Complexity of Medicine Regimens and Patient Perception of Medicine Burden

Effect of Multi-Dose Dispensing on Medication Regimen Complexity: A Real-World Study

(1) Background: Older patients frequently require dosing aids, such as multi-dose medication dispensing (MMD) when they experience medication regimen complexity (MRC) with increased drug use. However, the evaluations of the efficacy of MMD alterations remain limited. (2) Methods: A total of 1120 patients were included in the study who were discharged from hospital during the study period of January to March 2019. The Medication Regimen Complexity Index (MRCI) score, a validated 65-item tool in Korea (MRCI-K), was used to quantify MRC. The original MRCI-K scores, representing the typical administration based on prescription information, were compared to recalculated MRCI-K scores measured following MMD during the hospital dispensing period. Differences in MRCI-K across the top four wards based on the numbers of discharge prescription medications were assessed, and the overall scores were categorized into quartiles to identify MMD's impact within each group. We confirmed the effect of MMD based on the patient's admission diagnosis depending on MRCI. (3) Results: The mean (standard deviation) of original MRCI scores was 26.2 (13.4), which decreased to 18.9 (8.8) after applying MMD. The decrease in MRCI scores after MMD was statistically significant in all four wards, with the Orthopedic Surgery ward showing the biggest decrease. The patients with MRCI scores in the highest quartile group demonstrated the greatest improvement as a result of the implementation of MMD. Respiratory diseases exhibited the highest baseline MRCI scores due to formulation complexity, and ear, nose, and throat patients demonstrated the most significant reduction in MRC after MMD, depending on the diagnostic criteria at administration. (4) Conclusions: We confirmed the reduction in MRC after applying MMD, as a significant decrease in MRCI-K scores. This study highlights the need to deliver effective pharmacist-led services to identify patients who would benefit from MMD.

A Delphi Method for Development of a Barrett's Esophagus Question Prompt List as a Communication Tool for Optimal Patient-physician Communication

BACKGROUND METHODS

The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1).

RESULTS

Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds.

CONCLUSIONS

With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.

Caregiver Burden Correlates With Complexity of Drug Regimen in Non-oncological Palliative Medicine

BACKGROUND

Progressive chronic diseases presume a complex treatment plan that depends on the number of symptoms, their severity, and comorbidities. Drug management is an essential responsibility of the family caregiver of a palliative care patient, but has received limited attention in field research.

STUDY QUESTIONS

The aim of this study is to identify the complexity of the therapeutic plan followed at home by cancer or noncancer patients needing palliative care, and to assess its impact on the burden of the family caregivers.

STUDY DESIGN

This observational study was conducted at patient's admission in a palliative care department. The study involved cancer and noncancer patients and their primary family caregivers. To measure the care burden, the Burden Scale for Family Caregiver was used and for the complexity of the therapeutic plan, the Medication Regime Complexity Index.

MEASURES AND OUTCOMES

To measure the care burden, the Burden Scale for Family Caregiver was used and for the complexity of the therapeutic plan, the Medication Regime Complexity Index.

RESULTS

One hundred and forty patients were enrolled with their family caregivers: patients with nononcological pathologies (n = 63) and patients with cancer (n = 77). Caregiver's burden score is statistically significantly correlated with the complexity of the medical plan in both groups (P = 0.32 and P = 0.012 respectively). The average family caregiver's burden was significantly higher in the nononcological group (45 ± 14.45 vs. 36.52 ± 15.05; P = 0.001). The number of medications that family caregivers administer daily for patients without cancer is higher than in the other subset (8.25 ± 4.94 vs. 5.89 ± 4.93; P = 0.004). Opioids were more frequently used for pain control in cancer patients (5 vs. 72; P = 0.0001).

CONCLUSIONS

The caregiver's burden is high for nononcological patients. The complexity of the treatment plan (number of drugs and frequency of administration) is significantly correlated with the care burden. Further studies are needed to understand which interventions targeted on family caregivers will minimize the burden of care.

Medication-related burden and associated factors among diabetes mellitus patients at Felege Hiwot Comprehensive Specialized Hospital in northwest Ethiopia

Background

Evaluating the medicine burden from the patients' perspective is essential for getting good health outcomes of diabetes mellitus (DM) management. However, data are limited regarding this sensitive area. Thus, the study was aimed to determine the medication-related burden (MRB) and associated factors among DM patients at Felege Hiwot Comprehensive Specialized Hospital (FHCSH) in northwest Ethiopia.

Methods

A cross-sectional study was conducted on 423 systematically selected DM patients attending the DM clinic of FHCSH from June to August 2020. The medication-related burden was measured by using the Living with Medicines Questionnaire version 3 (LMQ-3). Multiple linear regression was used to identify factors associated with medication-related burden and reported with 95% confidence interval (CI). p-value <0.05 was considered as statistically significant to declare an association.

Results

The mean LMQ-3 score was 126.52 ( ± 17.39). The majority of the participants experienced moderate (58.9%, 95% CI: 53.9-63.7) to high (26.2%, 95% CI: 22.5-30.0) degrees of medication burden. Nearly half (44.9%, 95% CI: 39.9-49.7) of the participants were non-adherent to their prescribed medications. VAS score (B = 12.773, p = 0.001), ARMS score (B = 8.505, p = 0.001), and fasting blood glucose (FBS) on visit (B = 5.858, p = 0.003) were significantly associated with high medication-related burden.

Conclusion

A significant number of patients suffered from high medication-related burden and non-adherence to long-term medicine. Therefore, multidimensional intervention to decrease MRB and to upgrade adherence is required to increase patients' quality of life.

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06−1.19), 1.17 (1.1−1.24), and 1.21 (1.14−1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75−0.97] vs. 0.88 [0.76−0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71−0.93) and 0.87 (0.77−0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

Polypharmacy, Medication-Related Burden and Antiretroviral Therapy Adherence in People Living with HIV Aged 50 and Above: A Cross-Sectional Study in Hunan, China

PURPOSE

People living with HIV (PLWHIV) are susceptible to non-communicable diseases (NCDs) because of aging and infections. This means that the number of non-HIV medications increases, along with issues of polypharmacy and medication-related burden. The purpose of this study was to identify the current situation of polypharmacy and medication-related burden among PLWHIV aged 50 and above, as well as the relation between medication-related burden and antiretroviral therapy (ART) adherence.

PATIENTS AND METHODS

A cross-sectional study was conducted with 185 participants recruited from two HIV clinics in Yuelu District Center for Disease Control (CDC) and Changsha First Hospital in Hunan, China. Participants filled questionnaires about comorbidities, polypharmacy, medication-related burden, ART adherence and sociodemographic characteristics.

RESULTS

Among the participants, 40% were receiving polypharmacy, and PLWHIV, who were female (β = 5.946; 95% CI = 1.354, 10.541), had a lower monthly income (β = -4.777; 95% CI = -6.923, -2.632), and took more drugs (β = 2.200; 95% CI = 1.167, 3.233) were more likely to report a higher level of medication-related burden. The score of ART adherence was negatively associated with medication-related burden (r_s = -0.250 p = 0.001).

CONCLUSION

The findings suggest that more attention should be paid to the issues of polypharmacy and targeted interventions should be developed to reduce medication-related burden among older PLWHIV.

Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease: the MIMeRiC randomized controlled trial

Background

In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence.

Methods

This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient’s clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use.

Results

316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin–angiotensin–aldosterone system inhibitors.

Conclusions

Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health.

Trial registration: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02178-0.

Exploring polypharmacy burden among elderly patients with chronic diseases in Chinese community: a cross-sectional study

Background

In the long-term use of multiple medications for elderly patients diagnosed with chronic diseases, medication problems are prominent, which seriously reduces their quality of life. The burden of medications of patients critically affects their medication beliefs, behaviors and disease outcomes. It may be a solution to stress the burden of medications of patients. Its medication issues develops a novel perspective. The present study aimed to exploit the Chinese version of Living with Medicines Questionnaire-3(C-LMQ-3) to quantify the medicines burden of elderly patients diagnosed with chronic diseases in China, and evaluate the relevant demographic characteristics of sub-populations with high medicines burden.

Methods

The survey was distributed to elderly patients aged ≥ 60 years with chronic disease by using ≥ 5 medicines, C-LMQ-3 scores and domain scores were compared by the characteristics of elderly patients by employing descriptive statistics and performing statistical tests.

Results

On the whole, 430 responses were analyzed, and the participants were aged between 60 and 91 years, with the average age of 73.57 years (SD: 7.87). Most of the responses were female (61.7 %) with middle school education (38.5 %). Moreover, 54.1 % of the participants lived with spouse only, 16.2 % had both spouse and children, and 10.0 % lived alone. As indicated from regression analysis, higher C-LMQ-3 scores were associated with those who were with low education level, 60–69 years-old, using ≥ 11 medicines, using medicines ≥ 3 times a day, income per month (RMB) ≤ 3000, and who having higher monthly self-paid medication (RMB) ≥ 300 (p < 0.01). Burden was mainly driven by cost-related burden, concerns about medicines, and the lack of autonomy over medicine regimens.

Conclusions

This study presents the preliminary evidence to elderly patients diagnosed with chronic diseases in mainland China that pay attention to multiple medications burden may help reduce the Drug Related Problems, whereas some elderly patients have a higher burden of medication. Chinese health care providers are required to primarily evaluate and highlight such patients, and formulate relevant intervention strategies to ensure medication adherence and daily medication management of elderly patients with polypharmacy.

Medication-Related Burden and Medication Adherence Among Geriatric Patients in Kuwait: A Cross-Sectional Study

The evaluation of medicines burden from the patients’ perspectives is a crucial endeavor to identify any barriers that may hinder achieving optimal health outcomes. Therefore, this study was designed, firstly to identify the prevalence of medication-related burden among geriatrics and factors influencing this burden. Secondly, to determine the prevalence of medication adherence and the correlation between the burden and adherence. A cross-sectional study was performed using Living with Medicines Questionnaire version-3 (LMQ-3) and Adherence to Refills and Medications Scale (ARMS) questionnaire. Four hundred and fifty patients attending primary healthcare centers were invited to participate, and 424 (94.2%) agreed. Data were collected via face-to-face structured interviews. The vast majority of respondents (97.4%; 95% CI: 95.3–98.6) perceived to suffer from minimum (35.4%) to moderate (62.0%) degrees of medicine burden. The median (IQR) LMQ overall score was 112 (21) indicating a moderate burden. LMQ-3 overall scores revealed a significant trend toward higher perceived burden among respondents aged ≥ 75 years, males, non-Kuwaitis, residents in Al-Farwaniyah and Al-Jahra governorates, using oral and nonoral formulations, paying prescription charges, and needing support with using medicines (p <0.05). Almost 55% (95% CI: 49.8–59.5) of respondents were nonadherent to their medications. The median (IQR) ARMS overall score was 20 (7.0) indicating low adherence to medications. There was a significant positive correlation between LMQ-3 and ARMS scores (p<0.001) showing that the higher the medications burden the lower the level of medication adherence. The key findings of this study underscore the need for multifaceted interventions that could be targeted at the identified problems to reduce medication burden and improve medication adherence.

Medication Regimen Complexity Index Prediction of Adverse Drug Reaction-Related Hospital Admissions

BACKGROUND

The relationship between the medication regimen complexity index (MRCI) and adverse drug reaction (ADR)-related hospital admissions has not yet specifically been investigated.

OBJECTIVE

To evaluate the MRCI and compare with medication count for prediction of ADR-related hospital admissions in older patients.

METHODS

This was a retrospective analysis of a prospectively collected convenience sample of 768 unplanned medical admissions of Australians aged 65 years old and older. The sample consisted of 115 (15.0%) ADR-related unplanned hospital admissions and 653 (85.0%) non-ADR-related unplanned medical admissions. The MRCI score was calculated from the medical records and analyzed to predict ADR-related hospital admissions.

RESULTS

The cohort had a median age of 81 years, 5 comorbidities, and 11 medications, with a slight majority of women. The MRCI score was not significantly different in patients who had ADR-related admissions compared with other medical admissions-38.5 versus 34.0, respectively; Wilcoxon Rank Sum test W = 33 522; P = 0.067. The medication count was significantly different between the ADR-related admissions compared with other medical admissions: 12 versus 10; W = 32 508; P = 0.021. However, the medication count was not a strong predictor of ADR-related admissions; unadjusted odds ratio = 1.044; 95% CI = 1.006-1.084.

CONCLUSION AND RELEVANCE

The MRCI score did not discriminate between ADR-related admissions and other medical admissions despite taking time to calculate with potential for inconsistent application. Medication count is more readily applicable with marginally greater relevance in this cohort; however, both measures do not appear to be useful when used alone for clinicians to identify patients at risk of ADRs.

Impact of Medication Regimen Simplification on Medication Administration Times and Health Outcomes in Residential Aged Care: 12 Month Follow Up of the SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.

Cross-Cultural Adaptation and Reliability Testing of Chinese Version of the Living with Medicines Questionnaire in Elderly Patients with Chronic Diseases

BACKGROUND

The Living with Medicines Questionnaire (LMQ-3) is a reliable, valid instrument used to assess the medication-related burden of patients with chronic disease using long-term medication, but it has not been used in China.

PURPOSE

To translate and cross-culturally adapt the LMQ-3 into Chinese and assess its reliability and validity among elderly patients with chronic disease.

METHODS

After translation and back-translation, views from an expert group and cognitive interviews with elderly persons using multiple medicines were used to ensure the cultural relevance of the LMQ-3. Then, 412 participants aged 60-92 years were recruited from three communities in Zhengzhou to complete the instrument. Item analysis, internal consistency, content validity, exploratory factor analysis (EFA) and reliability testing were performed.

RESULTS

Item analysis identified nine items for possible removal, which were discussed with the originating team. Internal consistency testing confirmed the suitability of removing two of these items, which concurred with the views of the expert group and cognitive interviews. All other items were retained, but four were modified for clarification without changing their meaning, resulting in a 39-item instrument. EFA of this 39-item measure yielded an eight-factor model, similar to the English version. Cronbach's alpha of the Chinese version of LMQ-3 (C-LMQ-3) for elderly patients with chronic diseases was 0.855, and alpha values for the eight domains ranged from 0.822 to 0.932. Test-retest reliability was satisfactory, with ICC values for the eight domain scores ranging from 0.751 to 0.881.

CONCLUSION

With only minor modifications compared to the English version, the 39-item C-LMQ-3 is a valid tool, with adequate reliability, which can be used to assess the medication-related burden of long-term use of multiple medicines in elderly patients in China.

Pharmacotherapy related quality of life in Thai patients with chronic diseases

Background Little was known about patient's pharmacotherapy related quality of life (PTRQoL) and its differences between disease groups. Objective First, to assess PTRQoL in Thai patients with chronic diseases using the Patient-Reported Outcomes Measure of Pharmaceutical Therapy for Quality of Life (PROMPT-QoL). Second, to determine the differences in PROMPT-QoL domain scores and total scores between disease groups. Setting Three public university hospitals in Bangkok, Thailand. Method Eleven hundred and fifty-six adult outpatients continuously taking medicines to treat their diseases for at least 3 months were conveniently sampled. Bonferroni post hoc tests were used to determine the differences in eight PROMPT-QoL domain scores and total scores between 14 disease groups. Main outcome measure The descriptive statistics of PROMPT-QoL domains and the total score. Results Approximately two-thirds of all patients preferred to use only medicines for treating their diseases. Impacts of Medicines and Side-Effects and Medicine and Disease Information yielded the highest (87.3) and lowest (55.4) mean domain scores, respectively. The other domains and the total score provided the average scores between 65 and 75, which were interpreted as moderate-to-good. Bonferroni post hoc tests showed that there were five domains providing significantly different scores between disease groups. They included Medicine and Disease Information, Satisfaction with Medicine Effectiveness, Impacts of Medicines and Side-effects, Convenience, and Therapeutic Relationships with Healthcare Providers domains. Conclusion Pharmacotherapy related quality of life in Thai patients is moderate-to-good. Five of eight pharmacotherapy related quality of life domain scores differed by disease groups.

Exploring Medicines Burden Among Adults in New Zealand: A Cross-Sectional Survey

BACKGROUND

Using medicines regularly can be a burden for some people and can contribute to reduced adherence. In New Zealand, relatively few studies have examined people's medicine-taking experiences and most involved older people, although medicine burden is also an issue for younger people. The UK-developed "Living with Medicines Questionnaire" (LMQ-3) is an instrument designed to quantify medicine burden.

OBJECTIVE

The objective was to quantify medicines burden among New Zealand adults, using the LMQ-3, to identify any sub-populations with high medicine burden and to identify specific issues that may need to be addressed.

SETTING

The study was set in New Zealand and included seven national patient support group websites, and five community pharmacies in Dunedin.

METHODS

The survey was distributed to adults ≥18 years using ≥ one medicine for ≥3 months. LMQ-3 scores and domain scores were compared by patient characteristics using descriptive statistics and statistical tests.

RESULTS

In total, 472 responses were analysed: 327/417 (78.4%) from patient support group websites and 145/360 (40.3%) from community pharmacies. Most commonly participants were female (295, 62.5%), ≥65 years (236, 50.0%), European (422, 89.4%), retired (232, 49.2%), university educated (203, 43.0%), used medicines independently (449, 95.1%), and paid for prescriptions (429, 90.9%). Most used <10 medicines (415, 87.9%) and <three times daily (356, 75.4%). From LMQ scores, 30.5% had a high burden (≥111). Regression analysis indicated that higher LMQ-3 scores were associated with those who were unemployed, aged 18-29 years, using ≥5 medicines, or using medicines <3 times a day (p<0.01). Burden was mainly driven by a perceived lack of autonomy over medicine regimens, or concerns about medicines and side effects.

CONCLUSION

Three quarters of New Zealand participants experienced moderate or high medicine burden. Being unemployed, aged 18-29 years, or using more (or more frequent) medicines, were associated with higher burden. These groups should become the target for interventions seeking to reduce medicine burden.