"My patients are better than yours": optimistic bias about patients' medication adherence by European health care professionals

From non-adherence to adherence: Can innovative solutions resolve a longstanding problem?

Non-adherence to medication is a longstanding problem, profoundly affecting patient outcomes and sustainability of healthcare systems. Historically, non-adherence has been observed since the time of Hippocrates, however, when potent drugs became available in the midst of the 20th century, it became a pivotal concern. Despite numerous studies and interventions designed, medication adherence rates remain suboptimal, currently reaching about 50 % still, as described in WHO report two decades ago. What is worse, many healthcare professionals feel neither responsible nor able to change it. Enhancing adherence requires in-depth understanding of the concept, as many intuitive approaches fail to work. For example, contrary to expectations, patient education alone proves insufficient when addressing this issue. Both behavioural models and recent experience reflecting low acceptance of COVID-19 vaccinations strongly suggest that patients' decisions are driven by emotions, which often results in intentional non-adherence. Several technical innovations, such as smart inhalers and electronic pill dispensers, offer potential solutions. However, their effectiveness varies, and standardized certification procedures are lacking. Altogether, technical solutions do not eliminate the problem entirely. To move forward, social and health system innovation is equally needed. Multiple stakeholders could benefit from improved adherence, therefore their greater involvement is advisable to create an adherence-supporting environment. In conclusion, despite available evidence-based interventions, non-adherence remains a complex challenge. Technical and social innovations, combined with a shift in policy priorities, could lead to improved medication adherence and better patient outcomes. The global tide of non-communicable chronic conditions, and aging of societies urges us to take this problem seriously.

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

OBJECTIVE

Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions.

DESIGN

Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture.

SETTING

Regional hospital and the associated primary care units (South-Eastern Norway).

PARTICIPANTS

The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50).

OUTCOME MEASURES

Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management).

RESULTS

In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%).

CONCLUSION

Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice.

Reimbursed medication adherence enhancing interventions in 12 european countries: Current state of the art and future challenges

Background: Medication non-adherence jeopardises the effectiveness of chronic therapies and negatively affects financial sustainability of healthcare systems. Available medication adherence-enhancing interventions (MAEIs) are utilised infrequently, and even more rarely reimbursed. The aim of this paper was to review reimbursed MAEIs across selected European countries.

Methods: Data on reimbursed MAEIs were collected from European countries at the ENABLE Cost Action expert meeting in September 2021. The identified MAEIs were analysed and clustered according to their characteristics, direct vs. indirect relation to adherence, and the targeted adherence phase.

Results: Out of 12 contributing countries, 10 reported reimbursed MAEIs, 28 in total, of which 20 were identified as MAEIs targeting adherence directly. Reimbursed MAEIs were most often performed by either doctors (n = 6), nurses (n = 6), or pharmacists (n = 3). The most common types of MAEIs were education (n = 6), medication regimen management (n = 5), and adherence monitoring feedback (n = 4). Only seven reimbursed MAEIs were technology-mediated, whereas 11 addressed two interlinked phases of medication adherence, i.e., implementation and persistence.

Conclusion: Our review highlights the scarcity of reimbursed MAEIs across the selected European countries, and calls for their more frequent use and reimbursement.

Medication, Healthcare Follow-up, and Lifestyle Nonadherence: Do They Share the Same Risk Factors?

Barriers to medication adherence may differ from barriers in other domains of adherence. In this study, we assessed the association between pre-kidney transplantation (KT) factors with nonadherent behaviors in 3 different domains post-KT.

METHODS

We conducted a prospective cohort study with patient interviews at initial KT evaluation (baseline-nonadherence predictors in sociodemographic, condition-related, health system, and patient-related psychosocial factors) and at ≈6 mo post-KT (adherence outcomes: medications, healthcare follow-up, and lifestyle behavior). All patients who underwent KT at our institution and had ≈6-mo follow-up interview were included in the study. We assessed nonadherence in 3 different domains using continuous composite measures derived from the Health Habit Survey. We built multiple linear and logistic regression models, adjusting for baseline characteristics, to predict adherence outcomes.

RESULTS

We included 173 participants. Black race (mean difference in adherence score: -0.72; 95% confidence interval [CI], -1.12 to -0.32) and higher income (mean difference: -0.34; 95% CI, -0.67 to -0.02) predicted lower medication adherence. Experience of racial discrimination predicted lower adherence (odds ratio, 0.31; 95% CI, 0.12-0.76) and having internal locus of control predicted better adherence (odds ratio, 1.46; 95% CI, 1.06-2.03) to healthcare follow-up. In the lifestyle domain, higher education (mean difference: 0.75; 95% CI, 0.21-1.29) and lower body mass index (mean difference: -0.08; 95% CI, -0.13 to -0.03) predicted better adherence to dietary recommendations, but no risk factors predicted exercise adherence.

CONCLUSIONS

Different nonadherence behaviors may stem from different motivation and risk factors (eg, clinic nonattendance due to experiencing racial discrimination). Thus adherence intervention should be individualized to target at-risk population (eg, bias reduction training for medical staff to improve patient adherence to clinic visit).

Primary care clinicians' perspectives on clinical decision support to enhance outcomes of online obesity treatment in primary care: A qualitative formative evaluation

Objective

Online behavioral treatment for obesity produces clinically-meaningful weight losses among many primary care patients. However, some patients experience poor outcomes (i.e., failure to enroll post-referral, poor weight loss, or premature disengagement). This study sought to understand primary care clinicians' perceived utility of a clinical decision support system (CDSS) that would alert clinicians to patients' risk for poor outcome and guide clinician-delivered rescue interventions to reduce risk.

Methods

Qualitative formative evaluation was conducted in the context of an ongoing pragmatic clinical trial implementing online obesity treatment in primary care. Interviews were conducted with 14 nurse care managers (NCMs) overseeing patients' online obesity treatment. Interviews inquired about the potential utility of CDSS in primary care, desired alert frequency/format, and priorities for alert types (non-enrollment, poor weight loss, and/or early disengagement). We used matrix analysis to generate common themes across interviews.

Results

Nearly all NCMs viewed CDSS as potentially helpful in clinical practice. Alerts for patients at risk for disengagement were of highest priority, though all alert types were generally viewed as desirable. Regarding frequency and delivery mode of patient alerts, NCMs wanted to balance the need for prompt patient intervention with minimizing clinician burden. Concerns about CDSS emerged, including insufficient time to respond promptly and adequately to alerts and the need to involve other support staff for patients requiring ongoing rescue intervention.

Conclusions

NCMs view CDSS for online obesity treatment as potentially feasible and clinically useful. For optimal implementation in primary care, CDSS must minimize clinician burden and facilitate collaborative care.

Man vs. Machine: Comparing Physician vs. Electronic Health Record-Based Model Predictions for 30-Day Hospital Readmissions

BACKGROUND

Electronic health record (EHR)-based readmission risk prediction models can be automated in real-time but have modest discrimination and may be missing important readmission risk factors. Clinician predictions of readmissions may incorporate information unavailable in the EHR, but the comparative usefulness is unknown. We sought to compare clinicians versus a validated EHR-based prediction model in predicting 30-day hospital readmissions.

METHODS

We conducted a prospective survey of internal medicine clinicians in an urban safety-net hospital. Clinicians prospectively predicted patients' 30-day readmission risk on 5-point Likert scales, subsequently dichotomized into low- vs. high-risk. We compared human with machine predictions using discrimination, net reclassification, and diagnostic test characteristics. Observed readmissions were ascertained from a regional hospitalization database. We also developed and assessed a "human-plus-machine" logistic regression model incorporating both human and machine predictions.

RESULTS

We included 1183 hospitalizations from 106 clinicians, with a readmission rate of 20.8%. Both clinicians and the EHR model had similar discrimination (C-statistic 0.66 vs. 0.66, p = 0.91). Clinicians had higher specificity (79.0% vs. 48.9%, p < 0.001) but lower sensitivity (43.9 vs. 75.2%, p < 0.001) than EHR model predictions. Compared with machine, human was better at reclassifying non-readmissions (non-event NRI + 30.1%) but worse at reclassifying readmissions (event NRI - 31.3%). A human-plus-machine approach best optimized discrimination (C-statistic 0.70, 95% CI 0.67-0.74), sensitivity (65.5%), and specificity (66.7%).

CONCLUSION

Clinicians had similar discrimination but higher specificity and lower sensitivity than EHR model predictions. Human-plus-machine was better than either alone. Readmission risk prediction strategies should incorporate clinician assessments to optimize the accuracy of readmission predictions.

Hypertension healthcare professional beliefs and behaviour regarding patient medication adherence: a survey conducted among European Society of Hypertension Centres of Excellence

PURPOSE

Little is known on the beliefs, perceptions and practices of hypertension specialists in addressing non-adherence to therapy. Therefore, a survey was undertaken amongst healthcare professionals (HCPs) managing hypertension in the European Society of Hypertension (ESH) Centres of Excellence.

MATERIALS AND METHODS

Cross-sectional data were obtained between December 2020 and April 2021 using an online anonymous structured questionnaire including 26 questions/136 items, that was sent to all ESH Excellence centres.

RESULTS

Overall 67 from 187 centres (37.3%) responded and 200 HCPs from 30 countries answered the questionnaire. Participants (60% men) were mainly physicians (91%) and nurses (8%) from University hospitals (77%). Among physicians, 83% had >10 years professional experience. Average time dedicated to discuss medications was 1-5 min in 48% and 6-10 min in 29% of cases. Interviews with patients about adherence were the most frequently used assessment method. Chemical detection of medications in urine was available in 36% of centres. One third of physicians involved their patients regularly in treatment decisions. The most frequent methods to improve adherence included simplification of medication therapy, more frequent visits, and home blood pressure monitoring.

CONCLUSIONS

The level of implementation of tools to detect and improve adherence in hypertension management by HCPs in ESH excellence centres is low. Structured educational activities focussing on adherence management and access to the newest objective measures to detect non-adherence might improve these deficits.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Adherence to treatment in paediatric patients - results of the nationwide survey in Poland

Background

Due to high prevalence, non-adherence to prescribed treatment seriously undermines the effectiveness of evidence-based therapies in paediatric patients. In order to change this negative scenario, physicians need to be aware of adherence problem, as well as of possible solutions. Unfortunately, full potential of adherence-targeting interventions is still underused in Poland. Therefore, the aim of this study was to assess the knowledge, attitudes and behaviours toward non-adherence in Polish paediatricians.

Methods

An anonymous cross-sectional nationwide survey was conducted in the convenience sample of Polish doctors providing care to paediatric patients. The survey focused on the prevalence of non-adherence, its causes, and interventions employed. Primary studied parameter was perceived prevalence of non-adherence in paediatric patients. Reporting of this study adheres to STROBE guidelines.

Results

One thousand and thirty-three responses were eligible for analysis. Vast majority of respondents were female (85.9%), most of them worked in primary care (90.6%). The respondents represented all 16 Polish Voivodeships, with the biggest number coming from the Mazowieckie Voivodeship (n = 144, 13.9%). Survey participants believed that on average 28.9% of paediatric patients were non-adherent to medication. More than half of the respondents (n = 548, 53.0%) were convinced that their own patients were more adherent than average. Duration of the professional practice strongly correlated with a lower perceived prevalence of non-adherence. Professionals with more than 40 years of practice believed that the percentage of non-adherent patients was <=20% particularly often (OR = 3.82 (95% CI 2.11–6.93) versus those up to 10 years in practice). Out of all respondents, they were also most often convinced that their own patients were more adherent than the general population (P < 0.01). Consequently, they underestimated the need for training in this area.

Conclusions

Physicians taking care of Polish paediatric patients underestimated the prevalence of medication non-adherence and believed that this was a problem of other doctors. This optimistic bias was particularly pronounced in older doctors. These results identify important barriers toward improving patient adherence that are worth addressing in the pre- and post-graduate education of Polish physicians. They also put some light over the challenges that educational activities in this area may face.

The SPUR Model: A Framework for Considering Patient Behavior

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Roughly half of all drugs that are prescribed for chronic treatments are not taken by the patients in question. Initiatives designed to support patients and help them modify their behavior are enhanced by personalization, and a number of profiling tools exist to help customize such interventions. Most of these tools were originally designed as paper-based questionnaires, but the growth of digital adherence technologies (DATs) illuminate the need for the development of digital profiling systems that can interact with fully automated patient interfaces.

OBJECTIVE

The objective of this study was to examine existing frameworks from medicine, psychology, sociology, consumer behavior, and economics to elaborate a comprehensive, quantitative profiling approach that can be used to drive the customization of patient support initiatives.

RESULTS

Building primarily on Icek Ajzen's Theory of Planned Behavior (TPB), the Health Belief Model (HBM) was used to inform the beliefs about behavior posited in the TPB, while incorporating established factors regarding self-efficacy in the "control" elements of the TPB and selected social and psychological factors in the other constituents of the model. The resulting SPUR (Social, Psychological, Usage, Rational) framework represents a holistic, profiling tool with detailed, quantitative outputs that describe a patient's behavioral risks and the drivers of that risk.

CONCLUSION

An interactive, digital questionnaire built around SPUR represents a potentially useful tool for those desirous of building interactive digital support programs for patients with chronic diseases.

Transitions in Rheumatic Disease: Pediatric to Adult Care

Although it has been widely acknowledged for more than two decades that transition from pediatric to adult care is a vulnerable time for adolescents and young adults with rheumatic diseases, current primary and subspecialty care transition and transfer processes remain inadequate. Barriers to improving transition include complex health care systems, neurodevelopmental challenges of adolescents and young adults, and insufficient transition-related education and resources for health care providers. Standardized, evidence-based transition interventions are sorely needed to establish best practices. Quality improvement approaches such as the Six Core Elements of Health Care Transition offer opportunities to improve transition care for teens and young adults.

Understanding Medication Nonadherence after Kidney Transplant

Alloimmunity remains a barrier to long-term graft survival that necessitates lifelong immunosuppressive therapy after renal transplant. Medication nonadherence has been increasingly recognized as a major impediment to achieving effective immunosuppression. Electronic medication monitoring further reveals that nonadherence manifests early after transplant, although the effect is delayed. The etiology of nonadherence is multifactorial, with the strongest risk factors including past nonadherence and being an adolescent or young adult. Other risk factors with smaller but consistently important effects include minority race/ethnicity, poor social supports, and poor perceived health. In children, risk factors related to parental and child psychologic and behavioral functioning and parental distress and burden are also important. Qualitative systematic reviews highlight the need to tailor interventions to each transplant recipient's unique needs, motivations, and barriers rather than offer a one size fits all approach. To date, relatively few interventions have been studied, and most studies conducted were underpowered to allow definitive conclusions. If the kidney transplant community's goal of "one transplant for life" is to become a reality, then solutions for medication nonadherence must be found and implemented.