Medication management strategies used by older adults with heart failure: A systems-based analysis

A Practical Tool for Measuring Home-Based Cardiac Rehabilitation Self-Management Behavior: A Multiphase Cross-Sectional Study

BACKGROUND

Optimal self-management is the key to home-based cardiac rehabilitation for patients with heart disease. At present, there is a lack of a specific assessment tool to evaluate the home-based cardiac rehabilitation self-management behavior in patients with heart disease. Therefore, the aim of this study was to develop the Home-Based Cardiac Rehabilitation Self-Management Scale and validate its psychometric properties among patients with coronary heart disease.

METHODS AND RESULTS

A multiphase cross-sectional study was conducted that study covered 3 phases: (1) item generation and revision, (2) item evaluation and preliminary exploration, and (3) assessment of the psychometric properties of the scale. A scale with 21 items was developed to measure the home-based cardiac rehabilitation self-management behavior. The content validity index of the scale was 0.980. In exploratory factor analysis, the 5-factor structure supported by eigenvalues and screen plot explained 74.326% of the total variation. In confirmatory factor analysis, all fitting indicators were acceptable, further supporting the construct validity of the scale. The criterion validity of the scale was 0.783. In the reliability analysis, the Cronbach's α coefficient of the scale was 0.882, with a dimensionality range of 0.780 to 0.936. The split-half reliability coefficient and test-retest reliability coefficient were 0.774 and 0.770, respectively.

CONCLUSIONS

This study is the first to develop and validate a practical tool. This scale can comprehensively and accurately assess the self-management behavior of patients with heart disease in a home-based cardiac rehabilitation environment.

Factors influencing initial implementation of an online community-based exercise intervention with adults living with HIV: a systems approach

Introduction

Online community-based exercise (CBE) is a digital health intervention and rehabilitation strategy that promotes health among people living with HIV. Our aim was to describe the factors influencing initial implementation of a pilot online CBE intervention with adults living with HIV using a systems approach, as recommended by implementation science specialists.

Methods

We piloted the implementation of a 6-month online CBE intervention and 6-month independent exercise follow up, in partnership with the YMCA in Toronto, Canada. We recruited adults living with HIV who identified themselves as safe to engage in exercise. The intervention phase included personalized exercise sessions online with a personal trainer; exercise equipment; access to online exercise classes; and a wireless physical activity monitor. Two researchers documented implementation factors articulated by participants and the implementation team during early implementation, defined as recruitment, screening, equipment distribution, technology orientation, and baseline assessments. Data sources included communication with participants; daily team communication; weekly team discussions; and in-person meetings. We documented implementation factors in meeting minutes, recruitment screening notes, and email communication; and analyzed the data using a qualitative descriptive approach using a systems engineering method called Cognitive Work Analysis.

Results

Thirty-three adults living with HIV enrolled in the study (n = 33; median age: 52 years; cis-men: 22, cis-women: 10, non-binary: 1). Fifty-five factors influencing implementation, spanned five layers: (i) Natural, including weather and the COVID-19 virus; (ii) Societal, including COVID-19 impacts (e.g. public transit health risks impacting equipment pick-ups); (iii) Organizational, including information dissemination (e.g. tech support) and logistics (e.g. scheduling); (iv) Personal, including physical setting (e.g. space) and digital setting (e.g. device access); and (v) Human, including health (e.g. episodic illness) and disposition (e.g. motivation). The implementation team experienced heightened needs to respond rapidly; sustain engagement; and provide training and support. Additional organizational factors included a committed fitness training and research team with skills spanning administration and logistics, participant engagement, technology training, physical therapy, and research ethics.

Conclusion

Fifty-five factors spanning multiple layers illustrate the complexities of online CBE with adults living with HIV. Initial implementation required a dedicated, rehabilitation-centred, multi-skilled, multi-stakeholder team to address a diverse set of factors.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Applying Stress and Coping Theory to Understand Diuretic Adherence Experiences in Persons with Heart Failure

Despite the benefits of diuretics for treating the symptoms of heart failure (HF), patients may report side effects and intentionally not adhere to diuretic regimens. Positive internal motivators, such as positive emotions, may benefit individuals in their adaptation to medication-related stress. However, there has been limited study of these potential motivators in those with HF. Using a descriptive qualitative approach, 82 adults taking diuretics for HF were interviewed. This study applied stress and coping theory to understand the diuretic-taking experiences of patients with HF. Data analysis revealed three themes: (a) diuretics are bothersome, (b) staying positive in the mid of hardship, and (c) adapting to endure. Findings suggest that adherent participants stayed positive amid the perceived hardship, maintaining resilient and grateful attitudes. Adherent participants adapted to bothersome diuretic effects and utilized creative strategies. More research is needed to understand the relationships between resilience, adaptive coping, and diuretic adherence.

Exploring how caregivers for people living with dementia use strategies to overcome work system constraints

Informal caregivers for persons living with dementia (PLWD) require interventions that incorporate caregiving context. We used the Patient Work System model to characterize caregiving context by identifying work system constraints experienced by caregivers during dementia care events (e.g., managing behavioral symptoms of dementia) and strategies used to overcome constraints. We conducted twenty semi-structured interviews with caregivers. We performed upward abstraction and strategy mapping and identified seven work system constraints and eight strategies used to overcome constraints across three care events. We found that strategies used by caregivers either directly modified a constraint or emphasized other positive work system components to overcome a constraint. For example a caregiver modified their bathroom to support the PLWD in bathing themselves properly and safely. These findings provide an understanding of how real-world context influences how caregivers deliver dementia care and the design and implementation of systems that support dementia caregivers.

Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis

BACKGROUND

Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety.

OBJECTIVES

To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern.

DESIGN

We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs.

PARTICIPANTS

We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category.

APPROACH

Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes.

KEY RESULTS

Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented.

CONCLUSIONS

Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.

Coping with chronic cardiovascular disease in Iran: A qualitative study

The effects of chronic cardiovascular disease can challenge the achievement of treatment goals and recovery outcomes. This study explores the ways in which patients cope with the effects of chronic cardiovascular disease, from the perspectives of patients, family caregivers, and health professionals. The qualitative study was conducted from May 2019 to September 2020 in Isfahan, Iran. Thirteen people with chronic cardiovascular disease, 6 family caregivers, and 16 healthcare professionals participated in semi-structured individual interviews. Transcripts were analysed thematically. Findings suggest that people with chronic cardiovascular disease use a range of coping strategies, both positive and negative, to adjust to their conditions. The positive strategies include managing their health-related symptoms, drawing on religious or spiritual beliefs, and accessing social and relational supports. Negative strategies can include over-reliance on family members for support, leading to reduced activity and loss of independence. Understanding the nature of the strategies used by patients provides an important means by which health service providers can support patients to further develop positive coping strategies. This, in turn, will enable patients to achieve higher levels of wellbeing.

Medication Nonadherence or Self-care? Understanding the Medication Decision-Making Process and Experiences of Older Adults With Heart Failure

BACKGROUND

More than half of all patients with heart failure (HF) do not take medications as prescribed, resulting in negative health outcomes. Research has shown that medication adherence may be intentional rather than the ability to follow prescribed regimens, yet very little is known about medication-taking decisions in older patients with HF.

OBJECTIVE

The purpose of this qualitative study was to gain insight into the decision-making processes and experiences of older patients with HF by exploring the different aspects in choosing to take or not take medications as prescribed in the community setting.

METHODS

Using a narrative inquiry approach, the personal narratives of 11 adults 65 years or older who took at least 2 daily medications for HF were gathered using in-depth, semistructured interviews. The data in this study were organized and analyzed using Riessman's framework for narrative analysis.

RESULTS

Participants made intentional decisions to take particular medications differently than prescribed. A worrisome symptom prompted a naturalistic decision-making process. When a medication interfered with attaining a personal goal, participants coped by individualizing their medication regimen. Participants did not consider taking a medication differently than prescribed as nonadherence but a necessary aspect of maintaining a personal level of health, which could be seen as self-care.

CONCLUSIONS

The older patient with HF should be carefully assessed for nonadherence. The development of interventions that are patient specific, target medications with the greatest potential for nonadherence, and use easy-to-access resources may promote decisions for medication adherence. More research is needed to develop interventions that promote decisions for medication adherence.

Personal Health Information Management Among Older Adults: Scoping Review

Background

Older adults face growing health care needs and could potentially benefit from personal health information management (PHIM) and PHIM technology. To ensure effective PHIM and to provide supportive tools, it is crucial to investigate the needs, challenges, processes, and tools used by this subpopulation. The literature on PHIM by older adults, however, remains scattered and has not provided a clear picture of what we know about the elements that play a role in older adults’ PHIM.

Objective

The goal of our review was to provide a comprehensive overview of extant knowledge on PHIM by older adults, establish the status quo of research on this topic, and identify research gaps.

Methods

We carried out a scoping review of the literature from 1998 to 2020, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) framework. First, we executed a broad and structured search. We then carried out a qualitative analysis of papers pertinent to the topic taking into consideration the five elements of the patient work system as follows: (1) personal-level factors, (2) PHIM tasks, (3) tools used, (4) physical settings of PHIM activities, and (5) socio-organizational aspects.

Results

The review included 22 studies. Consolidated empirical evidence was related to all elements of the patient work system. Multiple personal factors affected PHIM. Various types of personal health information were managed (clinical, patient-generated, and general) and tools were used (electronic, paper-based, and others). Older adults’ PHIM was intertwined with their surroundings, and various individuals participated. The largest body of evidence concerned personal factors, while findings regarding the physical environment of PHIM were scarce. Most research has thus far examined older adults as a single group, and scant attention has been paid to age subgroups.

Conclusions

Opportunities for further PHIM studies remain across all elements of the patient work system in terms of empirical, design science, or review work.

Naturalistic Decision Making in Everyday Self-care Among Older Adults With Heart Failure

BACKGROUND

Every day, older adults living with heart failure make decisions regarding their health that may ultimately affect their disease trajectory. Experts describe these decisions as instances of naturalistic decision making influenced by the surrounding social and physical environment and involving shifting goals, high stakes, and the involvement of others.

OBJECTIVE

This study applied a naturalistic decision-making approach to better understand everyday decision making by older adults with heart failure.

METHODS

We present a cross-sectional qualitative field research study using a naturalistic decision-making conceptual model and critical incident technique to study health-related decision making. The study recruited 24 older adults with heart failure and 14 of their accompanying support persons from an ambulatory cardiology center. Critical incident interviews were performed and qualitatively analyzed to understand in depth how individuals made everyday health-related decisions.

RESULTS

White, male (66.7%), older adults' decision making accorded with a preliminary conceptual model of naturalistic decision making occurring in phases of monitoring, interpreting, and acting, both independently and in sequence, for various decisions. Analyses also uncovered that there are barriers and strategies affecting the performance of these phases, other actors can play important roles, and health decisions are made in the context of personal priorities, values, and emotions.

CONCLUSIONS

Study findings lead to an expanded conceptual model of naturalistic decision making by older adults with heart failure. In turn, the model bears implications for future research and the design of interventions grounded in the realities of everyday decision making.

Household medication safety practices during the COVID-19 pandemic: a descriptive qualitative study protocol

INTRODUCTION

Those who are staying at home and reducing contact with other people during the COVID-19 pandemic are likely to be at greater risk of medication-related problems than the general population. This study aims to explore household medication practices by and for this population, identify practices that benefit or jeopardise medication safety and develop best practice guidance about household medication safety practices during a pandemic, grounded in individual experiences.

METHODS AND ANALYSIS

This is a descriptive qualitative study using semistructured interviews, by telephone or video call. People who have been advised to 'cocoon'/'shield' and/or are aged 70 years or over and using at least one long-term medication, or their caregivers, will be eligible for inclusion. We will recruit 100 patient/carer participants: 50 from the UK and 50 from Ireland. Recruitment will be supported by our patient and public involvement (PPI) partners, personal networks and social media. Individual participant consent will be sought, and interviews audio/video recorded and/or detailed notes made. A constructivist interpretivist approach to data analysis will involve use of the constant comparative method to organise the data, along with inductive analysis. From this, we will iteratively develop best practice guidance about household medication safety practices during a pandemic from the patient's/carer's perspective.

ETHICS AND DISSEMINATION

This study has Trinity College Dublin, University of Limerick and University College London ethics approvals. We plan to disseminate our findings via presentations at relevant patient/public, professional, academic and scientific meetings, and for publication in peer-reviewed journals. We will create a list of helpful strategies that participants have reported and share this with participants, PPI partners and on social media.

Patient decision-making personas: An application of a patient-centered cognitive task analysis (P-CTA)

Personas can be used to understand patterns of variation in patients' performance of cognitive work, particularly self-care decision making. In this study, we used a patient-centered cognitive task analysis (P-CTA) to develop self-care decision-making personas. We collected data from 24 older adults with chronic heart failure and 14 support persons, using critical incident and fictitious scenario interviews. Qualitative analyses produced three personas but revealed that individuals exemplify different personas across situations. The Rule-Following persona seeks clear rules, exercises caution under uncertainty, and grounds actions in confidence in clinician experts. The Researching persona seeks information to gain better understanding, invents strategies, and conducts experiments independently or with clinicians. The Disengaging persona does not actively seek rules or information and does not attempt to reduce uncertainty or conduct experiments. We discuss the situational nature of personas, their use in design, and the benefits of P-CTA for studying patient decision making.

An integrative review on facilitators and barriers in delivering and managing injectable therapies in chronic conditions: A part of the ACNAP project 'injectable medicines among patients with cardiovascular conditions'

INTRODUCTION

Although preventive health and therapeutics have benefited from advances in drug development and device innovation, translating these evidence-based treatments into real-world practice remains challenging.

AIM

The current integrative review aims to identify facilitators and barriers and perceptions in delivering and managing injectable therapies from patient perspectives.

METHODS

An integrative review was conducted in the databases of PubMed, CINAHL, PsycINFO and Cochrane. Keywords were used "Injectable therapy", "IV therapy", "SC therapy", "long term injectable therapies", "self-administered injectable therapy", "patients", "caregivers", "family", "carers", "facilitators", "barriers", "perspectives", "needs", "expectations", "chronic disease", "cardiovascular disease" linked with the words "OR" and "AND". The search was limited from January 2000 to July 2019. Inclusion and exclusion criteria were used.

RESULTS

Twenty studies were identified from the literature search. Studies followed qualitative, quantitative methodology and mixed methods. Facilitators included: health improvement, prevention of disease complications, taking control of their disease, effectiveness of the medication and convenience in management. Barriers included: fear of needles, insulin will cause harm, poor perception of the benefits of injectable therapies on their quality of life, inconvenience in self-management, social stigma, impact on daily living, financial barriers, lack of education. Perceptions included: 'treatment of last resort', 'life becomes less flexible', 'injectables were punishment/restriction', 'personal failure of self-management'.

CONCLUSION

Evidence shows how to create effective communication and shared decision-making relationships to provide best possible care to patients who need injectable therapy and support for self-management. Future research might help guide response to the fears and barriers of the patients using patients' perspectives.

Patient work from a context and time use perspective: a mixed-methods study protocol

INTRODUCTION

Self-management is widely promoted but less attention is focused on the work required from patients. To date, many individuals struggle to practise self-management. 'Patient work', a concept that examines the 'work' involved in self-management, is an approach to understanding the tasks, effort, time and context from patient perspective. The purpose of our study is to use a novel approach combining non-obstructive observations via digital devices with in-depth qualitative data about health behaviours and motivations, to capture the full range of patient work experienced by people with type 2 diabetes and chronic comorbidities. It aims to yield comprehensive insights about 'what works' in self-management, potentially extending to populations with other chronic health conditions.

METHODS AND ANALYSIS

This mixed-methods observational study involves a (1) prestudy interview and questionnaires, (2) a 24-hour period during which participants wear a camera and complete a time-use diary, and a (3) poststudy interview and study feedback. Adult participants living with type 2 diabetes with at least one chronic comorbidity will be recruited using purposive sampling to obtain a balanced gender ratio and of participants using insulin and those using only oral medication. Interviews will be analysed using thematic analysis. Data captured by digital devices, diaries and questionnaires will be used to analyse the duration, time, context and patterns of health-related behaviours.

ETHICS AND DISSEMINATION

The study was approved by the Macquarie University Human Research Ethics Committee for Medical Sciences (reference number 5201700718). Participants will carry a wallet-sized card that explains the purpose of the study to third parties, and can remove the camera at any stage. Before the poststudy interview begins, participants will view the camera images in private and can delete any images. Should any images be used in future publications or presentations, identifying features such as human faces and names will be obscured.