Help needed in medication self-management for people with visual impairment: case–control study

Background

Visual impairment (VI) is rising in prevalence and contributing to increasing morbidity, particularly among older people. Understanding patients’ problems is fundamental to achieving optimal health outcomes but little is known about how VI impacts on self-management of medication.

Aim

To compare issues relating to medication self-management between older people with and without VI.

Design and setting

Case–control study with participants aged ≥65 years, prescribed at least two long-term oral medications daily, living within the community.

Method

The study recruited 156 patients with VI (best corrected visual acuity [BCVA] 6/18 to 3/60) at low-vision clinics; community optometrists identified 158 controls (BCVA 6/9 or better). Researchers visited participants in their homes, administered two validated questionnaires to assess medication adherence (Morisky; Medication Adherence Report Scale [MARS]), and asked questions about medication self-management, beliefs, and support.

Results

Approximately half of the participants in both groups reported perfect adherence on both questionnaires (52.5% Morisky; 43.3%, MARS). Despite using optical aids, few (3%) with VI could read medication information clearly; 24% had difficulty distinguishing different tablets. More people with VI (29%) than controls (13%) (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.6 to 5.0) needed help managing their medication, from friends (19% versus 10%) or pharmacists (10% versus 2.5%; OR = 4.4, 95% CI = 1.4 to 13.5); more received social service support (OR = 7.1; 95% CI = 3.9 to 12.9).

Conclusion

Compared to their peers without VI, older people with VI are more than twice as likely to need help in managing medication. In clinical practice in primary care, patients’ needs for practical support in taking prescribed treatment must be recognised. Strategies for effective medication self-management should be explored.     

Older adults with multi-morbidity: medication management processes and design implications for personal health applications

Background

Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults’ needs, preferences, and practices.

Objective

The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA.

Methods

We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling.

Results

We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers.

Conclusions

This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.     

Medication use in European primary care patients with lower respiratory tract infection: an observational study

Background

It is largely unknown what medication is used by patients with lower respiratory tract infection (LRTI).

Aim

To describe the use of self-medication and prescribed medication in adults presenting with LRTI in different European countries, and to relate self-medication to patient characteristics.

Design and setting

An observational study in 16 primary care networks in 12 European countries.

Method

A total of 2530 adult patients presenting with LRTI in 12 European countries filled in a diary on any medication used before and after a primary care consultation. Patient characteristics related to self-medication were determined by univariable and multivariable logistic regression analysis.

Results

The frequency and types of medication used differed greatly between European countries. Overall, 55.4% self-medicated before consultation, and 21.5% after consultation, most frequently with paracetamol, antitussives, and mucolytics. Females, non-smokers, and patients with more severe symptoms used more self-medication. Patients who were not prescribed medication during the consultation self-medicated more often afterwards. Self-medication with antibiotics was relatively rare.

Conclusion

A considerable amount of medication, often with no proven efficacy, was used by adults presenting with LRTI in primary care. There were large differences between European countries. These findings should help develop patient information resources, international guidelines, and international legislation concerning the availability of over-the-counter medication, and can also support interventions against unwarranted variations in care. In addition, further research on the effects of symptomatic medication is needed.     

Patients' views of antidepressants: from first experiences to becoming expert

Background

The majority of patients discontinue antidepressant treatment earlier than prescribed. The factors behind this and the influences on patients'' choices about whether to take medication remain poorly understood.

Aim

To explore factors that influence patients'' decisions about taking antidepressant medication.

Design of study

Qualitative interview study.

Setting

Interviews were conducted across three sites: London, East Lancashire, and North East England.

Method

Semi-structured interviews were conducted with a purposive sample of 65 primary care patients who were prescribed antidepressants in the past year for depression or mixed anxiety/depression.

Results

Participants described their first course of antidepressants as typically occurring when they had ‘hit rock bottom’, having exhausted all other possibilities; therefore, there was little sense of a positive choice at this stage. There would typically follow a period of experimentation where it was usual to stop and restart medication, often several times. Ultimately, these recurring cycles lead to participants becoming more expert about their condition and better able to make an informed decision about medication. For younger participants, recovery typically remained a goal, although for older people there was often an acceptance that their condition, and medication use, would be long term.

Conclusion

Participants'' accounts demonstrated how they could become expert at managing their condition through a process of trial and error.     

Impact of Patient Access to Internet Health Records on Glaucoma Medication: Randomized Controlled Trial

Background

Glaucoma is one of the leading causes of blindness. Reduction of intraocular pressure is the only proven way to prevent progression of glaucomatous optic neuropathy. The majority of glaucoma patients need to use antiglaucoma ophthalmic solutions over the course of their life. Thus, good adherence and persistency of glaucoma treatment are important factors for better glaucoma care.

Objective

The purpose of this study was to investigate the impact of an Internet-based glaucoma care support system on glaucoma medication use.

Methods

Patients were randomly divided into two groups. The non–Internet access (NIA) group consisted of patients who had access to the Internet-based glaucoma care support system during the 4-year period only when they were examined by ophthalmologists. The Internet access (IA) group consisted of patients who had the same Internet-based glaucoma care support system access as the NIA group for the first 2 years following enrollment but who were also given free access to the glaucoma care support system for the remaining 2 years. Changes in glaucoma medication use were investigated.

Results

In total, 81 patients in the IA group and 90 patients in the NIA group satisfied the study protocol. The number of antiglaucoma ophthalmic solutions used during the study period significantly increased in the NIA group (P<.03) but not in the IA group. The percentages of patients with unchanged, increased, and decreased antiglaucoma ophthalmic solution use during the study period were 61.1% (55/90), 17.8% (16/90), and 3.3% (3/90), respectively, in the NIA group, and 56.8% (46/81), 8.6% (7/81), and 13.6% (11/81), respectively, in the IA group (P<.001). Internet access significantly shifted from an increasing intraocular pressure trend to a decreasing trend in the IA group (P=.002) among the patients who did not have any medication changes.

Conclusions

Allowing patients to browse their medical data may reduce the use and improve the effectiveness of glaucoma medication.

Trial Registration

UMIN-CTR Clinical Trial Number: UMIN000006982; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000008238&language=E (Archived by WebCite at http://www.webcitation.org/6MRPQeEAv).     

Revised guidelines for cardiovascular risk management — time to stop medication? A practice-based intervention study

Background

According to the new Dutch guideline for cardiovascular risk management, patients with a low risk of cardiovascular mortality may have insufficient benefit to warrant medication. Therefore, numerous patients per general practice may be treated unnecessarily.

Aim

To explore the feasibility and consequences of a re-evaluation programme for patients without target organ damage who were treated for hypertension and/or hypercholesterolaemia.

Design and setting

Practice-based intervention study in six general practices.

Method

Patients treated for hypertension and/or hypercholesterolaemia without target organ damage (n = 833) were invited to re-evaluate their cardiovascular risk and were advised whether or not to stop medication. Patients who discontinued medication were followed for 6 months. To determine indicators for successful stopping, logistic regression analyses were performed, and differences between practices were analysed.

Results

About two-thirds of the patients were re-evaluated and 61% of them had a low calculated risk, especially younger patients, females, and non-smokers. Of these, 42% were advised to stop medication, especially younger patients and non-smokers. Of those who discontinued medication, 40% had restarted within 6 months. After 6 months, 80 of the 833 patients (9.6%) had not restarted medication. There were no important side effects related to stopping medication.

Conclusion

Over 50% of patients without target organ damage treated for hypertension and/or hypercholesterolaemia may have insufficient benefit to warrant medication. Younger patients, females, and non-smokers in particular are more likely to have an insufficient indication for medication. GPs’ and nurse practitioners’ views seem to play a role in advising to stop or to restart medication.     

Lost to Follow-Up in Asthmatics Does Not Mean Treatment Failure: Causes and Clinical Outcomes of Non-Adherence To Outpatient Treatment In Adult Asthma

Purpose

Long-term asthma management is recommended to asthmatics; however, many patients do not adhere to follow-up treatment. It is unclear why many asthmatics do not adhere to follow-up treatment and long-term clinical course after discontinuation of asthma management. This study investigates the factors associated with loss to follow-up and observes the clinical course in asthmatics who discontinued asthma treatment.

Methods

A retrospective investigation was conducted after reviewing medical records of adult patients who were newly diagnosed with asthma at a university hospital in Seoul, South Korea from January 2005 to March 2007. We compared baseline demographics and the clinical and laboratory profiles of patients to see if they successfully adhered to the treatment at an outpatient clinic for at least 3 years. The clinical course and asthma control status were surveyed by telephone for patients who were lost to follow-up within 3 years.

Results

A total of 351 (73.9%) out of 475 patients were lost to follow-up within 3 years of asthma diagnosis. Patients lost to follow-up were younger and had clinical features of less severe asthma at time of diagnosis (higher FEV1 and PC20, and lower grade treatments) compared to patients who adhered to the follow-up for longer than 3 years (all P<0.05). Among the 198 responders to the telephone survey, 124 responders (62.6%) answered that they eventually discontinued asthma medication. A significantly higher proportion of the 124 responders who discontinued asthma treatment maintained symptom improvement compared to the 74 responders who continued asthma medication (77.4% vs. 55.4%, P=0.003).

Conclusions

Almost three quarters of newly diagnosed asthmatics discontinued asthma medication within 3 years despite a medical recommendation. There are considerable numbers of asthmatics who can maintain long-term asthma control status without medication.     

How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis

Background

Chronic kidney disease (CKD) is associated with increased cardiovascular mortality and morbidity as well as progression to established renal failure. Interventions in primary care, particularly the lowering of blood pressure in individuals with CKD and proteinuria and diabetes, can slow disease progression. This evidence base is codified in national guidance and in a simplified form in pay-for-performance targets. Prior to conducting the QICKD study — a cluster of quality-improvement interventions with reduction of blood pressure as its primary outcome measure — a diagnostic analysis was conducted to assess the relevance of the intended interventions.

Aim

To understand practitioners'' views of CKD and its management.

Method

Focus groups were held in five locations across England. Experienced facilitators developed a standardised approach and analysed data using the ‘framework’ approach.

Results

Practitioners varied in their views of CKD and their embracing of the guidance. Some sought to implement the full guidance, others only the pay-for-performance targets. Nearly all practitioners had reservations as to whether CKD was really a disease; problematised the diagnosis of CKD purely on an estimate of glomerular filtration rate; questioned whether CKD in older people was part of natural ageing; and had experienced difficulty in explaining the condition to patients without frightening them. Most reported both problems and scepticism concerning the blood pressure targets, and acknowledged educational gaps.

Conclusion

Practitioners have disparate views about CKD. The quality-improvement interventions in the QICKD study will need to incorporate a large element of education. CKD guidelines may have been introduced without sufficient educational support.     

Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

Background

The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.

Aim

To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.

Design of study

Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months'' participation in pharmaceutical care.

Setting

In 2002, 760 patients, aged ≥75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.

Method

Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients'' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form–36 Health Survey (SF-36), and serious adverse events.

Results

The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.

Conclusion

The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.     

'You know what boys are like': pre-diagnosis experiences of parents of children with autism spectrum conditions

Background

The importance of early identification and intervention for children with autism spectrum conditions (ASC) has been established. However, there are often considerable delays from initial concern (by parent or professional) to diagnosis. Little is known about parents'' experiences of primary care in the pre-diagnosis period.

Aim

To identify feasible improvements to the management of primary care consultations with parents of children who might have ASC.

Design and setting

UK-based qualitative interview study.

Method

Semi-structured interviews with a diverse qualitative sample of 24 parents of children, aged between 3 and 11 years, who were diagnosed with ASC.

Results

Three types of parental concern emerged: first, parents who had no concerns about their children''s development before their diagnosis; secondly, parents who reported that they had some concerns but had not raised them with health professionals (passive concern); and thirdly, parents who had raised concerns about their children with health professionals (active concern). The passively concerned parents could not pin down exactly what it was about their children''s development that concerned them. Many of the actively concerned parents had been prematurely reassured by health professionals that there was nothing wrong. This left them feeling isolated and alone. Actively concerned parents who already had a child diagnosed with ASC did not experience a delay in diagnosis.

Conclusion

Health professionals should acknowledge parents'' concerns carefully; contrary to intentions, early reassurance may result in parents feeling that their concerns have not been heard. Parents may be the best resource in identifying ASC.     

Unfashionable tales: narratives about what is (still) great in NHS general practice

Background

There is clear evidence that general practice has become a less popular career choice and among GPs there are high levels of dissatisfaction and demotivation. Little empirical evidence has emerged to indicate which factors contribute intrinsic value to the working lives of GPs and sustain their ongoing commitment.

Aim

To understand which aspects of work continue to motivate and engage senior GPs by exploring their narrative accounts.

Design and setting

This was part of a qualitative study in which senior GPs and hospital specialists contributed narratives in which they reflected on their working lives.

Method

Individual, open interviews were conducted with eight GPs who had graduated in the early 1980s. Thematic analysis and situational analysis mapping were used to identify and connect related themes.

Results

During interviews in which doctors drew on a wide range of encounters and experiences, they revealed which aspects of work were associated with greater intrinsic rewards and contributed to their continuing motivation. Having chosen careers that suited their preferred settings and working practices, they recounted adjustments made in response to new challenges and confirmed experiencing greater enjoyment when performing roles affirming their sense of providing valued health care.

Conclusion

This study’s findings offer an alternative angle from which to consider the current unpopularity of general practice careers. The article proposes that long-term engagement of practitioners may be achieved through provision of adequate supportive resources to allow them to enact a sense of medical identity that matches with their acquired expectations of their role in the NHS.     

Patients' experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study

Background

Self-management of hypertension, comprising self-monitoring of blood pressure with self-titration of medication, improves blood pressure control, but little is known regarding the views of patients undertaking it.

Aim

To explore patients’ views of self-monitoring blood pressure and self-titration of antihypertensive medication.

Design and setting

Qualitative study embedded within the randomised controlled trial TASMINH2 (Telemonitoirng and Self Management in the Control of Hypertension) trial of patient self-management of hypertension from 24 general practices in the West Midlands.

Method

Taped and transcribed semi-structured interviews with 23 intervention patients were used. Six family members were also interviewed. Analysis was by a constant comparative method.

Results

Patients were confident about self-monitoring and many felt their multiple home readings were more valid than single office readings taken by their GP. Although many patients self-titrated medication when required, others lacked the confidence to increase medication without reconsulting with their GP. Patients were more comfortable with titrating medication if their blood pressure readings were substantially above target, but were reluctant to implement such a change if readings were borderline. Many planned to continue self-monitoring after the study finished and report home readings to their GP, but few wished to continue with a self-management plan.

Conclusion

Participants valued the additional information and many felt confident in both self-monitoring blood pressure and self-titrating medication. The reluctance to change medication for borderline readings suggests behaviour similar to the clinical inertia seen for physicians in analogous circumstances. Additional support for those lacking in confidence to implement prearranged medication changes may allow more patients to undertake self-management.     

Asylum seekers' expectations of and trust in general practice: a qualitative study

Background

The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems.

Aim

This study explored how migrants'' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role.

Design of study

Two qualitative methods.

Setting

Glasgow, UK.

Method

Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders'' accounts with World Health Organization statistics.

Results

Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders'' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience.

Conclusion

GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals'' expectations in a GPled system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.     

‘Someone batting in my corner’: experiences of smoking-cessation support via text message

Background

The txt2stop trial demonstrated that smoking-cessation support delivered by text message doubles biochemically verified abstinence at 6 months. There was no significant heterogeneity in any of the pre-specified subgroups.

Aim

To explore participants’ experiences of the txt2stop intervention via a qualitative study using telephone interviews.

Design and setting

Qualitative telephone interviews in the community.

Method

Thematic content analysis of 1283 feedback forms was conducted to develop a topic guide for 25 telephone interviews. Key themes were identified and described. Any differences in the experiences of those who did, and did not, successfully quit were specifically explored.

Results

Participants liked the fact that smoking-cessation support delivered by text message was convenient, easy to access, and chemical free. They reported that the intervention was a reminder that they were quitting and why, provided emotional support, was a reminder of the physical benefits of stopping smoking, and they saved messages so they could refer back to them. However, the intervention was not helpful for all. Receiving texts about smoking could also stimulate craving, and the timing, frequency, and duration of messages were not optimal for some participants. Those who did not quit reported that additional factors influenced them, such as periods of stress or social events, or reported that they had been unable to cope with the physical effects of withdrawal, and combining text-message support with medication could help with this.

Conclusion

Although the intervention did stimulate craving in some participants at some times, recipients reported that it also provided emotional support and reinforcement at temporally appropriate moments. It was successful at helping people to quit smoking but could be used together with other forms of smoking-cessation support.     

Apprehensive parents: a qualitative study of parents seeking immediate primary care for their children

Background

Children are more frequent users of out-of-hours primary care than other age groups, although their medical problems are less urgent.

Aim

To gain insight into the health-seeking behaviour of parents who ask for immediate medical attention for their children.

Design of study

Qualitative analysis of interviews and telephone calls.

Setting

A general practice out-of-hours cooperative that caters for approximately 300 000 people in The Netherlands.

Method

A semi-structured interview was conducted with 27 parents who had consulted their own GP or an out-of-hours facility for primary care because they wanted urgent medical attention for their child who was sick. Forty-four telephone calls from parents seeking medical care for a child were analysed.

Results

Recognising symptoms in a child started with the observation of a deviation from the child''s normal appearance or behaviour. Parents decided to contact medical services when they felt they lost control of the situation. Most parents consulted because they wanted to rule out or prevent serious disease, not because of the condition itself; not wanting to take a risk with their child was an important motivation. In an attempt to rule out serious disease at home, parents also attempted diagnostic procedures they had copied from professionals.

Conclusion

Worry of parents and their health-seeking behaviour can be seen as an expression of the central role of risk regulation in modern society. Doctors need to realise their own contribution to the way parents want to rule out serious disease in their children. Improving parents'' knowledge will not solve the problem of inappropriate use of out-of-hours facilities.