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Zhang X, Sim Y, Tsang CCS, Wang J, Finch CK. The association between comprehensive medication review and medication adherence among medicare beneficiaries with chronic obstructive pulmonary disease. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 15:100470. [PMID: 39050144 PMCID: PMC11267052 DOI: 10.1016/j.rcsop.2024.100470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 07/27/2024] Open
Abstract
Background Medicare Part D plans are required to provide Medication therapy management (MTM) services to eligible beneficiaries to optimize medication utilization. Comprehensive medication review (CMR) is a core element of the MTM program. Despite the availability of advanced medical treatment for patients with chronic obstructive pulmonary disease (COPD), medication adherence to maintenance medications poses a continued challenge for patients with COPD. Objective To examine the effects of CMR on medication adherence among patients with COPD. Methods Medicare data for 2016-2017 linked to Area Health Resource Files were analyzed. The study population was Medicare beneficiaries with COPD. The intervention group consisted of beneficiaries who received CMR in 2017 but not in 2016. Patients who were eligible for MTM services but did not receive these services in 2016 or 2017 made up the control group. Propensity score matching was used to select an intervention and control group with balanced characteristics. The study outcome was adherence to COPD medications with the proportion of days covered at or above 80%. A difference-in-differences approach was adopted in the logistic regression analyses with an interaction term between the status of CMR receipt and the year 2017. Results The study sample included 25,564 patients with COPD. The proportions of adherent patients were similar in the control group in both years but increased significantly from 60.08% in 2016 to 69.38% in 2017 in the intervention group (P < .001). The odds of medication adherence in the intervention group increased from 2016 to 2017 by 59% more than in the control group (adjusted odds ratio = 1.59, 95% confidence interval = 1.48-1.71). Conclusions Receiving CMR was associated with improved adherence to COPD medications among Medicare beneficiaries. Policymakers should ensure that Medicare beneficiaries with COPD receive CMR.
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Affiliation(s)
| | | | - Chi Chun Steve Tsang
- Department of Clinical Pharmacy & Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Junling Wang
- Department of Clinical Pharmacy & Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Christopher K. Finch
- Department of Clinical Pharmacy & Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
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Hachemi D, Leguelinel-Blache G, Bouvet S, Roux-Marson C, Plouvier N, Kinowski JM, Castelli C, Dubois F. Clinical impact of pharmaceutical consultations in patients treated for chronic obstructive pulmonary disease: Study protocol for a randomized controlled trial (BPCObs study). Contemp Clin Trials Commun 2024; 37:101249. [PMID: 38269046 PMCID: PMC10805915 DOI: 10.1016/j.conctc.2023.101249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/05/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is an irreversible chronic respiratory disease which outcome depends on medication adherence. Pharmacists may increase this adherence by advising patients on inhaler devices proper use. This paper presents the protocol for a randomized controlled trial, which assesses impact of pharmaceutical consultations on COPD exacerbations, medical care, adherence to inhaler devices and quality of life. Methods This trial will include 226 COPD patients treated with inhaler devices: 94 in a control group, 66 receiving a pharmaceutical consultation at hospital and 66 receiving up to 12 pharmaceutical consultations corresponding to dispensing at their community pharmacy. The aim of these interventions is to inform patients about COPD medication, train them in the use of inhaler devices and improve adherence. Patients included by hospital pharmacist will be randomly assigned to the control and hospital experimental groups. Community pharmacists (CP) will include patients in the experimental community group. CPs will follow-up all study patients for 12 months. Primary outcome is the mean number of COPD exacerbations. Secondary outcomes include number of medical consultations, emergency visits and hospitalizations, patients' adherence devices and quality of life. Discussion This is the first French trial which assesses both hospital and community pharmaceutical interventions on COPD patients. Study limitations include recruitment and CP adherence to follow-up. Indeed, the success of this trial depends on the willingness of CPs to collect the data. This work is the first step towards building a network of CPs trained for clinical research. Trial registration Clinicaltrials.gov, NCT03704545. Registered on October 12th, 2018. https://clinicaltrials.gov/ct2/show/NCT03704545?cond=COPD&cntry=FR&city=nimes&draw=2&rank=1.
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Affiliation(s)
- Djamila Hachemi
- Department of Pharmacy, CHU Nimes, Univ Montpellier, Nimes, France
| | - Géraldine Leguelinel-Blache
- Department of Pharmacy, CHU Nimes, Univ Montpellier, Nimes, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
- Department of Law and Health Economics, Univ Montpellier, Montpellier, France
| | - Sophie Bouvet
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, CHU Nimes, Univ Montpellier, Nimes, France
| | - Clarisse Roux-Marson
- Department of Pharmacy, CHU Nimes, Univ Montpellier, Nimes, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
| | - Nathalie Plouvier
- Department of Pulmonology, CHU Nimes, Univ Montpellier, Nimes, France
| | - Jean-Marie Kinowski
- Department of Pharmacy, CHU Nimes, Univ Montpellier, Nimes, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
| | - Christel Castelli
- Department of Law and Health Economics, Univ Montpellier, Montpellier, France
- Department of Clinic Research, AESIO SANTE Méditerranée Beau Soleil Clinic, Montpellier, France
| | - Florent Dubois
- Department of Pharmacy, CHU Nimes, Univ Montpellier, Nimes, France
- Desbrest Institute of Epidemiology and Public Health (IDESP), Univ Montpellier, INSERM, Montpellier, France
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Nguyen T, Truong MTX, Lam DN, Nguyen HTT, Huynh AM, Duong VK, Vo TPM, Nguyen TH, Cao TTM, Pham ST, Tran BLT, Van Nguyen L. Effectiveness of clinical pharmacist intervention on medication adherence in patients with chronic obstructive pulmonary disease - A randomized controlled study. PATIENT EDUCATION AND COUNSELING 2024; 118:108037. [PMID: 37931404 DOI: 10.1016/j.pec.2023.108037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES In patients with chronic obstructive pulmonary disease (COPD), non-adherence remains challenging to achieve optimal disease control. Our study aimed to determine the impact of pharmacist-led educational interventions on COPD management, focusing mainly on medication adherence. METHODS We conducted a 1-month open-labeled, randomized, controlled study at Ba Ria Hospital, Vietnam. COPD outpatients were randomly assigned to the intervention group or control group. Pharmacist-delivered education emphasized medication adherence, disease, and medication knowledge. The primary outcome was the between-group difference in medication adherence after the intervention, as assessed by the general medication adherence scale (GMAS). RESULTS Of 181 recruited patients, 180 completed the follow-up. After the intervention, the results indicated a significant improvement in medication adherence rate between the two groups (90.1% vs. 66.3%, p < 0.001). Patient behavior was the most common barrier to non-adherence but was effectively reduced at the endpoint. The Modified Medical Research Council (mMRC) scale of dyspnea and inhalation technique also improved significantly in intervention patients. CONCLUSIONS Pharmacist intervention can considerably improve medication adherence and knowledge of COPD patients. PRACTICE IMPLICATIONS This study promotes the value of clinical pharmacists in patient education to achieve better adherence and enhance population health, especially in resource-limited nations like Vietnam.
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Affiliation(s)
- Thang Nguyen
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam.
| | - Mai Thi Xuan Truong
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Dung Ngoc Lam
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam.
| | | | - Anh Mai Huynh
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Vy Khanh Duong
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Thu Pham Minh Vo
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Thao Huong Nguyen
- Faculty of Pharmacy, Ho Chi Minh University of Medicine and Pharmacy, Ho Chi Minh, Viet Nam
| | - Thuy Thi My Cao
- Department of Respiratory Medicine, Can Tho Central General Hospital, Can Tho, Viet Nam
| | - Suol Thanh Pham
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Bao Lam Thai Tran
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
| | - Lam Van Nguyen
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Viet Nam
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Gagné M, Karanikas A, Green S, Gupta S. Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis. BMJ Open Respir Res 2023; 10:e001716. [PMID: 37730281 PMCID: PMC10510936 DOI: 10.1136/bmjresp-2023-001716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/04/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada. METHODS We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint. RESULTS We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year. CONCLUSIONS Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.
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Affiliation(s)
- Myriam Gagné
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Aliki Karanikas
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Samantha Green
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir Gupta
- Division of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Bivolaru S, Constantin A, Vlase CM, Gutu C. COPD Patients' Behaviour When Involved in the Choice of Inhaler Device. Healthcare (Basel) 2023; 11:healthcare11111606. [PMID: 37297746 DOI: 10.3390/healthcare11111606] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Inhaler therapy plays a crucial role in controlling respiratory symptoms in patients with chronic obstructive pulmonary disease (COPD). Incorrect or partially correct use of inhaler devices causes many chronic obstructive pulmonary disease (COPD) patients to continue to have respiratory symptoms due to poor drug deposition in the airways as a result of poor inhaler technique, leading to increased healthcare costs due to exacerbations and multiple emergency room presentations. Choosing the right inhaler device for each individual patient is a bigger challenge for doctors and chronic obstructive pulmonary disease (COPD) patients. The type of inhaler device and the correct inhaler technique depends on the control of symptoms in chronic obstructive pulmonary disease (COPD). Physicians treating patients with chronic obstructive pulmonary disease (COPD) play a central role in educating patients about the correct use of inhalation devices. The steps for the correct use of inhalation devices should be taught to patients by doctors in the presence of the family so that if the patient has difficulties handling the device correctly, the family can support them. METHODS Our analysis included 200 subjects divided into two groups-recommended group (RG) and chosen group (CG)-and aimed primarily to identify the behaviour of chronic obstructive pulmonary disease (COPD) patients when faced with deciding which type of inhaler device is most suitable for them. The two groups were monitored three times during the 12-month follow-up period. Monitoring required the physical presence of the patient at the investigating physician's office. The study included patients who were smokers, ex-smokers, and/or with significant exposure to occupational pollutants, aged over 40 years diagnosed with chronic obstructive pulmonary disease (COPD), risk group B and C according to the GOLD guideline staging, and on inhaled ICS+LABA treatment, although they had an indication for LAMA+LABA dual bronchodilation treatment. Patients presented for consultation on their own initiative for residual respiratory symptoms under background treatment with ICS+LABA. The investigating pulmonologist who offered consultations to all scheduled patients, on the occasion of the consultation, also checked the inclusion and exclusion criteria. If the patient did not meet the study entry criteria, they were assessed and received the appropriate treatment, and if the study entry criteria were met, the patient signed the consent and followed the steps recommended by the investigating pulmonologist. As a result, patient entry into the study was randomised 1:1, meaning that the first patient was recommended the inhaler device by the doctor and the next patient entered into the study was left to decide for themselves which type of device was most suitable for them. In both groups, the percentage of patients who had a different choice of inhaler device from that of their doctor was statistically significant. RESULTS Compliance to treatment at T12 was found to be low, but compared to results previously published on compliance, in our analysis, compliance was higher and the only reasons identified as responsible for the better results were related to the selection of the target groups and the regular assessments, where, in addition to reviewing the inhaler technique, patients were encouraged to continue treatment, thus creating a strong bond between patient and doctor. CONCLUSIONS Our analysis revealed that empowering patients by involving them in the inhaler selection process increases adherence to inhaler treatment, reduces the number of mistakes in inhaler use of the inhaler device, and implicitly the number of exacerbations.
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Affiliation(s)
- Sorin Bivolaru
- Clinical Medical Department, University of Medicine and Pharmacy Carol Davila Bucharest, 030167 Bucharest, Romania
| | - Ancuta Constantin
- Department of Cardio-Thoracic Pathology, Carol Davila University of Medicine and Pharmacy Bucharest, 030167 Bucharest, Romania
| | | | - Cristian Gutu
- Department of Medical Clinical, Dunarea de Jos University of Galati, 800008 Galati, Romania
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van Lieshout J, Lacroix J, van Halteren A, Teichert M. Effectiveness of a Pharmacist-Led Web-Based Medication Adherence Tool With Patient-Centered Communication: Results of a Clustered Randomized Controlled Trial. J Med Internet Res 2022; 24:e16141. [PMID: 35389359 PMCID: PMC9030914 DOI: 10.2196/16141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/30/2020] [Accepted: 02/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background Growing numbers of people use medication for chronic conditions; nonadherence is common, leading to poor disease control. A web-based tool to identify an increased risk for nonadherence with related potential individual barriers might facilitate tailored interventions and improve adherence. Objective This study aims to assess the effectiveness of a newly developed tool aimed at improving medication adherence. Methods We performed a cluster randomized controlled trial in patients initiating cardiovascular or oral blood glucose–lowering medication. Participants were recruited from community pharmacies. They completed an online questionnaire comprising assessments of their risk for medication nonadherence and subsequently of barriers to adherence. In pharmacies belonging to the intervention group, individual barriers displayed in a graphical profile on a tablet were discussed by pharmacists and patients with high nonadherence risk in face-to-face meetings and shared with their general practitioners and practice nurses. Tailored interventions were initiated by pharmacists. Barriers of control patients were not presented nor discussed and these patients received usual care. The primary outcome was the effectiveness of the intervention on medication adherence at 8 months’ follow-up between patients with an increased nonadherence risk from the intervention and control groups, calculated from dispensing data. Results Data from 492 participants in 15 community pharmacies were available for analyses (intervention 253, 7 pharmacies; control 239, 8 pharmacies). The intervention had no effect on medication adherence (B=–0.01; 95% CI –0.59 to 0.57; P=.96), nor in the post hoc per-protocol analysis (B=0.19; 95% CI –0.50 to 0.89; P=.58). Conclusions This study showed no effectiveness of a risk stratification and tailored intervention addressing personal barriers for medication adherence. Various potential explanations for lack of effectiveness were identified. These explanations relate, for instance, to high medication adherence in the control group, study power, and fidelity. Process evaluation should elicit possible improvements and inform the redesign of intervention and implementation. Trial Registration The Netherlands National Trial Register NTR5186; https://tinyurl.com/5d8w99hk
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Affiliation(s)
- Jan van Lieshout
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joyca Lacroix
- Department of Brain, Behavior & Cognition, Philips Research, Eindhoven, Netherlands
| | - Aart van Halteren
- Department of Chronic Disease Management, Philips Research, Eindhoven, Netherlands
| | - Martina Teichert
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, Netherlands
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Harrison OK, Marlow L, Finnegan SL, Ainsworth B, Pattinson KTS. Dissociating breathlessness symptoms from mood in asthma. Biol Psychol 2021; 165:108193. [PMID: 34560173 PMCID: PMC9355895 DOI: 10.1016/j.biopsycho.2021.108193] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/09/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
It is poorly understood why asthma symptoms are often discordant with objective medical tests. Differences in interoception (perception of internal bodily processes) may help explain symptom discordance, which may be further influenced by mood and attention. We explored inter-relationships between interoception, mood and attention in 63 individuals with asthma and 30 controls. Questionnaires, a breathing-related interoception task, two attention tasks, and standard clinical assessments were performed. Questionnaires were analysed using exploratory factor analysis, and linear regression examined relationships between measures. K-means clustering also defined asthma subgroups. Two concordant asthma subgroups (symptoms related appropriately to pathophysiology, normal mood) and one discordant subgroup (moderate symptoms, minor pathophysiology, low mood) were found. In all participants, negative mood correlated with decreased interoceptive ability and faster reaction times in an attention task. Our findings suggest that interpreting bodily sensations relates to mood, and this effect may be heightened in subgroups of individuals with asthma.
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Affiliation(s)
- Olivia K Harrison
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Switzerland; Department of Psychology, University of Otago, Dunedin, New Zealand; Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Lucy Marlow
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom; Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sarah L Finnegan
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Ben Ainsworth
- Department of Psychology, University of Bath, United Kingdom
| | - Kyle T S Pattinson
- Wellcome Centre for Integrative Neuroimaging, and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.
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Abstract
Background Although electronic monitoring is the “gold standard” for adherence monitoring, the range of inhaler devices on the market exceeds the availability of appropriate monitoring devices. Simple tools, applicable across a range of inhalers, are needed to assess patients’ adherence to prescribed inhaled medication. This study reports on the validation of an Inhaler Adherence Questionnaire (IAQ). Methods Seventy-four adults who self-reported doctor diagnosed asthma and who were prescribed daily inhaled corticosteroids (ICS) for asthma contributed data for these analyses. These participants were part of a larger study, investigating factors associated with non-adherence to prescribed daily inhaled corticosteroid medication. Participants were informed the research was investigating asthma management without explicit mention that medication adherence was being monitored. Inhaled corticosteroid medication adherence was measured in two ways. Firstly, participants completed the 6-item IAQ at enrolment. Secondly, ICS via pressurised Metered Dose Inhaler (pMDI) use was monitored electronically using the DoserCT which recorded daily use over 6 weeks. During the 6 weeks of prospective medication monitoring via the DoserCT we did not have contact with participants so that the adherence measure would reflect usual self-management behaviour. Results Two of the six questions in the IAQ had poor face validity and their exclusion from the questionnaire resulted in improved internal consistency. Mean days adherent were 37.1, 29.2 and 33.2% for subjects with IAQ scores of 0, 1 and 2 respectively. Higher IAQ scores of 3 and 4 were associated with greater mean days adherent of 73.7 and 67.4% respectively. A cut-point of 2 or less had a sensitivity of 73% and a specificity of 80% for detecting non-adherence. The area under the ROC curve was 0.764 (p < 0.001). Conclusions The modified 4-item IAQ is simple, quick to complete and useful for measuring adherence with prescribed daily inhaled medication. This validation of the IAQ provides evidence for its utility in research and it will be important to validate this simple, inexpensive tool for use in clinical practice.
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Apter AJ, Perez L, Han X, Ndicu G, Localio A, Park H, Mullen AN, Klusaritz H, Rogers M, Cidav Z, Bryant-Stephens T, Bender BG, Reisine ST, Morales KH. Patient Advocates for Low-Income Adults with Moderate to Severe Asthma: A Randomized Clinical Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3466-3473.e11. [PMID: 32673877 DOI: 10.1016/j.jaip.2020.06.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few interventions have targeted low-income adults with moderate to severe asthma despite their high mortality. OBJECTIVE To assess whether a patient advocate (PA) intervention improves asthma outcomes over usual care (UC). METHODS This 2-armed randomized clinical trial recruited adults with moderate to severe asthma from primary care and asthma-specialty practices serving low-income neighborhoods. Patients were randomized to 6 months of a PA intervention or UC. PAs were recent college graduates anticipating health care careers, who coached, modeled, and assisted participants with preparations for asthma-related medical visits, attended visits, and confirmed participants' understanding of provider recommendations. Participants were followed for at least a year for patient-centered asthma outcomes: asthma control (primary outcome), quality of life, prednisone requirements, emergency department visits, and hospitalizations. RESULTS There were 312 participants. Their mean age was 51 years (range, 19-93 years), 69% were women, 66% African American, 8% Hispanic/Latino, 62% reported hospitalization for asthma in the year before randomization, 21% had diabetes, and 61% had a body mass index of 30 or more. Asthma control improved over 12 months, more in the intervention group (-0.45 [95% CI, -0.67 to -0.21]) than in the UC group (-0.26 [95% CI, -0.53 to -0.01]), and was sustained at 24 months but with no statistical difference between groups. The 6-month rate of emergency department visits decreased in the intervention (-0.90 [95% CI, -1.56 to -0.42]) and UC (-0.42 [95% CI, -0.72 to -0.06]) groups over 12 months. The cost of the PA program was $1521 per patient. Only 64% of those assigned had a PA visit. CONCLUSIONS A PA may be a promising intervention to improve and sustain outcomes in this high-risk population if expanded to address factors that make keeping appointments difficult.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Xiaoyan Han
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Grace Ndicu
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Anna Localio
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Hami Park
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Alyssa N Mullen
- Temple Physicians, Inc, Temple University Health System, Philadelphia, Pa
| | - Heather Klusaritz
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Marisa Rogers
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Zuleyha Cidav
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa
| | | | | | | | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Tangirala NC, O'Conor R, Wolf MS, Wisnivesky JP, Federman AD. Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease. COPD 2020; 17:74-80. [PMID: 31948266 DOI: 10.1080/15412555.2020.1712688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated (r = 0.33, p < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, p=.49). Findings were similar for COPD patients: r = 0.26, p = 0.003; kappa 0.19, p = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.
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Affiliation(s)
- Neelima C Tangirala
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jarab AS, Mukattash TL. Exploring variables associated with medication non-adherence in patients with COPD. Int J Clin Pharm 2019; 41:1202-1209. [DOI: 10.1007/s11096-019-00895-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022]
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12
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Home visits for uncontrolled asthma among low-income adults with patient portal access. J Allergy Clin Immunol 2019; 144:846-853.e11. [PMID: 31181221 DOI: 10.1016/j.jaci.2019.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/11/2019] [Accepted: 05/14/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Asthma disproportionately affects low-income and minority adults. In an era of electronic records and Internet-based digital devices, it is unknown whether portals for patient-provider communication can improve asthma outcomes. OBJECTIVE We sought to estimate the effect on asthma outcomes of an intervention using home visits (HVs) by community health workers (CHWs) plus training in patient portals compared with usual care and portal training only. METHODS Three hundred one predominantly African American and Hispanic/Latino adults with uncontrolled asthma were recruited from primary care and asthma specialty practices serving low-income urban neighborhoods, directed to Internet access, and given portal training. Half were randomized to HVs over 6 months by CHWs to facilitate competency in portal use and promote care coordination. RESULTS One hundred seventy (56%) patients used the portal independently. Rates of portal activity did not differ between randomized groups. Asthma control and asthma-related quality of life improved in both groups over 1 year. Differences in improvements over time were greater for the HV group for all outcomes but reached conventional levels of statistical significance only for the yearly hospitalization rate (-0.53; 95% CI, -1.08 to -0.024). Poor neighborhoods and living conditions plus limited Internet access were barriers for patients to complete the protocol and for CHWs to make HVs. CONCLUSION For low-income adults with uncontrolled asthma, portal access and CHWs produced small incremental benefits. HVs with emphasis on self-management education might be necessary to facilitate patient-clinician communication and to improve asthma outcomes.
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Weerahandi H, Wisnivesky JP, O'Conor R, Wolf MS, Federman AD. The Relationship of Illness Beliefs with Hospital and Emergency Department Utilization in Chronic Obstructive Pulmonary Disease. J Gen Intern Med 2019; 34:923-928. [PMID: 30847827 PMCID: PMC6544700 DOI: 10.1007/s11606-019-04833-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/17/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, Brooklyn, NY, USA.
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Jardim JR, Nascimento OA. The Importance of Inhaler Adherence to Prevent COPD Exacerbations. Med Sci (Basel) 2019; 7:E54. [PMID: 30939829 PMCID: PMC6524014 DOI: 10.3390/medsci7040054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/25/2019] [Indexed: 11/16/2022] Open
Abstract
It has been shown that the better outcomes of chronic obstructive pulmonary disease (COPD) are closely associated with adherence to drug therapy, independent of the treatment administered. The clinical trial Towards a Revolution in COPD Health (TORCH) study clearly showed in a three year follow up that patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality. The Latin American Study of 24-hour Symptoms in Chronic Obstructive Pulmonary Disease (LASSYC), a real-life study, evaluated the self-reported inhaler adherence in COPD patients in seven countries in a cross-sectional non-interventional study and found that approximately 50% of the patients had good adherence, 30% moderate adherence and 20% poor adherence. Adherence to inhaler may be evaluated by the specific inhaler adherence questionnaire, the Test of Adherence to Inhalers (TAI). Several factors may predict the incorrect use of inhalers or adherence in COPD outpatient, including the number of devices and the daily dosing frequency. Ideally, patient education, simplicity of the device operation, the use of just one device for multiple medications and the best adaptation of the patient to the inhaler should guide the physician in prescribing the device.
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Affiliation(s)
- Jose R Jardim
- Respiratory Division, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/Unifesp), São Paulo 04023-062, Brazil.
- Pulmonary Rehabilitation Unit, EPM/Unifesp, São Paulo 04023-062, Brazil.
- Regional Medical Expert at GlaxoSmithKline (GSK), Rio de Janeiro 22783-110, Brazil.
| | - Oliver A Nascimento
- Respiratory Division, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/Unifesp), São Paulo 04023-062, Brazil.
- Pulmonary Rehabilitation Unit, EPM/Unifesp, São Paulo 04023-062, Brazil.
- Faculdade de Medicina São Leopoldo Mandic/Instituto São Leopoldo Mandic, Campinas 13045-755, Brazil.
- Internal Medical Expert at GlaxoSmithKline (GSK), Rio de Janeiro 22783-110, Brazil.
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15
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Bogart M, Stanford RH, Laliberté F, Germain G, Wu JW, Duh MS. Medication adherence and persistence in chronic obstructive pulmonary disease patients receiving triple therapy in a USA commercially insured population. Int J Chron Obstruct Pulmon Dis 2019; 14:343-352. [PMID: 30863037 PMCID: PMC6388782 DOI: 10.2147/copd.s184653] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION This longitudinal, retrospective cohort study of patients with COPD describes baseline characteristics, adherence, and persistence following initiation of inhaled corticosteroids (ICS)/long-acting β2-agonists (LABA)/long-acting muscarinic antagonists (LAMA) from multiple inhaler triple therapy (MITT). METHODS Patients aged ≥40 years receiving MITT between January 2012 and September 2015 were identified from the IQVIA™ Real-world Data Adjudicated Claims-USA database. MITT was defined as subjects with ≥1 overlapping days' supply of three COPD medications (ICS, LABA, and LAMA). Adherence (proportion of days covered, PDC) and discontinuation (defined as a gap of 1, 30, 60, or 90 days of supply in any of the three components of the triple therapy) were calculated for each patient over 12 months of follow-up. In addition, analyses were stratified by number of inhalers. RESULTS In total, 14,635 MITT users were identified (mean age, 62 years). Mean PDC for MITT at 12 months was 0.37%. Mean PDC for the ICS/LABA and LAMA component at 12 months was 49% (0.49±0.31; median, 0.47) and 54% (0.54±0.33; 0.56), respectively. The proportion of adherent patients (PDC ≥0.8) at 12 months was 14% for MITT. Allowing for a 30-day gap from last day of therapy, 86% of MITT users discontinued therapy during follow-up. CONCLUSION Patients with COPD had low adherence to and persistence with MITT in a real-world setting. Mean PDC for each single inhaler component was higher than the mean PDC observed with MITT. Reducing the number of inhalers may improve overall adherence to intended triple therapy.
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Effects of health literacy and cognitive abilities on COPD self-management behaviors: A prospective cohort study. Respir Med 2019; 160:105630. [PMID: 30850277 DOI: 10.1016/j.rmed.2019.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Low rates of adherence to self-management behaviors are common among patients with COPD. Health literacy and cognitive abilities may influence engagement in self-management behaviors. We sought to assess the association between health literacy and cognitive abilities with self-management behaviors in patients with COPD. METHODS We conducted an observational cohort study among American adults with COPD in New York, New York, and Chicago, Illinois. Outcomes included adherence to COPD medication, metered dose inhaler (MDI) and dry powder inhaler (DPI) technique, receipt of vaccination, and routine healthcare appointments. Health literacy was measured with the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of global, fluid (working memory, processing speed, executive function) and crystallized (verbal) ability. RESULTS Adequate health literacy was associated with adequate adherence to COPD medications (OR 1.46; 95% CI, 1.02-2.08), correct MDI (OR 1.66; 95% CI, 1.13-2.44) and DPI (OR 2.17; 95% CI, 1.30-3.64) technique. Fluid abilities were also associated with medication behaviors and visiting a regular healthcare provider, while crystalized abilities were not. Global cognitive abilities were associated with correct inhaler technique. No other associations were found with non-medication self-management behaviors. CONCLUSIONS COPD patients with limited health literacy and deficits in fluid cognitive abilities have lower rates of adherence and poorer inhaler technique than individuals with adequate health literacy and greater fluid cognitive abilities. These findings highlight the importance of considering the health literacy level and cognitive ability when caring for and educating patients with COPD.
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Lee JK, Rhee CK, Kim K, Ra SW, Lee JH, Jung KS, Yoo KH, Kim YI, Kim DK. Prescription Status and Clinical Outcomes of Methylxanthines and Leukotriene Receptor Antagonists in Mild-to-Moderate Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2019; 14:2639-2647. [PMID: 31819397 PMCID: PMC6885559 DOI: 10.2147/copd.s216326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 11/11/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Methylxanthines and leukotriene receptor antagonists (LTRA) are not a first-line medical treatment for chronic obstructive pulmonary disease (COPD) but are frequently prescribed despite limited evidence. We aimed to elucidate the real prescribing status and clinical impacts of these agents in early COPD patients. METHODS Patients with mild-to-moderate COPD (FEV1>50%) were selected from the Korean National Health and Nutrition Examination Survey data between 2007 and 2012. Besides analyzing the prescription status of methylxanthines and LTRA and the contributing factors to the prescription, we evaluated the clinical impacts of these drugs on the exacerbation, hospitalization, and medical costs. RESULTS Of 2269 patients with mild-to-moderate COPD, 378 patients (16.7%) were under medical treatments, and the users of methylxanthines and/or LTRA were 279 patients (12.3%); however, only 139 patients (6.1%) were inhaler users. The contributing factors for the prescription of methylxanthines were a comorbidity of asthma or allergic disease, poor lung function, low quality of life, prescribing doctor from the specialty of internal medicine, and an institution type of private hospital. The prescription of LTRA was associated with the comorbidity of allergic disease. The methylxanthine and/or LTRA users had more hospital utilization but did not have significant differences in acute exacerbations and medical cost for hospital utilization, compared with the non-users. CONCLUSION Methylxanthines and LTRA were used in a significant proportion of patients with mild-to-moderate COPD in real fields without favorable impacts on the exacerbations, hospitalizations, or medical costs. The use of more effective inhaled medications should be encouraged.
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Affiliation(s)
- Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungjoo Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Won Ra
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jae Ha Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ki-Suck Jung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Kwang Ha Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Yoo-Il Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea
- Correspondence: Deog Kyeom Kim Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, #395 Shindaebang-2-Dong, Dongjak-Gu, Seoul156-707, Republic of KoreaTel +82-2-870-2228Fax +82-2-831-0714 Email
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Hunt V, Anderson D, Lowrie R, Montgomery Sardar C, Ballantyne S, Bryson G, Kyle J, Hanlon P. A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD. NPJ Prim Care Respir Med 2018; 28:38. [PMID: 30305634 PMCID: PMC6180130 DOI: 10.1038/s41533-018-0105-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/13/2018] [Accepted: 08/07/2018] [Indexed: 01/12/2023] Open
Abstract
UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p < 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality. Clinical pharmacists, working in collaboration with respiratory specialists, can help people who live at home with chronic obstructive pulmonary disease (COPD) better manage their medications and symptoms. In a non-randomised pilot study, Richard Lowrie from the NHS Greater Glasgow and Clyde,
UK, and colleagues found that patients with COPD who receive standard at-home care—which includes visits to GP surgeries and hospital-based respiratory out-patient clinics, and visits from respiratory specialist nurses—were more likely to experience exacerbations and need lengthy hospital stays than those who additionally received home visits from a clinical pharmacist. The pharmacist, in consultation with the patient’s respiratory physician, often proposed medication changes and suggested additional testing or referrals that presumably explain the improved health outcomes. The authors conclude that a large, randomised trial is warranted to further evaluate the merits of this collaborative intervention for community dwelling patients with COPD.
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Affiliation(s)
- Vicki Hunt
- East Renfrewshire Health and Social Care Partnership Eastwood Health and Care Centre, Drumby Crescent, Glasgow, Scotland, United Kingdom
| | | | - Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom.
| | - Colette Montgomery Sardar
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom
| | - Susan Ballantyne
- Prescribing Support Pharmacy Team, North East Glasgow HSCP, Glasgow, United Kingdom
| | - Graeme Bryson
- Glasgow City Health and Social Care Partnership, Glasgow, United Kingdom
| | - John Kyle
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Peter Hanlon
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Abdulsalim S, Unnikrishnan MK, Manu MK, Alrasheedy AA, Godman B, Morisky DE. Structured pharmacist-led intervention programme to improve medication adherence in COPD patients: A randomized controlled study. Res Social Adm Pharm 2018; 14:909-914. [DOI: 10.1016/j.sapharm.2017.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 10/22/2017] [Indexed: 12/24/2022]
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Graf J, Lucke T, Herrera R, Watz H, Holle R, Vogelmeier C, Ficker JH, Jörres RA. Compatibility of medication with PRISCUS criteria and identification of drug interactions in a large cohort of patients with COPD. Pulm Pharmacol Ther 2018; 49:123-129. [PMID: 29421666 DOI: 10.1016/j.pupt.2018.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
Abstract
Patients with COPD are often of advanced age and have a high number of medications due to their lung disease and comorbidities. Thus they are at risk for unwanted effects from drugs, either due to age or due to interactions between drugs. These issues are not clarified. We therefore assessed the number of medications and potential adverse effects in a large cohort of patients with COPD. The analysis was performed in 2741 patients of the German COPD cohort COSYCONET, using baseline data (visit 1) and follow-up data after about 1.5 years (visit 3). Spirometric GOLD grades 1-4 were found in 8/35/32/9% of patients and GOLD groups ABCD in 7/25/4/48% of patients, while the remaining patients (n = 450, 16.4%) could not be classified according to GOLD criteria. The compatibility of medication with age was evaluated via the PRISCUS list, drug interactions via the AiD clinic system, whereby only drug combinations occurring in at least 10 patients were considered (nine unwanted interactions, one wanted interaction). The median numbers of medications were 5 or more in all patient categories, among them 3 or more non-respiratory medications. In the total population there were 153 patients (10.2%) aged ≥65 years who had any medication of the PRISCUS list with intermediate or low risk. Serious adverse combinations of drugs according to AiD occurred in 114 patients (4.2%), while the number of unwanted but only potentially clinically relevant combinations was 175 (6.4%). The number of wanted combinations was 219 (8.0%). These numbers did not markedly change when restricting the analysis to patients of GOLD grades 1-4. Moreover, the results were similar for visit 1 and visit 3. We conclude that in a large cohort of COPD patients about 10% of patients aged at least 65 years had medications that could interfere with their age and that the proportions of patients with either unwanted or wanted drug interactions were both in the range of 8-10%. These results suggest that problems arising from the high number of medications were not very frequent in the COPD cohort analysed.
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Affiliation(s)
- Jana Graf
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital LMU Munich, München, Germany; Comprehensive Pneumology Center Munich, DZL, German Center for Lung Research, München, Germany
| | - Tanja Lucke
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital LMU Munich, München, Germany; Comprehensive Pneumology Center Munich, DZL, German Center for Lung Research, München, Germany
| | - Ronald Herrera
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital LMU Munich, München, Germany; Center for International Health, Ludwig-Maximilians-University (LMU) Munich, München, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North, Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Rolf Holle
- German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Comprehensive Pneumology Center Munich (CPC-M), Neuherberg, Germany
| | - Claus Vogelmeier
- Pulmonary and Critical Care Medicine, Department of Medicine, University Medical Center Giessen and Marburg, Philipps-University, Marburg, Germany
| | - Joachim H Ficker
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Klinikum Nuremberg, Nürnberg, Germany; Paracelsus Medical University Nuremberg, Nürnberg, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital LMU Munich, München, Germany; Comprehensive Pneumology Center Munich, DZL, German Center for Lung Research, München, Germany.
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Adherence to Maintenance Medications among Older Adults with Chronic Obstructive Pulmonary Disease. The Role of Depression. Ann Am Thorac Soc 2018; 13:1497-504. [PMID: 27332765 DOI: 10.1513/annalsats.201602-136oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Among individuals with chronic obstructive pulmonary disease (COPD), depression is one of the most common yet underrecognized and undertreated comorbidities. Although depression has been associated with reduced adherence to maintenance medications used in other conditions, such as diabetes, little research has assessed the role of depression in COPD medication use and adherence. OBJECTIVES The objective of this study was to assess the impact of depression on COPD maintenance medication adherence among a nationally representative sample of Medicare beneficiaries newly diagnosed with COPD. METHODS We used a 5% random sample of Medicare administrative claims data to identify beneficiaries diagnosed with COPD between 2006 and 2010. We included beneficiaries with 2 years of continuous Medicare Parts A, B, and D coverage and at least two prescription fills for COPD maintenance medications after COPD diagnosis. We searched for prescription fills for inhaled corticosteroids, long-acting β-agonists, and long-acting anticholinergics and calculated adherence starting at the first fill. We modeled adherence to COPD maintenance medications as a function of new episodes of depression, using generalized estimated equations. MEASUREMENTS AND MAIN RESULTS Our primary outcome was adherence to COPD maintenance medications, measured as proportion of days covered. The exposure measure was depression. Both COPD and depression were assessed using diagnostic codes in Part A and B data. Covariates included sociodemographics, as well as clinical markers, including comorbidities, COPD severity, and depression severity. Of 31,033 beneficiaries meeting inclusion criteria, 6,227 (20%) were diagnosed with depression after COPD diagnosis. Average monthly adherence to COPD maintenance medications was low, peaking at 57% in the month after first fill and decreasing to 35% within 6 months. In our adjusted regression model, depression was associated with decreased adherence to COPD maintenance medications (odds ratio, 0.93; 95% confidence interval, 0.89-0.98). CONCLUSIONS New episodes of depression decreased adherence to maintenance medications used to manage COPD among older adults. Clinicians who treat older adults with COPD should be aware of the development of depression, especially during the first 6 months after COPD diagnosis, and monitor patients' adherence to prescribed COPD medications to ensure best clinical outcomes.
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Montes de Oca M, Menezes A, Wehrmeister FC, Lopez Varela MV, Casas A, Ugalde L, Ramirez-Venegas A, Mendoza L, López A, Surmont F, Miravitlles M. Adherence to inhaled therapies of COPD patients from seven Latin American countries: The LASSYC study. PLoS One 2017; 12:e0186777. [PMID: 29140978 PMCID: PMC5687703 DOI: 10.1371/journal.pone.0186777] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/06/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This study assessed the adherence profiles to inhaled therapies and the agreement between two patient self-report adherence methods in stable COPD lpatients from seven Latin American countries. METHODS This observational, cross-sectional, multinational, multicenter study involved 795 COPD patients (post-bronchodilator forced expiratory volume in 1 second/forced vital capacity [FEV1/FVC] <0.70). Adherence to inhaled therapy was assessed using the specific Test of Adherence to Inhalers (10-item TAI) and the generic 8-item Morisky Medication Adherence Scale (MMAS-8) questionnaires. The percentage agreement and the kappa index were used to compare findings. RESULTS 59.6% of patients were male (69.5±8.7 years); post-bronchodilator FEV1 percent predicted was 50.0±18.6%. Mean values for 10-item TAI and MMAS-8 questionnaires were 47.4±4.9 and 6.8±1.6, respectively. Based on the TAI questionnaire, 54.1% of patients had good, 26.5% intermediate, and 19.4% poor adherence. Using the MMAS-8 questionnaire, 51% had high, 29.1% medium, and 19.9% low adherence. According to both questionnaires, patients with poor adherence had lower smoking history, schooling but higher COPD Assessment Test score, exacerbations in the past-year and post-bronchodilator FEV1. The agreement between 10-item TAI and MMAS-8 questionnaires was moderate (Kappa index: 0.42; agreement: 64.7%). CONCLUSION Suboptimal adherence to medication was frequent in COPD patients from Latin America. Low adherence was associated with worse health status impairment and more exacerbations. There was inadequate agreement between the two questionnaires. Greater effort should be made to improve COPD patients' adherence to treatment, and assessment of adherence with more specific instruments, such as the TAI questionnaire, would be more convenient in these patients. CLINICAL TRIAL REGISTRATION NCT02789540.
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Affiliation(s)
| | - Ana Menezes
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | | | | | | | | | - Laura Mendoza
- Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Ana López
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Filip Surmont
- AstraZeneca, Wilmington, Delaware, United States of America
| | - Marc Miravitlles
- Department of Pneumology, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES) Barcelona, Spain
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Negewo NA, Gibson PG, Wark PA, Simpson JL, McDonald VM. Treatment burden, clinical outcomes, and comorbidities in COPD: an examination of the utility of medication regimen complexity index in COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2929-2942. [PMID: 29062230 PMCID: PMC5638593 DOI: 10.2147/copd.s136256] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background COPD patients are often prescribed multiple medications for their respiratory disease and comorbidities. This can lead to complex medication regimens resulting in poor adherence, medication errors, and drug–drug interactions. The relationship between clinical outcomes and medication burden beyond medication count in COPD is largely unknown. Objectives The aim of this study was to explore the relationships of medication burden in COPD with clinical outcomes, comorbidities, and multidimensional indices. Methods In a cross-sectional study, COPD patients (n=222) were assessed for demographic information, comorbidities, medication use, and clinical outcomes. Complexity of medication regimens was quantified using the validated medication regimen complexity index (MRCI). Results Participants (58.6% males) had a mean (SD) age of 69.1 (8.3) years with a postbronchodilator forced expiratory volume in 1 second % predicted of 56.5 (20.4) and a median of five comorbidities. The median (q1, q3) total MRCI score was 24 (18.5, 31). COPD-specific medication regimens were more complex than those of non-COPD medications (median MRCI: 14.5 versus 9, respectively; P<0.0001). Complex dosage formulations contributed the most to higher MRCI scores of COPD-specific medications while dosing frequency primarily drove the complexity associated with non-COPD medications. Participants in Global Initiative for Chronic Obstructive Lung Disease quadrant D had the highest median MRCI score for COPD medications (15.5) compared to those in quadrants A (13.5; P=0.0001) and B (12.5; P<0.0001). Increased complexity of COPD-specific treatments showed significant but weak correlations with lower lung function and 6-minute walk distance, higher St George’s Respiratory Questionnaire and COPD assessment test scores, and higher number of prior year COPD exacerbations and hospitalizations. Comorbid cardiovascular, gastrointestinal, or metabolic diseases individually contributed to higher total MRCI scores and/or medication counts for all medications. Charlson Comorbidity Index and COPD-specific comorbidity test showed the highest degree of correlation with total MRCI score (ρ=0.289 and ρ=0.326; P<0.0001, respectively). Conclusion In COPD patients, complex medication regimens are associated with disease severity and specific class of comorbidities.
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Affiliation(s)
- Netsanet A Negewo
- Priority Research Centre for Healthy Lungs.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle
| | - Peter Ab Wark
- Priority Research Centre for Healthy Lungs.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle
| | - Jodie L Simpson
- Priority Research Centre for Healthy Lungs.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle.,School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
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Adherence and healthcare utilization among older adults with COPD and depression. Respir Med 2017; 129:53-58. [PMID: 28732836 DOI: 10.1016/j.rmed.2017.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 05/04/2017] [Accepted: 06/02/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Adherence to chronic obstructive pulmonary disease (COPD) maintenance medications and antidepressants may reduce healthcare utilization among multimorbid individuals with COPD and depression. We quantified the independent effects of adherence to antidepressants and COPD maintenance medications on healthcare utilization among individuals co-diagnosed with COPD and depression. PROCEDURES We conducted a retrospective cohort study using a 2006-2012 5% random sample of Medicare beneficiaries co-diagnosed with COPD and depression who had two or more prescription fills of both COPD maintenance medications and antidepressants. We measured adherence to medications using the proportion of days covered per 30-day period. The primary outcomes were all-cause emergency department (ED) visits and hospitalizations. Beneficiaries were followed over a minimum 12-month follow-up period. RESULTS Of the 16,075 beneficiaries meeting inclusion criteria, 21% achieved adherence ≥80% to COPD maintenance medications and 55% achieved adherence ≥80% to antidepressants. Compared to no use and controlling for antidepressant adherence and potential confounders, higher (≥80%) levels of adherence to COPD maintenance medications were associated with decreased risk of ED visits (hazard ratio (HR) 0.79; 95% CI 0.74, 0.83) and hospitalizations (HR 0.82; 95% CI 0.78, 0.87). Similarly, higher levels (≥80%) of adherence to antidepressants resulted in decreased risk of ED visits (HR 0.74; 95% CI 0.70, 0.78) and hospitalizations (HR 0.77; 95% CI 0.73, 0.81) compared to no use. CONCLUSIONS Clinicians can assist in the improved management of their multimorbid patients' health by treating depression among patients with COPD and monitoring and encouraging adherence to the regimens they prescribe.
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Apter AJ, Morales KH, Han X, Perez L, Huang J, Ndicu G, Localio A, Nardi A, Klusaritz H, Rogers M, Phillips A, Cidav Z, Schwartz JS. A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial. Contemp Clin Trials 2017; 56:34-45. [PMID: 28315481 PMCID: PMC5503302 DOI: 10.1016/j.cct.2017.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/24/2022]
Abstract
Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Knashawn H Morales
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xiaoyan Han
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingru Huang
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Ndicu
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Localio
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alyssa Nardi
- Temple Physicians, Inc., Temple University Health System, Philadelphia, PA 19129, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Marisa Rogers
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis Phillips
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Zuleyha Cidav
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - J Sanford Schwartz
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
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Kleppe M, Lacroix J, Ham J, Midden C. A dual-process view on medication adherence: The role of affect. J Health Psychol 2017; 24:1033-1042. [PMID: 28810401 DOI: 10.1177/1359105317690599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Medication non-adherence has been recognised as one of the major problems in health care that leads to preventable costs and hospitalisations. This study aimed to assess the role of affect in medication adherence. We propose a dual-process framework of medication adherence based on the reflective-impulsive model, which includes both cognitive and affective processes. We tested this framework in a cross-sectional study (N = 525). The results supported this framework by illustrating the clear role of both cognitive and affective processes.
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Affiliation(s)
- Mieke Kleppe
- 1 HAN University of Applied Sciences, The Netherlands.,2 Philips Research Eindhoven, The Netherlands.,3 Eindhoven University of Technology, The Netherlands
| | | | - Jaap Ham
- 3 Eindhoven University of Technology, The Netherlands
| | - Cees Midden
- 3 Eindhoven University of Technology, The Netherlands
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Volpato E, Banfi P, Pagnini F. A psychological intervention to promote acceptance and adherence to non-invasive ventilation in people with chronic obstructive pulmonary disease: study protocol of a randomised controlled trial. Trials 2017; 18:59. [PMID: 28166828 PMCID: PMC5294889 DOI: 10.1186/s13063-017-1802-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/17/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND People with chronic obstructive pulmonary disease (COPD) sometimes experience anxiety, depression and comorbid cognitive deficits. Rather than being merely a consequence of symptom-related physical impairments these additional problems may be part of the clinical course of the condition. The relationship between the physical and psychological aspects of the condition is illustrated by the patterns of use of non-invasive ventilation (NIV); NIV is often rejected or used inappropriately, resulting in clinical deterioration and an increase in health care costs. The study aims to analyse the effects of psychological support on the acceptance of, and adherence to, NIV. The primary outcome will be a latent variable related to indices of use of NIV equipment and adherence to treatment regime; while survival rates and psychological variables will constitute the secondary outcomes. METHODS A two-arm randomised controlled trial will be conducted. We aim to recruit 150 COPD patients for whom NIV is indicated. The experimental group will receive a brief course of psychological support that will include counselling, relaxation and mindfulness-based exercises. In some cases, it will also include neuropsychological rehabilitation exercises. Support will be delivered via four to eight meetings at the HD Respiratory Rehabilitation Unit, at home or via telemedicine. Controls will receive standard care and watch educational videos related to the management of their disease. DISCUSSION This investigation will gain insight about the role of a psychological intervention as part of a treatment plan during the process of adaptation to NIV in COPD patients. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02499653 . Registered on 14 July 2015.
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Affiliation(s)
- Eleonora Volpato
- Department of Psychology, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 1, 20123 Milan, Italy
- HD Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Via Capecelatro 66, 20148 Milan, Italy
| | - Paolo Banfi
- HD Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Via Capecelatro 66, 20148 Milan, Italy
| | - Francesco Pagnini
- Department of Psychology, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 1, 20123 Milan, Italy
- Department of Psychology, Harvard University, Cambridge, MA USA
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George J, Munro K, McCaig DJ, Stewart DC. Prescription Medications: Beliefs, Experiences, Behavior, and Adherence of Sheltered Housing Residents. Ann Pharmacother 2016; 40:2123-9. [PMID: 17077169 DOI: 10.1345/aph.1h355] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Data on medication utilization among residents of sheltered housing complexes (SHCs) are limited. Objective: To evaluate the extent of nonadherence to prescribed medications among residents of SHCs and identify factors associated with nonadherence. Methods: A 58 item, pre-piloted questionnaire with validated items for patient self-assessment of medication risk; adherence; disability; health beliefs, experiences, and behavior; and general items on demographics, health, and medication use was mailed to 1137 SHC residents in Aberdeen, Scotland. Predictors of nonadherence (Morisky score >0) were identified using logistic regression. Results: Of the 695 (61.1%) respondents, 645 (mean ± SD age, 78.2 ± 7.8 y) reported using prescribed drugs. Nonadherence was reported by 176 of 627 (28.1%) residents. The predictors of nonadherence were: disagreeing with the statement, “I ensure I have enough medicines so that I don't run out” (OR 0.48; 95% CI 0.30 to 0.77), agreeing with the statements, “I make changes in the recommended management to suit my lifestyle” (OR 1.32; 95% CI 1.09 to 1.60) and “I get confused about my medicines” (OR 1.39; 95% CI 1.10 to 1.77), younger age (OR 0.96; 95% CI 0.94 to 0.99), not getting help from someone to use the medications correctly (OR 2.20; 95% CI 1.21 to 3.99), and agreeing with the statement, “I am concerned about the side effects from my medicines” (OR 1.31; 95% CI 1.05 to 1.63). Conclusions: Over one-quarter of SHC residents were found to be nonadherent to prescribed drugs. Risk factors for nonadherence include younger age, confusion about drugs, lack of support for drug supply and administration, interference of treatment recommendations with lifestyle, and a perceived view of risks outweighing benefits in using recommended drug therapy.
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Affiliation(s)
- Johnson George
- School of Pharmacy, The Robert Gordon University, School-hill, Aberdeen, Scotland.
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Davis E, Marra C, Gamble JM, Farrell J, Lockyer J, FitzGerald JM, Abu-Ashour W, Gillis C, Hawboldt J. Effectiveness of a pharmacist-driven intervention in COPD (EPIC): study protocol for a randomized controlled trial. Trials 2016; 17:502. [PMID: 27737686 PMCID: PMC5064938 DOI: 10.1186/s13063-016-1623-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 09/25/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) are often nonadherent with medications and have poor inhaler technique. Community pharmacists can help to improve health-related quality of life and overall outcomes in patients with COPD. We aim to measure the effectiveness of a systematic, pharmacist-driven intervention on patients with diagnosed COPD. METHODS/DESIGN This pragmatic, parallel-group, cluster randomized controlled trial is designed to determine the effectiveness of a multifactorial, pharmacist-led intervention on medication adherence, inhaler technique, health-related quality of life, health care resource utilization including COPD exacerbations, and use of medications. Participating pharmacies in Newfoundland and Labrador (NL), Canada will be randomly assigned to either the intervention or the control group. The intervention group will deliver an enhanced form of care that emphasizes COPD management. The control group will provide usual care and a COPD education pamphlet. Included patients will be aged 40 years or older, have a physician-confirmed diagnosis of COPD, and be able to answer questionnaires in English. The primary outcomes are the between-group difference in the change from baseline to 6 months in medication adherence using the Medication Possession Ratio (MPR) and the Morisky Medication Adherence Scale (MMAS-8). The secondary outcomes are also measured from baseline to 6 months, and include the proportion of patients with a clinically significant change in adherence, the proportion of patients defined as having "good adherence," the mean MPR between groups, quality of life as measured by the St. George's Respiratory Questionnaire, medication inhalation technique using a pharmacist-scored checklist, health care resource utilization and antibiotic and orally administered corticosteroid use for COPD exacerbations. Differences between groups will be analyzed at the individual patient level while controlling for clustering effect. DISCUSSION A pharmacist-led COPD intervention has the potential to improve patient medication adherence, thus increasing quality of life, possibly decreasing pulmonary exacerbations and reducing utilization of acute health care resources. Methods and results taken from this study could be used to enhance the delivery of COPD care by community pharmacists in a real-world setting. This would serve to enhance COPD population health and quality of life. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) ISRCTN78138190 , registered on 3 February 2016.
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Affiliation(s)
- Erin Davis
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
- Memorial University Faculty of Medicine, Discipline of Family Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - Carlo Marra
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - John-Michael Gamble
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
- Memorial University Faculty of Medicine, Discipline of Family Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - Jamie Farrell
- Memorial University Faculty of Medicine, Discipline of Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
- NL Eastern Health, Respiratory Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - Joe Lockyer
- Memorial University Faculty of Medicine, Discipline of Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
- NL Eastern Health, Respiratory Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - J. Mark FitzGerald
- Division of Respiratory Medicine, The University of British Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9 Canada
| | - Waseem Abu-Ashour
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - Charlie Gillis
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
| | - John Hawboldt
- Memorial University School of Pharmacy, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
- NL Eastern Health, Respiratory Medicine, 300 Prince Philip Dr., St. John’s, NL A1B 3V6 Canada
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Di Martino M, Ventura M, Cappai G, Lallo A, Davoli M, Agabiti N, Fusco D. Adherence to Long-Acting Bronchodilators After Discharge for COPD: How Much of the Geographic Variation is Attributable to the Hospital of Discharge and How Much to the Primary Care Providers? COPD 2016; 14:86-94. [PMID: 27419396 DOI: 10.1080/15412555.2016.1202225] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In moderate-severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007-2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially 'reflect' the clinical approach of hospitals of discharge.
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Affiliation(s)
- Mirko Di Martino
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Martina Ventura
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Giovanna Cappai
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Adele Lallo
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Marina Davoli
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Nera Agabiti
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Danilo Fusco
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
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Hilbink M, Lacroix J, Bremer-van der Heiden L, van Halteren A, Teichert M, van Lieshout J. Effectiveness of a medication-adherence tool: study protocol for a randomized controlled trial. Trials 2016; 17:274. [PMID: 27255080 PMCID: PMC4891916 DOI: 10.1186/s13063-016-1393-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 05/05/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Research shows that more than half of the people taking medication for a chronic condition are non-adherent. Nonadherence hinders disease control with a burden on patient quality of life and healthcare systems. We developed a tool that provides insight into nonadherence risks and barriers for medication-adherence including an intervention strategy to overcome those barriers. This study aims to assess the effectiveness of using this adherence tool in starters with cardiovascular or oral blood glucose-lowering medication to improve medication-adherence. METHODS/DESIGN In a cluster-randomized controlled trial 25 pharmacies in the Netherlands will be randomized to the intervention or control arm. Patients registered in a general practice participating in a collaborative can be included when they start cardiovascular or oral blood glucose-lowering medication prescribed by their general practitioner. Participants complete an assessment consisting of measuring nonadherence risk and potential barriers to adherence. For patients with an increased nonadherence risk, a graphic barrier profile is created, showing to what extent eight cognitive, emotional, or practical barriers are present. All patients will fill in the medication-adherence assessment twice: between 1 and 2 weeks after the start of the medication and after 8 months. The intervention strategy consists of discussing this barrier profile to overcome barriers. Pharmacists and assistants of the intervention pharmacies are trained in discussing the profile and to offer a tailored intervention to overcome barriers. In the control arm, patients receive care as usual. The primary outcome is medication-adherence of patients with a high risk of nonadherence at 8 months follow-up. Secondary outcomes include the difference in the percentage of patients with an increased nonadherence risk between intervention and control group after 8 months, the predictive values of the baseline questionnaire in the control group in relation to medication-adherence after 8 months, medication-adherence after 1 year follow-up, and barriers and facilitators in the implementation of the tool. DISCUSSION This manuscript presents the protocol for a cluster-randomized clinical trial on the use of an adherence tool to improve medication-adherence. This study will provide insight into the effectiveness of the tool in starters with cardiovascular or oral blood glucose-lowering medication in improvement of medication-adherence. TRIAL REGISTRATION The Netherlands National Trial Register, NTR5186 . Registered on 18 May 2015.
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Affiliation(s)
- Mirrian Hilbink
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, PO box 9101, Code: 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands
| | - Joyca Lacroix
- Behavior, Cognition & Perception, Philips Research, Eindhoven, The Netherlands
| | | | - Aart van Halteren
- Behavior, Cognition & Perception, Philips Research, Eindhoven, The Netherlands
| | - Martina Teichert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, PO box 9101, Code: 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands
| | - Jan van Lieshout
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, PO box 9101, Code: 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.
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Trifilieff A, Ethell BT, Sykes DA, Watson KJ, Collingwood S, Charlton SJ, Kent TC. Comparing the cardiovascular therapeutic indices of glycopyrronium and tiotropium in an integrated rat pharmacokinetic, pharmacodynamic and safety model. Toxicol Appl Pharmacol 2015; 287:9-16. [DOI: 10.1016/j.taap.2015.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 12/17/2022]
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Kale MS, Federman AD, Krauskopf K, Wolf M, O’Conor R, Martynenko M, Leventhal H, Wisnivesky JP. The Association of Health Literacy with Illness and Medication Beliefs among Patients with Chronic Obstructive Pulmonary Disease. PLoS One 2015; 10:e0123937. [PMID: 25915420 PMCID: PMC4411058 DOI: 10.1371/journal.pone.0123937] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 03/09/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Low health literacy is associated with low adherence to self-management in many chronic diseases. Additionally, health beliefs are thought to be determinants of self-management behaviors. In this study we sought to determine the association, if any, of health literacy and health beliefs among elderly individuals with COPD. METHODS We enrolled a cohort of patients with COPD from two academic urban settings in New York, NY and Chicago, IL. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Using the framework of the Self-Regulation Model, illness and medication beliefs were measured with the Brief Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ). Unadjusted analyses, with corresponding Cohen's d effect sizes, and multiple logistic regression were used to assess the relationships between HL and illness and medication beliefs. RESULTS We enrolled 235 participants, 29% of whom had low health literacy. Patients with low health literacy were more likely to belong to a racial minority group (p<0.001), not be married (p = 0.006), and to have lower income (p<0.001) or education (p<0.001). In unadjusted analyses, patients with low health literacy were less likely to believe they will always have COPD (p = 0.003, Cohen's d = 0.42), and were more likely to be concerned about their illness ((p = 0.04, Cohen's d = 0.17). In analyses adjusted for sociodemographic factors and other health beliefs, patients with low health literacy were less likely to believe that they will always have COPD (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65-0.94). In addition, the association of low health literacy with expressed concern about medications remained significant (OR: 1.20, 95% CI: 1.05-1.37) though the association of low health literacy with belief in the necessity of medications was no longer significant (OR: 0.92, 95% CI: 0.82-1.04). CONCLUSIONS In this cohort of urban individuals with COPD, low health literacy was prevalent, and associated with illness beliefs that predict decreased adherence. Our results suggest that targeted strategies to address low health literacy and related illness and medications beliefs might improve COPD medication adherence and other self-management behaviors.
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Affiliation(s)
- Minal S. Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Alex D. Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Katherine Krauskopf
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Michael Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Rachel O’Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Melissa Martynenko
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Howard Leventhal
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
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George J, Kong DCM, Santamaria NM, Ioannides-Demos LL, Stewart K. Adherence to Disease Management Interventions for COPD Patients: Patients' Perspectives. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2006.tb00630.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - David CM Kong
- Department of Pharmacy Practice; Monash University, The Alfred
| | | | - Lisa L Ioannides-Demos
- Ambulatory and Community Services, The Alfred, Department of Epidemiology and Preventive Medicine; Monash University
| | - Kay Stewart
- Department of Pharmacy Practice; Monash University; Parkville Victoria
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Krauskopf K, Federman AD, Kale MS, Sigel KM, Martynenko M, O’Conor R, Wolf MS, Leventhal H, Wisnivesky JP. Chronic Obstructive Pulmonary Disease Illness and Medication Beliefs are Associated with Medication Adherence. COPD 2015; 12:151-64. [PMID: 24960306 PMCID: PMC4305045 DOI: 10.3109/15412555.2014.922067] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Almost half of patients with COPD do not adhere to their medications. Illness and medication beliefs are important determinants of adherence in other chronic diseases. Using the framework of the Common Sense Model of Self-Regulation (CSM), we determined associations between potentially modifiable beliefs and adherence to COPD medications in a cohort of English- and Spanish-speaking adults with COPD from New York and Chicago. Medication adherence was assessed using the Medication Adherence Report Scale. Illness and medication beliefs along CSM domains were evaluated using the Brief Illness Perception Questionnaire (B-IPQ) and the Beliefs about Medications Questionnaire (BMQ). Unadjusted analysis (with Cohen's d effect sizes) and multiple logistic regression were used to assess the relationship between illness and medication beliefs with adherence. The study included 188 participants (47% Black, 13% Hispanics); 109 (58%) were non-adherent. Non-adherent participants were younger (p < 0.001), more likely to be Black or Hispanic (p = 0.001), to have reported low income (p = 0.02), and had fewer years of formal education (p = 0.002). In unadjusted comparisons, non-adherent participants reported being more concerned about their COPD (p = 0.011; Cohen's d = 0.43), more emotionally affected by the disease (p = 0.001; Cohen's d = 0.54), and had greater concerns about COPD medications (p < 0.001, Cohen's d = 0.81). In adjusted analyses, concerns about COPD medications independently predicted non-adherence (odds ratio: 0.52, 95% confidence interval: 0.36-0.75). In this cohort of urban minority adults, concerns about medications were associated with non-adherence. Future work should explore interventions to influence patient adherence by addressing concerns about the safety profile and long-term effects of COPD medications.
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Affiliation(s)
- Katherine Krauskopf
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Minal S Kale
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith M Sigel
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa Martynenko
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel O’Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Howard Leventhal
- Institute of Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Kleppe M, Lacroix J, Ham J, Midden C. The development of the ProMAS: a Probabilistic Medication Adherence Scale. Patient Prefer Adherence 2015; 9:355-67. [PMID: 25784791 PMCID: PMC4356448 DOI: 10.2147/ppa.s76749] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Current self-report medication adherence measures often provide heavily skewed results with limited variance, suggesting that most participants are highly adherent. This contrasts with findings from objective adherence measures. We argue that one of the main limitations of these self-report measures is the limited range covered by the behaviors assessed. That is, the items do not match the adherence behaviors that people perform, resulting in a ceiling effect. In this paper, we present a new self-reported medication adherence scale based on the Rasch model approach (the ProMAS), which covers a wide range of adherence behaviors. The ProMAS was tested with 370 elderly receiving medication for chronic conditions. The results indicated that the ProMAS provided adherence scores with sufficient fit to the Rasch model. Furthermore, the ProMAS covered a wider range of adherence behaviors compared to the widely used Medication Adherence Report Scale (MARS) instrument, resulting in more variance and less skewness in adherence scores. We conclude that the ProMAS is more capable of discriminating between people with different adherence rates than the MARS.
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Affiliation(s)
- Mieke Kleppe
- Human Technology Interaction, Eindhoven University of Technology, Eindhoven, the Netherlands
- Behavior, Cognition and Perception, Philips Research, Eindhoven, the Netherlands
- Correspondence: Mieke Kleppe, High Tech Campus 36, 5656 AE Eindhoven, the Netherlands, Email
| | - Joyca Lacroix
- Behavior, Cognition and Perception, Philips Research, Eindhoven, the Netherlands
| | - Jaap Ham
- Human Technology Interaction, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Cees Midden
- Human Technology Interaction, Eindhoven University of Technology, Eindhoven, the Netherlands
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Albertson TE, Harper R, Murin S, Sandrock C. Patient considerations in the treatment of COPD: focus on the new combination inhaler umeclidinium/vilanterol. Patient Prefer Adherence 2015; 9:235-42. [PMID: 25673975 PMCID: PMC4321647 DOI: 10.2147/ppa.s71535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Medication adherence among patients with chronic diseases, such as COPD, may be suboptimal, and many factors contribute to this poor adherence. One major factor is the frequency of medication dosing. Once-daily dosing has been shown to be an important variable in medication adherence in chronic diseases, such as COPD. New inhalers that only require once-daily dosing are becoming more widely available. Combination once-daily inhalers that combine any two of the following three agents are now available: 1) a long-acting muscarinic antagonist; 2) a long acting beta2 agonist; and 3) an inhaled corticosteroid. A new once-daily inhaler with both a long-acting muscarinic antagonist, umeclidinium bromide, and a long acting beta2 agonist, vilanterol trifenatate, is now available worldwide for COPD treatment. It provides COPD patients convenience, efficacy, and a very favorable adverse-effects profile. Additional once-daily combination inhalers are available or will soon be available for COPD patients worldwide. The use of once-daily combination inhalers will likely become the standard maintenance management approach in the treatment of COPD because they improve medication adherence.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
- Department of Medicine, Veterans Administration Northern California Health Care System, Mather, CA, USA
- Department of Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
- Correspondence: Timothy E Albertson, Department of Internal Medicine, 4150 V Street, Suite 3100, Sacramento, CA 95817, Email
| | - Richart Harper
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
- Department of Medicine, Veterans Administration Northern California Health Care System, Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
- Department of Medicine, Veterans Administration Northern California Health Care System, Mather, CA, USA
| | - Christian Sandrock
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA
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Steinberg M, Pervanas H. Assessment of Proper Medication Inhaler Technique in Adult Patients. J Pharm Technol 2014; 30:195-200. [DOI: 10.1177/8755122514553987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Many medications used to manage pulmonary disease are delivered via unique inhalation devices. Proper technique in using these devices is required for effective medication delivery. Objective: To assess the degree of proper inhaler technique among adult patients. Methods: Patients using inhalers were identified and then interviewed by pharmacy personnel regarding inhaler use. Checklists were used to document the adherence to manufacturers’ directions for each respective inhaler, and data were then tabulated and assessed for the number and types of inhalers used, incorrectly performed steps in using the inhalers, as well as demographic information of patients. Results: Of the 129 patients that were interviewed, a total of 212 inhalers were used. Twenty-five percent of inhalers (/212) were used incorrectly, with the 3 most common errors being improper priming or lack of test sprays, lack of proper exhalation prior to inhaling the medication, and absence or improper cleaning of inhalers. Furthermore, less than 4% of patients reported being instructed by a pharmacist on proper inhaler use. Conclusion: Inhaler technique among adult patients is substandard and is a key area for pharmacists to become more proactive in educating patients.
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Blasi F, Raddi F, Miravitlles M. Interactive Monitoring Service and COPD: Is it Possible to Reduce Nonadherence? COPD 2014; 12:227-32. [PMID: 25093542 DOI: 10.3109/15412555.2014.933796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) represents one of the main causes of death worldwide. It affects hundreds of millions of people and is likely to spread further in the coming years. Despite the chronic nature of the disease and the proven efficacy of current therapies, treatment nonadherence is unfortunately common and too often related to treatment failure, disease exacerbations, hospitalizations, and high healthcare costs. At present, studies aimed to assess and improve patients' adherence in chronic respiratory diseases--and especially in COPD--are limited, but a review of the few data available makes it clear that there is a need for an innovative approach that leverages health technology to encourage patients to adhere to prescribed chronic treatments.
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Affiliation(s)
- Francesco Blasi
- 1Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico , Milano , Italy
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Newman S. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert Opin Drug Deliv 2014; 11:365-78. [PMID: 24386924 DOI: 10.1517/17425247.2014.873402] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The inhaled route has many advantages, but requires the patient to use, and to master the use of, an inhaler device. Poor inhaler technique and non-adherence to therapy lead to a highly variable lung dose in clinical practice, with subsequent loss of clinical efficacy and wastage of economic resources. AREAS COVERED This paper discusses problems of poor inhaler technique, non-adherence to inhaler therapy, other issues relating to the precision of dose delivery, the consequences of these problems and how they can be addressed. EXPERT OPINION The precision of dosing by the pulmonary route can be improved by appropriate choice of inhaler device and by education. It is vital to educate patients about their disease, about the importance of taking prescribed medications and about correct inhaler use. One-on-one sessions with healthcare professionals probably represent the most effective educational method. For some drugs and patient groups, inhalers containing small microprocessors may also be used to control inhalation technique, and hence, to obtain a more reproducible lung dose. As the range of drugs delivered by inhalation increases, the need for correct inhaler technique, adherence to therapy and precise dosing becomes more and more important.
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Bryant J, McDonald VM, Boyes A, Sanson-Fisher R, Paul C, Melville J. Improving medication adherence in chronic obstructive pulmonary disease: a systematic review. Respir Res 2013; 14:109. [PMID: 24138097 PMCID: PMC4015036 DOI: 10.1186/1465-9921-14-109] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/14/2013] [Indexed: 12/18/2022] Open
Abstract
Adherence to medication among individuals with chronic obstructive pulmonary disease (COPD) is suboptimal and has negative impacts on survival and health care costs. No systematic review has examined the effectiveness of interventions designed to improve medication adherence. Electronic databases Medline and Cochrane were searched using a combination of MeSH and keywords. Eligible studies were interventions with a primary or secondary aim to improve medication adherence among individuals with COPD published in English. Included studies were assessed for methodological quality using the Effective Practice and Organisation of Care (EPOC) criteria. Of the 1,186 papers identified, seven studies met inclusion criteria. Methodological quality of the studies was variable. Five studies identified effective interventions. Strategies included: brief counselling; monitoring and feedback about inhaler use through electronic medication delivery devices; and multi-component interventions consisting of self-management and care co-ordination delivered by pharmacists and primary care teams. Further research is needed to establish the most effective and cost effective interventions. Special attention should be given to increasing patient sample size and using a common measure of adherence to overcome methodological limitations. Interventions that involve caregivers and target the healthcare provider as well as the patient should be further explored.
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Affiliation(s)
- Jamie Bryant
- Priority Research Centre for Health Behaviour, University of Newcastle & Hunter Medical Research Institute, HMRI Building, University of Newcastle, Callaghan, NSW 2308, Australia.
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Di Martino M, Agabiti N, Bauleo L, Kirchmayer U, Cascini S, Pistelli R, Colamesta V, Patorno E, Pinnarelli L, Fusco D, Perucci CA, Davoli M. Use patterns of long-acting bronchodilators in routine COPD care: the OUTPUL study. COPD 2013; 11:414-23. [PMID: 24090036 DOI: 10.3109/15412555.2013.839646] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND COPD is the fourth leading cause of death in the world. In the case of exacerbations or persistent symptoms, regular treatment with long-acting bronchodilators is recommended to control the symptoms, reduce exacerbations and improve health status. Objectives. To describe patterns of drug utilization among patients diagnosed with COPD, to measure continuity with long-acting bronchodilators, to identify determinants of not receiving long-acting therapy continuously. METHODS We identified a cohort of patients discharged from hospital with diagnosis of COPD between 2006 and 2008. Patients were observed for a two-year follow-up period, starting from the day of discharge. Follow-up was segmented in six-month periods, in order to dynamically evaluate prescription patterns of Long-Acting Beta-Agonists (LABA), tiotropium, and inhaled corticosteroids. Patients with prescriptions for LABA and/or tiotropium in each of the six-month periods were defined as "continuously treated with long-acting bronchodilators." The degree of drug treatment coverage was measured through the Medication Possession Ratio (MPR). Logistic regression was performed to identify determinants of not receiving long-acting bronchodilators continuously. RESULTS A total of 11,452 patients diagnosed with COPD were enrolled. Only 34.8% received long-acting bronchodilators continuously. The MPR was greater than 75% in 19.6% of cases. Among the determinants of not receiving long-acting bronchodilators continuously, older age and co-morbidities played an important role. CONCLUSIONS In clinical practice, the COPD pharmacotherapy is not consistent with clinical guidelines. Medical education is needed to disseminate evidence-based prescribing patterns for COPD, and to raise awareness among physicians and patients on the health benefits of an appropriate pharmacological treatment.
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Affiliation(s)
- Mirko Di Martino
- 1Department of Epidemiology, Lazio Regional Health Service , Roma , Italy
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Apter AJ, Wan F, Reisine S, Bogen DK, Rand C, Bender B, Bennett IM, Gonzalez R, Priolo C, Sonnad SS, Bryant-Stephens T, Ferguson M, Boyd RC, Have TT, Roy J. Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults. J Asthma 2013; 50:850-60. [PMID: 23800333 PMCID: PMC4118639 DOI: 10.3109/02770903.2013.812655] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. OBJECTIVE To conduct a pilot study to assess feasibility, acceptability and preliminary evidence of effectiveness. METHODS A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a non-professional, modeled preparations for a medical visit, attended the visit and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid (ICS) adherence, asthma control, quality of life, FEV1, emergency department (ED) visits and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. RESULTS 100 adults participated: age 47 ± 14 years, 75% female, 71% African-American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p = 0.001) but not significantly in the PA group (p = 0.30). Both PA and MI groups demonstrated improved asthma control (p = 0.01 in both) and quality of life (p = 0.001, p = 0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. CONCLUSION The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life.
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Affiliation(s)
- Andrea J. Apter
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine
- Department of Medicine
- University of Pennsylvania
| | - Fei Wan
- Department of Biostatistics and Epidemiology
- University of Pennsylvania
| | | | | | | | | | | | - Rodalyn Gonzalez
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine
- Department of Medicine
- University of Pennsylvania
| | - Chantel Priolo
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine
- Department of Medicine
- University of Pennsylvania
| | | | | | | | | | - Thomas Ten Have
- Department of Biostatistics and Epidemiology
- University of Pennsylvania
| | - Jason Roy
- Department of Biostatistics and Epidemiology
- University of Pennsylvania
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Chronic obstructive pulmonary disease (COPD) patients' disease-related preferences : a study using conjoint analysis. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2013; 6:93-101. [PMID: 23526399 DOI: 10.1007/s40271-013-0007-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the management of chronic obstructive pulmonary disease (COPD), knowledge of disease attributes and preferences that are important to patients is crucial. This knowledge may support drug development and optimization of COPD management strategies. OBJECTIVE To assess patient preferences in COPD and to use the conjoint methodology in order to propose a self-assessment tool based on patients' preferences gained from this conjoint analysis. This tool might then be used in future observational study settings. METHODS A two-step procedure was applied: an initial qualitative research module consisting of interviews with eight COPD patients served to assess COPD patients' health state in-depth, their attitudes towards COPD and their information sources regarding the disease, symptomatology, unmet needs, and their preferences for future COPD medications. In the main quantitative research part of the study, 300 patients (with an average age of 55 years) from across Germany suffering from COPD (n = 225 with stage II and n = 75 with stage III COPD) participated. Each participant was presented with 15 different scenarios during the conjoint exercise. Additionally, the Clinical COPD Questionnaire (CCQ) had to be completed and attitudes towards COPD were assessed. RESULTS According to the participants, the three COPD attributes of the highest relative importance were dyspnea, performance capability, and sleep quality. Frequency of administration of the medication, onset of medication, and emotional state due to COPD base medication played only a minor role. COPD symptoms were reported to have the highest impact on quality of life, according to the CCQ. CONCLUSIONS Our study proposes an alternative utility-based approach of a self-reported health state concept, utilizing the fact that patients with moderate to severe COPD would trade, e.g., ease of administration and onset of medication for relief from dyspnea.
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Mulhall AM, Lach LA, Krzywkowski-Mohn SM, Welge JA, Panos RJ. Therapeutic paralysis in veterans with COPD. Respir Med 2013; 107:1547-57. [PMID: 23827725 DOI: 10.1016/j.rmed.2013.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/27/2013] [Accepted: 05/30/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is a common disorder of Veterans that causes significant morbidity and mortality. To measure Veterans' perceptions about COPD, the effect of COPD on their lives and health, and their needs for improved health, we performed a postal survey. METHODS 3263 Veterans with a diagnosis of COPD who received care at the Cincinnati Veterans Affairs Medical Center in 2008 were stratified into quintiles by Veterans Health Administration-associated COPD healthcare cost and uniformly sampled. RESULTS 493 of 1000 surveys (49%) were completed and returned. COPD had different effects on respondents in top and bottom quintiles (highest and lowest COPD-related cost) for: knowledge of COPD diagnosis (89% vs. 73%, p = 0.03); activities affected by breathing, including work (69% vs. 45%), recreation (85% vs. 62%), change in living arrangements (36% vs 16%), and increased need for help (54% vs. 25%) (p < 0.05 for all comparisons); emotional effect of respiratory symptoms, including depression (53% vs. 30%), fear (41% vs. 15%), and helplessness (49% vs. 24%) (p < 0.05 for all comparisons). 91% of Veterans were prescribed inhalers and one-quarter had difficulties using them. 25% of Veterans did nothing when they had symptoms of an exacerbation. CONCLUSIONS COPD has profound effects on Veterans' breathing related activities and generates many negative emotions. Primary care providers are critical in conveying the diagnosis of COPD and providing information about the disease and its management. Veterans with COPD adhere poorly to their medications, and report little instruction about COPD or its management.
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Affiliation(s)
- Aaron M Mulhall
- Department of Internal Medicine, University of Cincinnati Academic Health Center, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
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Ghosh D, Allgar V, Elliott MW. Identifying poor compliance with CPAP in obstructive sleep apnoea: A simple prediction equation using data after a two week trial. Respir Med 2013; 107:936-42. [DOI: 10.1016/j.rmed.2012.10.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 10/14/2012] [Accepted: 10/15/2012] [Indexed: 11/30/2022]
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Alsalman AJ, Smith WR. Expanding the framework of assessing adherence and medication-taking behavior. J Pain Palliat Care Pharmacother 2013; 27:114-24. [PMID: 23621173 DOI: 10.3109/15360288.2013.765532] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This analysis critiques recently published concepts of medication adherence assessment and elucidates the importance of finding new measures of adherence. Improving concepts and methods of adherence assessment is key to improving adherence outcomes. It proposes a new framework that contains more inclusive concepts and more standardized terminology. These new concepts and terms not only describe adherence and its specific measures in more detail, but also describe all medication-taking behavior. It argues for the integration of and measurement of behavior associated with specific dose times, types, or schedules. Last, it describes promising research enabled by the new framework that, if implemented, might lead to improved adherence.
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Affiliation(s)
- Abdulkhaliq J Alsalman
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA 23298, USA
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Huetsch JC, Uman JE, Udris EM, Au DH. Predictors of adherence to inhaled medications among Veterans with COPD. J Gen Intern Med 2012; 27:1506-12. [PMID: 22782274 PMCID: PMC3475808 DOI: 10.1007/s11606-012-2130-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 03/06/2012] [Accepted: 05/23/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Factors contributing to medication nonadherence among patients with chronic obstructive pulmonary disease (COPD) are poorly understood. OBJECTIVES To identify patient characteristics that are predictive of adherence to inhaled medications for COPD and, for patients on multiple inhalers, to assess whether adherence to one medication class was associated with adherence to other medication classes. DESIGN Cohort study using data from Veteran Affairs (VA) electronic databases. PARTICIPANTS This study included 2,730 patients who underwent pulmonary function testing between 2003 and 2007 at VA facilities in the Northwestern United States, and who met criteria for COPD. MAIN MEASURES We used pharmacy records to estimate adherence to inhaled corticosteroids (ICS), ipratropium bromide (IP), and long-acting beta-agonists (LABA) over two consecutive six month periods. We defined patients as adherent if they had refilled medications to have 80 % of drug available over the time period. We also collected information on their demographics, behavioral habits, COPD severity, and comorbidities. KEY RESULTS Adherence to medications was poor, with 19.8 % adherent to ICS, 30.6 % adherent to LABA, and 25.6 % adherent to IP. Predictors of adherence to inhaled therapies were highly variable and dependent on the medication being examined. In adjusted analysis, being adherent to a medication at baseline was the strongest predictor of future adherence to that same medication [(Odds ratio, 95 % confidence interval) ICS: 4.78 (3.21-7.11); LABA: 6.56 (3.89-11.04); IP: 13.96 (9.88-19.72)], [corrected] but did not reliably predict adherence to other classes of medications. [corrected]. CONCLUSIONS Among patients with COPD, past adherence to one class of inhaled medication strongly predicted future adherence to the same class of medication, but only weakly predicted adherence to other classes of medication.
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Affiliation(s)
- John C. Huetsch
- Health Services Research and Development, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101 USA
- Department of Internal Medicine, Washington University School of Medicine, St Louis, MO USA
| | - Jane E. Uman
- Health Services Research and Development, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101 USA
| | - Edmunds M. Udris
- Health Services Research and Development, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101 USA
| | - David H. Au
- Health Services Research and Development, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101 USA
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA
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