategies for cholesterol reduction. The following topics are reviewed: current guidelines for treatment of elevated cholesterol levels; trends in awareness, attitudes and practices of the public and health professionals; reports of interventions for cholesterol reduction; and health policy issues and research needs related to cholesterol education. This review suggests that several major challenges lie ahead for widespread and effective educational management of high cholesterol levels. These include development of practical screening and education systems, establishment of feasible financing arrangements, effective communication of complex information to patients, and techniques for long-term maintenance of reductions in cholesterol levels.

How can patient education contribute to improved health care under prospective pricing?

Clinicians and policy makers are faced with one central dilemma under prospective pricing: how to maintain high quality of care with restricted financial resources. Patient education is one element of care which has been proposed to have the ability to improve the quality of care, while reducing costs for some conditions. This paper reviews the empirical evidence which touches on this question, including preoperative education, home care education, cooperative care units, diabetes patient education, and others. The evidence indicates that patient education can improve the quality of care, while in some cases also reducing the cost of providing medical care. This conclusion has important policy implications under conditions of reduced resources for medical care, as is occurring under prospective pricing in the United States.

Nutrition education for risk factor reduction and patient education: a review

Studies of adult nutrition education and counseling for weight reduction, diabetes, cancer, low-fat diets, sodium-restricted diets, and renal diets are reviewed and synthesized. Nutrition education consists of three phases: assessment or problem diagnosis, intervention, and evaluation and monitoring. This article examines the importance of accurate problem diagnosis, the use of behavioral and biological measures of nutrition education effectiveness, and the types and effects of reported strategies. In addition, the issues of maintaining behavioral changes, nutrition education providers and their training, and settings for nutrition education are discussed. Implications and suggestions for advances in practice, theory, and research in patient nutrition education are presented.