Educational intervention for older people with asthma: A randomised controlled trial

ObjectivesTo improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.MethodsCommunity dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.ResultsIntervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.ConclusionAsthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.Practical implicationsUse of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

Risk factors for asthma exacerbation in patients presenting to an emergency unit of a national referral hospital in Kampala,Uganda

Background

Asthma exacerbations are caused by a variety of risk factors. Reducing exposure to these risk factors improves the control of asthma and reduces medication needs. Knowledge of the particular risk factors is essential in formulating controlling and treatment protocols. This study set out to determine the risk factors for asthma exacerbations in patients presenting to the emergency unit of Mulago Hospital.

Methods

An unmatched case-control study involving 43 cases and 43 controls was conducted from November 2011 through February 2012. Asthma patients with exacerbations presenting to Mulago hospital''s emergency unit were chosen as cases. The controls were asthma patients recruited from the hospital''s outpatient department who had not had an exacerbation in the past 7 days. The study variables were age, sex, level of education, adherence to treatment, exercise, upper respiratory tract infections, household pets, smoking, strong emotions, exposure to in house wood or charcoal burning, weather, use of corticosteroids, beta-blockers and non-steroidal anti-inflammatory drugs. Univariate and multivariate statistical analysis was done using SPSS version 16 to identify independent risk factors for exacerbations.

Results

Lack of corticosteroid use (OR =22.109; 95% Confidence interval 6.952 to 70.315; p<0.001) and presence of upper respiratory tract infections (OR 4.516; CI 1.258–16.213; p=0.018) were significantly associated with exacerbations.

Conclusion

Lack of corticosteroid use and upper respiratory tract infections are associated with exacerbations in asthma patients presenting to the Emergency unit of Mulago Hospital     

Exploring the impact of depressive symptoms and medication beliefs on medication adherence in hypertension--a primary care study

Objective

This study aimed to assess the levels of adherence in a sample of hypertensive patients being cared for in primary care in Northern Ireland and to explore the impact of depressive symptoms and medication beliefs on medication adherence.

Methods

The study was conducted in 97 community pharmacies across Northern Ireland. A questionnaire containing measures of medication adherence, depressive symptoms and beliefs about medicines was completed by 327 patients receiving antihypertensive medications.

Results

Analysis found that 9.3% of participants were non-adherent with their antihypertensive medication (self-report adherence scale) and 37.9% had scores indicative of depressive symptoms as determined by the Center for Epidemiological Studies Depression Scale (CES-D). In the univariate analysis, concerns about medications had negative effects on both adherence and depressive symptomatology. However, logistic regression analysis revealed that patients over the age of 50 were more likely to be adherent with their medication than those younger than 50. Depressive symptomatology and medication beliefs (concerns) were not significantly related to adherence in the regression analysis.

Conclusion

Depressive symptomatology was high in the sample as measured by the CES-D. Age was the only significant predictor of medication adherence in this population.

Practice implications

Health care professionals should consider the beliefs of the patient about their hypertensive medications and counsel younger patients on adherence.     

Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings

Objective

Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior.

Methods

We reviewed literature on interventions that fell into these domains and were published between January 2007 and May 2013. Two reviewers abstracted information and categorized studies by intervention type.

Results

We identified 60 studies, of which 40% focused on patient education. Other intervention types included augmented pharmacy services, decision aids, shared decision-making, and clinical review of patient adherence. Medication adherence was an outcome in most (70%) of the studies, although 50% also examined patient-centered outcomes.

Conclusions

We identified a large number of medication management interventions that incorporated patient-centered care and improved patient outcomes. We were unable to determine whether these interventions are more effective than traditional medication adherence interventions.

Practice Implications

Additional research is needed to identify effective and feasible approaches to incorporate patient-centeredness into the medication management processes of the current health care system, if appropriate.     

Modifiable risk factors for adherence to adjuvant endocrine therapy among breast cancer patients

Objective

Breast cancer incidence and mortality are declining due to improvements in early detection and treatment. One advance in treatment is the development of adjuvant endocrine therapy (AET) for women with hormone receptor positive breast cancer. Despite strong evidence linking AET to better health outcomes, AET adherence continues to be suboptimal. This study tests the hypothesis that patient beliefs about medication mediate the relationship between frequency of physician communication and AET adherence.

Methods

This cross-sectional study utilizes data from patient self-report and medical chart abstraction (N = 200). Survey measures included frequency of physician communication, patient beliefs about medicine, AET adherence, and demographic characteristics.

Results

Necessity beliefs mediated the relationship between frequency of physician communication and medication adherence (necessity beliefs β = .18, p < .05; physician communication β = .13, p > .05). There was no evidence of medication concerns mediating the relationship between frequency of physician communication and medication adherence.

Conclusion

More frequent physician communication that shapes what patients believe about AET importance may be associated with greater AET adherence; however, frequent physician communication that shapes patient concerns about side effects may not be associated with greater AET adherence.

Practice implications

Research is needed to enhance understanding of the type of physician communication that is most consistently associated with patient beliefs about medication and AET adherence.     

Development and content of a group-based intervention to improve medication adherence in non-adherent patients with rheumatoid arthritis

Objective

To describe the systematic development and content of a short intervention to improve medication adherence to disease-modifying anti-rheumatic drugs in non-adherent patients with rheumatoid arthritis (RA).

Methods

The intervention mapping (IM) framework was used to develop the intervention. The following IM steps were conducted: (1) a needs assessment; (2) formulation of specific intervention objectives; (3) inventory of methods and techniques needed to design the intervention and (4) production and piloting of the intervention.

Results

The intervention (consisting of two group sessions led by a pharmacist, a homework assignment, and a follow-up call) aims to improve the balance between necessity and concern beliefs about medication, and to resolve practical barriers in medication taking. The central communication method used is motivational interviewing.

Conclusion

By applying the IM framework, we were able to create a feasible, time-efficient and promising intervention to improve medication adherence in non-adherent RA patients. Intervention effects are currently being assessed in a randomized controlled trial.

Practice implications

This paper could serve as a guideline for other health care professionals when developing similar interventions. If the RCT demonstrates sufficient effectiveness of this intervention in reducing medication non-adherence in RA patients, the intervention could be embedded in clinical practice.     

Asthma severity and child quality of life in pediatric asthma: A systematic review

Objective

To systematically review evidence of asthma severity as a correlate of child quality of life (QOL) in pediatric asthma.

Methods

Online bibliographic databases (PsycINFO, PsycARTICLES, and MEDLINE) were used to identify relevant studies that specifically considered the relationship between asthma severity and child QOL.

Results

Fourteen studies matching inclusion and exclusion criteria were reviewed. Asthma severity was significantly related to child QOL in nine of these studies. Informant of QOL and type of QOL measure were found to influence the strength of the relationship between severity and child QOL in pediatric asthma.

Conclusions

Findings suggest that asthma severity is a correlate of child QOL. Children whose asthma symptoms are not well-managed are likely to experience an impaired level of QOL. Findings also suggest the need to utilize asthma-specific QOL measures and an informant of QOL other than the child's parent in order to receive the most accurate information about the child's level of functioning.

Practice implications

Researchers and healthcare providers basing clinical outcomes on QOL assessments should consider asthma severity in their evaluations. Further, researchers and healthcare providers should recognize the continued need to reduce asthma severity and improve asthma symptom control in their attempts to improve the QOL of children with asthma.     

Time perspective and medication adherence among individuals with hypertension or diabetes mellitus

Objective

The study determined if time perspective was associated with medication adherence among people with hypertension and diabetes.

Methods

Using the Health Beliefs Model, we used path analysis to test direct and indirect effects of time perspective and health beliefs on adherence among 178 people who participated in a community-based survey near Washington, D.C. We measured three time perspectives (future, present fatalistic, and present hedonistic) with the Zimbardo Time Perspective Inventory and medication adherence by self-report.

Results

The total model demonstrated a good fit (RMSEA = 0.17, 90% CI [0.10, 0.28], p = 0.003; comparative fit index = 0.91). Future time perspective and age showed direct effects on increased medication adherence; an increase by a single unit in future time perspective was associated with a 0.32 standard deviation increase in reported adherence. There were no significant indirect effects of time perspective with reported medication adherence through health beliefs.

Conclusion

The findings provide the first evidence that time perspective plays an under-recognized role as a psychological motivator in medication adherence.

Practice implications

Patient counseling for medication adherence may be enhanced if clinicians incorporate consideration of the patient's time perspective.     

A health literacy pilot intervention to improve medication adherence using Meducation technology

Objective

To determine whether antihypertensive medication adherence could improve using a Meducation^® technology health literacy intervention.

Methods

We conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation^® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months.

Results

There was a 42% enrollment rate (n = 23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients’ average systolic blood pressure (0.5 mmHg), diastolic blood pressure (1.5 mmHg), and body weight (3.6 pounds) (p > 0.05).

Conclusions

A health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes.

Practice implications

Health literacy interventions may improve adherence while requiring relatively few resources to implement.     

Information needs and preferences of women as they proceed through radiotherapy for breast cancer

Objective

While radiotherapy is commonly employed in the treatment of breast cancer, many women know little about treatment and experience treatment related anxiety. The aims of this study were to: Prioritise breast cancer patients’ radiotherapy related information needs and concerns; determine unmet information needs; ascertain which information sources patients prefer to receive; and explore whether information provision reduces anxiety and depression.

Methods

A longitudinal survey was administered at four time points: after initial consultation with radiation oncologist, after the planning appointment, within first week of treatment and after treatment completion. Data was analysed using generalised estimating equations.

Results

123 women participated. Women were most concerned about the impact treatment would have on their health in the future. Women identified high information needs prior to treatment planning and commencing treatment. Women's anxiety at baseline (mean = 6.07, SD = 3.89) did not significantly drop until after treatment commencement (mean = 5.33, SD = 4.15).

Conclusion

This study demonstrates that women's information needs and anxiety levels are high until treatment commencement.

Practice implications

In order to reduce patients’ psychological distress, information needs and concerns we recommend that a greater focus is placed on providing information to patients prior to treatment planning and prior to treatment.     

The Effects of Combining Web-Based eHealth With Telephone Nurse Case Management for Pediatric Asthma Control: A Randomized Controlled Trial

Background

Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.

Objectives

To test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.

Methods

We identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.

Results

Of 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).

Conclusions

Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00214383","term_id":"NCT00214383"}}NCT00214383; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00214383","term_id":"NCT00214383"}}NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)     

A text messaging intervention to promote medication adherence for patients with coronary heart disease: A randomized controlled trial

Objective

Pharmacologic treatment for secondary prevention of coronary heart disease (CHD) is critical to prevent adverse clinical outcomes. In a randomized controlled trial, we compared antiplatelet and statin adherence among patients with CHD who received: (1) text messages (TM) for medication reminders and education, (2) educational TM only, or (3) No TM.

Methods

A mobile health intervention delivered customized TM for 30 days. We assessed and analyzed medication adherence with electronic monitoring devices [Medication Event Monitoring System (MEMS)] by one-way ANOVA and Welch tests, two-way TM response rates by t-tests, and self-reported adherence (Morisky Medication Adherence Scale) by Repeated Measures ANOVA.

Results

Among 90 patients (76% male, mean age 59.2 years), MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken (p = 0.02), percentage number of doses taken (p = 0.01), and percentage of prescribed doses taken on schedule (p = 0.01). TM response rates were higher for antiplatelets than statins (p = 0.005). Self-reported adherence revealed no significant differences among groups.

Conclusion

TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses.

Practice implications

Feasibility and high satisfaction were established. Mobile health interventions show promise in promoting medication adherence.     

Low literacy is associated with uncontrolled blood pressure in primary care patients with hypertension and heart disease

Objectives

To evaluate the association between low literacy and uncontrolled blood pressure (BP) and their associations with medication adherence.

Methods

Cross-sectional study of 423 urban, primary care patients with hypertension and coronary disease. The relationship between low literacy (Rapid Estimate of Adult Literacy in Medicine ≤ 44) and uncontrolled BP (≥140/90 mmHg, ≥130/80 mmHg for patients with diabetes) was evaluated by crude and adjusted logistic regression. Relationships with self-reported adherence and refill adherence were explored using adjusted linear and logistic regression.

Results

Overall, 192 (45%) subjects had low literacy and 227 (52.9%) had uncontrolled BP. Adjusting for age, gender, race, employment, education, mental status, and self-reported adherence, low literacy was associated with uncontrolled BP (OR 1.75, 95% CI 1.06–2.87). Lower self-reported adherence was associated with uncontrolled BP; the relationship between refill adherence and uncontrolled BP was not statistically significant.

Conclusion

Low literacy is independently associated with uncontrolled BP.

Practice implications

Awareness of the relationships among patient literacy, BP control, and medication adherence may guide healthcare providers as they communicate with patients.     

Motivation to quit smoking among parents of urban children with asthma

Objective

To identify factors associated with motivation to quit smoking among parents of urban children with asthma.

Methods

We analyzed data from parents who smoke and had a child enrolled in the School-Based Asthma Therapy (SBAT) trial. We assessed asthma symptoms, children's cotinine, and parent smoking behaviors. Motivation to quit smoking was assessed by a 10-point continuous measure (1, not at all motivated; 10, very motivated).

Results

209 parents smoked (39% of sample), and children's mean cotinine was 2.48 ng/ml. Motivation to quit was on average 6.9, and 47% of parents scored ≥8 on the scale. Parents who believed their child's asthma was not under good control, and parents who strongly agreed their child's asthma symptoms would decrease if they stop smoking had higher motivation to quit compared to their counterparts (p < .05). In a multivariate analysis, parents who believed their child's asthma was not under control had more than twice the odds of reporting high motivation to quit.

Conclusion

Parents’ perception of the risks of smoking to their child with asthma is associated with motivation to quit.

Practice implications

Raising awareness about the effect of smoking and quitting on children's asthma might increase motivation to quit among parents.     

Effectiveness of a group-based intervention to change medication beliefs and improve medication adherence in patients with rheumatoid arthritis: A randomized controlled trial

Objective

To assess the effect of a group-based intervention on the balance between necessity beliefs and concern beliefs about medication and on medication non-adherence in patients with rheumatoid arthritis (RA).

Methods

Non-adherent RA patients using disease-modifying anti-rheumatic drugs (DMARDs) were randomized to an intervention or control arm. The intervention consisted, amongst others, of two motivational interviewing-guided group sessions led by the same pharmacist. Control patients received brochures about their DMARDs. Questionnaires were completed up to 12 months follow-up.

Results

123 patients (mean age: 60 years, female: 69%) were randomized. No differences in necessity beliefs and concern beliefs about medication and in medication non-adherence were detected between the intervention and control arm, except at 12 months’ follow-up: participants in the intervention arm had less strong necessity beliefs about medication than participants in the control arm (b: −1.0 (95% CI: −2.0, −0.1)).

Conclusion

This trial did not demonstrate superiority of our intervention over the control arm in changing beliefs about medication or in improving medication adherence over time.

Practice implications

Absent intervention effects might have been due to, amongst others, selection bias and a suboptimal treatment integrity level. Hence, targeting beliefs about medication in clinical practice should not yet be ruled out.     

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma

Background

Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma.

Supportive care needs in patients with cardiovascular disorders

Objectives

Unmet medical needs are a focus in cardiovascular disorder (CVD) research. However, few studies have investigated patients’ perceived needs. The present study examined supportive care needs in patients with CVD and their relation to health characteristics.

Methods

In total 260 in-patients with CVD were consecutively assessed with the supportive care needs survey. Primarily, frequency and content of unmet needs were examined. Secondarily, CVD-diagnoses were compared and correlations with risk factors, treatment characteristics, mood-state and quality of life were analyzed.

Results

Supportive care needs were indicated by 21% of all patients: unmet health information (37%) and psychological (23%) needs were most frequent. The number of unmet needs did not differ between most CVD-diagnoses. Unmet needs were not related to cardiac risk factors. However, treatment characteristics (r = .17–.23, p < .01), anxiety (r = .44–.71, p < .01), depression (r = .38–.63, p < .01), physical (r = .21–.47, p < .01) and mental (r = .29–.65, p < .01) quality of life were associated with unmet needs.

Conclusions

Supportive care needs are common in patients with CVD. They are based on patients’ treatment characteristics, emotions and subjective well-being rather than on cardiac factors.

Practice implications

Needs assessments in patients with CVD could detect unmet needs, enhance patient education and communication and, therefore, effectively target patients’ perceived needs and medical needs.     

Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure

Objective

To assess the relationship between patients’ trust in their physician and self-reported adoption of lifestyle modification behaviors and medication adherence for control of hypertension.

Methods

Longitudinal analysis of data from a randomized controlled trial of interventions to enhance hypertensive patients’ adherence to medications and recommended lifestyle modifications. Two hundred patients were seen by 41 physicians at 14 urban primary care practices in Baltimore, Maryland, and followed for 12 months.

Results

Seventy percent of patients reported complete trust in their physician. In adjusted analyses, patients with complete trust had higher odds of reporting that they were trying to lose weight (OR = 2.27, 95% CI = 1.38–3.74) than did patients with less than complete trust in their physician. Though not statistically significant, the odds of reporting trying to cut back on salt and engaging in regular exercise were greater in patients with complete trust. We observed no association for reports of medication adherence.

Conclusion

Trust in one's physician predicts attempts to lose weight among patients with hypertension, and may contribute to attempts to reduce salt and increase exercise.

Practice implications

Strengthening patient–physician relationships through efforts to enhance trust may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension.