A self-management support program for older Australians with multiple chronic conditions: a randomised controlled trial

Motivational interviewing to support medication adherence in older patients: Barriers and facilitators for implementing in hospital setting according to healthcare professionals

OBJECTIVE

The aim of this study was to understand through Healthcare professionals' (HCPs) opinions the barriers and facilitators to implement MI in older hospitalized patients.

METHODS

A qualitative study with semi-structured interviews was performed among 23 HCPs involved in the medication management of older hospitalized patients (geriatricians, nurses, psychologists and pharmacists). A thematic analysis was conducted using a deductive approach through the Theoretical Domain Framework (TDF), and an inductive approach.

RESULTS

The thematic analysis reported 25 factors influencing MI implementation, mapped into 8 TDF themes, and including 13 facilitators, 8 barriers, and 4 both. The main factors identified were: 'cognitive and sensory disorders' (barrier), 'having dedicated time and HCPs' (facilitator and barrier), and the 'HCP's awareness about MI' (facilitator). Ten factors were identified as specific to the older population.

CONCLUSIONS

Implementing MI in a hospital setting with older patients presented both barriers and facilitators.

PRACTICE IMPLICATIONS

To ensure successful MI implementation, it is important to take into account the older patients' context, the hospital environment, and the HCPs-related factors.

Chronic Pain Self-Management Strategies for Older Adults: An Integrative Review

INTRODUCTION

Due to the complex nature of chronic pain, especially in older adults, a biopsychosocial approach is more effective than an isolated approach for its management. Furthermore, when patients are actively engaged in their pain management, they are more likely to be successful than relying totally on others.

OBJECTIVE

To analyze the self-management strategies currently used by older adults with chronic pain.

METHOD

An integrative review was conducted through seven online databases, searching for scientific studies on this topic published in the last 10 years.

RESULTS AND CONCLUSION

Fifty-eight studies were included in the final sample. Research on chronic pain self-management for older adults has increased in recent years. Although a diversity of chronic physical painful conditions are being investigated, many conditions are still under-investigated. Online and in-person strategies are currently adopted, demonstrating similar results. Positive results are evidenced by strategies including health promotion, mind control, social participation and take-action fields. Major results come from a combination of strategies focusing on biopsychosocial aspects of pain management. Results include not only the reduction of pain itself, but increased self-efficacy, adoption of health behaviors and improvement of functionality, among others, i.e., improved QoL, despite pain.

Impact of Chronic Disease Self-Management Program on the Self-Perceived Health of People in Areas of Social Vulnerability in Asturias, Spain

The Chronic Disease Self-Management Program (CDSMP) focuses on a health promotion perspective with a salutogenic approach, reinforcing the pillars of self-efficacy. The aim of this study was to assess the impact of the CDSMP on Self-perceived Health (SPH) in disadvantaged areas of Asturias, España. The study included vulnerable adults with experience of chronic diseases for over six months, along with their caregivers. The intervention consisted of a six-session workshop led by two trained peers. SPH was evaluated by administering the initial item of the SF-12 questionnaire at both baseline and six months post-intervention. To evaluate the variable "Change in SPH" [improvement; remained well; worsening/no improvement (reference category)], global and disaggregated by sex multivariate multinomial logistic regression models were applied. There were 332 participants (mean = 60.5 years; 33.6% were at risk of social vulnerability; 66.8% had low incomes). Among the participants, 22.9% reported an improvement in their SPH, without statistically significant sex-based differences, while 38.9% remained in good health. The global model showed age was linked to decreased "improvement" probability (RRRa = 0.96), and the "remaining well" likelihood drops with social risk (RRRa = 0.42). In men, the probability of "remaining well" decreased by having secondary/higher education (RRRa = 0.25) and increased by cohabitation (RRRa = 5.11). Women at social risk were less likely to report "remaining well" (RRRa = 0.36). In conclusion, six months after the intervention, 22.9% of the participants had improved SPH. Age consistently decreased the improvement in the different models.

My Wellbeing Journal: Development of a communication and goal-setting tool to improve care for older adults with chronic conditions and multimorbidity

BACKGROUND

Chronic conditions and multimorbidity, the presence of two or more chronic conditions, are increasingly common in older adults. Effective management of chronic conditions and multimorbidity in older adults requires a collaborative and person-centred approach that considers the individual's goals, preferences and priorities. However, ensuring high-quality personalised care for older adults with multimorbidity can be challenging due to the complexity of their care needs, limited time and a lack of patient preparation to discuss their personal goals and preferences with their healthcare team.

OBJECTIVE

To codesign a communication and goal-setting tool, My Wellbeing Journal, to support personalised care planning for older adults with chronic conditions and multimorbidity.

DESIGN

We drew on an experience-based codesign approach to develop My Wellbeing Journal. This article reports on the final end-user feedback, which was collected via an online survey with older adults and their carers.

SETTING AND PARTICIPANTS

Older adults with chronic conditions, multimorbidity and informal carers living in Australia. Personalised care planning was considered in the context of primary care.

RESULTS

A total of 88 participants completed the online survey. The survey focused on participants' feedback on the tool in terms of effectiveness, efficiency, satisfaction and errors encountered. This feedback resulted in modifications to My Wellbeing Journal, which can be used during clinical encounters to facilitate communication, goal setting and progress tracking.

DISCUSSION AND CONCLUSIONS

Clinicians and carers can use the tool to guide discussions with older adults about their care planning and help them set realistic goals that are meaningful to them. The findings of this study could be used to inform the development of recommendations for healthcare providers to implement person-centred, goal-oriented care for older adults with chronic conditions and multimorbidity.

PATIENT OR PUBLIC CONTRIBUTION

Older adults living with chronic conditions and multimorbidity and their carers have contributed to the development of a tool that has the potential to significantly enhance the experience of personalised care planning. Their direct involvement as collaborators has ensured that the tool is optimised to meet the standards of effectiveness and usability.

The engagement of older people living with chronic lung disease in a peer support community-based exercise programme: A qualitative study

BACKGROUND

Chronic lung disease is a common and complex condition. Pulmonary rehabilitation programmes-either hospital-based or in the community are recommended in evidence-based clinical practice guidelines.

AIM

To explore the experience of older people with chronic lung disease involved in a peer support community-based exercise maintenance programme.

DESIGN AND METHOD

Participants were a part of the Lungs in Action programme run in a local community leisure centre through Lung Foundation Australia. All the programme participants (n = 25) were invited by an independent person through email and/or letter to participate in the study and provided with a participant information and consent form. Participants who returned consent forms were scheduled for group interviews. Participants were recruited over a 2-week period between 30 August and 13 September 2022. We conducted qualitative group interviews using a semi-structured interview guide to explore the experiences of older people living with chronic lung disease. Data were analysed using reflexive thematic analysis.

RESULTS

A total of 14 participants (eight female and six male) aged between 64 and 86 years were interviewed. Three themes emerged from the data: motivation, authentic social engagement, and sustainable achievement. Motivation stemmed from the participants' perceived health benefits, and from the trainers' motivation and encouragement. Participants discussed how sharing experiences created an environment of trust and understanding, fun and friendship. Social engagement and creating authentic relationships were key aspects raised by participants. Feeling more confident in themselves and being able to accomplish physical tasks, making activities of daily living more manageable featured highly in participants' responses.

DISCUSSION AND CONCLUSION

Community-based peer support exercise groups enable environments for people with chronic lung disease to maintain physical fitness, and to connect with others to form friendships and have fun.

Organisation and integrated healthcare approaches for people living with HIV, multimorbidity, or both: a systematic review

BACKGROUND

Universal recommendation for antiretroviral drugs and their effectiveness has put forward the challenge of assuring a chronic and continued care approach to PLHIV (People Living with HIV), pressured by aging and multimorbidity. Integrated approaches are emerging which are more responsive to that reality. Studying those approaches, and their relation to the what of delivery arrangements and the how of implementation processes, may support future strategies to attain more effective organizational responses.

METHODS

We reviewed empirical studies on either HIV, multimorbidity, or both. The studies were published between 2011 and 2020, describing integrated approaches, their design, implementation, and evaluation strategy. Quantitative, qualitative, or mixed methods were included. Electronic databases reviewed cover PubMed, SCOPUS, and Web of Science. A narrative analysis was conducted on each study, and data extraction was accomplished according to the Effective Practice and Organisation of Care taxonomy of health systems interventions.

RESULTS

A total of 30 studies, reporting 22 different interventions, were analysed. In general, interventions were grounded and guided by models and frameworks, and focused on specific subpopulations, or priority groups at increased risk of poorer outcomes. Interventions mixed multiple integrated components. Delivery arrangements targeted more frequently clinical integration (n = 13), and care in proximity, community or online-telephone based (n = 15). Interventions reported investments in the role of users, through self-management support (n = 16), and in coordination, through multidisciplinary teams (n = 9) and continuity of care (n = 8). Implementation strategies targeted educational and training activities (n = 12), and less often, mechanisms of iterative improvement (n = 3). At the level of organizational design and governance, interventions mobilised users and communities through representation, at boards and committees, and through consultancy, along different phases of the design process (n = 11).

CONCLUSION

The data advance important lessons and considerations to take steps forward from disease-focused care to integrated care at two critical levels: design and implementation. Multidisciplinary work, continuity of care, and meaningful engagement of users seem crucial to attain care that is comprehensive and more proximal, within or cross organizations, or sectors. Promising practices are advanced at the level of design, implementation, and evaluation, that set integration as a continued process of improvement and value professionals and users' knowledge as assets along those phases.

TRIAL REGISTRATION

PROSPERO number CRD42020194117.

Efficacy of a multidimensional self-management intervention on low-education women with metabolic syndrome: a cluster randomized controlled trial

Low-education women, a substantially older population, are subject to increased risks of metabolic syndrome and consequent cardiometabolic diseases; early detection and effective management were urgently needed. Ninety-nine women with metabolic syndrome, age 61 and education ≤ 6 years, from four community units were randomly assigned to either a self-management intervention (n = 51) or a control arm (n = 48). The intervention consisted of five dimensions, physical activity and diet modifications (daily exercise classes and two nutrition courses), goal setting, coaching and peer support, problem-solving, and self-monitoring. The control arm received an education leaflet. Assessments were performed at baseline, six months, and 18 months. Compared with the control, the intervention participants improved the overall rate of meeting the recommended servings for six health foods, including vegetables, dairy products, and nuts (except whole grains, fruits, and protein); the rate of meeting regular leisure-time physical activity; and criteria biomarkers-waist circumference, fasting blood glucose, high-density lipoprotein cholesterol (except blood pressure and triglycerides); as well as body weight and body mass index; consequently decreased the number of risk factors and rate of metabolic syndrome. In conclusion, the multidimensional self-management intervention improved physical activity, healthy eating, and metabolic syndrome risks among low-education women with metabolic syndrome.

Use of Motivational Interviewing in Older Patients with Multiple Chronic Conditions and Their Informal Caregivers: A Scoping Review

The use of motivational interviewing is relatively new in multiple chronic conditions (MCCs). A scoping review was conducted according to JBI methodology to identify, map and synthesize existing evidence on the use of motivational interviewing to support self-care behavior changes in older patients with MCCs and to support their informal caregivers in promoting patient self-care changes. Seven databases were searched, from database inception to July 2022, for studies that used motivational interviewing in interventions for older patients with MCCs and their informal caregivers. We identified 12 studies, reported in 15 articles, using qualitative, quantitative, or mixed-method designs, conducted between 2012 and 2022, describing the use of motivational interviewing for patients with MCCs. We could not locate any study regarding its application for informal caregivers. The scoping review showed that the use of motivational interviewing is still limited in MCCs. It was used mainly to improve patient medication adherence. The studies provided scant information about how the method was applied. Future studies should provide more information about the application of motivational interviewing and should address self-care behavior changes relevant to patients and healthcare providers. Informal caregivers should also be targeted in motivational interviewing interventions, as they are essential for the care of older patients with MCCs.

Chinese Community Home-Based Aging Institution Elders' Self-Management of Chronic Non-Communicable Diseases and Its Interrelationships with Social Support, E-Health Literacy, and Self Efficacy: A Serial Multiple Mediation Model

Background

The Chinese population is aging, and chronic non-communicable diseases (NCDs) prevalence is correspondingly increasing, along with associated disability and healthcare costs. Although self-management has been associated with social support and is a recognized priority, its mediating variables have not been studied in detail, particularly among old people with chronic diseases.

Purpose

To examine the mediating role of e-health literacy and general self-efficacy in the relationship between social support and self-management of chronic NCDs in Chinese community home-based aging institution residents.

Patients and Methods

A random sample of 289 community home-based aging institution elders (≥60 years) with chronic NCDs in China was recruited. Questionnaire data were recorded on self-reported socio-demographics, self-management, social support, e-health literacy, and general self-efficacy. Pearson's correlation analysis identified the relationship between these factors and self-management. Serial multiple mediation model was used to test the hypothesized relationships.

Results

The self-management mean (±SD) score was 29.39 ± 9.60, and the level of self-management was medium. Social support (r = 0.283; P < 0.001), e-health literacy (r = 0.566; P < 0.001), and general self-efficacy (r = 0.477; P < 0.001) were positively associated with self-management. Furthermore, social support indirectly influenced self-management through three pathways: independent mediation of e-health literacy (effect = 0.234, P < 0.001), independent mediation of general self-efficacy (effect = 0.515, P < 0.001), and chain mediation of e-health literacy and general self-efficacy (effect = 0.075, P < 0.001).

Conclusion

In Chinese community home-based aging institution elders, the relationship between self-reported self-management and social support is positively affected by the independent mediating effect of e-health literacy and general self-efficacy and the serial mediating effect of e-health literacy and general self-efficacy. Targeted self-management programs for elders with chronic NCDs have theoretical support, which could improve the health status and quality of life in this population.

Comparison of short and long forms of the Flinders program of chronic disease SELF-management for participants starting SGLT-2 inhibitors for congestive heart failure (SELFMAN-HF): protocol for a prospective, observational study

Introduction

Congestive heart failure (CHF) causes significant morbidity and mortality. It is an epidemic, and costs are escalating. CHF is a chronic disease whose trajectory includes stable phases, periods of decompensation, and finally palliation. Health services and medical therapies must match the various patient needs. Chronic disease self-management (CDSM) programmes that are patient-focused, identify problems and set actionable goals that appear as a logical, cost-friendly method to navigate patient journeys. There have been challenges in standardising and implementing CHF programmes.

Methods and analysis

SELFMAN-HF is a prospective, observational study to evaluate the feasibility and validity of the SCRinHF tool, a one-page self-management and readmission risk prediction tool for CHF, with an established, comprehensive CDSM tool. Eligible patients will have CHF with left ventricular ejection fraction <40% and commenced sodium glucose co-transporter-2 inhibitors (SGLT2-i) within 6 months of recruitment. The primary endpoint is the 80% concordance in readmission risk predicted by the SCRinHF tool. The study will recruit >40 patients and is expected to last 18 months.

Ethics and dissemination

This study has been approved by the St Vincent's ethics committee (approval no. LRR 177/21). All participants will complete a written informed consent prior to enrolment in the study. The study results will be disseminated widely via local and international health conferences and peer-reviewed publications.

Evaluation of a technology-enhanced, integrated community health and wellness program for seniors (HWePS): protocol of a non-randomized comparison trial

BACKGROUND

Healthy aging for all in the community is a shared public health agenda for countries with aging populations, but there is a lack of empirical evidence on community-wide preventive models that promote the health of older people residing in socially-disadvantaged communities. The Health and Wellness Program for Seniors (HWePS) is a technology-enhanced, multi-level, integrated health equity intervention model. This study evaluates the effect of the HWePS on the health and well-being of older adults residing in urban, low-income communities.  METHODS/DESIGN: HWePS is a prospective, non-randomized comparison trial conducted in an intervention and a control neighborhood (dong) in Seoul, South Korea, over 12 months. Older people who reside in the small areas and meet the inclusion/exclusion criteria are eligible to participate. The multi-level, multi-faceted HWePS intervention is a preventive community care model for older residents guided by the expanded chronic care model, the comprehensive health literacy intervention model, and the Systems for Person-centered Elder Care model along with health equity frameworks. HWePS consists of four components: a health literacy intervention based on individual and community needs assessments, personalized (self-)care management featuring nurse coaching and peer support, a healthy-living and healthy-aging community initiative, and information and communication technology (ICT) systems. The primary outcomes are self-reported health and health-related quality of life. Outcome assessors and data analysts are blinded to group assignment. Process evaluation will be also conducted.

DISCUSSION

As a multi-level health equity project, HWePS has adopted a novel study design that simultaneously targets individual- and community-level factors known to contribute to health inequality in later life in the community. The study will provide insights into the effectiveness and implementation process of an integrated, multi-level, preventive community care model, which in turn can help improve the health outcomes of older residents and reduce disparities in underserved urban communities.

TRIAL REGISTRATION

ISRCTN29103760. Registered 2 September 2021, https://www.isrctn.com/ISRCTN29103760.

Specific content for collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care

BACKGROUND

In primary care (PC) many patients suffer from multimorbidity involving depression and/or anxiety. Collaborative care (CC) has shown promising results for patients with depression, anxiety, and multimorbidity involving depression. However, specific content in CC for patients with multimorbidity involving depression and/or anxiety is unknown.

OBJECTIVE

(i) To examine the effect of CC interventions in patients with multimorbidity involving depression and/or anxiety compared with usual care; (ii) to identify specific content of CC.

METHODS

We conducted a systematic literature review of randomized controlled trial studies evaluating CC models for adults with multimorbidity involving depression and/or anxiety in PC settings. PubMed, CINAHL, Web of Science, and PsycInfo were searched in December 2019. We conducted a qualitative synthesis using an existing framework and developed a new framework to map the content for each studied intervention.

RESULTS

We identified 1,447 studies. Twelve publications were included. Eleven had medium-to-high quality of CC for patients with multimorbidity involving depression. Specific content of CC in these studies is: A stepped care model, involving medication and psychotherapy delivered by a nurse or psychologist Care Manager (CM) focusing on problem-solving techniques; follow-up including monitoring of symptoms and function, and relapse prevention strategies; scheduled CM supervision.

CONCLUSIONS

Specific content for CC for patients with multimorbidity involving depression is identified from current research. Research gaps were found regarding CC for patients with multimorbidity and anxiety, depression and anxiety, and depression and/or anxiety and more than 2 diseases.

A systematic review of impact of person-centred interventions for serious physical illness in terms of outcomes and costs

BACKGROUND

Person-centred care (PCC) is being internationally recognised as a critical attribute of high-quality healthcare. The International Alliance of Patients Organisations defines PCC as care that is focused and organised around people, rather than disease. Focusing on delivery, we aimed to review and evaluate the evidence from interventions that aimed to deliver PCC for people with serious physical illness and identify models of PCC interventions.

METHODS

Systematic review of literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched AMED, CINAHL, Cochrane Library, Embase, Medline, PsycINFO, using the following key concepts: patient/person-centred care, family centred care, family based care, individualised care, holistic care, serious illness, chronic illness, long-term conditions from inception to April 2022. Due to heterogeneity of interventions and populations studied, narrative synthesis was conducted. Study quality was appraised using the Joanna Briggs checklist.

RESULTS

We screened n=6156 papers. Seventy-two papers (reporting n=55 different studies) were retained in the review. Most of these studies (n=47) were randomised controlled trials. Our search yielded two main types of interventions: (1) studies with self-management components and (2) technology-based interventions. We synthesised findings across these two models:Self-management component: the interventions consisted of training of patients and/or caregivers or staff. Some studies reported that interventions had effect in reduction hospital admissions, improving quality of life and reducing costs of care.Technology-based interventions: consisted of mobile phone, mobile app, tablet/computer and video. Although some interventions showed improvements for self-efficacy, hospitalisations and length of stay, quality of life did not improve across most studies.

DISCUSSION

PCC interventions using self-management have some effects in reducing costs of care and improving quality of life. Technology-based interventions improves self-efficacy but has no effect on quality of life. However, very few studies used self-management and technology approaches. Further work is needed to identify how self-management and technology approaches can be used to manage serious illness.

PROSPERO REGISTRATION NUMBER

CRD42018108302.

Systematic review of patient-engagement interventions: potentials for enhancing person-centred care for older patients with multimorbidity

INTRODUCTION

Person-centred care based on systematic and comprehensive patient-engagement is gaining momentum across healthcare systems. Providing care that is responsive to the needs, values and priorities of each patient is important for patients, relatives and providers alike, not least for the growing population of older patients living with multi-morbidity and associated complex care trajectories.

OBJECTIVES

The aim of this systematic review is to investigate the effects of patient engagement interventions for older patients with multimorbidity.

METHODS

Systematic review conducted in August 2021. Two reviewers independently screened the international databases Embase and PubMed. Reviewers carried out duplicate and independent data extraction and assessment of study quality. Grading of Recommendations Assessment, Development and Evaluation was used to assess the quality of the evidence for each study.

RESULTS

We included twelve studies from primary care setting and hospitals. The included studies were heterogeneous in terms of characteristics of populations, types of interventions to enhance patient-engagement, outcome measures and length of follow-up. Nine of the 12 included studies found significant improvements in health and patient-reported outcomes such as higher quality-adjusted life-years, fewer hospital visits and disease specific symptoms. Quality of the included studies was of low to moderate.

CONCLUSION

This review identifies potential beneficial effects of interventions to enhance patient-engagement in older adults with multimorbidity. Nevertheless, the limited and very diverse evidence-based calls for more robust studies into efficient approaches to engaging older adults with multimorbidity in care trajectories.

Interventions for improving medication adherence in community-dwelling older people with multimorbidity: A systematic review and meta-analysis

BACKGROUND

Multimorbidity is highly prevalent amongst older people. Compared with those with a single disease, older people with multimorbidity are more susceptible to medication nonadherence, which causes adverse health outcomes and increased health care costs. The effectiveness of interventions for improving medication adherence in this population is still unclear.

OBJECTIVE

To evaluate the effectiveness of interventions to improve medication adherence for community-dwelling older people with multimorbidity.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ten databases: Airiti Library, China National Knowledge Infrastructure, Cochrane CENTRAL, EBSCO CINAHL, OVID EMBASE, OVID MEDLINE, Proquest Central, PsycINFO, Wanfang Database and Web of Science Core Collection.

REVIEW METHODS

Studies evaluating the effects of interventions on medication adherence in community-dwelling older people with multimorbidity were included. Two researchers independently performed the study selection, data extraction and risk assessment. Intervention effects were pooled by random-effects meta-analysis.

RESULTS

A total of nine studies with 3,292 participants were included. Studies on self-management interventions revealed a significant and modest improvement in medication adherence (n = 3 studies; SMD 0.52; 95% CI 0.04 to 0.99; p = 0.03, I² = 43%). Studies using electronic health interventions demonstrated a small yet significant benefit for medication adherence (n = 2 studies; SMD 0.22; 95% CI 0.02 to 0.42; p = 0.03, I² = 0%). There was no pooled significant effect of medication review on medication adherence (n = 4 studies; SMD -0.03; 95% CI -0.21 to 0.15; p = 0.74, I² = 68%). Most of the studies failed to yield a significant improvement in patients' health outcomes.

CONCLUSIONS

Self-management interventions and electronic health interventions might be effective in improving medication adherence for older people with multimorbidity. Future adherence interventions are needed to demonstrate improvements in medication adherence and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020150500.

Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review

BACKGROUND

Multimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review updated and narrowed the focus of a previous Cochrane review and aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care.

METHODS

We searched eight databases and two trials registers up to 9 September 2019. Two review authors independently screened potentially eligible titles and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health-related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative.

RESULTS

We included 16 RCTs with 4753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall, the certainty of the evidence was graded as low due to significant variation in study participants and interventions.

CONCLUSIONS

There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

A community-based nurse-led medication self-management intervention in the improvement of medication adherence in older patients with multimorbidity: protocol for a randomised controlled trial

Background

Older patients suffering from multimorbidity are at high risk of medication nonadherence. It has been well established that self-management support is an effective strategy to enhance medication adherence for patients with chronic conditions. However, little is known about the effect of the medication self-management intervention in older patients with multimorbidity. This paper presents the protocol for a study that aims to evaluate the effectiveness of a nurse-led medication self-management intervention in improving medication adherence and health outcomes for community-dwelling older patients with multimorbidity.

Methods

The study protocol follows the recommendations of the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement. This study is a multicentre, single-blind, two-arm randomised controlled trial. Older patients with multimorbidity will be recruited from three community health centres in Changsha, China. A total of 136 participants will be randomly allocated to receive usual care or usual care plus the medication self-management intervention. The intervention will be delivered by community nurses. The 6-week intervention includes three face-to-face education sessions and two weekly follow-up phone calls. Participants in the control group continue to receive all respects of usual care offered by community healthcare providers, including chronic disease management, drug prescription, referral to hospital specialists, health education and consultations regarding patients’ diseases and treatments during centre visits. The primary outcome is medication adherence as measured by the 5-item Medication Adherence Report Scale. Secondary outcomes include medication self-management capacity (medication knowledge, medication beliefs, medication social support, medication skills, and medication self-efficacy), treatment experiences (medication treatment satisfaction and treatment burden), quality of life, and utilisation of healthcare services. All outcomes will be measured at baseline, immediately post-intervention, and at 3-month post-intervention.

Discussion

This study will provide evidence about the effectiveness of a medication self-management intervention, delivered by nurses, for older patients with multimorbidity and adherence problems. It is expected that the results of the study, if proven effective in improving patients’ adherence and health outcomes, will provide evidence-based self-management support strategies for healthcare providers in routine chronic disease management in community settings.

Trial registration

The trial is registered at ChiCTR.org.cn (ChiCTR2000030011; date February 19, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02097-x.

Self-Management of Chronic Diseases: A Descriptive Phenomenological Study

Chronic diseases are a priority for health-care systems and patient-centered care. They cause long-term issues and have a number of physical, psychological, and social effects. Patients with chronic diseases require ongoing care and support in order to manage them. The aim of this study was to understand the experiences of patients with chronic conditions who were able to practice self-management. The study was conducted in Izmir province, Turkey with 10 patients with a chronic disease (e.g., hypertension, diabetes, arthritis) who attended two family health-care centers. A phenomenological approach was used and three main themes were identified: social support, disease management, and self-awareness and empowerment. It was determined that the subthemes of "definition of a chronic disease," "perceived barriers," "emotional and spiritual state," "self-monitoring," and "diet and medication management" had a significant influence on self-management. The results demonstrated that patients' health outcomes can be affected by their experiences and behaviors. Health-care professionals should design and implement self-care programs that take into account all the variables that affect patients' self-management of their disease.

Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain-A Scoping Review and Theoretical Models

(1) Background: Adherence to and the maintenance of treatment regimens are fundamental for pain self-management and sustainable behavioural changes. The first aim was to study older adults’ (>65 years) levels of adherence to and maintenance of musculoskeletal pain self-management programmes in randomized controlled trials. The second aim was to suggest theoretical models of adherence to and maintenance of a behaviour. (2) Methods: The study was conducted in accordance with the recommendations for a scoping review and the PRISMA-ScR checklist. Capability, motivation and opportunity were used to categorize the behavioural change components in the theoretical models. (3) Results: Among the four studies included, components targeting adherence were reported in one study, and maintenance was reported in two studies. Adherence was assessed by the treatment attendance rates, and maintenance was assessed by the follow-up data of outcome measures. For adherence, the capability components were mostly about education and the supervision, grading and mastery of exercise to increase self-efficacy. The motivation components included the readiness to change, self-monitoring and goal setting; and the opportunity components included booster sessions, feedback and social support. For maintenance, the capability components consisted of identifying high-risk situations for relapse and problem-solving skills. The motivation components included self-regulation and self-efficacy for problem solving, and the opportunity components included environmental triggers and problem solving by using social support. (4) Conclusion: There are several behavioural change components that should be used to increase older adults’ levels of adherence to and maintenance of a pain self-management behaviour.

Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged)

OBJECTIVE

To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations.

METHODS

Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate.

RESULTS

8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured.

CONCLUSION

The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare.

PRACTICE IMPLICATIONS

There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

Effective implementation approaches for healthy ageing interventions for older people: A rapid review

BACKGROUND AND OBJECTIVES

Systematic reviews on healthy ageing interventions have primarily focused on assessing their effectiveness, not the implementation processes underpinning them, and the factors influencing program effectiveness. This has created a knowledge gap about what are effective implementation approaches, and how to scale up such interventions at the population level. Our aim in this rapid review was to synthesise the evidence on implementation of effective healthy ageing interventions, and to identify the factors that influence population-level implementation of these interventions.

DESIGN AND METHODS

Following the PRISMA checklist, we searched for papers in six databases: Ovid Medline, Ovid Embase, CENTRAL, CINAHL, PsycArticles and PsycINFO. A narrative synthesis was used to summarise the results.

RESULTS

Twenty-nine articles reporting on 21 healthy ageing interventions (studies) were included in the review. The findings show that a wide range of approaches to implementation were used including collaborative partnership, co-design, use of volunteers, person centred-care, and self-directed/professional-led approaches. The key implementation drivers were the use of behavioural change techniques, social interaction, tailoring of interventions, booster sessions, and multi-component and multi-professional team approach to intervention design and delivery.

CONCLUSION

The effectiveness of healthy ageing interventions is contingent on a number of factors including the type of implementation approaches used, the context in which programs are implemented, and the specific mechanisms that may be at play at the individual older adult level.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations

BACKGROUND

Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options.

OBJECTIVES

To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis.

MAIN RESULTS

We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'.

AUTHORS' CONCLUSIONS

Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care?

BACKGROUND

The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed.

AIM

To estimate how often DDI is managed in primary care, using antibiotics dispensing data.

DESIGN AND SETTING

Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics.

METHOD

Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use.

RESULTS

From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation.

CONCLUSION

DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.