Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

Racial differences in beliefs of physician prescribing practices for low-cost pharmacy options

BACKGROUND

Previous studies have reported that certain populations are sensitive to high out-of-pocket drug costs, and drug noncompliance leads to poorer health outcomes.

OBJECTIVE

Our aim was to measure patient awareness of discount pharmacy options, cost barriers to medication access, and beliefs about health care provider's use of low-cost medications.

METHODS

This cross-sectional 17-item survey was administered to patients in the emergency department of an urban trauma center in February 2011. Differences in responses by sex and race groups were assessed. A logistic regression model was created to estimate the association of sociodemographic factors and medication use with awareness of discount pharmacy options.

RESULTS

Five hundred and fifty-two surveys were analyzed. Among respondents who were prescribed medications within the past year, three fourths of patients felt comfortable asking physicians for cheaper medicines. Slightly more than half were aware of low-cost pharmacy options, and 78% of these respondents correctly listed at least one of these pharmacies. Caucasian patients were more comfortable than African American patients asking for cheaper medicines (82.5% vs. 72.2%; p < 0.05) and were more aware of low-cost prescription programs (63.9% vs. 43.5%; p < 0.001). When adjusted for insurance status and current medication use, Caucasian patients were 2.7 times more likely to name a valid discount pharmacy option compared to African Americans (95% confidence interval 1.85-4.07).

CONCLUSIONS

This study suggests populations may be more uncomfortable initiating a discussion about medication costs and selection of lower-cost alternatives. Health care providers may need to develop communication strategies in which medication cost is addressed with sensitivity and consistency.

Enablers and barriers affecting medication-taking behaviour in aging men with benign prostatic hyperplasia

OBJECTIVES

To identify the enablers and barriers affecting medication-taking behaviour in aging men with benign prostatic hyperplasia.

METHODS

A total of 40 patients attending the urology outpatient clinic in Melbourne in 2012 were screened. Patients who successfully met the inclusion criteria were interviewed using a structured interview schedule. Information regarding the patient's medication, demographic data and presence of co-morbidities was collected. Content analysis was compared with patient demographic and medical data, contributing to the analysis.

RESULTS

Problems with medication-taking were reported in 58% of patients. All patients without co-morbidities reported issues regarding their medications, whereas only 27% of patients with co-morbidities reported concerns regarding their medications. Statistical analysis revealed that patients without co-morbidities were significantly more likely (p = 0.002) to have complaints with their medications compared to those with co-morbidities. Furthermore, patients with co-morbidities who required help of caregivers to assist with their medication-taking were significantly less likely (p = 0.05) to have complaints with their medications compared to patients who self-managed.

CONCLUSIONS

Older patients with caregivers who assisted managing their medication-taking had better adherence. Those receiving aid from their caregivers were significantly less likely to have complaints regarding their medications as opposed to those not requiring a caregiver. This highlights the importance of having support for medication-taking in patients with co-morbidities to assist with better adherence.

Development and validation of the General Health Numeracy Test (GHNT)

OBJECTIVE

Because existing numeracy measures may not optimally assess 'health numeracy', we developed and validated the General Health Numeracy Test (GHNT).

METHODS

An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity.

RESULTS

On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20=0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p<.001). Furthermore, both versions were associated with participants' understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses.

CONCLUSIONS

The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy.

PRACTICE IMPLICATIONS

Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.

A user-study measuring the effects of lexical simplification and coherence enhancement on perceived and actual text difficulty

PURPOSE

Low patient health literacy has been associated with cost increases in medicine because it contributes to inadequate care. Providing explanatory text is a convenient approach to distribute medical information and increase health literacy. Unfortunately, writing text that is easily understood is challenging. This work tests two text features for their impact on understanding: lexical simplification and coherence enhancement.

METHODS

A user study was conducted to test the features' effect on perceived and actual text difficulty. Individual sentences were used to test perceived difficulty. Using a 5-point Likert scale, participants compared eight pairs of original and simplified sentences. Abstracts were used to test actual difficulty. For each abstract, four versions were created: original, lexically simplified, coherence enhanced, and lexically simplified and coherence enhanced. Using a mixed design, one group of participants worked with the original and lexically simplified documents (no coherence enhancement) while a second group worked with the coherence enhanced versions. Actual difficulty was measured using a Cloze measure and multiple-choice questions.

RESULTS

Using Amazon's Mechanical Turk, 200 people participated of which 187 qualified based on our data qualification tests. A paired-samples t-test for the sentence ratings showed a significant reduction in difficulty after lexical simplification (p<.001). Results for actual difficulty are based on the abstracts and associated tasks. A two-way ANOVA for the Cloze test showed no effect of coherence enhancement but a main effect for lexical simplification, with the simplification leading to worse scores (p=.004). A follow-up ANOVA showed this effect exists only for function words when coherence was not enhanced (p=.008). In contrast, a two-way ANOVA for answering multiple-choice questions showed a significant beneficial effect of coherence enhancement (p=.003) but no effect of lexical simplification.

CONCLUSIONS

Lexical simplification reduced the perceived difficulty of texts. Coherence enhancement reduced the actual difficulty of text when measured using multiple-choice questions. However, the Cloze measure results showed that lexical simplification can negatively impact the flow of the text.

The 'perfect storm' and acute coronary syndrome onset: do psychosocial factors play a role?

The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk.

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study

Background

Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients’ side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician’s as well as the patient’s view.

Methods

With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.

Results

Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient’s non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.

Conclusions

Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

Health literacy of Dutch adults: a cross sectional survey

BACKGROUND

Relatively little knowledge is available to date about health literacy among the general population in Europe. It is important to gain insights into health literacy competences among the general population, as this might contribute to more effective health promotion and help clarify socio-economic disparities in health. This paper is part of the European Health Literacy Survey (HLS-EU). It aims to add to the body of theoretical knowledge about health literacy by measuring perceived difficulties with health information in various domains of health, looking at a number of competences. The definition and measure of health literacy is still topic of debate and hardly any instruments are available that are applicable for the general population. The objectives were to obtain an initial measure of health literacy in a sample of the general population in the Netherlands and to relate this measure to education, income, perceived social status, age, and sex.

METHODS

The HLS-EU questionnaire was administered face-to-face in a sample of 925 Dutch adults, during July 2011. Perceived difficulties with the health literacy competences for accessing, understanding, appraising and applying information were measured within the domains of healthcare, disease prevention and health promotion. Multiple linear regression analyses were applied to explore the associations between health literacy competences and education, income, perceived social status, age, and sex.

RESULTS

Perceived difficulties with health information and their association with demographic and socio-economic variables vary according to the competence and health domain addressed. Having a low level of education or a low perceived social status or being male were consistently found to be significantly related to relatively low health literacy scores, mainly for accessing and understanding health information.

CONCLUSIONS

Perceived difficulties with health information vary between competences and domains of health. Health literacy competences are associated with indicators of socio-economic position and with the domain in which health information is provided.

PictureRx: Illustrated medication instructions for patients with limited health literacy

OBJECTIVES

To describe the role of illustrated medication instructions in pharmacy practice, the evidence for their use, and our experience with their implementation.

PRACTICE DESCRIPTION

PictureRx is applicable to all pharmacy practice settings.

PRACTICE INNOVATION

PictureRx enables pharmacists to rapidly produce evidence-based, illustrated medication instructions that are well understood by patients of all health literacy levels.

RESULTS

PictureRx has been studied in a number of settings. The tool was successfully deployed at a busy outpatient pharmacy and in a medical clinic for the underserved and was pilot tested among elderly community-dwelling Medicare recipients. In each of these settings, PictureRx was received favorably by patients, pharmacists, and other health care providers. It improved patients' satisfaction with the pharmacy and knowledge about their medications. Ongoing research is assessing whether PictureRx enhances medication management among Latinos.

CONCLUSION

PictureRx helps pharmacists address challenges related to low health literacy and can be implemented in a broad range of practice environments. Ongoing research will delineate the extent to which PictureRx reduces health disparities.

The relationship among health literacy, health knowledge, and adherence to treatment in patients with rheumatoid arthritis

BACKGROUND

Patients with poor health literacy often lack the knowledge needed to manage their treatment.

OBJECTIVE

The aim of this cross-sectional study is to determine whether health literacy is a predictor of health knowledge and/or adherence to medication treatment in patients with rheumatoid arthritis.

METHOD

The study was completed in an urban, outpatient rheumatology setting. Health literacy was measured using the Test of Functional Health Literacy in Adults. The Arthritis Knowledge Questionnaire was modified to measure medication specific health knowledge, and the Morisky Medication Adherence scale was used to measure adherence. Researchers used regression analyses to determine if health literacy was a predicator of knowledge and/or adherence.

RESULTS

Participants (N = 125) had high mean health literacy scores. The average medication knowledge score was 0.73. Adherence to medication regimen was 0.84. Controlling for patient covariates, health literacy was positively associated with education, race, and age. In adjusted analyses, health literacy was a significant predictor of health knowledge but not adherence. Race, neighborhood income, and confidence with contacting provider about medications were predictors of adherence.

CONCLUSION

Study findings indicate that health literacy is independently associated with medication knowledge but not medication adherence in patients with rheumatoid arthritis. These results provide useful information for planning initiatives to support individuals with disease self-management.

A qualitative and quantitative analysis of the characteristics of gout patient education resources

Patient education is an important aspect of gout management, but there is evidence that many patients lack adequate knowledge of their condition. Our aim was to examine the characteristics of gout patient education resources. Ten gout patient information resources were examined for readability (Flesch-Kincaid reading level, the Simple Measure of Gobbledygook measure and the Flesch Reading Ease Score), qualitative characteristics such as figure and jargon use and whether they included information on the major points of gout. The median readability grade level of the examined resources was 8.5. The difference in readability grade level between the highest and the lowest education resource was 6.3 grade levels. The information content of the resources was high with an average of only 3.9 proposed criteria of 19 (19 %) absent from the resources. Jargon use was low and concepts were usually explained. However, important information regarding acute flare prophylaxis during urate-lowering therapy initiation and titration and treating serum uric acid to target was absent from 60 % of the patient education resources. There was poor use of key messages at the start. Gout patient resources have a wide range of readability. Thirty percent of resources were above the average reading level of rheumatology outpatients reported in previous studies. Sixty percent of gout patient resources omit education items that could impact on patient adherence and in turn patient outcomes. Further research is needed into the literacy levels and education requirements of patients with gout.

Association of brief health literacy screening and blood pressure in primary care

Health literacy impacts health outcomes. However, the relationship to blood pressure is inconsistent. This study aimed to determine whether health literacy, assessed by clinic staff, is associated with blood pressure among patients with hypertension. The design was a cross-sectional study of a large sample of primary care patient encounters in 3 academic medical center clinics in Nashville, Tennessee. Health literacy was assessed using the Brief Health Literacy Screen, with higher scores indicating higher health literacy. Blood pressure was extracted from the electronic health record. Using 23,483 encounters in 10,644 patients, the authors examined the association of health literacy with blood pressure in multivariable analyses, adjusting for age, gender, race, education, and clinic location. Independent of educational attainment, 3-point increases in health literacy scores were associated with 0.74 mmHg higher systolic blood pressure (95% CI [0.38, 1.09]) and 0.30 mmHg higher diastolic blood pressure (95% CI [0.08, 0.51]). No interaction between education and health literacy was observed (p = .91). In this large primary care population of patients with hypertension, higher health literacy, as screened in clinical practice, was associated with a small increase in blood pressures. Future research is needed to explore this unexpected finding.

Rethinking adherence: a health literacy-informed model of medication self-management

Medication adherence has received a great deal of attention over the past several decades; however, its definition and measurement remain elusive. The authors propose a new definition of medication self-management that is guided by evidence from the field of health literacy. Specifically, a new conceptual model is introduced that deconstructs the tasks associated with taking prescription drugs; including the knowledge, skills and behaviors necessary for patients to correctly take medications and sustain use over time in ambulatory care. This model is then used to review and criticize current adherence measures as well as to offer guidance to future interventions promoting medication self-management, especially among patients with low literacy skills.

Functional health literacy in Switzerland--validation of a German, Italian, and French health literacy test

OBJECTIVE

This study aimed to translate and validate German, Italian, and French versions of the Short-Test of Functional Health Literacy (S-TOFHLA), to be used in Switzerland and its neighboring countries.

METHODS

The original English version of the S-TOFHLA was translated by applying standardized translation methods and cultural adaptations. 659 interviews were conducted with Swiss residents in their preferred language (249 German, 273 Italian, and 137 French). To assess the validity of the measures, known predictors for health literacy (age, education, and presence of a chronic condition) were tested.

RESULTS

For all three language versions, results show that younger participants, participants with a higher education and participants with chronic medical conditions had significantly higher levels of health literacy. Furthermore, the three health literacy scales categorized participants into three health literacy levels with most people possessing either inadequate or adequate levels. The highest levels of health literacy were found in the Swiss-German sample (93%), followed by the Swiss-French (83%) and Swiss-Italian (67%) samples.

CONCLUSION

The German, Italian, and French versions of the S-TOFHLA provide valid measures of functional health literacy.

PRACTICE IMPLICATIONS

The translated versions can be used in the three different language regions of Switzerland as well as in neighboring countries following 'country specific' adjustments and validations.

Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): a randomized controlled trial

BACKGROUND

Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.

OBJECTIVE

To test the effect of two low-literacy interventions on medication adherence.

DESIGN

Randomized controlled trial, 2 × 2 factorial design.

PARTICIPANTS

Adults with coronary heart disease in an inner-city primary care clinic.

INTERVENTIONS

For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.

MAIN MEASURES

The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG<0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.

KEY RESULTS

Most of the 435 participants were elderly (mean age=63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG<0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR=2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR=2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR=1.89; 95 % CI, 0.99 to 3.60).

CONCLUSIONS

The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.

Contextualizing an expanded definition of health literacy among adolescents in the health care setting

The current emphasis on preventive health care and wellness services suggests that measures of skills and competencies needed to effectively navigate the health care system need to be better defined. We take an expanded perspective of health literacy and define it as a set of skills used to organize and apply health knowledge, attitudes and practices relevant when managing one's health environment. It is an emerging area of inquiry especially among adults and those with chronic conditions; however, it has been less studied among adolescent populations. To begin operationalizing this concept in a manner appropriate for teens in a health systems context, we explored knowledge, attitudes and practices related to health and preventive health care in 12 focus groups with publicly insured adolescents (N = 137), aged 13-17 years, as well as eight key informant interviews with physicians who serve publicly insured teens. Five dimensions emerged that provide a preliminary framework for an expanded definition of health literacy among adolescents. These include: (i) navigating the system, (ii) rights and responsibilities, (iii) preventive care, (iv) information seeking and (v) patient-provider relationship. This robust definition of health literacy contextualizes the concept in a health environment where individuals must be informed and skilled health care consumers.

Greater Adherence to Mass Drug Administration Against Lymphatic Filariasis through Traditional Village Forums in Fiji

Objective: The aim of this study was to elucidate the roles of knowledge related to lymphatic filariasis (LF), contributions of taking roles in community activities to eradicate LF and participation in traditional village forums in adherence to mass drug administration (MDA) in a preventive chemotherapy program targeted at the community residents.

Materials and Methods: A survey on ingestion of diethylcarbamazine (DEC) and albendazole (ALB), knowledge related to LF, taking roles in community activities and participation in traditional village forums was carried out for 400 adult subjects randomly selected from the Central Division of Fiji within three months after the MDA campaign in 2010 in the respective communities. Multilevel logistic regression analysis and multilevel linear regression analysis were performed to examine relationships between knowledge, community activities, traditional village forums and ingestion of anti-filarial drugs. The LF knowledge score was defined as a factor score of five knowledge variables.

Results: Among 324 respondents, 40.4% of them ingested both DEC and ALB. Participation in traditional village forums was independently and significantly related to ingestion of DEC and ALB (OR=1.78, 95% CI=1.04–3.05) and taking roles in community activities for MDA (OR=1.87, 95% CI=1.18–2.94), regardless of the subject’s gender, education, knowledge and taking roles in community activities. Taking roles in community activities for MDA was independently related to the LF knowledge score (β=0.24, 95% CI=0.15–0.33).

Conclusion: Participation in traditional village forums in Fiji was related to taking roles in community activities for MDA and associated with adherence to MDA regimen regardless of the educational attainment of the individual residents.

Adherence to antiepilepsy drug therapy

Adherence to antiepilepsy drug (AED) therapy is critical for effective disease management, yet adherence and persistence rates are low due to several barriers. The definitions of adherence (80% rate of total pills taken, medication possession ratio, and days covered by prescriptions filled) and methods of measurement (patient self-reports, serum drug levels, pill counts, electronic bottle tops, and reviews of pharmacy records) are not without limitations, and their applicability to epilepsy is not clear. The use of simple adherence scales during office visits can provide an overall impression of a patient's adherence and can serve as a basis for practitioner-patient dialog. Efforts to improve adherence should focus on provider and healthcare system determinants versus those focused only on the patient. These interventions include non-judgmental communication, patient education, simplification of the dosage regimen with once-daily therapies, and the use of patient reminders.

Comparative analysis of print and multimedia health materials: a review of the literature

OBJECTIVE

Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy.

METHODS

A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining.

RESULTS

Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development.

CONCLUSIONS

Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials.

PRACTICE IMPLICATIONS

Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input.

Pharmacy effect on adherence to antidiabetic medications

BACKGROUND

There have been a number of studies relating medication adherence to patient characteristics. There is less research on influence of health care providers on patients' medication-taking behavior.

OBJECTIVES

To evaluate the pharmacy-level effect on medication adherence for patients receiving antidiabetic medications.

RESEARCH DESIGN

This was a hypothesis-driven retrospective study using cross-sectional design and insurance claims data. The main analytical interest was the pharmacy-level effect on proportion of days covered as the measure of medication adherence. Multilevel random and mixed-effect models were used to tease out the pharmacy-level effect on patient outcomes.

SUBJECTS

The study population consisted individuals aged 18-64 years, insured under employer-sponsored private health plans.

RESULTS

We estimated models with and without covariates. In both models, pharmacy cluster effect was statistically significant (P<0.001). In the model without covariates, pharmacy cluster effect accounted for 12.8% (95% confidence interval, 12.4%-13.1%) of total variance in adherence, whereas in the model with covariates pharmacies accounted for 12.1% (95% confidence interval, 11.6%-12.4%) of total variance. Covariates associated significantly with adherence were age, sex, mail order pharmacy, and prescription drug copay.

CONCLUSIONS

The results suggest significant variation in medication adherence attributable to pharmacy factor, independent of other effects. The underlying reason could be varying level of influence from pharmacies' efforts to inform or influence patients to take medications in prescribed manners. More research is necessary to better understand the effect of specific pharmacy characteristics and practice styles differences.

Reducing costs of acute care for ambulatory care-sensitive medical conditions: the central roles of comorbid mental illness

BACKGROUND

New patient-centered models of ambulatory care aim to substitute better primary care for preventable acute care within existing primary care practices. This study aims to identify whether mental illness and other characteristics of primary care patients are related to risk for an acute event for an ambulatory care-sensitive condition (ACSC).

METHODS

We conducted a 2-year, longitudinal analysis comparing ambulatory care-sensitive admissions and emergency department (ED) visits for a cohort of 18,526 primary care patients followed in 5 veterans affairs (VA) primary care sites. We compared rates, risks, and costs of ACSC-related acute events during a follow-up year for patients with and without mental illness seen during the previous year in primary care.

RESULTS

The 12-month rate of ACSC admissions was 31.7 admissions per 1000 patients with mental health diagnoses compared with 21.0 admissions per 1000 patients without (P=0.0009). The ACSC-associated ED visit rate was also significantly higher (P<0.0001). In adjusted analyses controlling for demographics, chronic disease, illness severity, and prior ambulatory care, those with depression or drug use disorders had higher odds of receiving ACSC-related acute care (odds ratio=1.10, 95% confidence interval: 1.03, 1.17 for depression; odds ratio=1.48, 95% confidence interval: 1.05, 1.99 for drug use disorders). Costs per admission and ED visit were similar across patient groups. Higher medication use and lower medication regimen complexity were significantly associated with decreased risk for ACSC events.

CONCLUSIONS

Prior mental health diagnoses and medication use were independent risk factors for ACSC-related acute care. These risk factors require focused attention if the full benefits of new primary care models are to be achieved.

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

Background

Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications.

Methods

We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers’ assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication.

Results

1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%).

Conclusions

Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.

Predictors of medication adherence postdischarge: the impact of patient age, insurance status, and prior adherence

BACKGROUND

Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence.

METHODS

The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence.

RESULTS

The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI -7.6% to -1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence.

CONCLUSIONS

In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions.

Medication adherence to multidrug regimens

Despite the fact that medication adherence has been extensively described in the literature over the last several decades, a quote by Becker and Maiman from over 35 years ago best captures the current state of our understanding: “Patient compliance[sic adherence] has become the best documented, but least understood, health behavior.” Future research is greatly needed to identify and translate safe and effective interventions into routine clinical practice to improve adherence. Only then can we begin to make significant improvements to the medication use process and, in turn, the health of older adults.

Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults

OBJECTIVE

To review the relationship between health literacy and adherence to cardiovascular/diabetes medication.

DATA SOURCES

We searched EMBASE (1974-February 2012) and MEDLINE (1948-February 2012). Search terms included health literacy, numeracy, health education and related terms, health literacy measurement tools, and medication adherence.

STUDY SELECTION AND DATA EXTRACTION

English-language articles of all study designs were considered. Articles were included if they had a measurement of health literacy and medication adherence and if participants were older adults taking drugs for cardiovascular illness or diabetes mellitus.

DATA SYNTHESIS

A total of 1310 citations were reviewed, including 9 articles that reported on 7 research studies. Most studies were retrospective, and all were based in the US. Because there was considerable diversity in measurements, participant characteristics, and outcome measures, we conducted a narrative synthesis rather than a meta-analysis. In assessing study validity, we looked at participant selection, method of measuring health literacy and medication adherence, missing data or losses, and adjustment for confounders. Of the 7 included studies, only 1 found a demonstrable association between health literacy and refill adherence. One clinical trial failed to show significant improvements in medication adherence after an intervention to improve health literacy.

CONCLUSIONS

The current evidence does not show a definite association between health literacy and medication adherence in older adults with cardiovascular disease or diabetes mellitus. In the absence of a definite link, efforts to develop interventions to improve health literacy would not necessarily improve adherence to cardiovascular medications. There is an urgent need for robust studies outside of the US, with wider, generalized recruitment of participants.

Health literacy in Ireland: reading between the lines

Health literacy may be defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. While health literacy has become a vibrant area of international research, Ireland has lagged behind and to date few data exist. This article summarises the research that has been carried out in Ireland, highlighting key findings and recommendations. With several new initiatives in place such as the Crystal Clear health literacy Awards, it is expected that Ireland will lag behind in this field no longer. Inadequate health literacy is at epidemic levels in Ireland and is fast becoming recognised as a national issue. Simplification of the healthcare system, in its entirety is required but the much needed financial investment will only be made after original research, demonstrating successful interventions has been conducted. With a trend worldwide towards personalized medicine, this theme should be extended to include tailor-made personalized health care information. An investment in health literacy will ultimately increase a patient's self-esteem, compliance, capacity to self-manage and most importantly patient outcomes and safety.

Measuring health literacy in individuals with diabetes: a systematic review and evaluation of available measures

OBJECTIVE

To identify instruments used to measure health literacy and numeracy in people with diabetes; evaluate their use, measurement scope, and properties; discuss their strengths and weaknesses; and propose the most useful, reliable, and applicable measure for use in research and practice settings.

METHODS

A systematic literature review was conducted to identify the instruments. Nutbeam's domains of health literacy and a diabetes health literacy skill set were used to evaluate the measurement scope of the identified instruments and to evaluate their applicability in people with diabetes.

RESULTS

Fifty-six studies were included, from which one diabetes-specific (LAD) and eight generic measures of health literacy (REALM, REALM-R, TOFHLA, s-TOFHLA, NVS, 3-brief SQ, 3-level HL Scale, SILS) and one diabetes-specific (DNT) and two generic measures of numeracy (SNS, WRAT) were identified. These instruments were categorized into direct measures, that is, instruments that assess the performance of individuals on health literacy skills and indirect measures that rely on self-report of these skills. The most commonly used instruments measure selective domains of health literacy, focus mainly on reading and writing skills, and do not address other important skills such as verbal communication, health care system navigation, health-related decision making, and numeracy. The structure, mode, and length of administration and measurement properties were found to affect the applicability of these instruments in clinical and research settings. Indirect self- or clinician-administered measures are the most useful in both clinical and research settings.

CONCLUSION

This review provides an evaluation of available health literacy measures and guidance to practitioners and researchers for selecting the appropriate measures for use in clinical settings and research applications.

Assessing health literacy in heart failure patients

BACKGROUND

Health literacy has important implications for health interventions and clinical outcomes. The Shortened Test of Functional Health Literacy in Adults (S-TOFHLA) is a timed test used to assess health literacy in many clinical populations. However, its usefulness in heart failure (HF) patients, many of whom are elderly with compromised cognitive function, is unknown. We investigated the relationship between the S-TOFHLA total score at the recommended 7-minute limit and with no time limit (NTL).

METHODS AND RESULTS

We enrolled 612 rural-dwelling adults with HF (mean age 66.0 ± 13.0 years, 58.8% male). Characteristics affecting health literacy were identified by multiple regression. Percentage of correct scores improved from 71% to 86% (mean percent change 15.1 ± 18.1%) between the 7-minute and NTL scores. Twenty-seven percent of patients improved ≥1 literacy level with NTL scores (P < .001). Demographic variables explained 24.2% and 11.1% of the variance in % correct scores in the 7-minute and the NTL scores, respectively. Female gender, younger age, higher education, and higher income were related to higher scores.

CONCLUSION

Patients with HF may be inaccurately categorized as having low or marginal health literacy when the S-TOFHLA time limits are enforced. New ways to assess health literacy in older adults are needed.

A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity

BACKGROUND

Medication nonadherence is a common problem among the elderly.

OBJECTIVE

To conduct a systematic review of the published literature describing potential nonfinancial barriers to medication adherence among the elderly.

METHODS

The PubMed and PsychINFO databases were searched for articles published in English between January 1998 and January 2010 that (1) described "predictors," "facilitators," or "determinants" of medication adherence or that (2) examined the "relationship" between a specific barrier and adherence for elderly patients (ie, ≥65 years of age) in the United States. A manual search of the reference lists of identified articles and the authors' files and recent review articles was conducted. The search included articles that (1) reviewed specific barriers to medication adherence and did not solely describe nonmodifiable predictors of adherence (eg, demographics, marital status), (2) were not interventions designed to address adherence, (3) defined adherence or compliance and specified its method of measurement, and (4) involved US participants only. Nonsystematic reviews were excluded, as were studies that focused specifically on people who were homeless or substance abusers, or patients with psychotic disorders, tuberculosis, or HIV infection, because of the unique circumstances that surround medication adherence for each of these populations.

RESULTS

Nine studies met inclusion criteria for this review. Four studies used pharmacy records or claims data to assess adherence, 2 studies used pill count or electronic monitoring, and 3 studies used other methods to assess adherence. Substantial heterogeneity existed among the populations studied as well as among the measures of adherence, barriers addressed, and significant findings. Some potential barriers (ie, factors associated with nonadherence) were identified from the studies, including patient-related factors such as disease-related knowledge, health literacy, and cognitive function; drug-related factors such as adverse effects and polypharmacy; and other factors including the patient-provider relationship and various logistical barriers to obtaining medications. None of the reviewed studies examined primary nonadherence or nonpersistence.

CONCLUSION

Medication nonadherence in the elderly is not well described in the literature, despite being a major cause of morbidity, and thus it is difficult to draw a systematic conclusion on potential barriers based on the current literature. Future research should focus on standardizing medication adherence measurements among the elderly to gain a better understanding of this important issue.

Health literacy and self-care of patients with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Today's complex healthcare system relies heavily on sophisticated self-care regimens. To navigate the system and follow self-care protocols, patients must be able to understand and use health information, which requires health literacy. However, nearly 90 million Americans lack the necessary health literacy skills to adequately care for themselves in the face of a complex healthcare system and self-care regimens. Understanding how to effectively care for one's self is thought to improve heart failure symptoms and patient outcomes, but little is actually known about how health literacy influences self-care in patients with heart failure. The purpose of this pilot study was to examine the relationship between health literacy and self-care of patients with heart failure.

SUBJECTS AND METHODS

Patients with a diagnosis of heart failure were recruited from a variety of community settings. Participants completed the Short-Form Test of Functional Health Literacy (measured health literacy), the Self-care Index of Heart Failure (measured self-care maintenance, management, and confidence), and a demographic questionnaire. Spearman ρ correlations were used to assess the strength of the relationship between health literacy level and self-care scores.

RESULTS AND CONCLUSIONS

Among the 49 participants recruited, health literacy was positively related to self-care maintenance (Rs = 0.357, P = .006). Health literacy had a negative relationship with self-care management (Rs = -0.573, P = .001). There was no association between health literacy and self-care confidence (Rs = 0.201, P = .083). This project provides preliminary data regarding the association between health literacy and self-care in heart failure, showing support for higher health-literate patients performing more self-care maintenance, which has been shown to improve patient outcomes in heart failure. Patients with higher health literacy trended toward having greater self-care confidence, which can increase the likelihood of performing self-care, but this finding was not statistically significant. It was unexpected to find that lower health-literate patients performed more self-care management.

Medication-taking beliefs and diabetes in American Samoa: a qualitative inquiry

In American Samoa (AS), nearly 22% of adults have type 2 diabetes. Diabetes is best managed by diet and lifestyle modifications and strict medication adherence. Cultural aspects might affect medication-taking beliefs, and thereby influence medication adherence. This study aims to explore diabetes medication-taking experiences and knowledge and related cultural beliefs in AS adults with diabetes and healthcare providers. Six focus groups were conducted with 39 AS adults with diabetes and individual interviews were performed with 13 diabetes healthcare providers. Data were transcribed and analyzed using NVivo 8 software. Themes pertaining to medication taking and adherence were identified. Patients and providers reported that barriers such as confusion about medications and concern about medication costs negatively influence medication taking, while cultural values and obligations both positively and negatively impact medication adherence. These findings help elucidate the relationship between medication-taking beliefs and culture in AS adults with diabetes and highlight the importance of continued research within this population.

Social support in type II diabetes care: a case of too little, too late

Coping with type II diabetic patients is increasingly posing large financial burdens, sorely felt especially by growing economies. Self-management has been found to be an effective approach towards maintaining good control in diabetics. However, although efforts at implementing self-management have had initial success, there has been a lack of sustainability. This review examines the different components impinging on self-care among type II diabetic patients. These include the critical role of social support, the need for support from health care providers, the value of support from family and friends, the influence of sex and cultural factors in self-care behavior, the benefits of peer support, and the role of literacy in diabetes self-care. Despite the mounting evidence for the effectiveness of social support in diabetes care, and the various stakeholders including this in their clinical guidelines, there has only been a lukewarm response from policy-makers towards ensuring its implementation. Hence, more effort is required from health care providers in moving away from just understanding the effects of new drugs and subsequently putting their patients on these drugs, and going back to the basics of communicating with the patients, understanding their woes, and helping to motivate/empower their patients. This paper analyzes the various components of social support, their influence on diabetes self-care, and how health care providers can help in this process.

Association of health literacy with complementary and alternative medicine use: a cross-sectional study in adult primary care patients

Background

In the United States, it is estimated that 40% of adults utilize complementary and alternative medicine (CAM) therapies. Recently, national surveys report that over 90 million adults have inadequate health literacy. To date, no study has assessed health literacy and its effect on CAM use. The primary objective of this study was to assess the relationship between health literacy and CAM use independent of educational attainment. Second objective was to evaluate the differential effect of health literacy on CAM use by race.

Methods

351 patients were recruited from an outpatient primary care clinic. Validated surveys assessed CAM use (I-CAM-Q), health literacy (REALM-R), and demographic information. We compared demographics by health literacy (adequate vs. inadequate) and overall and individual CAM categories by health literacy using chi square statistics. We found a race by health literacy interaction and ran sequential logistic regression models stratified by race to test the association between health literacy and overall CAM use (Model 1), Model 1 + education (Model 2), and Model 2 + other demographic characteristics (Model 3). We reported the adjusted effect of health literacy on CAM use for both whites and African Americans separately.

Results

75% of the participants had adequate literacy and 80% used CAM. CAM use differed by CAM category. Among whites, adequate health literacy was significantly associated with increased CAM use in both unadjusted (Model 1, OR 7.68; p = 0.001) and models adjusted for education (Model 2, OR 7.70; p = 0.002) and other sociodemographics (Model 3, OR 9.42; p = 0.01). Among African Americans, adequate health literacy was not associated with CAM use in any of the models.

Conclusions

We found a race by literacy interaction suggesting that the relationship between health literacy and CAM use differed significantly by race. Adequate health literacy among whites is associated with increased CAM use, but not associated with CAM use in African Americans.

Toward identifying the causes and combinations of causes increasing the risks of nonadherence to medical regimens: combined results of two German self-report surveys

OBJECTIVES

This study aimed to identify the causes of the nonadherence (NA) of German patients to their prescribed medication. In the course of the investigation, the NA risk profiles resulting from the combination of the various causes were identified.

METHODS

Two cross-sectional surveys with a total of 1517 patients (comprising 1177 patients contacted by telephone and forming survey 1 and a different set of 340 patients interviewed in-depth and face-to-face forming survey 2) were conducted. Self-reported NA was measured by the generic Morisky Medication Adherence Scale (MMAS). Survey 1 used a four-item MMAS and Survey 2 an eight-item MMAS.

RESULTS

Approximately 35% to 40% of the patients can be described as nonadherent. In survey 1, a few causes explain the NA (chronic disease, younger age, and fewer medications required to be taken). The more detailed survey 2 shows that the existence of intentional NA has considerably more influence than any other causal factors. Positive medication beliefs, a positive mood, and a good patient-doctor relationship reduce the NA risk. Furthermore, patients who are easily able to recognize the correct medication, as evidenced by ability to correctly identify the packaging, have a reduced NA probability. Concerning additive risk, patients who are chronically ill but display no other causes of risk have an NA probability of 10.4%. By contrast, in patients displaying all the identified causes of risk, the rate increases to 93.9%.

CONCLUSIONS

About one-third of patients can be classified as nonadherent. Intentional/medication-based NA causal factors explain the NA considerably better than do socioeconomics. The existence of more than one cause of risk considerably increases the NA risk of a patient.

Adherence to antihypertensive treatment and its determinants among urban slum dwellers in Kolkata, India

A cross-sectional study was conducted to determine the prevalence and predictors of adherence to modern antihypertensive pharmacotherapy among slum dwellers in Kolkata, India. Prevalence of adherence based on patient self-reports of consuming ≥80% of the prescribed medications over a recall period of 1 week was found to be 73% (95% confidence interval = 68%-78%). Compared with their counterparts, the following patients were more likely to be adherent to treatment: patients hypertensive for ≥5 years (2.98 times), those whose hypertension was detected during checkups for conditions related to hypertension (2.35 times), those living with ≤4 family members (2.01 times), those with family income of ≥3000 rupees (2.56 times), those who were getting free drugs (4.16 times), patients perceiving current blood pressure to be under control (2.23 times), and those satisfied with current treatment (3.77). Those adherent to their prescribed medications were 1.71 times more likely to achieve adequate control of hypertension compared with those who were not adherent.

Patients' literacy skills: more than just reading ability

Limited literacy contributes to suboptimal care and outcomes for patients. The Institute of Medicine noted that future work in health literacy should consider multiple literacy skills. However, lacking empirical evidence of the relationship between different literacy skills, reading skills are often used as proxies of literacy in research and practice. Using a community-based sample of 618 individuals residing in Boston, Massachusetts, and Providence, Rhode Island, the authors conducted a principal component analysis on measures of four literacy skills--reading, numeracy, oral (speaking), and aural (listening)--to examine whether and to what extent literacy can, or should, be represented by a single measure. The first principal component represented overall literacy and could only explain 60% of the total variation in literacy skills among individuals. The second principal component differentiated between numeracy/reading and the oral/aural exchange. While reading and numeracy best represent overall literacy, patients' relative strengths may vary. Those with moderate reading ability may have high oral and aural language skills. Conversely, people who have difficulties speaking with or understanding a provider may read well. Effective communication with patients should rely on the oral exchange and written health information, and not rely on a single literacy skill.

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Secondary preventive medication persistence and adherence 1 year after stroke

OBJECTIVE

Data on long-term use of secondary prevention medications following stroke are limited. The Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) Registry assessed patient, provider, and system-level factors influencing continuation of prevention medications for 1 year following stroke hospitalization discharge.

METHODS

Patients with ischemic stroke or TIA discharged from 106 hospitals participating in the American Heart Association Get With The Guidelines-Stroke program were surveyed to determine their use of warfarin, antiplatelet, antihypertensive, lipid-lowering, and diabetes medications from discharge to 12 months. Reasons for stopping medications were ascertained. Persistence was defined as continuation of all secondary preventive medications prescribed at hospital discharge, and adherence as continuation of prescribed medications except those stopped according to health care provider instructions.

RESULTS

Of the 2,880 patients enrolled in AVAIL, 88.4% (2,457 patients) completed 1-year interviews. Of these, 65.9% were regimen persistent and 86.6% were regimen adherent. Independent predictors of 1-year medication persistence included fewer medications prescribed at discharge, having an adequate income, having an appointment with a primary care provider, and greater understanding of why medications were prescribed and their side effects. Independent predictors of adherence were similar to those for persistence.

CONCLUSIONS

Although up to one-third of stroke patients discontinued one or more secondary prevention medications within 1 year of hospital discharge, self-discontinuation of these medications is uncommon. Several potentially modifiable patient, provider, and system-level factors associated with persistence and adherence may be targets for future interventions.

Development and evaluation of a medication counseling workshop for physicians: can we improve on 'take two pills and call me in the morning'?

BACKGROUND

Physicians often do not provide adequate medication counseling.

PURPOSE

To develop and evaluate an educational program to improve physicians' assessment of adherence and their medication counseling skills, with attention to health literacy.

METHODS

We compared internal medicine residents' confidence and counseling behaviors, measured by self-report at baseline and one month after participation in a two-hour interactive workshop.

RESULTS

Fifty-four residents participated; 35 (65%) completed the follow-up survey. One month after training, residents reported improved confidence in assessing and counseling patients (p<0.001), including those with low health literacy (p<0.001). Residents also reported more frequent use of desirable behaviors, such as assessing patients' medication understanding and adherence barriers (p<0.05 for each), addressing costs when prescribing (p<0.01), suggesting adherence aids (p<0.01), and confirming patient understanding with teach-back (p<0.05).

CONCLUSION

A medication counseling workshop significantly improved residents' self-reported confidence and behaviors regarding medication counseling one month later.

[Medication adherence in patients with chronic diseases: significance and new approaches]

Many patients post stroke or with other chronic diseases do not continue to take their evidence-based medication. Patients with reduced medication adherence are characterized by increased cardiovascular morbidity and mortality. The number of elderly individuals with chronic conditions requiring polypharmacy will continue to increase. The following strategies are discussed to enhance adherence: individual advice and continuous counselling of the patients and the caregivers, individualized pharmacotherapy, and medication management including combination pills and unit doses. Medication adherence represents a field of research with increasing importance for patient outcomes and healthcare costs. Measures to improve adherence may be equally important to the development of novel drugs. However, prospective clinical studies evaluating the effects of the proposed interventions on clinical endpoints are rare and therefore evidence-based recommendations are missing.