Medication knowledge, adherence and predictors among people with heart failure and chronic obstructive pulmonary disease

Effect of an in-hospital medication self-management intervention (SelfMED) on medication adherence in polypharmacy patients postdischarge: protocol of a pre-post intervention study

INTRODUCTION

Healthcare providers usually manage medication for patients during hospitalisation, although patients are expected to self-manage their medication after discharge. A lack of self-management competencies is found to be associated with low adherence levels and medication errors harming patients' health. Currently, patients seldom receive support or education in medication self-management. When self-management is allowed during hospitalisation, it is rarely provided using a structured, evidence-based format. Therefore, an in-hospital medication self-management intervention (ie, SelfMED) was developed based on current evidence. To date, empirical data demonstrating the effect of SelfMED on medication adherence are lacking. This study primarily aims to evaluate the effect of the SelfMED intervention on medication adherence 2 months postdischarge in polypharmacy patients, as compared with usual care.

METHODS AND ANALYSIS

A multicentre pre-post intervention study will be conducted. The study will start with a control phase investigating usual care (ie, medication management entirely provided by healthcare providers), followed by an intervention period, investigating the effects of the SelfMED intervention. SelfMED consists of multiple components: (1) a stepped assessment evaluating patients' eligibility for in-hospital medication self-management, (2) a monitoring system allowing healthcare providers to follow up medication management and detect problems and (3) a supportive tool providing healthcare providers with a resource to act on observed problems with medication self-management. Polymedicated patients recruited during the control and intervention periods will be monitored for 2 months postdischarge. A total of 225 participants with polypharmacy should be included in each group. Medication adherence 2 months postdischarge, measured by pill counts, will be the primary outcome. Secondary outcomes include self-management, medication knowledge, patient and staff satisfaction, perceived workload and healthcare service utilisation.

ETHICS AND DISSEMINATION

The ethics committee of the Antwerp University Hospital approved the study (reference no: B3002023000176). Study findings will be disseminated through peer-reviewed publications, conference presentations and summaries in layman's terms.

TRIAL REGISTRATION NUMBER

ISRCTN15132085.

The Development of Recommendations for Healthcare Providers to Support Patients Experiencing Medication Self-Management Problems

Medication self-management problems such as the inability to correctly obtain, understand, organize, administer or monitor medication can result in negative patient outcomes. However, supportive tools for healthcare providers to assist patients with medication self-management problems are lacking. This study aimed to develop recommendations for healthcare providers to support patients with polypharmacy who experience medication self-management problems. A three-phase study was conducted starting with (1) the mapping of medication self-management problems, followed by (2) a scoping review providing a list of relevant interventions and actions for each respective problem and (3) a three-round modified e-Delphi study with experts to reach consensus on the relevance and clarity of the recommended interventions and actions. The cut-off for consensus on the relevance and clarity of the recommendations was set at 80% expert agreement. Experts could propose additional recommendations based on their professional experience and expertise. The experts (n = 23) involved were healthcare professionals (i.e., nurses, pharmacists, and physicians) with specific expertise in medication management of patients with polypharmacy. Simultaneous with the second e-Delphi round, a panel of patients with polypharmacy (n = 8) evaluated the usefulness of recommendations. Results obtained from the patient panel were fed back to the panel of healthcare providers in the third e-Delphi round. Descriptive statistics were used for data analysis. Twenty medication self-management problems were identified. Based on the scoping review, a list of 66 recommendations for healthcare providers to support patients with the identified medication self-management problems was composed. At the end of the three-round e-Delphi study, the expert panel reached consensus on the relevance and clarity of 67 recommendations, clustered according to the six phases of the medication self-management model by Bailey et al. In conclusion, this study resulted in a guidance document including recommendations that can serve as a resource for healthcare providers to support patients with polypharmacy in case of medication self-management problems. Future research should focus on the evaluation of the feasibility and user-friendliness of the guide with recommendations in clinical practice.

Thai Patients' Drug Safety Knowledge and Perceptions Relating to Different Forms of Written Medicine Information: A Comparative Study

PURPOSE

The aim of the study was to evaluate the medication safety knowledge, quality of the written medicine information (WMI), and perceptions of taking the medicines in patients receiving package inserts (PIs) in comparison with patient information leaflets (PILs).

METHODS

A cross-sectional, comparative study was conducted from December 2020 to May 2021 at two university hospitals in Thailand. Outpatients who visited the pharmacy departments and were prescribed one of the three medicines: atorvastatin, celecoxib, or metformin were randomly selected by a permuted block randomization. The medication safety knowledge was measured using a set of validated and closed questions. The quality of the WMI was measured by the Consumer Information Rating Form (CIRF). Satisfaction with information and perceptions of the benefits and risks of medications were rated by the participants using a visual analog scale (0 to 10).

RESULTS

Of the 1150 invited patients, 750 completed the questionnaires (65.2%). A higher proportion of respondents with high level of medication safety knowledge was found in those reading the PILs than the PIs (44.5% and 20.8%, respectively). The type of leaflet received was a significant predictor of the high knowledge level (p < 0.001). The mean CIRF scores were significantly higher among those reading the PILs than the PIs (p < 0.001). Patients reading the PILs were also more satisfied with the information and had more positive perceptions of the benefits from taking medicines and intention to adhere than those reading the PIs. Patients' perceptions of risks after reading both leaflets were moderate (median score = 5.0), with the PIL group having slightly more concern about risks than the PI group.

CONCLUSION

The PILs showed superior effectiveness to the PIs in enhancing knowledge about medication safety, providing greater satisfaction with the information, and positive perceptions of benefit and intention to comply with the medications. PILs should be provided more frequently to patients receiving medicines than PIs.

Multidimensional factors affecting medication adherence among patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

This study aimed to investigate the effects of socioeconomic-, patient-, treatment-, condition- and health system-related factors on medication adherence in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Medication adherence is essential for the management of chronic diseases. The World Health Organization created a Multidimensional Adherence Model (MAM) and showed that medication adherence is affected by a combination of numerous factors.

DESIGN

A descriptive correlational study was conducted.

METHODS

A total of 114 patients with COPD were included. Data were collected on five dimensions based on the MAM framework. Medication adherence, self-efficacy and symptoms were evaluated using the Adherence to Refills and Medications Scale-7 (ARMS-7), COPD Self-Efficacy Scale (CSES) and COPD Assessment Test (CAT), respectively. The data were analysed using descriptive statistics, correlational statistics and structural equation modelling. The STROBE checklist was used.

RESULTS

The ARMS-7 scores were associated with the body mass index of patients (F = 4.245, p = .017), smoke pack-years (r = .277, p = .004) and the CSES total score (β = -0.249, p = .002) in patient-related factors. The ARMS-7 score was not associated with socio-economic and health system-related factors. The ARMS-7 score showed a significant correlation between COPD diagnosis duration (r = -.276, p = .003) and the total number of drugs (r = -.215, p = .022) in treatment-related factors. The ARMS-7 scores were associated with the number of comorbid illnesses of patients with COPD in condition-related factors (F = 3.533, p = .033).

CONCLUSION

This study showed that medication adherence in COPD was mostly affected by patient-, treatment- and condition-related factors.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals should establish training and counselling programs to increase the medication adherence level of patients, particularly for patients who are newly diagnosed, require multiple drugs and have comorbid diseases or low self-efficacy.

What Happens after Hospital Discharge? Deficiencies in Medication Management Encountered by Geriatric Patients with Polypharmacy

This study aimed to describe post-discharge medication self-management by geriatric patients with polypharmacy, to describe the problems encountered and to determine the related factors. In a multicenter study from November 2019 to March 2020, data were collected at hospital discharge and two to five days post-discharge. Geriatric patients with polypharmacy were questioned about medication management using a combination of validated (MedMaIDE) and self-developed questionnaires. Of 400 participants, 70% did self-manage medication post-discharge. Patients had a mean of four different deficiencies in post-discharge medication management (SD 2.17, range 0-10). Knowledge-related deficiencies were most common. The number of medicines and the in-hospital provision of medication management by nurses were significant predictors of post-discharge medication management deficiencies. In addition to deficiencies in knowledge, medication-taking ability and obtaining medication, non-adherence and disrupted continuity of medication self-management were common in geriatric patients with polypharmacy post-discharge. Improvements in in-hospital preparation could avoid medication self-management problems at home.

What impact do chronic disease self-management support interventions have on health inequity gaps related to socioeconomic status: a systematic review

Background

The social gradient in chronic disease (CD) is well-documented, and the ability to effectively self-manage is crucial to reducing morbidity and mortality from CD. This systematic review aimed to assess the moderating effect of socioeconomic status on self-management support (SMS) interventions in relation to participation, retention and post-intervention outcomes.

Methods

Six databases were searched for studies of any design published until December 2018. Eligible studies reported on outcomes from SMS interventions for adults with chronic disease, where socioeconomic status was recorded and a between-groups comparison on SES was made. Possible outcomes were participation rates, retention rates and clinical or behavioural post-intervention results.

Results

Nineteen studies were retrieved, including five studies on participation, five on attrition and nine studies reporting on outcomes following SMS intervention. All participation studies reported reduced engagement in low SES cohorts. Studies assessing retention and post-intervention outcomes had variable results, related to the diversity of interventions. A reduction in health disparity was seen in longer interventions that were individually tailored. Most studies did not provide a theoretical justification for the intervention being investigated, although four studies referred to Bandura’s concept of self-efficacy.

Conclusions

The limited research suggests that socioeconomic status does moderate the efficacy of SMS interventions, such that without careful tailoring and direct targeting of barriers to self-management, SMS may exacerbate the social gradient in chronic disease outcomes. Screening for patient disadvantage or workload, rather than simply recording SES, may increase the chances of tailored interventions being directed to those most likely to benefit from them. Future interventions for low SES populations should consider focussing more on treatment burden and patient capacity.

Trial registration

PROSPERO registration CRD42019124760. Registration date 17/4/19.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

BACKGROUND

Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence.

OBJECTIVES

The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice.

METHODS

Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research.

FINDINGS

Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.

Avaliação da compreensão da farmacoterapia entre idosos atendidos na Atenção Primária à Saúde de Belo Horizonte, MG, Brasil

Resumo Os idosos apresentam maior número de doenças, levando a maior uso de medicamentos e a farmacoterapia mais complexa. O objetivo do estudo foi avaliar o nível de compreensão da farmacoterapia entre idosos e fatores associados. Realizou-se estudo transversal analítico em Unidades Básicas de Saúde. Foram investigadas as características sociodemográficas, clínicas, funcionais e relativas ao uso de medicamentos. O nível de compreensão foi obtido após a análise de concordância entre a resposta do entrevistado e a informação contida na prescrição para: nome do medicamento, dose, frequência, indicação, precauções e efeitos adversos. O nível global de compreensão foi classificado como insuficiente em caso de discordância ≥ 30%. Dos 227 idosos entrevistados, 51,1% apresentaram compreensão insuficiente em relação aos medicamentos. Realizou-se regressão logística multivariada para observar os fatores associados à compreensão da farmacoterapia, sendo menor escolaridade e dependência para uso dos medicamentos os que apresentaram associação com a compreensão insuficiente (p < 0,05). É necessário implementar estratégias para aumentar a qualidade das orientações fornecidas aos idosos e garantir seu cumprimento.

Prevalence and predictors of inadequate patient medication knowledge

OBJECTIVES

To assess medication knowledge in adult patients and to explore its determinants.

METHOD

Cross-sectional study. Medication knowledge was the primary outcome and was assessed using a previously validated questionnaire. A multivariate logistic regression analysis was performed to explore the association between medication knowledge and the factors included in the model.

RESULTS

Seven thousand two hundred seventy-eight patients participated in the study. 71.9% (n = 5234) (95% CI: 70.9%-73.0%) of the surveyed patients had an inadequate knowledge of the medication they were taking. The dimensions obtaining the highest level of knowledge were the 'medication use process' and 'therapeutic objective of medication'. The items 'frequency' (75.4%), 'dosage' (74.5%) and 'indication' (70.5%) had the highest percentage of knowledge. Conversely, 'medication safety' represented the dimension with the lowest scores, ranging from 12.6% in the item "contraindications" to 15.3% in the item 'side effects'. The odds ratio (OR) of having an inadequate medication knowledge increased for unskilled workers (OR: 1.33; 85% CI:1.00-1.78; P = 0.050), caregivers (OR:1.46; 95% CI:1.18-1.81; P < 0.001), patients using more than one medication (OR: 1.14; 95% CI: 1.00-1.31; P = 0.050) and patients who did not know the name of the medication they were taking (OR: 2.14, 95% CI: 1.71-2.68 P < 0.001).

CONCLUSION

Nearly three quarters of the analysed patients had inadequate knowledge regarding the medicines they were taking. Unskilled workers and caregivers were at a higher risk of lacking of medication knowledge. Other factors that correlated with inadequate medication knowledge were the use of more than one drug and not knowing the name of the medication dispensed.

The burden of non-adherence to cardiovascular medications among the aging population in Australia: a meta-analysis

BACKGROUND

Non-adherence to cardiovascular medications is a problem worldwide, even in Australia, which has a socialized medical system, Medicare.

OBJECTIVE

The aim of this systematic review was to evaluate the burden of non-adherence to cardiovascular medications and factors thereof in Australia.

DATA SOURCES

Pubmed, Embase, CINAHL, PsycInfo, Cochrane Library databases were searched.

ELIGIBILITY CRITERIA

Articles were included if they were in English, peer-reviewed and provided empirical data on adherence to cardiovascular medication for an Australian cohort.

METHODS

A meta-analysis of prevalence of medication non-adherence using the double arcsine square root transformed proportion was undertaken. Studies were pooled in homogenous prevalence groups and factors that differed across groups were ascertained.

RESULTS

Five studies, including eight datasets and 76,867 subjects were analyzed. Three more or less homogenous prevalence categories were discernable: low [19 %, 95 % confidence interval (CI) 15-24], moderate (26 %, 95 % CI 23-29) and high (43 %, 95 % CI 43-44; this was a single study) prevalence of non-adherence. There were minimal clear patterns across groups in relation to typical factors of non-adherence (patient, condition, healthcare system or socioeconomic factors). Measurements used for non-adherence were similar for six of the eight included datasets, suggesting this did not affect prevalence of non-adherence or inclusion in a prevalence group.

CONCLUSIONS

Non-adherence to cardiovascular medications is a serious problem in the aging Australian setting with an overall prevalence of between 14 and 43 %. The lack of patterns in the typical factors of non-adherence suggests that another factor, such as patients' beliefs about their conditions and medications, may be playing a stronger role in their non-adherence than clinical or sociodemographic factors. This is an area for further research.

Cost-effectiveness of 'Program We Care' for patients with chronic obstructive pulmonary disease: A case-control study

OBJECTIVES

To evaluate the effectiveness of a discharge program for patients with chronic obstructive pulmonary disease (COPD) patients on discharge from an emergency medical ward on discharge home rate, hospital length of stay (LOS), inpatient admission rate and cost.

BACKGROUND

Frequent visits to the emergency department (ED) and subsequent hospital admission are common among patients with COPD, which adds a burden to ED and hospital care. A discharge program was implemented in an ED emergency medical ward. The program consisted of multidisciplinary care, discharge planning, discharge health education on disease management, and continued support from the community nursing services.

METHODS

A retrospective case-control study was used. Data were retrieved and compared between 478 COPD program cases and 478 COPD non-program cases.

RESULTS

No significant difference was found in age, gender, and triage category, LOS in ED, and readmission rate between the program and non-program groups. The program group demonstrated a significantly higher discharge home rate from the ED (33.89% vs. 20.08%) and fewer medical admissions (40.59% vs. 55.02%) compared with the non-program group, resulting in lower total medical costs after the program was implemented.

CONCLUSION

The program provides insight on the strategic planning for discharge care in a short stay unit of emergency department.

Underuse of medication for circulatory disorders among unmarried women and men in Norway?

Background

It is well established that unmarried people have higher mortality from circulatory diseases and higher all-cause mortality than the married, and these marital status differences seem to be increasing. However, much remains to be known about the underlying mechanisms. Our objective was to examine marital status differences in the purchase of medication for circulatory diseases, and risk factors for them, which may indicate underuse of such medication by some marital status groups.

Methods

Using data from registers covering the entire Norwegian population, we analysed marital status differences in the purchase of medicine for eight circulatory disorders by people aged 50-79 in 2004-2008. These differences were compared with those in circulatory disease mortality during 2004-2007, considered as indicating probable differences in disease burden.

Results

The unmarried had 1.4-2.8 times higher mortality from the four types of circulatory diseases considered. However, the never-married in particular purchased less medicine for these diseases, or precursor risk factors of these diseases, primarily because of a low chance of making a first purchase. The picture was more mixed for the divorced and widowed. Both groups purchased less of some of these medicines than the married, but, especially in the case of the widowed, relatively more of other types of medicine. In contrast to the never-married, divorced and widowed people were as least as likely as the married to make a first purchase, but adherence rates thereafter, indicated by continuing purchases, were lower.

Conclusion

The most plausible interpretation of the findings is that compared with married people, especially the never-married more often have circulatory disorders that are undiagnosed or for which they for other reasons underuse medication. Inadequate use of these potentially very efficient medicines in such a large population group is a serious public health challenge which needs further investigation. It is possible that marital status differences in use of medicines for circulatory disorders combined with an increasing importance of these medicines have contributed to the widening marital status gap in mortality observed in several countries. This also requires further investigation.

How much do elders with chronic conditions know about their medications?

BACKGROUND

Patients with chronic diseases often undertake multiple medication regimes to manage their condition, prevent complications and to maintain their quality of life. A patient's medication knowledge has been defined as the awareness of drug name, purpose, administration schedule, adverse effects or side-effects and special administration instructions. Poor medication knowledge can have a negative impact on medication adherence and patient safety and, in increasing the use of medical resources. The objective of the study is to assess the medication knowledge of elderly patients with chronic disease conditions and the factors affecting this knowledge.

METHODS

A cross-sectional survey was conducted in patients aged ≥ 60 with chronic disease conditions or their caregivers were recruited from two general outpatient clinics and two medical outpatient clinics in the public sector. Participants were approached by trained interviewers to complete a semi-structured questionnaire to assess their understanding of the instructions and information relating to their regular medications, which included medication name, regimen, purpose and common side-effects and precautions.

RESULTS

A total of 412 patients were recruited with the mean age of 72.86 ± 7.70. Of those, 221 (54.2%) were male and 226 (55.4%) were of primary school educational level or below. The mean number of medications taken per patient was 3.75 ± 1.93. Overall, 52.7% of patients felt that healthcare staff or clinic pharmacists had very clearly explained the administration instruction of the prescribed medications whilst 47.9% had very clear explanations of drug purpose but only 11.4% felt they had very clear explanations of side-effects. 396 patients (96.1%) failed to recall any side effects or precautions of each of their prescribed medications, although 232 patients (58.4%) would consult a doctor if they encountered problems with their medications. Logistic regression analysis showed that for every additional medication prescribed, the likeliness of patients to recall side-effects of all the medications prescribed was significantly lowered by 35% (OR = 0.65; 95% CI = 0.44-0.94; P = 0.023). In addition, those who finished secondary school or higher education were likely to possess more knowledge of side-effects (OR = 9.88; 95% CI = 2.11-46.25; P = 0.004).

CONCLUSIONS

Patients who take medications for their chronic diseases generally lack knowledge on side-effects of their medications which could potentially affect medication compliance and medication safety.

A systematic review of patient self-reported barriers of adherence to antihypertensive medications using the world health organization multidimensional adherence model

Multiple barriers can influence adherence to antihypertensive medications. The aim of this systematic review was to determine what adherence barriers were included in each instrument and to describe the psychometric properties of the identified surveys. Barriers were characterized using the World Health Organization (WHO) Multidimensional Adherence Model with patient, condition, therapy, socioeconomic, and health care system/team-related barriers. Five databases (Medline, Embase, Health and Psychological Instruments, CINHAL, and International Pharmaceutical Abstracts [IPA]) were searched from 1980 to September 2011. Our search identified 1712 citations; 74 articles met inclusion criteria and 51 unique surveys were identified. The Morisky Medication Adherence Scale was the most commonly used survey. Only 20 surveys (39%) have established reliability and validity evidence. According to the WHO Adherence Model domains, patient-related barriers were most commonly addressed, while condition, therapy, and socioeconomic barriers were underrepresented. The complexity of adherence behavior requires robust self-report measurements and the inclusion of barriers relevant to each unique patient population and intervention.