Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation.

BACKGROUND: Although popular, clinical practice guidelines are not universally accepted by healthcare professionals. OBJECTIVES: To compare nurses' and physicians' actual and perceived rates of adherence to practice guidelines used in sedation of patients receiving mechanical ventilation and to describe nurses' and physicians' perceptions of guideline use. METHODS: Pairs of fellows and nurses caring for 60 eligible patients were asked separately about their rationale for medicating patients, effectiveness of medication, and their perceived adherence to the guidelines. Actual adherence was determined independently by review of medical records. An additional 18 nurses and 11 physicians were interviewed about perceptions of guideline use. RESULTS: Use of mechanical ventilation was the most common reason given by physicians (53%) and nurses (48%) for medicating patients, although reasons for administering medication to a given patient differed in up to 30% of cases. Physicians and nurses disagreed on the effectiveness of medication in 42% (P = .01) of cases. Physicians reported following guidelines in 69% of cases, but their actual adherence rate was only 20%. Clinicians sometimes had difficulty distinguishing among anxiety, pain, and delirium. Clinicians justified variations from guidelines by citing the value of individualized patient care. Nurses and physicians sometimes had different goals in the use of sedation. CONCLUSIONS: Physicians may think they are following sedation guidelines when they are not, and they may prescribe incorrect medications if the cause of agitation is misdiagnosed. Differences between physicians and nurses in values and perceptions may hamper implementation of clinical practice guidelines.     

Medication adherence among geriatric outpatients prescribed multiple medications

BackgroundPoor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outcomes.ObjectiveWe aimed to determine the prevalence and correlates of PMA in an older population with polypharmacy.MethodsBaseline data from 193 older adults from the Medication Safety Review Clinic Taiwan Study were analyzed. Patients were either prescribed ≥8 long-term medications or visited ≥3 different physicians between August and October 2007. PMA was defined as taking either <80% or >120% of prescribed amounts of a medication. Patients were classified as no (0%), low level (>0 but <25%), and high level (≥25%) PMA depending on what percentage of entire medication regimen taken reached PMA.ResultsMean (SD) age was 76 (6) years, and mean number of medications was 9 (3), with a mean medication class number of 4 (1). Of the 1713 medications reviewed, 19% had PMA. However, at patient level, 34%, 32%, and 34% of patients were classified as no, low level, and high level PMA, respectively. Correlates varied by levels of PMA. Compared with patients without PMA, higher medication class number and use of alimentary tract, psychotropic, and hematologic agents were associated with both low and high level PMA. History of dizziness was associated with low level PMA, and higher Mini Mental Status Examination score was associated with high level PMA.ConclusionsTo enhance medication adherence in older adults prescribed multiple medications, medication class numbers and certain high-risk medication classes should be taken into account. Physicians should also routinely assess systemic (eg, cognition) or drug-specific characteristics (eg, side effects).     

Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence

BACKGROUND: Adherence to medication is unacceptably low in both medical and psychiatric disorders. Explanatory models of illness beliefs and behaviors suggest that an individual's beliefs about a disorder and its treatment will influence their adherence. Given that beliefs about medications may influence adherence to antidepressants, we examined beliefs about medications in relation to antidepressant adherence in a primary care sample. OBJECTIVE: The purpose of this report is to 1) describe beliefs about medication in primary care patients prescribed antidepressants for depression; 2) examine the factor structure of the Beliefs about Medicines Questionnaire (BMQ) and compare it with the previously reported factor structure of the BMQ in medical conditions; and 3) examine the association of medication beliefs with self-reported medication adherence. RESULTS: Factor analysis indicates that the BMQ is valid in a sample of primary care patients receiving treatment for depression and has a similar factor structure to that obtained in samples of patients with chronic medical conditions. Beliefs about medications are significantly associated with self-reported adherence. Severity of depressive symptoms and specific concerns about antidepressants are significantly associated with self-reported medication-taking behavior. Findings suggest that in addition to telling patients how to take their medications, primary care physicians should also educate patients about the short- and long-term effects of the medication, how the medication works, and that antidepressants are not addictive.     

Using Handheld Devices to Promote Medication Adherence in Chronic Illness

Medication adherence is a key factor in maintaining optimal health outcomes in chronic illness. Best practices have not yet been identified to measure and increase adherence. The objective was to examine adherence related to the use of handheld devices that delivered electronic medication reminders in a sample of adults experiencing a chronic illness. Health literacy was assessed to reflect patient understanding of the medications prescribed by their health care providers. Study participants were given handheld devices that sounded alarms as medication reminders. The adherence rate was 89.64%, indicating that most participants remembered their medications.     

Testing a nurse-tailored HIV medication adherence intervention

BACKGROUND: The relationship between patient adherence and treatment outcomes has been documented across chronic health conditions, but the evidence base for effective adherence interventions in human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) requires more rigorous research and reporting. OBJECTIVES: The aims of this study were to determine whether a tailored, nurse-delivered adherence intervention program--Client Adherence Profiling and Intervention Tailoring (CAP-IT)--improved adherence to HIV medications, compared with standard care, and to identify the relationship among adherence measures. METHODS: A randomized controlled trial (RCT) with repeated measures was used to test the efficacy of CAP-IT over a 6-month period. A convenience sample of 240 participants was recruited from a freestanding public HIV/AIDS clinic in Houston, TX, that provides medical, psychological, and pharmaceutical services for over 5,000 clients. Study instruments and measures included demographics; chart audit to capture CD4 count, viral load, and prescribed medications; health literacy; and five measures of adherence (AIDS Clinical Trial Group-Revised Reasons for Missing Medications, Morisky Self-Report of Medication Non-Adherence, Pill Count, Medication Event Monitoring System [MEMS] caps, and Pharmacy Refill). RESULTS: A logistic regression using generalized estimating equations method showed no significant differences over time on the five medication-adherence measures between the experimental and control groups. Little correlation was documented among the five different adherence measures, and there was minimal correlation with clinical markers. DISCUSSION: It is unclear why the tailored adherence intervention was not efficacious in improving medication adherence. The findings suggest that these measures of medication adherence did not perform as expected and that, perhaps, they are not adequate measures of adherence. Effective and efficient adherence interventions are needed to address the barriers to medication adherence in HIV/AIDS.     

Perspectives Regarding Adherence to Prescribed Treatment in Highly Adherent HIV-Infected Gay Men.

Focus group methodology was used to describe the medication adherence experience of 24 HIV-infected gay men who reported being adherent to their medication regimens. A conceptualization of medication adherence as an evolving process consisted of challenges to adherence (learning the diagnosis, starting the medications, struggling with the medications, dealing with side effects, coping with stigma) as well as those factors supportive of adherence (believing in medications, finding motivating factors, using reminders, depending on others, owning the disease). Themes associated with challenges to adherence focused on diagnosis and the physical and emotional adjustments individuals made to incorporate antiretroviral medications into their daily lives and move toward medication adherence. The factors supportive of adherence were related to the ongoing behaviors identified with establishing and maintaining adherence behaviors. What can be taken from the study is that adherence is a complex and dynamic process rather than a static behavior.     

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.     

Determinants of patient adherence to an aerosol regimen

Patient adherence with prescribed inhaled therapy is related to morbidity and mortality. The terms "compliance" and "adherence" are used in the literature to describe agreement between prescribed medication and patient practice, with "adherence" implying active patient participation. Patient adherence with inhaled medication can be perfect, good, adequate, poor, or nonexistent, although criteria for such levels are not standardized and may vary from one study to another. Generally, nonadherence can be classified into unintentional (not understood) or intentional (understood but not followed). Failing to understand correct use of an inhaler exemplifies unintentional nonadherence, while refusing to take medication for fear of adverse effects constitutes intentional nonadherence. There are various measures of adherence, including biochemical monitoring of subjects, electronic or mechanical device monitors, direct observation of patients, medical/pharmacy records, counting remaining doses, clinician judgment, and patient self-report or diaries. The methods cited are in order of more to less objective, although even electronic monitoring can be prone to patient deception. Adherence is notoriously higher when determined by patient self-report, compared to electronic monitors. A general lack of adherence with inhaled medications has been documented in studies, and adherence declines over time, even with return clinic visits. Lack of correct aerosol-device use is a particular type of nonadherence, and clinician knowledge of correct use has been shown to be imperfect. Other factors related to patient adherence include the complexity of the inhalation regimen (dosing frequency, number of drugs), route of administration (oral vs inhaled), type of inhaled agent (corticosteroid adherence is worse than with short-acting beta2 agonists), patient awareness of monitoring, as well as a variety of patient beliefs and sociocultural and psychological factors. Good communication skills among clinicians and patient education about inhaled medications are central to improving adherence.     

Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study

OBJECTIVE: To examine the correlates of patient and provider attitudes toward insulin therapy. RESEARCH DESIGN AND METHODS: Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. RESULTS: Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. CONCLUSIONS: Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.     

Patient adherence to medication requirements for therapy of type 2 diabetes

Type 2 diabetes is a complex, progressive endocrine and metabolical disease that typically requires substantial lifestyle changes and multiple medications to lower blood glucose, reduce cardiovascular risk and address comorbidities. Despite an extensive range of available and effective treatments, < 50% of patients achieve a glycaemical target of HbA(1c) < 7.0% and about two-thirds die of premature cardiovascular disease. Adherence to prescribed therapies is an important factor in the management of type 2 diabetes that is often overlooked. Inadequate adherence to oral antidiabetes agents, defined as collecting < 80% of prescribed medication, is variously estimated to apply to between 36% and 93% of patients. All studies affirm that a significant proportion of type 2 diabetes patients exhibit poor adherence that will contribute to less than desired control. Identified factors that impede adherence include complex dosing regimens, clinical inertia, safety concerns, socioeconomic issues, ethnicity, patient education and beliefs, social support and polypharmacy. This review explores these factors and potential strategies to improve adherence in patients with type 2 diabetes.     

Factors that affect adherence to bipolar disorder treatments: a stated-preference approach

BACKGROUND: Medication nonadherence is high among patients with bipolar disorder, and may lead to poor clinical outcomes, decreased quality of life, and increased resource utilization. OBJECTIVE: To investigate the factors associated with nonadherence and to assess the effect of patient-stated preferences on stated adherence to hypothetical medications. RESEARCH DESIGN: A choice-format stated-preference Web survey was administered. In each choice question, patients were asked to choose among 2 or 3 different hypothetical medications. Each choice question was followed by a question asking patients about their likely adherence to the selected medication alternative. SUBJECTS: Patients (N = 469) with self-reported bipolar disorder completed the survey which was programmed and administered to members of a chronic-illness Web panel. MEASURES: Factors associated with stated adherence to current treatment were identified. The effects of socioeconomic characteristics and medication attributes on stated adherence to hypothetical medications were assessed. RESULTS: Patient socioeconomic characteristics affect patients' adherence. Being white and having more education has a significant positive effect on adherence. Self-reported current adherence is a strong factor in predicting adherence for better medications. Medication outcome attributes, especially severity of depressive episodes, strongly influence patients' stated adherence to treatment. Weight gain and cognitive effects of a medication most significantly affected patients' likely adherence to medications for bipolar disorder. CONCLUSIONS: Patients are the final health care decision makers; their satisfaction with a medication is likely to affect whether or not they adhere to the medication prescribed by their physician. In the case of bipolar disorder, this study suggests patients are likely to be more adherent to medications that reduce the severity of depressive episodes and do not cause weight gain or cognitive side effects. By understanding the factors that improve adherence, health care providers can optimize prescribing patterns, which may ultimately lead to more effective management and improvement in the patient's condition.     

Impact of a self-administration of medications programme on elderly inpatients' competence to manage medications: a pilot study

What is known and objectives: Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non‐adherence at home after discharge. Self‐administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients’ competence to manage medications and their medication adherence behaviours. Methods: The SAMP comprised three stages: education, progressing to supervised self‐administration and finally to independent self‐administration. Decisions to progress patients to the next level, and whether they passed or failed the SAMP, were made by the ward pharmacist and nursing staff. The Drug Regimen Unassisted Grading Scale (DRUGS) was used to assess patients’ competence to manage medications at various time points. Tablet count and the Tool for Adherence Behaviour Screening (TABS) were used as adherence measures. Results and discussion: Participants (n = 24) with a mean age of 77·4 years, were mainly female and generally had a high level of functioning. They were prescribed a mean of 9·0 medications at the time of commencing the SAMP. Twenty‐two of the 24 participants successfully completed the SAMP. DRUGS scores at discharge improved significantly (P < 0·001) compared with that before commencement of medication self‐administration. Participants reported a significant decrease (P = 0·02) in non‐adherent behaviour and a trend towards improved adherent behaviour (P = 0·08) after participation in the SAMP. What is new and conclusion: An inpatient SAMP improved elderly patients’ ability to competently manage and adhere to their prescribed medications regimen. This finding needs to be confirmed in a larger controlled trial.     

Screening tests for intended medication adherence among the elderly

BACKGROUND: Medication nonadherence is increasingly recognized as a cause of preventable adverse events, hospitalizations, and poor healthcare outcomes. While comprehensive medication adherence assessment for the elderly is likely to identify and prevent drug-related problems, it is time consuming for patient and healthcare providers alike. OBJECTIVE: To identify screening tools to predict elderly patients' intended medication adherence that are suitable for primary-care settings and community pharmacies. METHODS: This study evaluated 57 English-speaking persons aged 65 years and older who were from diverse socioeconomic backgrounds. Intended adherence was quantified, and the relationships to demographic, medical history, socioeconomic, and literacy variables were determined. RESULTS: In a multivariate analysis with the composite MedTake Test (a quantitative measure of each subject's intent to adhere to prescribed oral medications) as the dependent variable, independent predictors of intended adherence included: age, car ownership in the last 10 years, receipt of food assistance in the last 10 years, number of over-the-counter (OTC) medicines, and REALM (Rapid Estimate of Adult Literacy in Medicine). The strongest predictor was the REALM word-recognition pronunciation test (beta = 0.666; R2 = 0.271; p < 0.001). CONCLUSIONS: We observed that the REALM word-recognition pronunciation test, along with age, number of OTC drugs, and 2 socioeconomic questions, predicted the intent of seniors to correctly take their own prescribed oral medications.