Medication adherence: A call for action Bosworth, Hayden B., PhD; Granger, Bradi B., RN, PhD; Mendys, Phil, Pharm D ...
The American heart journal,
09/2011, Letnik:
162, Številka:
3
Journal Article
Recenzirano
Odprti dostop
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.
Approximately half of patients with atrial fibrillation and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs ...(NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3-4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.
Background Poor adherence to evidence-based medications in heart failure (HF) is a major cause of avoidable hospitalizations, disability, and death. To test the feasibility of improving medication ...adherence, we performed a randomized proof-of-concept study of a self-management intervention in high-risk patients with HF. Methods Patients with HF who screened positively for poor adherence (<6 Morisky Medication Adherence Scale 8-item) were randomized to either the intervention or attention control group. In the intervention group (n = 44), a nurse conducted self-management training before discharge that focused on identification of medication goals, facilitation of medication-symptom associations, and use of a symptom response plan. The attention control group (n = 42) received usual care; both groups received follow-up calls at 1 week. However, the content of follow-up calls for the attention control group was unrelated to HF medications or symptoms. General linear mixed models were used to evaluate the magnitude of change in adherence and symptom-related events at 3-, 6-, and 12-month follow-up clinic visits. Efficacy was measured as improved medication adherence using nurse-assessed pill counts at each time point. Results Pooled over all time points, patients in the intervention group were more likely to be adherent to medications compared with patients in the attention control group (odds ratio 3.92, t = 3.51, P = .0007). Conclusions A nurse-delivered, self-care intervention improved medication adherence in patients with advanced HF. Further work is needed to examine whether this intervention can be sustained to improve clinical outcomes.
Abstract Background Using regulatory focus theory, an intervention of daily weight loss-sustaining messages was developed and tested for acceptability, feasibility, and efficacy on helping people ...sustain weight loss. Methods Participants (n = 120) were randomized to a promotion, prevention, or an attention-control text message group after completion of a weight loss program. Participants completed baseline assessments, and reported their weight at 1 and 3 months postbaseline. Results Participants found the message content and intervention acceptable and valuable. A minimum of one message per day delivered at approximately 8:00 am was deemed the optimal delivery time and frequency. The sustained weight loss rate at month 3 for the control, promotion, and prevention groups was 90%, 95%, and 100%, respectively. Medium-to-large effects were observed for the promotion and prevention groups at month 1 and for prevention at month 3 relative to controls. The mean weight loss for promotion and prevention was 15 pounds, compared with 10 in the controls at month 3. Conclusion A clinically significant decrease in mean weight, higher rate of sustained weight loss, and medium-to-large effects on sustained weight loss occurred in the promotion and prevention interventions. Tools such as this text message-based intervention that are constructed and guided by evidence-based content and theoretical constructs show promise in helping people sustain healthy behaviors that can lead to improved health outcomes.
Executive function deficits in acute stroke Zinn, Sandra; Bosworth, Hayden B; Hoenig, Helen M ...
Archives of physical medicine and rehabilitation,
02/2007, Letnik:
88, Številka:
2
Journal Article
Recenzirano
To establish the frequency of executive dysfunction during acute hospitalization for stroke and to examine the relationship of that dysfunction to stroke severity and premorbid characteristics.
...Inception cohort study.
Inpatient wards at a Veterans Affairs hospital.
Consecutive sample of inpatients with radiologically or neurologically confirmed stroke. Final sample included 47 patients screened for aphasia and capable of neuropsychologic testing. Two nonstroke inpatient control samples (n=10 each) with either transient ischemic attack (TIA) or multiple stroke risk factors were administered the same research procedure and tests.
Not applicable.
Composite cognitive impairment ratio (CIR), calculated from 8 scores indicative of executive function on 6 neuropsychologic tests by dividing number of tests completed into the number of scores falling below cutoff point, defined as 1.5 standard deviations below normative population mean.
Stroke patients had a mean CIR of .61, compared with .48 for TIAs and .44 for stroke-risk-only. Analysis of variance revealed that CIRs of stroke-risk-only patients but not TIAs were lower than those of the stroke patients (P=.02). Impairment frequencies were at least 50% for stroke patients on most test scores. The Symbol Digit Modalities Test (75% impairment) and a design fluency measure distinguished stroke from nonstroke patients. CIR was not related to stroke severity in the stroke patient sample, but was related to estimated premorbid intelligence.
Executive function deficits are common in stroke patients. The data suggest that limitations in information processing due to these deficits may require environmental and procedural accommodations to increase rehabilitation benefit.
Background Cardiovascular disease (CVD) and diabetes account for one-third of the mortality difference between African American and white patients. We evaluated the effect of a CVD risk reduction ...intervention in African Americans with diabetes. Methods We randomized 359 African Americans with type 2 diabetes to receive usual care or a nurse telephone intervention. The 12-month intervention provided monthly self-management support and quarterly medication management facilitation. Coprimary outcomes were changes in systolic blood pressure (SBP), hemoglobin A1c (HbA1c), and low-density lipoprotein cholesterol (LDL-C) over 12 months. We estimated between-intervention group differences over time using linear mixed-effects models. The secondary outcome was self-reported medication adherence. Results The sample was 72% female; 49% had low health literacy, and 37% had annual income <$10,000. Model-based estimates for mean baseline SBP, HbA1c, and LDL-C were 136.8 mm Hg (95% CI 135.0-138.6), 8.0% (95% CI 7.8-8.2), and 99.1 mg/dL (95% CI 94.7-103.5), respectively. Intervention patients received 9.9 (SD 3.0) intervention calls on average. Primary providers replied to 76% of nurse medication management facilitation contacts, 18% of these resulted in medication changes. There were no between-group differences over time for SBP ( P = .11), HbA1c ( P = .66), or LDL-C ( P = .79). Intervention patients were more likely than those receiving usual care to report improved medication adherence (odds ratio 4.4, 95% CI 1.8-10.6, P = .0008), but adherent patients did not exhibit relative improvement in primary outcomes. Conclusions This intervention improved self-reported medication adherence but not CVD risk factor control among African Americans with diabetes. Further research is needed to determine how to maximally impact CVD risk factors in African American patients.
Background The Support, Education, and Research in Chronic Heart Failure (SEARCH) study was designed to assess the impact of a mindfulness-based psychoeducational intervention on clinical outcomes, ...depression, and quality of life in patients with chronic heart failure (CHF). Although research has shown that psychosocial factors including depression are important risk factors for adverse events in patients with CHF, no large clinical trials have investigated the efficacy of psychosocial interventions to reduce these factors in this population. Methods This was a prospective cohort study of 208 adults with left ventricular ejection fraction ≤40% and CHF geographically assigned to treatment or control groups with follow-up at 3, 6, and 12 months. Treatment groups met weekly for 8 consecutive weeks for training in mindfulness meditation, coping skills, and support group discussion. Results Subjects had a mean age of 61 years, left ventricular ejection fraction 26%, and median New York Heart Association class II. The majority were treated with angiotensin-converting enzyme inhibitors (80%) and β-blockers (86%). At baseline, patients in the treatment group had more severe CHF with higher New York Heart Association class ( P = .0209) and more severe psychological distress (Center of Epidemiology—Depression, Profile of Mood States; P < .05). When compared with controls, treatment resulted in lower anxiety (Profile of Mood States, P = .003), depression (Center of Epidemiology—Depression, P = .05), improved symptoms (Kansas City Cardiomyopathy Questionnaire symptom scale, P = .033) and clinical scores (Kansas City Cardiomyopathy Questionnaire clinical score, P = .024) over time. There were no treatment effects on death/rehospitalization at 1 year. Conclusions An 8-week mindfulness-based psychoeducational intervention reduced anxiety and depression; this effect was attenuated at 1 year. Importantly, the intervention led to significantly better symptoms of CHF at 12 months compared to control subjects. Our results suggest that interventions of this type might have a role in optimal therapy for CHF.
Abstract Background Colorectal cancer is a common and potentially deadly disease. While the U.S. has robust cancer data reporting, information from the Department of Veterans Affairs (VA) healthcare ...system is often underrepresented in national cancer data sources. In this article, we describe Veterans with incident colorectal cancer (CRC) in terms of their patient and tumor characteristics, as well as their mortality. Patients and Methods Patients diagnosed or treated with CRC at any VA institution from fiscal years 2009 to 2012 were identified using three data sources: 1) VA Central Cancer Registry (VACCR); 2) VA Corporate Data Warehouse (CDW); and 3) VA Reports and Measures Portal. CRC frequencies within the VA population and survival curves were examined descriptively and compared with national projections of SEER program data. Results There were 12,551 Veterans with CRC included in analysis. Median age at diagnosis was 65.5 years. Approximately 97% (n=12,229) of the CRC cases were diagnosed among men. Approximately 44% (n=5,517) of patients were diagnosed with localized disease. Three-year survival was associated with age (p<0.01) and stage (p<0.01) at diagnosis. We identified a possible decrease in VA CRC incidence over time. Conclusion While the VA CRC patient population is heavily skewed toward the male gender, patient and tumor characteristics are similar between incident CRC cases reported by VACCR and SEER. This suggests that research findings resulting from the VACCR might have applicability beyond the VA healthcare system setting.
Background Current guidelines recommend global risk assessment to guide vascular risk factor management; however, most provider-patient communication focuses on individual risk factors in isolation. ...We sought to evaluate the impact of personalized coronary heart disease and stroke risk communication on patients' knowledge, beliefs, and health behavior. Methods We conducted a randomized controlled trial testing personalized risk communication based on Framingham stroke and coronary heart disease risk scores compared with a standard risk factor education. A total of 89 patients were recruited from primary care clinics and followed up for 3 months. Outcomes included the following: risk perception and worry, risk factor knowledge, risk reduction preferences and decision conflict, medication adherence, health behaviors, and blood pressure. Results Participants had a very low understanding of numeric information, high perceived risk for stroke or myocardial infarction, and high proportion of medication nonadherence. Patients' ability to identify vascular risk factors increased with personalized risk communication (mean 1.8 additional risk factors, 95% CI 1.3-2.2) and standard risk factor education (mean 1.6 additional risk factors, 95% CI 1.1-2.1) immediately after the intervention but was not sustained at 3 months. Patients in the personalized group had less decision conflict than the standard risk factor education group over intended risk reduction strategies (5.9 vs 10.1, P = .003). There was no appreciable impact of either communication strategy on medication adherence, exercise, smoking cessation, or blood pressure. Conclusions Personalized risk communication was preferred by patients and had a small impact on risk reduction preferences and decision conflict but had no impact on patient beliefs or behavior compared with standard risk factor education.
Abstract Context Family members of seriously ill patients experience significant burden as they advocate with providers and participate in key decisions for loved ones. Most assessments focus on ...patient experience, yet family members' own quality of experience is central to comprehensive care. Objectives This study validated a measure of the quality of family experience, the QUAL-E (Fam), in palliative care. Methods We enrolled family members of terminally ill patients admitted to general medicine services at two hospitals. Items were based on foundational work originally done for the patient instrument, QUAL-E, and interviews of family members of terminally ill patients. Cognitive interviewing was used to refine items, which then underwent formal testing factor analysis. In the first sample, we assessed factor structure. A subsequent sample established predictive validity and test-retest reliability. Results The initial item pool was reduced to a four-domain, 35-item scale and administered to the validation sample. Further analyses produced a final brief scale comprising 17 items, demonstrating appropriate convergent and divergent validity. Test-retest reliability demonstrated expected levels of stability in a highly changeable population. The scale provides an assessment of family experience and includes subscales assessing relationship with health care provider and completion. Additional scale items assess symptom experience and issues of preparation. Conclusion The QUAL-E (Fam) is a companion instrument to the patient QUAL-E measure of quality of life at the end of life and is part of a package of assessment tools that can help evaluate the entire patient experience and contribute to quality care.
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