Negative impact of physician prescribed drug dosing schedule requirements on patient adherence to cardiovascular drugs

Pharmacist's interventions in factors contributing to medication errors reduces medication errors in self-management of patients in the rehabilitation ward

BACKGROUND

The number of medications, number of administrations per day, dosing frequency on indicated day, and medication from multiple prescriptions are the medication factors prone to medication errors in self-management that have been previously reported. However, whether pharmacists actually intervene in medication factors that affect medication error occurrences in self-management is unclear. Therefore, we conducted this study to clarify these issues.

METHOD

This study included patients who underwent self-management in the rehabilitation ward of Higashinagoya National Hospital. From April 2019 to March 2020, a one-pharmacist period existed, and from April 2020 to March 2021, a two-pharmacist period existed. The number of patient instructions and interventions were expected to increase with an increase in the number of pharmacists. Considering this to be an environment of differential interventions by pharmacists, a pre-post-test design was conducted with all self-managed patients in both the time periods. The primary and secondary endpoints were the proportion of medication error occurrences and proportion of pharmacist's interventions in medication factors, respectively.

RESULT

The proportions of medication error occurrences during the one-pharmacist and two-pharmacist periods were 41% (71/173) and 28% (51/180) (relative risk 0.690, 95% confidential interval 0.515-0.925), respectively. The proportion of pharmacist's interventions in medication factors in the one-pharmacist period was 13% (22/173) and 22% (40/180) in the two-pharmacist period; there was an increase in the proportion of pharmacist's interventions in medication factors in the two-pharmacist period.

CONCLUSION

The proportion of medication error occurrences was significantly lower in the two-pharmacist period than that in the one-pharmacist period. This can be attributed to the increase in the proportion of pharmacist's interventions in medication factors. Therefore, an environment in which pharmacists could intervene in the medication factors to prevent medication errors in advance is necessary.

Physician influence on medication adherence, evidence from a population-based cohort

BACKGROUND

The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence.

METHODS

We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect.

RESULTS

We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables.

INTERPRETATION

The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients.

Prevalence and patient-rated relevance of complexity factors in medication regimens of community-dwelling patients with polypharmacy

Purpose

To describe the prevalence of complexity factors in the medication regimens of community-dwelling patients with more than five drugs and to evaluate the relevance of these factors for individual patients.

Methods

Data were derived from the HIOPP-6 trial, a controlled study conducted in 9 general practices which evaluated an electronic tool to detect and reduce complexity of drug treatment. The prevalence of complexity factors was based on the results of the automated analysis of 139 patients’ medication data. The relevance assessment was based on the patients’ rating of each factor in an interview (48 patients included for analysis).

Results

A median of 5 (range 0–21) complexity factors per medication regimen were detected and at least one factor was observed in 131 of 139 patients. Almost half of these patients found no complexity factor in their medication regimen relevant.

Conclusion

In most medication regimens, complexity factors could be identified automatically, yet less than 15% of factors were indeed relevant for patients as judged by themselves. When assessing complexity of medication regimens, one should especially consider factors that are both particularly frequent and often challenging for patients, such as use of inhalers or tablet splitting.

Trial registration

The HIOPP-6 trial was registered retrospectively on May 17, 2021, in the German Clinical Trials register under DRKS-ID DRKS00025257.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-022-03314-1.

Analysis of factors contributing to medication errors during self-management of medication in the rehabilitation ward: a case control study

Background

In the rehabilitation ward, many elderly patients require continuous use of medication after a stroke or bone fracture, even after discharge. They are encouraged to self-manage their medications from the time of admission. Medication errors, such as a missed dose or incorrect administered medication can worsen conditions, resulting in recurrent strokes, fractures, or adverse effects. The study was aimed to identify risk factors, such as medication and prescription, contributing to errors in self-management of medication.

Methods

This study was conducted on patients who self-managed their medication in the rehabilitation ward of Higashinagoya National Hospital from April 2018 to March 2020. The patient background including age and sex were investigated. The medication factors examined include the number of medications and administrations per day, dosing frequency on indicated days, prescription and start date are the same, medications from multiple prescriptions, and one package or one tablet at each dosage. The group of medication error cases were defined as the medication error group and that of control cases as the no-medication error group. A logistic regression analysis was performed for factors related to medication errors.

Results

A total of 348 patients were included in the study, of which 154 patients made medication errors, with 374 total medication error cases. The median number of medications in the medication error group was six, and that in the no-medication error group was five. Statistically significant factors correlated with errors made during self-management of medication were the number of medications, number of administrations per day, dosing frequency on indicated days, and medication from multiple prescriptions.

Conclusions

When a patient is self-managing their medications, errors are likely to occur due to a high number of medicines they are taking and the complexity of the dosage regimen. Therefore, to prevent medication errors, reviewing the prescribed medications and devise ways to simplify the dosage regimens is crucial.

[Hospital medication adherence scale development in cardiovascular disorders]

OBJECTIVES

The consequences of non-adherence to prescribed cardiovascular drugs can be serious, with cardiovascular complications having been reported in both secondary and primary prevention. The objective of this study was to develop a new scale to assess medication adherence in patients with cardiovascular diseases during their hospitalization.

METHODS

A cohort of 219 high risk cardiovascular patients was evaluated for this study. Data on reasons for non-adherence were collected using the newly developed Medication Adherence Scale in Cardiovascular disorders (Mascard) and compared with physician assessment during medical consultations and the control of their cardiovascular risk factors.

RESULTS

The Mascard consists of 5 items has good psychometric properties and validity and correlated with physician assessment and control of cardiovascular risk factors.

CONCLUSIONS

This rapid and easy to use scale may be useful for health care practitioners in their assessment of medication adherence in inpatients with cardiovascular disorders.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

An Educational Intervention to Improve Statin Use: Cluster RCT at the Primary Care Level in Argentina

INTRODUCTION

Statins are essential drugs for high cardiovascular disease (CVD) risk management; however, there is still low adherence to good clinical practice guidelines for statin use at the primary care level in low- and middle-income countries. This study aimed to test whether a complex intervention targeting physicians improves treatment and control of hypercholesterolemia among patients with moderate to high CVD risk in Argentina.

STUDY DESIGN

Cluster RCT.

SETTING/PARTICIPANTS

Ten primary care centers from the public healthcare system of Argentina.

INTERVENTION

Primary care physicians in the intervention group received an educational program with three main components: (1) an intensive 2-day training workshop; (2) educational outreach visits; and (3) a mobile health application installed on the physician's smartphones.

MAIN OUTCOME MEASURES

Reduction in mean low-density lipoprotein cholesterol level, reduction in mean Framingham risk score, proportion of patients receiving an appropriate statin dose, and mean annual number of primary care center visits.

RESULTS

Data were analyzed in 2017-2018. Between April 2015 and April 2016, a total of 357 participants were enrolled (179 patients in the intervention group and 178 in the control group). The global follow-up rate was 97.2%. At the end of the follow-up period, there was no difference in low-density lipoprotein cholesterol levels in any of the follow-up points among the groups. Mean CVD risk had a significant net difference in the first 6 months in the intervention group versus the control group (-4.0, 95% CI = -6.5, -1.5). At the end of follow-up, there was an absolute 41.5% higher rate of participants receiving an appropriate statin dose in the intervention group versus the control group.

CONCLUSIONS

Although the intervention did not reach a reduction in cholesterol levels, it had a significant positive impact on the promotion of adequate use of clinical practice guidelines.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02380911.

[Simplifying complex drug therapies : Challenges and solutions]

The difficulties of managing a complex medication regimen are often underestimated in outpatient care. A large number of drugs (polypharmacy) and complicated dosage schemes or dosage forms may overstrain patients. Indeed, wrong drug administration can impair treatment success or cause adverse drug events.Patients are often unaware of the medication administration errors. Furthermore they do not voice administration problems, often because they are not aware of the potential to optimize their drug therapy. Medication regimen complexity can often be reduced by simple measures. However, feasible concepts for reducing medication regimen complexity in a structured way have been lacking in routine care so far.Electronic decision support facilitates systematic and efficient identification of factors that increase the complexity of a medication regimen. Furthermore, electronic decision aids may enable physicians and pharmacists to take appropriate measures in order to reduce medication regimen complexity. Personalizing the analysis and resulting measures to reduce medication regimen complexity might increase readiness of patients to implement changes in treatment and, thus, probably increase adherence. The first results of a prospective trial that is supported by the Federal Joint Committee (G-BA) Innovationsfonds (HIOPP-6, Komplexitätsreduktion in der Polypharmazie unter Beachtung von Patientenpräferenzen) will be available in autumn 2018 and answer these questions.

Contemporary rates and correlates of statin use and adherence in nondiabetic adults with cardiovascular risk factors: The KP CHAMP study

BACKGROUND

Statin therapy is highly efficacious in the prevention of fatal and nonfatal atherosclerotic events in persons at increased cardiovascular risk. However, its long-term effectiveness in practice depends on a high level of medication adherence by patients.

METHODS

We identified nondiabetic adults with cardiovascular risk factors between 2008 and 2010 within a large integrated health care delivery system in Northern California. Through 2013, we examined the use and adherence of newly initiated statin therapy based on data from dispensed prescriptions from outpatient pharmacy databases.

RESULTS

Among 209,704 eligible adults, 68,085 (32.5%) initiated statin therapy during the follow-up period, with 90.4% receiving low-potency statins. At 12 and 24 months after initiating statins, 84.3% and 80.2%, respectively, were actively receiving statin therapy, but only 42% and 30%, respectively, had no gaps in treatment during those time periods. There was also minimal switching between statins or use of other lipid-lowering therapies for augmentation during follow-up. Age≥50 years, Asian/Pacific Islander race, Hispanic ethnicity, prior myocardial infarction, prior ischemic stroke, hypertension, and baseline low-density lipoprotein cholesterol>100 mg/dL were associated with higher adjusted odds, whereas female gender, black race, current smoking, dementia were associated with lower adjusted odds, of active statin treatment at 12 months after initiation.

CONCLUSIONS

There remain opportunities for improving prevention in patients at risk for cardiovascular events. Our study identified certain patient subgroups that may benefit from interventions to enhance medication adherence, particularly by minimizing treatment gaps and discontinuation of statin therapy within the first year of treatment.