Comparing patient dissatisfaction and rational judgment in intentional medication non-adherence versus unintentional non-adherence

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Adherence Level to Arterial Hypertension Treatment: A Cross-Sectional Patient Survey and Retrospective Analysis of the NHS Prescription Database

One of the major problems in cardiology practice is poor adherence to antihypertensive medication. This study aimed to evaluate medication adherence; we also aim to investigate the predictors of intentional and unintentional non-adherence. We issued a survey containing questions about patient demographics, blood pressure control, pharmaceutical care, and adherence level to medication. Retrospective analysis of the prescription database of the National Health Service of the Republic of Latvia was performed. The prevalence of non-adherence was 45.9%. The lowest adherence rate (38.2%) was found among patients taking medication for 2–4.9 years. Even though 84.7% of respondents had a blood pressure monitor at home, only 25.3% of them reported measuring blood pressure regularly. There were differences between the groups of adherent patients in terms of the patients’ net income (p = 0.004), medication co-payments (p = 0.007), and whether the pharmacist offered to reduce the costs of drug therapy (p = 0.002). Roughly half of the prescriptions (50.4%) containing perindopril were purchased by patients from pharmacies. The medication adherence level and blood pressure control at home were assessed as low. Intentionally non-adherent respondents discontinued their medication because of fear of getting used to medicines. The pharmacists’ behaviour in terms of offering to reduce the costs of medications used was influenced by socio-economic factors.

Intentionality in adherence to long-term therapies. Results from an online survey of 3,001 patients with cardio-metabolic pathologies in France

PURPOSE

Some patients make a rational choice not to follow medical prescriptions; others fail to take their medications for reasons beyond their control, such as mere forgetfulness or a weak medication routine. The aim of this study was to elucidate the functioning of patient intentionality in medication adherence.

PATIENTS AND METHODS

This online study was conducted in metropolitan France in 2019. A cross-sectional survey of 50 questions was conducted with 3001 respondents diagnosed with diabetes, hypertension, and/or hypercholesterolemia identified from a panel of 54,000 people. These questions included a validated six-item questionnaire to detect nonadherence, two questions to detect intentional nonadherence by patients, and three questions on the effects of habit. Our questionnaire also included questions on the feelings of respondents regarding their doctor's attitude to their problems and needs, their trust in general practitioners (GP) and specialists, their sense of being involved in treatment decisions, and the influence of side effects and habits on patients' adherence. This study used the strategy of focusing on strictly adherent patients in the hope of finding ways to improve adherence. For this reason, we defined adherence as the absence of a positive response to the 6-item nonadherence screening questionnaire.

RESULTS

Of 3001 respondents, 1804 were diagnosed with hypertension, 1458 with hypercholesterolemia, and 774 with diabetes. Of the total number of patients, 72% were afflicted with one disease, 21% with two ailments, and 7% with three simultaneous illnesses. One-third (33%) of the patients did not tender a positive answer to the adherence questionnaire and were deemed adherent. 1) Thirty-two percent of the patients reported occasionally omitting their medication deliberately, and 84% said they had a reason for missing doses. These statements suggesting intentional nonadherence were negatively associated with adherence as identified via multivariate analysis (P = 0.0012 and P < 0.0001, for the first and second statement, respectively). 2) Univariate analyses revealed strong associations (P < 0.0001) between strict adherence on one hand and lack of intentional nonadherence, patient age, absence of drug side effects, taking drugs by habit, feeling involved in treatment decisions, getting information about treatment, and disease, and trust in doctors, on the other hand. 3) Specifically, univariate analysis of the absence of reported side effects revealed strong associations (P < 0.0001) with adequate information about medicines and diseases and trust in GP. These original data were consistent with the concept of the nocebo effect. 4) We observed a strong association between the absence of intentional nonadherence (statement of never deliberately missing medication) and respondent statements about generally sticking to the routine (P < 0.0001), ie, "I take my medication because I am used to taking it." This important result suggests that patients are strictly adherent in two ways: the absence of intentional nonadherence and reliance on habit, which we term as "unintentional adherence." 5) Finally, a multiple correspondence analysis illustrated all statistically significant relationships found in this study.

CONCLUSION

We present a new global model of adherence in which patient adherence was improved both by reducing intentional nonadherence and by promoting the abovementioned unintentional adherence by habit. This model highlights the role of shared decision-making and the trust felt by patients in their doctors. These results could exert a major impact on medical practice and education by demonstrating the importance of physicians' attitudes, involving the patient in decisions (shared decision-making), offering information about medicines and diseases (patient education), understanding the problems of patients, and taking their needs into account (empathy). The development of these attitudes should be an important aspect of the medical curricula.

Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence

Fibromyalgia is a chronic illness characterized by pain and fatigue. Persons with fibromyalgia experience increased the risk for poor mental and physical health-related quality of life, which may be dependent on multiple factors, including health beliefs, such as confidence in physicians and the health-care system, and health behaviors, such as treatment adherence. Respondents with fibromyalgia (n = 409) were recruited nationally, via support organizations, and completed self-report measures: Multidimensional Health Profile - Health Functioning Index (MHP-H), Short-Form-36 Health Survey (SF-36v2), and Medical Outcomes Study (MOS) Measure of Patient Adherence - General Adherence Items. In mediation models, belief in the healthcare system and health-care personnel, and health efficacy exerted an indirect effect through treatment adherence on mental and physical quality of life. Adaptive health beliefs and attitudes were related to greater treatment adherence and, in turn, to a better quality of life. Maladaptive health beliefs and mistrusting attitudes about physician-level and systemic-level healthcare provision are negatively related to both treatment adherence and consequent physical and mental health-related quality of life in persons with fibromyalgia. Future randomized controlled trials are needed to determine if therapeutic strategies to alter health values might improve adherence and self-rated health.

When patients' invisible work becomes visible: non-adherence and the routine task of pill-taking

While the biographical dimensions of chronic illness have been well researched, the concrete dimensions of patients' work have not been as thoroughly investigated as yet. With the growing concern for self-management, such research would be timely. This study aims to better understand patients' invisible work by highlighting the causes of unintentional non-adherence as well as strategies for adherence. For this purpose, it defines medical treatment adherence as the repetition of the pattern of tasks through which a patient succeeds, in a technical sense, in taking the right medication at the right time, in the right amount, for the right duration. Applying a failure modes and effects analysis approach to 48 semi-structured interviews with Dutch patients, it shows the negative impact of schedule changes, pressure, positioning changes, lack of backup pills and lack of verification tools. Symmetrically, it highlights the role of anchoring, sequencing, positioning, cueing, correcting and verifying. This result points to the need for an analytical approach of patients' work and treatment adherence that would build on the role of routines in organisations and in the workplace.

Smartphone Applications for Educating and Helping Non-motivating Patients Adhere to Medication That Treats Mental Health Conditions: Aims and Functioning

Background: Patients prescribed with medication that treats mental health conditions benefit the most compared to those prescribed with other types of medication. However, they are also the most difficult to adhere. The development of mobile health (mHealth) applications ("apps") to help patients monitor their adherence is fast growing but with limited evidence on their efficacy. There is no evidence on the content of these apps for patients taking psychotropic medication. The aim of this study is to identify and evaluate the aims and functioning of available apps that are aiming to help and educate patients to adhere to medication that treats mental health conditions. Method: Three platform descriptions (Apple, Google, and Microsoft) were searched between October 2015 and February 2016. Included apps need to focus on adherence to medication that treats mental health conditions and use at least a reinforcement strategy. Descriptive information was extracted and apps evaluated on a number of assessment criteria using content analysis. Results: Sixteen apps were identified. All apps included self-monitoring properties like reminders and psycho-educational properties like mood logs. It was unclear how the latter were used or how adherence was measured. Major barriers to medication adherence like patients' illness and medication beliefs and attitudes were not considered nor where information to patients about mediation side effects. Very few apps were tailored and none was developed based on established theories explaining the processes for successful medication adherence like cognitions and beliefs. Reported information on app development and validation was poor. Discussion: A variety of apps with different properties that tackle both intentional and unintentional non-adherence from a different perspective are identified. An evidence-based approach and co-creation with patients is needed. This will ensure that the apps increase the possibility to impact on non-adherence. Theories like social cognition models can be useful in ensuring that patients' education, motivation, skills, beliefs, and type of adherence are taken into consideration when developing the apps. Findings from this study can help clinicians and patients make informed choices and pursue policy-makers to integrate evidence when developing future apps. Quality-assurance tools are needed to ensure the apps are systematically evaluated.

Patient Preference for Aggressive Medication Therapies with Potentially Stronger Adverse Drug Reactions Revealed Using a Scenario-based Survey

 Some patients do not inform healthcare professionals of adverse drug reactions (ADRs) because they fear termination of aggressive medication therapies. Preferences for aggressive medication therapies may differ between patients and pharmacists. The goal of this study was to estimate whether pharmacists were able to accurately assess patient preference for aggressive medication therapies with potentially stronger ADRs. A cross-sectional study was conducted of hospitalized patients (35 to 74 years of age) receiving oral medications for a chronic disease or systemic chemotherapy at three hospitals in Japan. We estimated the extent of agreement between patient responses and pharmacist predictions using a scenario-based investigation (1) to examine the choice between an aggressive medication therapy and the standard therapy, and (2) to assess increased life expectancy as a result of aggressive medication therapy. The extent of agreement was estimated using the kappa statistic. Of 113 patients, 43 (38.1%) chose the aggressive medication therapy. Pharmacists correctly predicted the choice of 25 (58.1%) of these patients [kappa 0.32 (95% confidence interval 0.15-0.50)]. Of 111 patients, 42 (37.8%) expected one additional life expectancy year. However, pharmacists predicted that as many as 36 (85.7%) of these patients would require more years of added life expectancy before choosing an aggressive medication therapy [kappa 0.24 (0.08-0.40)]. Agreement between patients and pharmacists on the choice of aggressive medication therapy was generally poor. Pharmacists should make an effort to identify patients who might prefer more aggressive medication therapies with potentially stronger ADRs in order to minimize ADR risk.

Intentional Nonadherence as a Means to Exert Control

Medication adherence is a major issue for patients with a chronic illness, who sometimes rationally choose temporary nonadherence. This study aims at better understanding intentional nonadherence and especially why it seems to fluctuate over time. It is based on 48 semi-structured interviews conducted in a hospital in the Netherlands with patients who had been prescribed a medication for a chronic disease for at least 1 year, and who had either type 2 diabetes, hypertension, Parkinson's disease, inflammatory bowel disease, or chronic myeloid leukemia. The analysis uses a simplified version of the failure modes and effects analysis (FMEA) method. Intentional nonadherence appeared to be the result of the respondents' desire (a) to exert control over the treatment and its effects on their body, and (b) to control the hold of the treatment on their daily life. This result provides a rationale for the fluctuation of intentional nonadherence behavior.

Limited Time from the Diabetes Patients' Perspective: Need for Conversation with the Eye Specialist

PURPOSE

Facing the lack of time, busy retina consultants should be aware of how the patients would prefer that time is spent and whether they wish the specialist to talk more at the expense of other medical activities.

METHODS

810 persons with diabetes were asked to divide the time of 10 min between examination, consultation and treatment when envisioning a real-life scenario of diabetic retinopathy (NCT02311504).

RESULTS

With the increasing duration of diabetes, patients wanted significantly more time for diagnostics (p = 0.028), while age was found to be associated with less time for treatment (p = 0.009). Female subjects tended to prefer only little more time for talking (p = 0.051) in comparison with males, who slightly favored therapy (p = 0.025).

CONCLUSIONS

The large majority recognized the need for diagnostics in their allocation of time. If individual patients are confronted with the health care perspective of time constraints, this might improve the understanding of prioritization.

Establishing the relationship of inhaler satisfaction, treatment adherence, and patient outcomes: a prospective, real-world, cross-sectional survey of US adult asthma patients and physicians

Background

Inhaled asthma medications are the mainstay of treatment for chronic asthma. However, nonadherence rates for long-term inhaler therapy among adults are estimated to exceed 50 %. Nonadherence is associated with unfavorable clinical outcomes and diminished quality of life. Research suggests that adherence is associated with patients’ satisfaction with their treatment regimen and other factors, such as concomitant allergic rhinitis and tobacco use.

Methods

This prospective, cross-sectional survey of physicians and their patients evaluated the relationship between patient satisfaction with attributes of inhaler devices, treatment adherence, and clinical outcomes. Primary care and specialist physicians completed a physician-reported patient record form for patients with a confirmed asthma diagnosis. Patients for whom a physician-reported form was completed were invited to complete a patient-reported form. Both surveys collected information about demographics, symptoms, exacerbation history, treatment, smoking status, comorbidities, type of inhaler device, and treatment adherence. Patients also indicated the degree to which they were satisfied with attributes of their currently prescribed inhaler device(s). Partial least squares path modeling quantified relationships between latent variables and clinical outcomes.

Results

A total of 243 patients were included in our analysis and 41 % had poorly controlled asthma. More favorable clinical outcomes were significantly associated with greater patient satisfaction with drug delivery (P = 0.002), higher medication adherence (P = 0.049), no history of tobacco use (P < 0.001), and absence of comorbid allergic rhinitis (P = 0.005). Attributes associated with device satisfaction included patient perceptions of consistency in the amount of drug delivery to the lungs, ease of use, and feedback about the number of remaining doses.

Conclusions

Higher patient satisfaction with their asthma drug delivery inhaler device is a significant predictor of more favorable clinical outcomes while allergic rhinitis and smoking history were negatively associated with optimal control of asthma. These findings provide clinicians with opportunities to improve patients’ clinical outcomes by tailoring choice of inhaler device therapy and providing education about the correct way to use the device to ensure optimal outcomes. Patients will likely benefit from medical therapy to manage comorbid allergic rhinitis and smoking cessation interventions. Patients unable to stop smoking may require alternative medical therapies to improve their clinical outcomes.

Effect of endurance for adverse drug reactions on the preference for aggressive treatments in cancer patients

PURPOSE

Cancer patients receiving chemotherapy will sometimes conceal their discomfort, but an excessive endurance for adverse drug reactions (ADRs) can lead to a poorer prognosis. The aim of this study was to clarify the association between ADR endurance and a preference of cancer patients for aggressive treatments.

METHODS

A cross-sectional study was undertaken of inpatients under 75 years of age receiving injectable systemic chemotherapy or oral chronic medications at hospitals in Japan. Subjects were asked to respond to a validated questionnaire to assess the extent of their ADR endurance and whether they would choose a novel, more aggressive therapy if their life expectancy was estimated at 2 years.

RESULTS

Study participants were separated into the chemotherapy group (n = 36) and the non-chemotherapy group (n = 78). In the chemotherapy group, patients who had moderate ADR endurance scores were more likely to choose the new therapy (0-33, 34-67, and 68-100 points: 0.0, 54.5, and 27.3 %; χ (2) test, p = 0.15). Additionally, every patient on long-term chemotherapy (≥3 years) had high ADR endurance scores but did not choose the new, riskier treatment. In the non-chemotherapy group, the proportion of those choosing the new therapy was linearly associated with higher ADR endurance scores (25.9, 38.2, and 64.7 %; p = 0.04).

CONCLUSION

Cancer patients may prefer aggressive therapies, even when self-estimations of ADR endurance are not very high, especially if they have been receiving chemotherapy for a short period of time. These patients should be observed with great caution.

Psychosocial factors and surgical outcomes: are elderly depressed patients less satisfied with surgery?

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVE

In this study, we set out to assess the effect of preoperative depression on patient satisfaction after revision lumbar surgery.

SUMMARY OF BACKGROUND DATA

Patient satisfaction ratings are increasingly being used in health care as a proxy for quality of care. In the elderly, affective disorders such as depression have been shown to influence patient-reported outcomes and self-interpretation of health status.

METHODS

A total of 69 patients aged 65 years or older undergoing revision neural decompression and instrumented fusion for same-level recurrent stenosis-associated back and leg pain were included in this study. Preoperative Zung self-rating depression score, comorbidities, and postoperative satisfaction with surgical care and outcome were assessed for all patients. Baseline and 2-year visual analogue scale (VAS)-leg pain, VAS-back pain, Oswestry Disability Index, Short Form-12 physical component score and Short Form-12 mental component score, as well as health-state utility (EuroQol 5D) were assessed. Factors associated with patient satisfaction after surgical procedures were assessed via multivariate logistic regression analysis.

RESULTS

Compared with baseline, there was a statistically significant improvement in VAS-back pain 2.76±2.73 (pseudarthrosis [1.94±2.81], adjacent segment disease [4.35±3.16]), same-level recurrent stenosis [2±2.23]), VAS-leg pain 2.66±4.12, (adjacent segment disease [2.24±4.46] and same-level recurrent stenosis [3±3.78]). Two-year Oswestry Disability Index improved after surgery for pseudarthrosis (4.05±7.65), adjacent segment disease (6±13.63) and same-level recurrent stenosis (4.54±5.97). In a multivariate logistical regression model, increasing preoperative Zung self-rating depression scale scores were independently associated with patient dissatisfaction 2 years after revision lumbar surgery, (P<0.001).

CONCLUSION

This study demonstrates that independent of surgical effectiveness, baseline depression influence patient satisfaction with health care, 2 years after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality of care should account for patients' baseline depression as a potential confounder especially in this age group.

LEVEL OF EVIDENCE

3.

Intentional non-adherence to medications by older adults

'The extent to which an individual's medication-taking behaviour and/or execution of lifestyle changes, corresponds with agreed recommendations from a healthcare provider', is a highly complex behaviour, defined as adherence. However, intentional non-adherence is regularly observed and results in negative outcomes for patients along with increased healthcare provision costs. Whilst this is a consistent issue amongst adults of all ages, the burden of chronic disease is greatest amongst older adults. As a result, the absolute prevalence of intentional non-adherence is increased in this population. This non-systematic review of intentional non-adherence to medication highlights the extent of the problem amongst older adults. It notes that age, per se, is not a contributory factor in intentionally non-adherent behaviours. Moreover, it describes the difference in methodology required to identify such behaviours in contrast to reports of non-adherence in general: the use of focus groups, semi-structured, one-to-one interviews and questionnaires as opposed to pill counts, electronic medication monitors and analysis of prescription refill rates. Using Leventhal's Common-Sense Model of Self-Regulation, it emphasizes six key factors that may contribute to intentional non-adherence amongst older adults: illness beliefs, the perceived risks (e.g. dependence, adverse effects), benefits and necessity of potential treatments, the patient-practitioner relationship, inter-current physical and mental illnesses, financial constraints and pharmaceutical/pharmacological issues (poly-pharmacy/regimen complexity). It describes the current evidence for each of these aspects and notes the paucity of data validating Leventhal's model in this regard. It also reports on interventions that may address these issues and explicitly acknowledges the lack of evidence-based interventions available to healthcare practitioners. As a result, it highlights five key areas that require urgent research amongst older adults: (1) the overlap between intentional and unintentional non-adherence, particularly amongst those who may be frail or isolated; (2) the potential correlation between symptomatic benefit and intentional vs. unintentional non-adherence to medication; (3) an evaluation of the source of prescribing (i.e. a long-standing provider vs. an acute episode of care) and the patient-prescriber relationship as determinants of intentional and unintentional non-adherence; (4) the decision-making processes leading to selective intentional non-adherence amongst older adults with multiple medical problems; and (5) the development and evaluation of interventions designed to reduce intentional non-adherence, specifically addressing each of the aspects listed above.