Medication adherence: A call for action Bosworth, Hayden B., PhD; Granger, Bradi B., RN, PhD; Mendys, Phil, Pharm D ...
American heart journal/The American heart journal,
09/2011, Volume:
162, Issue:
3
Journal Article
Peer reviewed
Open access
Poor adherence to efficacious cardiovascular-related medications has led to considerable morbidity, mortality, and avoidable health care costs. This article provides results of a recent think-tank ...meeting in which various stakeholder groups representing key experts from consumers, community health providers, the academic community, decision-making government officials (Food and Drug Administration, National Institutes of Health, etc), and industry scientists met to evaluate the current status of medication adherence and provide recommendations for improving outcomes. Below, we review the magnitude of the problem of medication adherence, prevalence, impact, and cost. We then summarize proven effective approaches and conclude with a discussion of recommendations to address this growing and significant public health issue of medication nonadherence.
Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life.
The authors investigated ...whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes.
The authors randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC) (n = 75) or UC plus a palliative care intervention (UC + PAL) (n = 75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale HADS), spiritual well-being (measured via the FACIT-Spiritual Well-Being scale FACIT-Sp), hospitalizations, and mortality.
Patients randomized to UC + PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference = 9.49 points, 95% confidence interval CI: 0.94 to 18.05, p = 0.030; FACIT-Pal difference = 11.77 points, 95% CI: 0.84 to 22.71, p = 0.035). Depression improved in UC + PAL patients (HADS-depression difference = -1.94 points; p = 0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference = -1.83 points; p = 0.048). Spiritual well-being was improved in UC + PAL versus UC-alone patients (FACIT-Sp difference = 3.98 points; p = 0.027). Randomization to UC + PAL did not affect rehospitalization or mortality.
An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. (Palliative Care in Heart Failure PAL-HF; NCT01589601).
Background The COVID-19 pandemic resulted in a rapid implementation of telemedicine into clinical practice. This study examined whether early outpatient follow-up via telemedicine is as effective as ...in-person visits for reducing 30-day readmissions in patients with heart failure. Methods and Results Using electronic health records from a large health system, we included patients with heart failure living in North Carolina (N=6918) who were hospitalized between March 16, 2020 and March 14, 2021. All-cause readmission within 30 days after discharge was examined using weighted logistic regression models. Overall, 7.6% (N=526) of patients received early telemedicine follow-up, 38.8% (N=2681) received early in-person follow-up, and 53.6% (N=3711) did not receive follow-up within 14 days of discharge. Compared with patients without early follow-up, those who received early follow-up were younger, were more likely to be Medicare beneficiaries, had more comorbidities, and were less likely to live in an disadvantaged neighborhood. Relative to in-person visits, those with telemedicine follow-up were of similar age, sex, and race but with generally fewer comorbidities. Overall, the 30-day readmission rate (19.0%) varied among patients who received telemedicine visits (15.0%), in-person visits (14.0%), or no follow-up (23.1%). After covariate adjustment, patients who received either telemedicine (odds ratio OR, 0.55; 95% CI, 0.44-0.72) or in-person (OR, 0.52; 95% CI, 0.45-0.60) visits were similarly less likely to be readmitted within 30 days compared with patients with no follow-up. Conclusions During the COVID-19 pandemic, the use of telemedicine visits for early follow-up increased rapidly. Patients with heart failure who received outpatient follow-up either via telemedicine or in-person had better outcomes than those who received no follow-up.
Prior reports have documented extremely poor adherence to evidence-based medications among South Asian patients with established chronic cardiovascular diseases. Treatment adherence is now considered ...a part of the 'self-care' process, the determinants of which have not been adequately explored or explained among South Asian patients with chronic heart failure (CHF). Our objective was to qualitatively ascertain the determinants of the self-care process among Indian patients with a lived experience of heart failure.
We conducted in-depth interviews (audio-recorded) among 22 purposively sampled patients living with chronic heart failure, diagnosed at least 4 weeks prior to the interview and 17 caregivers (n = 39) in a tertiary care teaching hospital in Southern India. We employed an inductive analytical approach using Charmaz's constructivist grounded theory. Initial line-by-line coding and categorization was followed by memo writing, reflexive analysis after interviewing and analyzing four, eight and twelve patients, and at each stage further theoretical sampling was carried out until we reached thematic saturation. We used NVivo ver. 12 to analyze and organize data.
The mean age of our patients was 61 years and they represented 5 Indian states and spoke seven languages, distributed across socio-economic strata and literacy levels. We classified self-care determinants into 3 broad, simple categories and defined underlying themes namely, negative determinants (passivity, entrenched beliefs, negative affect, lack of knowledge, financial difficulties, and fatalism), intermediate factors (patient expectations, provider/hospital hopping) and facilitators or positive self-care determinants (intrinsic and extrinsic facilitators). Gender and the cultural background of patients' upbringing appear to shape these determinants, thereby affecting self-care decision making in chronic heart failure.
We have empirically described a unique set of self-care determinants among Indian chronic heart failure patients, which in turn are shaped by economic and socio-cultural factors. Assessing for and addressing these determinants during clinical interactions through multi-factorial approaches may help improve self-care among Indian CHF patients, thus improving treatment adherence and clinical outcomes.
To evaluate the impact of a lay health worker support role in the inpatient setting. Healthcare systems are facing critical nursing and nurse assistant staffing shortages. These disciplines can be ...challenging to recruit and retain, leading healthcare leaders to identify innovative staffing models. Whereas lay health workers have been used in the community and low-income setting, there is scant evidence of their use in the inpatient setting. We implemented a lay health worker role, called Patient Attendant Service Aides (PASAs), on two medical/surgical units at a community hospital. A pre/post-implementation design was used for this study. An online survey was provided to nurses, nursing assistants, and PASAs on the two medical/surgical units to assess their satisfaction and perceptions of the role. Nursing quality metrics, patient satisfaction, and nursing and nursing assistant turnover were evaluated before and after implementing the role. The online survey showed that nurses and nursing assistants felt that PASAs helped offload their workload, allowing them to focus on nursing-related tasks. PASAs felt supported by the team and believed they were making a meaningful contribution to the unit. There were slight improvements in patient satisfaction, although not significant. There was a significant improvement in nursing turnover on Unit A, from 71.1% to 21.6% (p = 0.009). This is one of the first studies to evaluate the use of lay health workers in the inpatient setting; we found this role to be a feasible way to offload tasks from clinical staff. This role may serve as a pathway for workforce development, as several PASAs are now enrolled in nursing assistant training. Nurse managers may consider using lay health workers in the inpatient setting as they face severe clinical staff shortages.
Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target ...metrics, and limited data exist to inform efforts to improve heart failure quality of care.
To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care.
This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020.
Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website.
The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed).
Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% 95% CI, -0.8% to 7.3%), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 95% CI, 0.93 to 1.21).
Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score.
ClinicalTrials.gov Identifier: NCT03035474.
•Conducting chlorhexidine gluconate (CHG) bathing audits can help sustainability•Direct observation audits are preferred; however, can be difficult to obtain•Our findings showed no difference between ...observed and self-reported compliance•Self-reported audit may be a practical proxy measure for CHG compliance
Measuring compliance with the appropriate chlorhexidine gluconate (CHG) bathing process through direct observation audits can be helpful in sustaining this important practice; however, capturing this data may be difficult. This study reports the differences between observed and self-reported CHG bathing process compliance audits. The difference between mean observed and self-reported compliance was not significant (p = .06), indicating that self-reported compliance may be an accurate, easy to obtain proxy measure for CHG bathing process compliance.
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