'Just keep taking them, keep hoping they'll work': A qualitative study of adhering to medications for multimorbidity

How do people with multimorbidity prioritise healthcare when faced with tighter financial constraints? A national survey with a choice experiment component

BACKGROUND

People with multimorbidity (i.e., two or more chronic conditions) experience increased out-of-pocket healthcare costs and are vulnerable to cost-related non-adherence to recommended treatment. The aim of this study was to understand how people with multimorbidity prioritise different healthcare services when faced with tighter budget constraints and how they experience cost-related non-adherence.

METHODS

A national cross-sectional online survey incorporating a choice experiment was conducted. Participants were adults aged 40 years or over with at least one chronic condition, recruited in Ireland (December 2021 to March 2022). The survey included questions about real-life experiences of cost-related non-adherence and financial burden. The choice experiment element involved participants identifying how they would prioritise their real-world healthcare utilisation if their monthly personal healthcare budget was reduced by 25%.

RESULTS

Among the 962 participants, 64.9% (n = 624) had multimorbidity. Over one third (34.5%, n = 332) of participants reported cost-related non-adherence in the previous 12 months, which included not attending a healthcare appointment and/or not accessing medication. Similar findings on prioritisation were observed on the choice task. When presented with the hypothetical tighter budget constraint, participants reduced expenditure on 'other healthcare (hospital visits, specialist doctors, etc.)' by the greatest percentage (50.2%) and medicines by the lowest percentage (24.8%). Participants with multimorbidity tended to have a condition they prioritised over others. On average, they reduced expenditure for their top-priority condition by 71% less than would be expected if all conditions were valued equally, while they reduced expenditure for their least prioritised condition by 60% more than would be expected. Independence, symptom control and staying alive were rated as the most important influencing factors when making prioritisation decisions (median score = 5 out of 5).

CONCLUSION

When faced with tighter financial constraints, people with multimorbidity tended to have a condition they prioritised over others. Participants were also more likely to prioritise medicines over other aspects of healthcare. Researchers, policymakers and clinicians should take greater consideration of the different ways people respond to tighter financial constraints. This could involve reducing the payment barriers to accessing care or clinicians discussing healthcare costs and coverage with patients as part of cost-of-care conversations.

Exploring medication self-management in polypharmacy: a qualitative systematic review of patients and healthcare providers perspectives

Purpose: Polypharmacy presents many challenges to patient medication self-management. This study aims to explore the self-management processes of medication in polypharmacy from the perspectives of both patients and healthcare providers, which can help identify barriers and facilitators to effective management. Methods: A systematic review of qualitative studies was performed by searching seven databases: PubMed, Web of Science, Cochrane Library, Embase, CINAHL, PsycINFO, and MEDLINE, from their establishment until August 2024. The Critical Appraisal Skills Programme (CASP) tool was employed to evaluate the quality of the studies included. The extracted data were then analysed thematically and integrated into The Taxonomy of Everyday Self-management Strategies (TEDSS) framework. Results: A total of 16 studies were included, involving 403 patients and 119 healthcare providers. Patient management measures were mapped into TEDSS framework, including categories such as medical management, support-oriented domains, and emotional and role management. Conclusion: Enhancing patients' proactive health awareness, improving medication literacy, balancing lifestyle adjustments with medication therapy, dynamically reviewing and optimizing medications, strengthening patients' social support networks, and helping patients integrate medication management into their daily life are the key elements that can effectively assist patients in self-managing their medications. Future interventions to improve patient medication self-management ability should be designed for these issues. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024524742.

Concurrent Medication Adherence in Hypertensive Patients With High-Risk Comorbidities

BACKGROUND

Hypertensive patients with high-risk comorbidities require medications for each condition, leading to greater burden. The number of chronic conditions can affect patients' concurrent medication adherence.

OBJECTIVE

We aimed to compare the characteristics of groups based on their concurrent medication adherence and investigate the association between the number of high-risk comorbidities and concurrent medication adherence for patients with hypertension and high-risk comorbidities.

METHODS

A secondary data analysis was performed with the 2018 Korea Health Panel Survey, including 2230 patients with hypertension and at least 1 high-risk comorbidity who were prescribed medications for at least 2 conditions. Using medication adherence for each condition, we identified 3 concurrent medication adherence groups: adherent, suboptimal, and nonadherent groups. Multinominal logistic regression was used to determine the association between the number of high-risk comorbidities and the concurrent medication adherence groups.

RESULTS

Adherent, suboptimal, and nonadherent groups included 85%, 11%, and 4% of the patients, respectively. Whereas having more high-risk comorbidities was associated with belonging to the suboptimal group compared with the adherent group (adjusted odds ratio, 1.46), having fewer high-risk comorbidities was associated with belonging to the nonadherent group compared with the adherent group (adjusted odds ratio, 0.52).

CONCLUSIONS

We identified 3 groups based on their concurrent medication adherence. Our results indicated that the relationship of the number of high-risk comorbidities with the concurrent medication adherence group was inconsistent.

Treatment Nonadherence among Multimorbid Chronic Disease Patients: Evidence from 3515 Subjects in Indonesia

Background and Objectives: Multimorbid patients require intensive treatment for their diseases. However, little research has been given to their treatment adherence as part of its management. This study aims to determine the prevalence and characteristics of chronic disease multimorbidity in Indonesia, alongside its treatment nonadherence. Materials and Methods: We conducted a cross-sectional study using the fifth Indonesian Family Life Survey database among adult subjects aged ≥ 15 years with multimorbidity. Our descriptive and multivariate analyses include sex, age, formal education, ethnicity, geographic residence, demographic residence, household size, insurance ownership, annual income, current self-perceived health status, missing active days, smoking behavior, and body mass index. Results: We identified 3515 multimorbid patients, constituting 30.8% prevalence across chronic disease patients. Hypertension was found to be a prevalent component of multimorbidity (61.2%), followed by digestive diseases (44.5%) and arthritis (30.3%). We identified that 36.4% of the subjects were nonadherent to their chronic disease treatment. Characteristics associated with nonadherence were found to be a good self-perception of health (aOR 1.79, 95% CI 1.54-2.08), active smoking behavior (aOR 1.51, 95% CI 1.14-1.99), no smoking behavior (aOR 1.44, 95% CI 1.08-1.90), missing seven active/productive days or less in the past month due to poor health (aOR 1.36, 95% CI 1.10-1.68), no insurance ownership (aOR 1.20, 95% CI 1.04-1.39), age of 15-65 years (aOR 1.25, 95% CI 1.01-1.55), income below IDR 40 million (aOR 1.23, 95% CI 1.04-1.46), and household size of 2-6 people (aOR 1.17, 95% CI 1.01-1.36). Conclusions: While the prevalence of multimorbidity in Indonesia is generally similar to that observed in previous studies, we have identified patient characteristics related to nonadherence. We suggest that patient's nonadherence was primarily dictated by their self-perception of health and treatment complexity. With the longstanding issue of nonadherence, this study indicated the need to consider creating patient-tailored treatment programs in clinical practice to improve adherence by considering individual patients' characteristics.

Characterizing Caregiver Roles and Conflict in Health Management Support to Older People With Multiple Chronic Conditions

Caregivers provide critical support for older adults managing multiple chronic conditions (MCCs), but few studies describe the assistance caregivers provide or identify factors influencing their provision of support. We conducted qualitative interviews with 25 caregivers to older adults with MCCs to describe caregivers' roles and identify the factors that influence caregivers' ability to carry out these roles. Transcripts were analyzed using the Framework Method. Caregivers supported the management of MCCs in several ways, including monitoring conditions, communicating with clinicians, and tracking health information. Disagreement, or conflicted relationships, between caregivers and older adults over health and behaviors influenced the provision of support, resulting in less involved and less effective caregivers. Caregivers in conflicted relationships were more challenged by resistance from older adults. Greater agreement, or collaboration, between caregivers and older adults resulted in more involved and effective caregivers. Addressing health-related conflict may enhance caregivers' capacity to support older adults with MCCs.

Living with Multimorbidity through Time: A Meta-Synthesis of Qualitative Longitudinal Evidence

The growing prevalence of multimorbidity places a strain on primary healthcare globally. The current study's aim was to identify, appraise, and synthesize published qualitative longitudinal research on individuals' experiences concerning living with multimorbidity through time. The authors searched two electronic databases, MEDLINE and CINAHL, and performed an additional literature search in Google Scholar. A thematic synthesis approach was used to analyze the qualitative data across the studies. A total of 10 reports that met the inclusion and exclusion criteria were included in the synthesis. Five descriptive themes emerged from the analysis of the living experiences of individuals with multimorbidity: (1) perceiving multimorbidity, (2) managing chronic conditions, (3) emotional struggles in everyday life with multimorbidity, (4) interactions with the healthcare system and healthcare professionals, and (5) family support. This meta-synthesis provides insights into the diverse perceptions of multimorbidity and how individuals cope with their chronic conditions in their daily lives. The findings highlight the importance of establishing effective patient-centered care that acknowledges and supports the multifaceted needs of this population. It is also recommended to involve a psychological component in the care of individuals with multimorbidity, as part of a collaborative and interprofessional approach.

Factors associated with medication adherence among older adults with multimorbidity: A culture perspective

Multimorbidity is a healthcare concern. To manage diseases, older adults with multimorbidity are expected to practice health behaviors, particularly medication adherence. Studies have examined adherence issues in older patients with multiple diseases, but it remains unclear which factors affect medication adherence. Therefore, this study aimed to identify the factors affecting medication adherence among older adults with multimorbidity. The participants were recruited from the outpatient departments of two hospitals in the Republic of Korea using convenience sampling. Data were collected using structured questionnaires and analyzed using multiple regression analysis. The results showed that those with a lower education level, no side effects, better health literacy, higher medication self-efficacy, and more social support exhibited better medication adherence. In addition, beliefs about medication were not related to medication adherence. These results suggest that providing individualized education, strengthening social support, and decreasing harmful side effects can improve medication adherence.

Psychosocial factors associated with medication burden among community-dwelling older people with multimorbidity

BACKGROUND

Older people with multimorbidity are often prescribed multiple medication treatments, leading to difficulties in self-managing their medications and negative experiences in medication use. The perceived burden arising from the process of undertaking medication self-management practices has been described as medication burden. Preliminary evidence has suggested that patients' demographic and clinical characteristics may impact their medication burden. Little is known regarding how psychosocial factors affect medication burden in older people with multimorbidity. The aim of this study was to identify psychosocial factors associated with medication burden among community-dwelling older people with multimorbidity.

METHODS

This is a secondary analysis of a cross-sectional study. A total of 254 older people with three or more chronic conditions were included in the analysis. Participants were assessed for demographics, medication burden, psychosocial variables (depression, medication-related knowledge, beliefs, social support, self-efficacy, and satisfaction), disease burden, and polypharmacy. Medication burden was measured using items from the Treatment Burden Questionnaire. Univariate and multivariate linear regression models explored factors associated with medication burden.

RESULTS

The mean age of participants was 70.90 years. Participants had an average of 4.40 chronic conditions, and over one-third had polypharmacy. Multivariate analysis showed that the participants' satisfaction with medication treatments (β = -0.32, p < 0.001), disease burden (β = 0.25, p = 0.009), medication self-efficacy (β = -0.21, p < 0.001), polypharmacy (β = 0.15, p = 0.016), and depression (β = 0.14, p = 0.016) were independently associated with medication burden. Other factors, including demographic characteristics, medication knowledge, medication beliefs, medication social support, and the number or specific types of chronic conditions, were not independently associated with medication burden.

CONCLUSIONS

Poor medication treatment satisfaction, great disease burden, low medication self-efficacy, polypharmacy, and depression may increase individuals' medication burden. Understanding psychosocial aspects associated with medication burden provides an important perspective for identifying older people who are overburdened by their medication treatments and offering individualised treatments to relieve their burden.

Exploring the Multidimensional Relationship Between Medication Beliefs and Adherence to Medications Among Older Adults Living With Multimorbidity Using Polynomial Regression: An Observational Cohort Study

BACKGROUND

People living with multimorbidity may hold complex beliefs about medicines, potentially influencing adherence. Polynomial regression offers a novel approach to examining the multidimensional relationship between medication beliefs and adherence, overcoming limitations associated with difference scores.

PURPOSE

To explore the multidimensional relationship between medication beliefs and adherence among people living with multimorbidity.

METHODS

Secondary analysis was conducted using observational data from a cohort of older adults living with ≥2 chronic conditions, recruited from 15 family practices in Ireland in 2010 (n = 812) and followed up in 2012 (n = 515). Medication beliefs were measured with the Beliefs about Medicines Questionnaire-Specific. Adherence was assessed with the medication possession ratio using prescription data from the national primary care reimbursement service. Polynomial regression was used to explore the best-fitting multidimensional models for the relationship between (i) beliefs and adherence at baseline, and (ii) beliefs at baseline and adherence at follow-up.

RESULTS

Confirmatory polynomial regression rejected the difference-score model, and exploratory polynomial regression indicated quadratic models for both analyses. Reciprocal effects were present in both analyses (slope [Analysis 1]: β = 0.08, p = .007; slope [Analysis 2]: β = 0.07, p = .044), indicating that adherence was higher when necessity beliefs were high and concern beliefs were low. Nonreciprocal effects were also present in both analyses (slope [Analysis 1]: β = 0.05, p = .006; slope [Analysis 2]: β = 0.04, p = .043), indicating that adherence was higher when both necessity and concern beliefs were high.

CONCLUSIONS

Among people living with multimorbidity, there is evidence that the relationship between medication beliefs and adherence is multidimensional. Attempts to support adherence should consider the combined role of necessity and concern beliefs.

Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.