Patients' beliefs and preferences regarding doctors' medication recommendations

[Factors influencing analgesic use patterns in patients with chronic tumor-associated pain. : A qualitative pilot study considering different groups of medications]

BACKGROUND

Patients are surviving tumor diseases longer and longer due to the improvement of tumor-specific therapy and pain is a common symptom. The gold standard for tumor-associated chronic pain is multimodal therapy. Non-adherence causes high costs and may put patients at risk. The aim of this study was to investigate the adherence behavior and subjective treatment compliance of patients with tumor-associated chronic pain. The focus was on the patients' perspective. Different groups of medications, such as NOPA, opioids, co-analgesics and cannabinoids, as well as non-drug treatments were included.

METHODS

Semistructured guided interviews with 10 patients with chronic tumor pain were conducted within a qualitative research approach. The interviews were recorded and transcribed. The evaluation was using a focused content structuring interview analysis according to Kuckartz and Rädiker.

RESULTS

Five main categories were defined. The central category based on the research question was "Adherence behavior from the patient's perspective." The category "Medication therapy" formed the framework of the study. Other main categories were "History of illness", "Relationship with treatment providers" and "Attitudes and beliefs". A total of 77 additional subcategories were formed and interpreted. Adherence behavior from the patients' perspective differed between the different medication groups. A palliative setting influenced treatment decisions and adherence. The medication regimens used were complex and dynamic, especially when there were multiple practitioners involved. Furthermore, there was ambiguity in the use of cannabinoids. Non-drug therapies were marginalized by patients. From the point of view of the patients interviewed, it was not so much the treatment providers who influenced their adherence behavior, but rather their own experiences, attitudes, and convictions.

DISCUSSION

The study included all medication groups and non-drug therapies equally, complementing previous literature in a qualitative setting. Adherence factors known from previous research were reflected in the subjective perception of the group of patients with chronic pain after tumor diseases. Marginalization of non-medication methods could be explained by the fact that multimodal therapy approaches were too rarely constantly used and controlled in the phase of chronification. Therefore, drug and non-drug therapies should be applied even more consistently to patients with tumor-associated pain.

College students' experiences early in the COVID-19 pandemic: Applications for ongoing support

OBJECTIVE

To explore U.S. college students' experiences during the onset of the COVID-19 pandemic.

PARTICIPANTS

Students at a Northeastern public university.

METHODS

Participants were interviewed via videoconference between April 1 and May 31, 2020. Interviews were audio-recorded and professionally transcribed; analyzed using deductive and inductive approaches to thematic analysis.

RESULTS

34 students (68% female; 56% racial/ethnic minority) participated. Deductively derived themes included: (1) trust/mistrust; (2) desire for change; (3) precarity; and (4) silver linings. Subthemes included variation in vaccine confidence, concern regarding inequalities, and anxiety about education. Building on deductively derived themes, we hypothesized that participation in change-oriented activities could benefit well-being and novel approaches to information dissemination may be needed to overcome institutional distrust.

CONCLUSIONS

This study offers insights into potential short and long-term pandemic impacts as well as mitigation strategies college and university faculty and administrations may consider.

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study

Methods

This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review.

Results

In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking).

Conclusion

The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

A Qualitative Study of Health Workers' Experiences During Early Surges in the COVID-19 Pandemic in the U.S.: Implications for Ongoing Occupational Health Challenges

Background

Health workers (HWs) have faced significant threats to physical and psychological health during the COVID-19 pandemic. The recent surges associated with the spread of the delta variant in the U.S., coupled with political resistance to effective public health mitigation strategies, indicate that the risks experienced early in the pandemic are not likely to abate soon. This study sought to better understand the experiences, thoughts, concerns, and recommendations of HWs during one of the first major surges in the U.S. and to explore how these experiences might inform efforts to mitigate potential ongoing COVID-related negative health and psychological impacts on HWs.

Methods

HWs were recruited using a multi-faceted approach tailored to public health mitigation guidelines. Semi-structured interviews were conducted via video conference with front line HWs, support staff, and opioid use disorder service organization providers between April 1 and July 9, 2020 using the Social-Ecological Model as a framework. Interviews were audio-recorded and professionally transcribed; transcripts were analyzed inductively and deductively using thematic analytic methods, generating major themes and subthemes.

Results

A total of 22 HWs participated in the study; 14 were female; 3 identified as a member of a racial or ethnic minority population. Major themes identified included: (1) Institutions, Infrastructure, and the Pandemic; (2) Working Under Fire; (3) The Political Becomes Personal and (4) Hope. Themes and subthemes explicated the ways in which phenomena at personal, interpersonal, community, organizational, and societal levels affected HWs experiences and suggested potential mechanisms through which negative effects on HW mental health and health may be mitigated.

Conclusions

Previous global infectious disease epidemics have had profound negative effects on HWs' health and mental health. This study suggests the potential for similar negative impacts that may be exacerbated by the U.S.'s current sociopolitical milieu. Efforts to systematically describe and quantify these effects and to intervene to mitigate them are warranted.

Considerations for Meeting Students' Mental Health Needs at a U.S. University During the COVID-19 Pandemic: A Qualitative Study

Objective

To better understand the potential ongoing effects of the COVID-19 pandemic on U.S. university students' mental health and to generate hypotheses as to how universities may best meet students' mental health needs.

Participants

Students at a large public university in the United States.

Methods

Students were invited via email to participate in either interviews or focus groups regarding their COVID-19 pandemic experiences, including mental health impacts. Recruitment took place in two waves. Sessions were led by student members of the research team and took place via video conference between December 2020 and June 2021. Interviews were audio-recorded and transcribed via Zoom and manually edited and de-identified by the research team. Interview data were analyzed deductively and inductively using a modified grounded theory approach.

Results

A total of 40 undergraduate and graduate students took part in the study. Major themes included: (1) Overall impact of the pandemic on mental health; (2) Sources of pandemic stress/mental health impacts; (3) Subsequent coping strategies; and (4) Suggestions for improving university support for student mental health. Subthemes were identified within each major theme. Students reported substantial anxiety and other mental health impacts and felt improvements in communication and access to mental health resources could better support students.

Conclusions

This study provides context for the ways in which the COVID-19 pandemic may be continuing to impact mental health in a north-American university setting and identifies suggestions for potential interventions that future studies may test for effectiveness.

Current practices, facilitators, and barriers experienced by program providers implementing the National Diabetes Prevention Program in Los Angeles County

Individuals with prediabetes can lower their diabetes risk by participating in the National Diabetes Prevention Program (National DPP), an evidence-based, group lifestyle change program that is taught by a certified lifestyle coach. To date, studies have not explicitly compared National DPP implementation across multiple settings (i.e., types of organizations) to understand comparative setting advantages or challenges to engaging priority groups. The purpose of this study was to gain an in-depth understanding of: (a) the variation in National DPP implementation across clinic, community-based, and digital settings and (b) associated facilitators and barriers. The study focused on three core implementation domains: recruitment, retention, and data reporting. This study used a descriptive, qualitative approach to identify current practices, facilitators, and barriers to National DPP implementation by conducting semistructured key informant interviews in spring 2018 with 12 organizations delivering the National DPP in Los Angeles County. There was a general commonality between in-person settings (clinics and community-based), while the experiences of digital providers were relatively distinct. Recruitment and retention were widely described by all settings as labor- and time-intensive, while data reporting was seen as relatively less burdensome. All respondents reported using multiple recruitment strategies. Lifestyle coaches were seen as key to retention, and they spent substantial time engaging with participants outside of class, which often was not accounted for in program costs. Data reporting was easier for organizations that invested in sophisticated data management systems and had staff with sufficient data experience. This study advances knowledge around the translation of the National DPP in diverse settings in the nation's largest county and highlights opportunities for targeted, setting-specific support.

Understanding characteristics of patients newly initiating ixekizumab: findings from the Corrona Psoriasis Registry

Background: Real-world data on patients newly initiating ixekizumab is limited. Our study describes the characteristics of patients who initiated ixekizumab and other biologics for psoriasis treatment in North American dermatological practices. Materials & methods: Characteristics of patients ascertained at registry enrollment are described via means and frequencies. Results: Compared with other biologic initiators, ixekizumab initiators had: longer disease duration (17.1 vs 15.1 years); more were considered least severe by body surface area (33 vs 26%); moderate-to-severe by IGA (56 vs 48%); were biologic-experienced (80 vs 52%); obese (54 vs 47%); and experienced greater impact in work productivity (5.3 vs 2.9%) versus other biologic initiators. Conclusion: Psoriasis patients initiating ixekizumab had more severe disease, biologic experience, and worse patient-reported outcomes than those initiating other biologics.

A cross-sectional study of pet owners' attitudes and intentions towards nutritional guidance received from veterinarians

BACKGROUND

Beliefs of pet owners strongly influence their decision-making surrounding their pets' diet. Thus, nutritional guidance is an essential component of veterinary practice and integral to managing rising rates of pet obesity. This study examined pet owners' trust of, perceived effectiveness of, and intentions to follow nutritional guidance received from their veterinarian in managing their pets' diet.

METHODS

A cross-sectional study of 1402 dog and cat owners in the USA and Canada was conducted using an online questionnaire tool. Data were analysed using descriptive statistics and logistic regression modelling.

RESULTS

Clients are concerned about the effectiveness of veterinary nutrition recommendations. Cat owners were more likely than dog owners to consider the nutritional guidance they receive from veterinarians effective for their pets' diet (1.75, P=0.04). Length of pet ownership, feeding dry diets and frequency of veterinary visits were all positively associated with owners considering veterinary nutritional guidance to be effective in managing pets' diet.

CONCLUSION

Identifying these perspectives can aid in developing strategies to provide nutrition support to pet owners to improve their perceptions of, self-efficacy with, and compliance with veterinary nutrition recommendations.

Reliability and Validity of the M-MALMAS Instrument to Assess Medication Adherence in Malay-Speaking Patients with Type 2 Diabetes

BACKGROUND

The English Malaysian Medication Adherence Scale (MALMAS) has been validated for assessing medication adherence of people with type 2 diabetes. However, Malay is the national language of Malaysia.

OBJECTIVES

The aim of this study was to cross-culturally adapt and validate the Malay MALMAS (M-MALMAS) in Malaysia.

METHODS

Adults with type 2 diabetes, who could understand Malay, were recruited between May 2016 and February 2017 from a primary care clinic in Kuala Lumpur, Malaysia. The M-MALMAS and the Malay version of the Morisky Medication Adherence Scale (MMAS-8) were administered at baseline to test for convergent validity. Four weeks later, the M-MALMAS was re-administered. Predictive validity of the M-MALMAS was assessed by correlating the medication adherence scores with levels of glycated haemoglobin (HbA_1c).

RESULTS

In total, 100 of 104 people agreed to participate (response rate = 96.2%). The overall Cronbach's α and McDonald's Ω for the M-MALMAS was 0.654 and 0.676, respectively (mean = 0.665). At test-retest, no significant difference was found for all items. The median total score interquartile range (IQR) of the M-MALMAS was 7.0 (6.0-8.0) and this was significantly correlated to the median total score of the Malay MMAS-8 [median (IQR) = 7.0 (5.8-8.0), p < 0.001]. HbA_1c levels were significantly lower among participants who were adherent to their medications (score: 6-8) versus those who were non-adherent (score < 6, p = 0.018). The sensitivity and specificity of the M-MALMAS was 92% and 32.8%, respectively.

CONCLUSIONS

The M-MALMAS was found to be a valid and reliable instrument for assessing medication adherence of people with type 2 diabetes in Malaysia. The M-MALMAS had a high sensitivity but its specificity was not as good.

Optimizing Communication About Topical Corticosteroids: A Quality Improvement Study

Background

Patients are often non-adherent to topical corticosteroids (TCS). This may be in part due to poor communication between patients and dermatologists.

Objectives

This quality improvement (QI) study aims to describe dermatologist–patient communication about TCS treatments and to compare communication before and after the implementation of an educational intervention.

Methods

This QI study assesses the communication between dermatologists and new dermatology outpatients receiving a TCS prescription in a tertiary care center. The QI intervention is 2-pronged, consisting of an educational pamphlet for patients and a communication workshop for the dermatology team. Encounters were audiotaped, and communication was analyzed using a coding system (MEDICODE). Phase 1 recordings happened preintervention and reflect the usual dermatologist–patient communication in this practice setting and phase 2 recordings were postintervention.

Results

Phase 1 reveals that dermatologists frequently address informational medication themes, such as naming the medications and informing patients about their proper use. They less frequently discuss patient experience themes, such as goals of treatment, adverse effects of treatments, and exploring patients’ emotions about medications (such as anxiety, fears, etc.). After the intervention, there was more frequent discussion of patient experience themes without increasing consultation length. But, in both phases, physicians address most themes as a monolog with little verbal input from patients.

Conclusions

Our study raises awareness regarding dermatologists’ communication patterns about TCS, identifying specific areas for improvement, such as discussions of adverse effects, and explicitly addressing patients’ attitudes and emotions. This is an essential step to foster a sense-making of TCS for patients.

Improving Influenza Vaccination Coverage Among Patients With COPD: A Pilot Project

Background and objective

Guidelines for chronic obstructive pulmonary disease (COPD) advocate regular influenza vaccination, which has been shown to reduce exacerbations. However, influenza vaccination rates remain low. This quality improvement project was initiated to help improve influenza vaccination rates in a tertiary hospital.

Methods

All patients with COPD in the airway program (TAP) in the National University Hospital at the end of 2013 were recruited. The interventions were implemented in 2014; thus, population was stratified into the pre-intervention group and post-intervention group. Those who died in 2014 were excluded. They were (1) patient education posters in the clinics on the need for regular influenza vaccination, (2) direct interventions by physicians, and (3) intervention by the nurses when vaccinations were neglected. Physicians were made aware of previous vaccination rates, vaccination card reminders were placed in the clinics, and a new electronic healthcare record system (EHR) was implemented. The patients were followed up till the end of 2015 or until death. When an influenza vaccination was administered, the patients were asked which of the interventions led to the vaccination. A questionnaire was delivered to the physicians to determine the interventions that led to any change in vaccination prescription practices.

Results

The pre-intervention influenza vaccination rate was low at 47.7%. The post-intervention influenza vaccination rate improved to 80.7% with the multi-pronged approach. Physicians initiated the majority of vaccinations (87.9%), while nurses helped intervene in a further 12.1%. Physicians’ vaccination prescription practices changed as a result of self-awareness of low vaccination rates, vaccination card reminders, and the new EHR. Patient education made minimal impact.

Conclusion

This project demonstrates that with regular audits to track progress and several easy-to-implement interventions, improving influenza vaccination rates is an achievable goal.

Early Antibiotics and Childhood Obesity: Do Future Risks Matter to Parents and Physicians?

To understand how parents and physicians make decisions regarding antibiotics and whether a potential associated risk of obesity would alter decisions, we conducted a qualitative study of parents and physicians who care for children. Parent focus groups and physician interviews used a guide focused on experience with antibiotics and perceptions of risks and benefits, including obesity. Content analysis was used to understand how a risk of obesity would influence antibiotic decisions. Most parents (n = 59) and physicians (n = 22) reported limited discussion about any risks at the time of antibiotic prescriptions. With an acute illness, most parents prioritized symptomatic improvement and chose to start antibiotics. Physicians' treatment preferences were varied. An obesity risk did not change most parents' or physicians' preferences. Given that parent-physician discussion at the time of acute illness is unlikely to change preferences, public health messaging may be a more successful approach to counter obesity and antibiotics overuse.

Patient Perception of Physicians and Medication Adherence Among Older Adults With Hypertension

Objective: To assess association between patient perception of physicians and adherence to antihypertensive medication among Medicare beneficiaries. Method: Logistic regression was used to assess association between the Patient Perception of Physicians Scale score and adherence to antihypertensive medication. The 2007 Medicare Current Beneficiary Survey data were used to create a 12-item patient perception of physician scale and 2008 Medicare Part D claims to assess adherence. Results: There were 2,510 beneficiaries included in the sample. The mean age was 76.4 years ( SD = ±6.88 years). Sixty-five percent of the sample was adherent in filling their antihypertensive medication. Beneficiaries with more favorable perceptions of their physician (scores 37 or higher) were more likely to be adherent to antihypertensive medications than beneficiaries with scores less than 37 (odds ratio [OR] = 1.341, 95% confidence interval [CI] = [1.101, 1.632], p = .0035). Discussion: These findings provide some evidence that patient perceptions of their physician are associated with adherence, and that the physician–patient relationship is an important factor.

Perceived Obstacles Faced by Diabetes Patients Attending University of Gondar Hospital, Northwest Ethiopia

Background

Diabetes mellitus (DM) is a non-communicable, chronic, and progressive disease that can lead to serious complications and even to premature death. A closer understanding of the DM patients’ specific obstacles will provide a greater clarity of the factors influencing their disease-related quality of life and coping with daily life. The study aimed to evaluate the obstacles of DM patients attending ambulatory clinic of the University of Gondar Hospital (UOGH), Northwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2017 at ambulatory clinic of the UOGH. A validated short version of the diabetic obstacle questionnaire was used. The internal reliability of the questionnaire was checked using Cronbach’s alpha and was found to be 92.5%. To determine any association between each of the nine sections of the questionnaire and age, sex, residence, educational status, and DM type, a binary logistic regression was performed.

Results

The mean age of respondents was 38.69 ± 15.39 years. Compared with patients with type 1 DM, patients with type 2 DM reported poorer relationships with medical professionals (adjusted odds ratio (AOR): 2.191, p-value = 0.027) and less support from families and friends (AOR: 1.913, p-value = 0.049). Patients coming from rural areas (AOR: 2.947, p = 0.002) and having no formal education (AOR: 2.078, p = 0.029) also received less support from families and friends.

Conclusion

DM patients in UOGH reported several obstacles related to patients’ relationship with health professionals, lack of support from their friends, lack of knowledge about DM, and lack of motivation to exercise. Effective efforts should be initiated to improve healthier environment to educate, care and preventive services for people with DM.

Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment

Patient-provider communication impacts adherence to therapy. We explored older adults' communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.

Navigating Poorly Charted Territory

American health care is complex, fragmented, and arcane rather than being patient centered. Many patients have considerable difficulty navigating this system. As a result, care is less timely, safe, effective, and efficient. Since navigation problems are more likely for those who are sicker and less educated, they contribute to inequity. Early solutions proposed for this problem focused on the use of yet another specialized professional, the “navigator,” to help individuals find their way through the system so they get the care they need. The author defines the patient navigation problem and its probable consequences and argues that research and action are needed to (a) document the problem empirically, (b) identify underlying organizational structures and behaviors that can make navigation easy or difficult, and (c) assess whether and how policies, regulations, and improvement strategies can influence these structures and behaviors.

Exploring the role of physician communication about adjuvant endocrine therapy among breast cancer patients on active treatment: a qualitative analysis

PURPOSE

To better understand how physicians communicate with breast cancer patients about adjuvant endocrine therapy (AET), we explored, from the breast cancer patient's perspective, dimensions of the patient-provider communication among women who were on active AET treatment.

METHODS

Qualitative methods using semi-structured in-depth interviews were conducted with breast cancer patients (n = 22) who filled a prescription for AET in the previous 12 months. Interview questions aimed to elicit experiences with AET. We reviewed and coded interview transcripts using qualitative principles of inductive reasoning to identify concepts and themes from interview data.

RESULTS

We grouped emergent themes into four major functions of physician-patient communication: (1) information exchange, (2) decision-making to take and continue AET, (3) enabling patient self-management and monitoring potential side effects, and (4) emotional support. Physicians exchanged information with patients in a way that they understood and enhanced patient's health literacy regarding the benefits and knowledge of AET. Physicians empowered patients to make decisions about their care. Patients expressed trust and confidence in their physician which helped them seek care when needed. Patients reported a high degree of self-efficacy to self-manage AET and were continuing treatment despite potential side effects.

CONCLUSIONS

The results from our study suggest that women's interactions and communication with their physician may be an important factor that contributes to the continued use of AET. Physicians who can communicate information about AET treatment benefits, purpose, and expectations in a way that patients can understand is a critical aspect of care that needs to be further studied.

Ethnic differences in initiation and timing of adjuvant endocrine therapy among older women with hormone receptor-positive breast cancer enrolled in Medicare Part D

The aim of this study was to determine whether there are racial/ethnic differences in initiation and timing of adjuvant endocrine therapy (AET) after Medicare Part D drug coverage. We conducted a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results-Medicare-linked data to assess ethnic, socio-demographic, and tumor characteristic variations in the initiation of AET among patients ≥65 with hormone receptor-positive breast cancer in 2007-2009 enrolled in Medicare Part D through 2010. Logistic regression models were performed to assess the association between race/ethnicity and the initiation of tamoxifen, aromatase inhibitors (AIs), and overall AET (tamoxifen or AIs) within the first 12 months of diagnosis. Of the 12,198 women with hormone receptor-positive breast cancer, 74.8 % received AET within 12 months of diagnosis, of which 17.3 % received tamoxifen and 82.8 % received AIs. After controlling for all variables, only Asian women were found to have a greater odds of initiation of overall AET compared to non-Hispanic white women (odds ratio (OR): 1.28, 95 % CI: 1.03-1.58). Hispanic Mexicans and non-Hispanic black patients had a significantly lower odds of tamoxifen initiation (0.70, 0.54-0.91; 0.25, 0.10-0.62). For AI initiation, Hispanic Mexicans and Asians had a higher odds compared to non-Hispanic white women (2.06, 1.34-3.10; 1.33, 1.11-1.61). A suboptimal proportion of women (25.2 %) did not initiate AET within 12 months of diagnosis and therefore did not receive the full benefits of treatment to reduce the risk of breast cancer recurrence and mortality. Racial/ethnic differences in the initiation of tamoxifen and AIs have important implications that require further investigation.

Individualized Treatment of Neovascular Age-Related Macular Degeneration: What are Patients Gaining? Or Losing?

The widespread use of drugs that bind diffusible vascular endothelial growth factor (VEGF) has revolutionized the treatment of neovascular age-related macular degeneration (AMD). The pivotal ranibizumab and aflibercept registration trials featured monthly intravitreal injections for 12 months, during which visual acuities and macular edema rapidly improved for the first 3 months and modest gains or stabilization continued until the primary endpoint. In many subsequent trials, patients were evaluated monthly and treated as-needed (PRN) according to the results of visual acuity (VA) testing, fundus examinations and optical coherence tomography scans. Compared to monthly-treated control groups, PRN treated patients require fewer injections during the first year but they also experience smaller VA gains (1-3 letters). A small number of prospective trials that directly compared monthly with PRN therapy showed that VA gains with discontinuous therapy lag slightly behind those achieved with monthly injections. Physicians recognize that monthly office visits with frequent intraocular injections challenge patients' compliance, accrue high drug and professional service costs, and clog office schedules with frequently returning patients. To decrease the numbers of both office visits and anti-VEGF injections without sacrificing VA gains, physicians have embraced the treat-and-extend strategy. Treat-and-extend has not been studied as rigorously as PRN but it has become popular among both vitreoretinal specialists and patients. Despite the possible risks associated with discontinuous therapy (decreased VA and increased macular fluid), most physicians individualize treatment (PRN or treat-and-extend) for the majority of their patients. This review chapter explores the many advantages of individualized therapy, while balancing these against suboptimal responses due to the decreased frequency of anti-VEGF injections.

The Malaysian Medication Adherence Scale (MALMAS): Concurrent Validity Using a Clinical Measure among People with Type 2 Diabetes in Malaysia

Medication non-adherence is a prevalent problem worldwide but up to today, no gold standard is available to assess such behavior. This study was to evaluate the psychometric properties, particularly the concurrent validity of the English version of the Malaysian Medication Adherence Scale (MALMAS) among people with type 2 diabetes in Malaysia. Individuals with type 2 diabetes, aged 21 years and above, using at least one anti-diabetes agent and could communicate in English were recruited. The MALMAS was compared with the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess its convergent validity while concurrent validity was evaluated based on the levels of glycated hemoglobin (HbA1C). Participants answered the MALMAS twice: at baseline and 4 weeks later. The study involved 136 participants. The MALMAS achieved acceptable internal consistency (Cronbach’s alpha=0.565) and stable reliability as the test-retest scores showed fair correlation (Spearman’s rho=0.412). The MALMAS has good correlation with the MMAS-8 (Spearman’s rho=0.715). Participants who were adherent to their anti-diabetes medications had significantly lower median HbA1C values than those who were non-adherence (7.90 versus 8.55%, p=0.032). The odds of participants who were adherent to their medications achieving good glycemic control was 3.36 times (95% confidence interval: 1.09-10.37) of those who were non-adherence. This confirms the concurrent validity of the MALMAS. The sensitivity of the MALMAS was 88.9% while its specificity was 29.6%. The findings of this study further substantiates the reliability and validity of the MALMAS, in particular its concurrent validity and sensitivity for assessing medication adherence of people with type 2 diabetes in Malaysia.

Psychosocial perspectives on sexual recovery after prostate cancer treatment

Many therapies for erectile dysfunction (ED) after prostate cancer treatment improve erectile firmness, yet, most couples stop using aids within 1-2 years. Patients and partners who expect immediate and complete success with their first ED treatment can be demoralized when they experience treatment failure, which contributes to reticence to explore other ED aids. Comprehensive patient education should improve sustainability and satisfaction with ED treatments. Pre-emptive and realistic information should be provided to couples about the probability of recovering natural erections. Beginning intervention early and using a couple-based approach is ideal. Recommendations are provided about the timing of ED treatment, the order of aid introduction, and combination therapies. Renegotiation of sexual activity is an essential part of sexual adaptation. From the outset of therapy, couples should be encouraged to broaden their sexual repertoire, incorporate erection-independent sexual activities, and continue to be sexual despite ED and reduced libido.

Advance care planning: a qualitative study of dialysis patients and families

BACKGROUND AND OBJECTIVES

More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients' and families' diverse needs can strengthen systematic efforts to improve ACP.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes.

RESULTS

Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black (n=1), Hispanic (n=4), Native American (n=4), Pacific Islander (n=1), white (n=11), and mixed (n=1). Three major themes with associated subthemes were identified. The first theme, "Prior experiences with ACP," revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, "Factors that may affect perspectives on ACP," included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, "Recommendations for discussing ACP," included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how.

CONCLUSIONS

Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may affect patient perspectives regarding ACP. This study's findings may inform clinical practice and will be useful in designing prospective intervention studies to improve patient and family experiences at the end of life.

[Original preparations versus generics--latanoprost: how similar is different?]

BACKGROUND

To test the interchangeability of the commercially available (in Germany) latanoprost drugs and their generics respectively, the concentration of the active substance was tested. Guidelines of the European Medicines Agency postulate a sufficient bioequivalence, if the range of the agent is within 80-125% of the original drug.

METHODS

All compounds of latanoprost were procured registered. The concentration of latanoprost and benzalkoniumchloride was measured by high-performance liquid chromatography (HPLC) in a validated reference labroratory for 23 generics. In addition, the mean volume of drops and the pH of the formulation were measured. The packaging label and the readability of the enclosed information leaflet were checked.

RESULTS

All products contained less than 50 μg/ml latanoprost. The deviating reduction of the active substance (mean: - 7.39%, ± 2.8%) was accompanied by fluctions of the eyedrops' mass (mean: 0.03 g, ± 0.002 g). The concentration of benzalkonium chloride was mostly increased (median: 5.45%, min: - 2.5%, max: 11.5%). The pH of the original drug and the generics (median 6.78, min: 6.62, max: 6.81) was similar to the original drug, but was significantly different from an unpreserved formulation (pH 7.18). Due to type size, the packaging leaflet was illegible for humans with impaired vision.

CONCLUSIONS

Before prescribing generics in ophthalmology, different factors have to be considered, which might influence the amount of IOP lowering in effect. In the absence of healthcare research it is still unclear, how different bottle forms of eyedrops--such as appearance (e.g. Cyrillic characters) or pressure point (administration)--reduce the adherence of glaucoma patients.

Barriers and facilitators for medication adherence in stroke patients: a qualitative study conducted in French neurological rehabilitation units

OBJECTIVE

To describe the perceptions of French patients, caregivers and healthcare professionals on stroke and secondary preventive medications.

METHOD

A qualitative study was conducted, based on four predetermined topics: stroke, secondary prevention medications, patient's experience, relationship between patient/caregiver and healthcare team.

RESULTS

Twenty-six interviews were conducted. Difficulties in taking medications, lack of knowledge on stroke and medication benefits, fear of over medication were identified as barriers for adherence in patients. Doubts about generic drugs were expressed by caregivers. Healthcare professionals reported lack of knowledge and absence of clinical symptoms as barriers. On the other hand, support from caregivers and healthcare professional support is essential for compliance in all participants. Patients and caregivers expressed that fear of recurrence was a facilitator for treatment compliance.

CONCLUSION

This study highlights the barriers and facilitators for stroke treatment adherence and underlines the similarities and differences between the perceptions of patients, caregivers and healthcare professionals. These results must be integrated into the future French educational programs to improve medication adherence.

Self-compassionate reactions to health threats

Four studies investigated the relationship between self-compassion, health behaviors, and reactions to illness. Participants completed measures of self-compassion, health-related thoughts and feelings, reactions to actual and hypothetical illnesses, and self-regulation. Study 1 revealed that self-compassion was related to health-related cognitions and affect for healthy and unhealthy participants. In Study 2, self-compassion predicted participants' reactions to actual illnesses beyond the influence of illness severity and other predictors of health behaviors. Self-compassionate people also indicated they would seek medical attention sooner when experiencing symptoms than people lower in self-compassion. Study 3 demonstrated that self-compassion is related to health-promoting behaviors even after accounting for self-regulatory capabilities and illness cognitions. Study 4 revealed that the relationship between self-compassion and health reactions is partially explained by a proactive approach to health, benevolent self-talk, and a motivation toward self-kindness. Overall, these studies demonstrate that self-compassion has important implications for health-promoting behaviors and reactions to illness.

Clinical relevance of target identity and biology: implications for drug discovery and development

Many of the most commonly used drugs precede techniques for target identification and drug specificity and were developed on the basis of efficacy and safety, an approach referred to as classical pharmacology and, more recently, phenotypic drug discovery. Although substantial gains have been made during the period of focus on target-based approaches, particularly in oncology, these approaches have suffered a high overall failure rate and lower productivity in terms of new drugs when compared with phenotypic approaches. This review considers the importance of target identity and biology in clinical practice from the prescriber's viewpoint. In evaluating influences on prescribing behavior, studies suggest that target identity and mechanism of action are not significant factors in drug choice. Rather, patients and providers consistently value efficacy, safety, and tolerability. Similarly, the Food and Drug Administration requires evidence of safety and efficacy for new drugs but does not require knowledge of drug target identity or target biology. Prescribers do favor drugs with novel mechanisms, but this preference is limited to diseases for which treatments are either not available or suboptimal. Thus, while understanding of drug target and target biology is important from a scientific perspective, it is not particularly important to prescribers, who prioritize efficacy and safety.

A systematic literature review of psychosocial and behavioral factors associated with initial medication adherence: a report of the ISPOR medication adherence & persistence special interest group

OBJECTIVES

Numerous factors influencing medication adherence in chronically ill patients are well documented, but the paucity of studies concerning initial treatment course experiences represents a significant knowledge gap. As interventions targeting this crucial first phase can affect long-term adherence and outcomes, an international panel conducted a systematic literature review targeting behavioral or psychosocial risk factors.

METHODS

Eligible published articles presenting primary data from 1966 to 2011 were abstracted by independent reviewers through a validated quality instrument, documenting terminology, methodological approaches, and factors associated with initial adherence problems.

RESULTS

We identified 865 potentially relevant publications; on full review, 24 met eligibility criteria. The mean Nichol quality score was 47.2 (range 19-74), with excellent reviewer concordance (0.966, P < 0.01). The most prevalent pharmacotherapy terminology was initial, primary, or first-fill adherence. Articles described the following factors commonly associated with initial nonadherence: patient characteristics (n = 16), medication class (n = 12), physical comorbidities (n = 12), pharmacy co-payments or medication costs (n = 12), health beliefs and provider communication (n = 5), and other issues. Few studies reported health system factors, such as pharmacy information, prescribing provider licensure, or nonpatient dynamics.

CONCLUSIONS

Several methodological challenges synthesizing the findings were observed. Despite implications for continued medication adherence and clinical outcomes, relatively few articles directly examined issues associated with initial adherence. Notwithstanding this lack of information, many observed factors associated with nonadherence are amenable to potential interventions, establishing a solid foundation for appropriate ongoing behaviors. Besides clarifying definitions and methodology, future research should continue investigating initial prescriptions, treatment barriers, and organizational efforts to promote better long-term adherence.

Patient characteristics associated with medication adherence

OBJECTIVE

Despite evidence indicating therapeutic benefit for adhering to a prescribed regimen, many patients do not take their medications as prescribed. Non-adherence often leads to morbidity and to higher health care costs. The objective of the study was to assess patient characteristics associated with medication adherence across eight diseases.

DESIGN

Retrospective data from a repository within an integrated health system was used to identify patients ≥18 years of age with ICD-9-CM codes for primary or secondary diagnoses for any of eight conditions (depression, hypertension, hyperlipidemia, diabetes, asthma or chronic obstructive pulmonary disease, multiple sclerosis, cancer, or osteoporosis). Electronic pharmacy data was then obtained for 128 medications used for treatment.

METHODS

Medication possession ratios (MPR) were calculated for those with one condition and one drug (n=15,334) and then for the total population having any of the eight diseases (n=31,636). The proportion of patients adherent (MPR ≥80%) was summarized by patient and living-area (census) characteristics. Bivariate associations between drug adherence and patient characteristics (age, sex, race, education, and comorbidity) were tested using contingency tables and chi-square tests. Logistic regression analysis examined predictors of adherence from patient and living area characteristics.

RESULTS

Medication adherence for those with one condition was higher in males, Caucasians, older patients, and those living in areas with higher education rates and higher income. In the total population, adherence increased with lower comorbidity and increased number of medications. Substantial variation in adherence was found by condition with the lowest adherence for diabetes (51%) and asthma (33%).

CONCLUSIONS

The expectation of high adherence due to a covered pharmacy benefit, and to enhanced medication access did not hold. Differences in medication adherence were found across condition and by patient characteristics. Great room for improvement remains, specifically for diabetes and asthma.

Adherence with medications used to treat osteoporosis: behavioral insights

Non-persistence (never starting or stopping medication prematurely) and non-compliance (taking medication inappropriately) with fracture prevention medication among those at high risk of fracture remain significant barriers to optimal reduction of osteoporotic fractures. Current research suggest that for patients to persist and comply with prescriptions for fracture prevention medication, they need to believe that they are at significant risk of fracture, that the prescribed medication can safely reduce their risk of fracture without exposing them to long-term harm, that equally effective non-medicinal therapies are not available, and that they can successfully execute medication use in the context of their daily task demands. Further research is needed to understand; a) the mental models of osteoporosis, fractures, and medications used to treat osteoporosis that patients employ when making decisions as to whether or not to take fracture prevention medication; and b) how patients arbitrage information from various sources (health care providers, family, friends, and other sources) to formulate their beliefs about osteoporosis and medications used to treat it.

Development of a men's Preference for Testosterone Replacement Therapy (P-TRT) instrument

BACKGROUND

This study used a standard research approach to create a final conceptual model and the Preference for the Testosterone Replacement Therapy (P-TRT) instrument.

METHODS

A discussion guide was developed from a literature review and expert opinion to direct one-on-one interviews with participants who used testosterone replacement therapy and consented to participate in the study. Data from telephone interviews were transcribed for theme analysis using NVivo 9 qualitative analysis software, analyzed descriptively from a saturation grid, and used to evaluate men's P-TRT. Data from cognitive debriefing for five participants were used to evaluate the final conceptual model and validate the initial P-TRT instrument.

RESULTS

Item saturation and theme exhaustion was achieved by 58 male participants of mean age 55.0 ± 10.0 (22-69) years who had used testosterone replacement therapy for a mean of 175.0 ± 299.2 days. The conceptual model was developed from items and themes obtained from the participant interviews and saturation grid. Items comprising eight dimensions were used for instrument development, ie, ease of use, effect on libido, product characteristics, physiological impact, psychological impact, side effects, treatment experience, and preference. Results from the testosterone replacement therapy preference evaluation provide a detailed insight into why most men preferred a topical gel product over an injection or patch.

CONCLUSION

Items and themes relating to use of testosterone replacement therapy were in concordance with the final conceptual model and 29-item P-TRT instrument. The standard research approach used in this study produced the P-TRT instrument, which is suitable for further psychometric development and use in clinical practice.

Therapeutic efficacy of bevacizumab for age-related macular degeneration: what are the implications of CATT for routine management?

CATT (Comparison of Age-related macular degeneration [AMD] Treatment Trials) examined the efficacy of ranibizumab and bevacizumab for the treatment of neovascular AMD. This prospective, randomized, but unblinded trial revealed a significant improvement in vision with both treatments in terms of visual acuity; importantly, patients with juxtafoveal choroidal neovascularization (CNV) and retinal pigment epithelial detachments were not excluded from the study. Monthly treatment with the drugs resulted in similar increases in visual acuity, although angiograms indicated that ranibizumab was superior in terms of reducing retinal fluid and leakage. As the study also differentiated between a fixed regimen and an as-needed (pro re nata [PRN]) dosing regimen, a larger sample size and Bonferroni statistical correction were necessary. The equivalence of the PRN dosing of bevacizumab to the monthly treatment could not be confirmed. Almost all of the frequent deviations from the protocol (referring to retreatment criteria: 25.7-28.5%) resulted in under-treatment. Since this applied to both drugs equally, under-treatment alone could not explain the larger loss of visual acuity observed in the bevacizumab PRN arm. The PRN regimen was generally associated with a larger lesion size after 12 months compared with the fixed treatment regimens. The investigators accepted the drawbacks of an incomplete masking to allow co-payment by Medicare. As assessments of drug trials are often politically motivated, the higher demands of a non-inferiority trial compared with a superiority design must be emphasized. A comparison of the per-protocol and last-observation-carried-forward analysis has not yet been published; ongoing subgroup analysis might highlight the impact of different lesion characteristics. While CATT provided further evidence for the efficacy of bevacizumab treatment, differences in adverse events between the two treatments (e.g. a higher rate of serious adverse events with bevacizumab compared with ranibizumab) were reported; however, these still have to be analysed, with the larger sample sizes of previous ranibizumab studies needing to be taken into account. Preclinical studies imply some differences between the drugs in terms of their adverse event profiles. A possible increased risk of adverse events could not be ruled out by previous clinical case series and CATT because the sample sizes and the follow-up intervals were not adequate. The large discrepancy in the price of bevacizumab versus ranibizumab in the US means a cost-benefit analysis is warranted. A lack of quality-of-life data has prevented calculation of an appropriate bevacizumab price in the context of its performance in the ophthalmological setting. Thus, CATT suggests that a favourable visual acuity might be achieved by very frequent administration of bevacizumab in patients with neovascular AMD. Although there are certain safety caveats, increased focus on subgroup analyses and obtaining longer follow-up data are expected to yield additional information of clinical relevance.

Validity and reliability of instruments designed to measure factors influencing the overuse of antibiotics

BACKGROUND

Antibiotic overuse is a global public health issue that is influenced by several factors. The degree and prevalence of antibiotic overuse is difficult to measure directly. A more practical approach, such as the use of a psycho-social measurement instrument, might allow for the observation and assessment of patterns of antibiotic use.

STUDY OBJECTIVE

The aim of this paper is to review the nature, validity, and reliability of measurement scales designed to measure factors associated with antibiotic misuse/overuse.

DESIGN

This study is descriptive and includes a systematic integration of the measurement scales used in the literature to measure factors associated with antibiotic misuse/overuse. The review included 70 international scientific publications from 1992 to 2010.

MAIN RESULTS

Studies have presented scales to measure antibiotic misuse. However, the workup of these instruments is often not mentioned, or the scales are used with only early-phase validation, such as content or face validity. Other studies have discussed the reliability of these scales. However, the full validation process has not been discussed in any of the reviewed measurement scales.

CONCLUSION

A reliable, fully validated measurement scale must be developed to assess the factors associated with the overuse of antibiotics. Identifying these factors will help to minimize the misuse of antibiotics.

Prevalent obstacles and predictors for people living with type 2 diabetes

Background. Type 2 diabetes (T2DM) is a chronic, progressive disease with serious micro- and macrovascular complications. A person affected by T2DM should learn to accept the new restricted lifestyle. Aims. The aim of the study was to identify the prevalence of obstacles in coping with daily life for people with T2DM and the magnitude of the relationships of the obstacles with various patient characteristics. Methods. Participants were recruited from randomly selected GPs' lists in Estonia. Respondents completed the Estonian version of the Diabetes Obstacles Questionnaire (DOQ). The statements were assessed on a 5-point scale. Biomedical and clinical variables were measured. The central tendency statistics and skewness and kurtosis for all statements were computed to find out those that reflect obstacles. Then obstacles of the DOQ were stratified. Multinomial logistic regression (MLR) was computed to estimate the influences of descriptive variables on the statements. Results and Conclusions. Altogether, 138 diabetic patients were enrolled in the study. Fourteen statements were identified as obstacles. Variables such as age, type of diabetes treatment, and BMI had significant effects on five of them. Younger age, BMI, and insulin nonuse were revealed as the strongest predictive characteristics for perceiving obstacles more often in coping with daily life.

Reasons for under-use of prescribed opioid medications by patients in pain

BACKGROUND

With the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do not take their medications as prescribed and find nonadherence rates of approximately 25%.

OBJECTIVE

To identify the prevalence of under-use of opioid medications and the reasons and implications of under-use.

DESIGN

As part of a variety of structured assessments, subjects were asked detailed questions about how they used their opioid medication in their daily lives.

PARTICIPANTS

One hundred ninety-one veterans who received an opioid prescription for any pain problem within the 12 months before the interview.

MEASURES

We defined a patient who under-used his/her medication as one who took less than their prescribed dose of medication and reported that pain impaired their ability to engage in normal daily activities.

RESULTS

Under-use of opioids (20%) was more common than over-use (9%), consistent with research on medication adherence. Patients who under-used their opioids offered the same reasons for under-use that patients report for other medications. However, while under-users reported more pain than other opioid users they filled only slightly fewer opioid prescriptions. Communication problems between patients and providers about opioids were common.

CONCLUSIONS

Improved communication between patients and providers and shared decision-making regarding opioid prescriptions may improve pain management and minimize the problems associated with over-prescription of opioids (i.e., diversion).

An evaluation of two decision-making scales for children with life-limiting illnesses

PURPOSE

Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses.

METHODS

Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses.

RESULTS

Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE.

CONCLUSION

Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.

Perception of improved state of health and subjective quality of life in Crohn's disease patients treated with Infliximab

BACKGROUND AND AIMS AND METHOD: Although Infliximab is a very potent therapy of refractory Crohn's disease, its administration requires iterative infusions in hospital and there are concerns regarding its long-term safety. The aim of this study was to assess in a sample of 51 patients suffering from CD the impact of type of treatment (intravenous Infliximab versus conventional therapy without Infliximab) on the evaluation of the state of health (CGI) and the quality of life (MOS-SF36). Secondary variables were also assessed: the impact of depression (MADRS), the impact of activity of the disease (Harvey-Bradshaw Index).

RESULTS

Overall, the assessments made using the CGI and the SF-36 revealed that the two types of treatment did not differ on the assessment of state of health and quality of life. A downward influence of depression and activity of the disease was observed.

CONCLUSION

Patients considered more efficacy of Infliximab than its potential side effects. It seems important to assess and to consider depression in order to improve medical care setting of Crohn's disease.