How do physicians conduct medication reviews?

Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis

OBJECTIVES

The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia.

DESIGN

A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group.

SETTING AND PARTICIPANTS

Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019.

METHODS

Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars.

RESULTS

The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period.

CONCLUSIONS AND IMPLICATIONS

Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic

As the population ages, more people will have comorbid disorders and polypharmacy. Medication should be reviewed regularly in order to avoid adverse drug reactions and medication‐related hospital visits, but this is often not done. As part of our student‐run clinic project, we investigated whether an interprofessional student‐run medication review program (ISP) added to standard care at a geriatric outpatient clinic leads to better prescribing. In this controlled clinical trial, patients visiting a memory outpatient clinic were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The medications of all patients were reviewed by a review panel (“gold standard”), resident, and in the intervention arm also by an ISP team consisting of a group of students from the medicine and pharmacy faculties and students from the higher education school of nursing for advanced nursing practice. For both groups, the number of STOPP/START‐based medication changes mentioned in general practitioner (GP) correspondence and the implementation of these changes about 6 weeks after the outpatient visit were investigated. The data of 216 patients were analyzed (control group = 100, intervention group = 116). More recommendations for STOPP/START‐based medication changes were made in the GP correspondence in the intervention group than in the control group (43% vs. 24%, P = < 0.001). After 6 weeks, a significantly higher proportion of these changes were implemented in the intervention group (19% vs. 9%, P = 0.001). The ISP team, in addition to standard care, is an effective intervention for optimizing pharmacotherapy and medication safety in a geriatric outpatient clinic.

Polypharmacy and Potentially Inappropriate Medication Use in Older Blacks with Diabetes Mellitus Presenting to the Emergency Department

Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60-92), most (n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority (n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs (r = .22, p = .004) and anticholinergic score (r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.

Interprofessional Medication Assessment has Effects on the Quality of Medication Among Home Care Patients: Randomized Controlled Intervention Study

OBJECTIVE

Multimorbidity and complex medications increase the risk of medication-related problems, especially in vulnerable home care patients. The objective of this study was to examine whether interprofessional medication assessment has an effect on medication quality among home care patients.

DESIGN

The FIMA (Finnish Interprofessional Medication Assessment) study was a randomized, controlled study comparing physician-led interprofessional medication assessment and usual care.

SETTING AND PARTICIPANTS

The FIMA study was conducted in home care settings in Finland. The participants were ≥65-year-old home care patients with ≥6 drugs daily, dizziness, orthostatic hypotension, or a recent fall.

METHODS

Primary outcome measures over the 6-month follow-up were number of drugs, drug-drug-interactions, medication-related risk loads, and use of potentially inappropriate medications (PIMs) examined by SFINX, RENBASE, PHARAO, and Meds75+ databases. The databases classified information as follows: A (no known pharmacologic or clinical basis for an increased risk), B (evidence not available/uncertain), C (moderately increased risk which may have clinical relevance), and D (high risk, best to avoid). Logistic regression adjusted for age, sex, and the baseline level of the outcome measure served as statistical methods.

RESULTS

The mean number of all drugs for home care patients (n = 512) was 15. The odds of drug-induced impairment of renal function (RENBASE D, P = .020) and medication-related risk loads for bleeding (PHARAO D, P = .001), anticholinergic effects (PHARAO D, P = .009), and constipation (PHARAO D, P = .003) decreased significantly in the intervention group compared with usual care. The intervention also reduced the odds of using PIMs (Meds75+ D, P = .005). There were no significant changes in drug-drug-interactions or number of drugs.

CONCLUSIONS AND IMPLICATIONS

FIMA intervention improved the medication quality of home care patients. Risks for renal failure, anticholinergic effects, bleeding, constipation, and the use of PIMs were reduced significantly.

A randomized clinical trial of a collaborative home-based diabetes intervention to reduce emergency department visits and hospitalizations in black individuals with diabetes

The prevalence of diabetes mellitus (DM) in black individuals (blacks) is twice that of white individuals (whites), and blacks are more likely to have worse glycemic control, less optimal medication regimens, and higher levels of mistrust in the medical system. These three factors account for higher rates of acute medical care use in blacks with DM. To address this disparity, we developed DM I-TEAM (Diabetes Interprofessional Team to Enhance Adherence to Medical Care), a home-based multidisciplinary behavioral intervention that integrates care from a community health worker (CHW), the participant's primary care physician (PCP), a DM nurse educator, and a clinical pharmacist. Treatment is delivered during 9 sessions over 1 year, and includes diabetes education and goal setting, telehealth visits with participants' PCP and a DM nurse educator, and comprehensive medication reviews by a pharmacist. We describe the rationale and methods for a randomized controlled trial to test the efficacy of DM I-TEAM to reduce emergency department (ED) visits and hospitalizations. We are enrolling 200 blacks with DM during an ED visit. Participants are randomized to DM I-TEAM or Usual Medical Care (UMC). Follow-up assessments are conducted at 6 and 12 months. The primary outcome is the number of ED visits and hospitalizations over 12 months, and is measured by participant self-report and medical record review. Secondary outcomes include hemoglobin A1c (HbA1c), number of potentially inappropriate medications (PIMs), and trust in health care.

Why deprescribing instead of not prescribing?

Prescribing medications involves complex cognitive processes, and mistakes in prescription can cause serious adverse events. Deprescribing is one of the last opportunities to prevent patient harm from the use of drugs that should be avoided, especially among older patients. This viewpoint article aims to discuss the prescription process and some essential concepts, such as polypharmacy, prescription of potentially inappropriate medications, and, particularly, the relevance of deprescribing and its relationship with the appropriate prescription of medications in older people.

'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial

INTRODUCTION

Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy.

METHODS AND ANALYSIS

Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed.

ETHICS AND DISSEMINATION

The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal.

MAIN FUNDING

Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'.

TRIAL REGISTRATION NUMBERS

Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).

Pharmacist-participated medication review in different practice settings: Service or intervention? An overview of systematic reviews

Introduction

Medication review (MR) is a pharmacy practice conducted in different settings that has a positive impact on patient health outcomes. In this context, systematic reviews on MR have restricted the assessment of this practice using criteria such as methodological quality, practice settings, and patient outcomes. Therefore, expanding research on this subject is necessary to facilitate the understanding of the effectiveness of MR and the comparison of its results.

Aim

To examine the panorama of systematic reviews on pharmacist-participated MR in different practice settings.

Methods

A literature search was undertaken in Biblioteca Virtual em Saúde (BVS), Embase, PubMed, Scopus, The Cochrane Library, and Web of Science databases through January 2018 using keywords for "medication review", "systematic review", and "pharmacist". Two independents investigators screened titles, abstracts, full texts; assessed methodological quality; and, extracted data from the included reviews.

Results

Seventeen systematic reviews were included, of which sixteen presented low to moderate methodological quality. Most of reviews were conducted in Europe (n = 7), included controlled primary studies (n = 16), elderly patients (n = 9), and long-term care facilities (n = 8). Seven reviews addressed MR as an intervention and thirteen reviews cited collaboration between physicians and pharmacists in the practice of MR. In addition, thirteen terminologies for MR were used and the main objective was to identify and solve drug-related problems and/or optimize the drug use (n = 11).

Conclusion

There is considerable heterogeneity in practice settings, population, definitions, terminologies, and approach of MR as well as poor description of patient care process in the systematic reviews. These facts may limit the comparison, summarization and understanding of the results of MR. Furthermore, the methodological quality of most systematic reviews was below ideal. Thus, international agreement on the MR process is necessary to assess, compare and optimize the quality of care provided.

Workflow process mapping to characterize office-based primary care medication use and safety: A conceptual approach

BACKGROUND

We developed the PCMedSafety conceptual framework to illustrate primary care medication safety transformation opportunities. PCMedSafety demonstrates the interrelationship between the practice-level primary care delivery system, medication workflow processes for common medication-related activities, and medication use and safety outcomes. This framework was used to conceptualize a workflow process mapping approach to characterize and evaluate the safety of medication-related activities performed in primary care practices.

OBJECTIVES

In this article, we conceptually describe how workflow process mapping of primary care medication-related activities can be used to: (1) understand and characterize common office-based primary care medication-related workflows, and (2) identify medication-related workflow process gaps and deviations and their impact on medication use and safety within office-based primary care.

METHODS

Workflow process mapping of primary care medication-related activities consists of 9 major steps, including: (1) identification of a primary care practice, (2) establishment of a workflow mapping team, (3) selection of medication-related activities, (4) development of ideal-state workflow process map(s), (5) selection of data elements and development of data collection form(s), (6) development of a workflow observation schedule, (7) completion of direct workflow observations, (8) development of observed workflow process map(s), and (9) data analysis to identify medication safety workflow gaps and deviations.

CONCLUSION

The medication workflow process mapping approach illustrated in this article can be used by primary care executive leadership, clinician leaders, primary care providers, and clinical pharmacists to identify, resolve, and prevent medication safety concerns within a primary care practices. Workflow gaps and deviations identified through workflow process mapping can be used to inform practice-specific opportunities for: (1) team-based primary care redesign to integrate clinical pharmacists into the expanded primary care team; (2) workforce development, including staff/provider training and role delegation for common primary care medication-related activities; and (3) improvements in workflow efficiency and consistency to reduce preventable medication errors.

STEADI: CDC's approach to make older adult fall prevention part of every primary care practice

INTRODUCTION

Primary care providers play a critical role in protecting older adult patients from one of the biggest threats to their health and independence-falls. A fall among an older adult patient cannot only be fatal or cause a devastating injury, but can also lead to problems that can effect a patient's overall quality of life.

METHODS

In response, the Centers for Disease Control and Prevention (CDC) developed the STEADI initiative to give health care providers the tools they need to help reduce their older adult patient's risk of a fall.

RESULTS

CDC's STEADI resources have been distributed widely and include practical materials and tools for health care providers and their patients that are designed to be integrated into every primary care practice.

CONCLUSION

As the population ages, the need for fall prevention efforts, such as CDC's STEADI, will become increasingly critical to safeguard the health of Americans.

PRACTICAL APPLICATIONS

STEADI's electronic health records (EHRs), online trainings, assessment tools, and patient education materials are available at no-cost and can be downloaded online at www.cdc.gov/STEADI. Health care providers should look for opportunities to integrate STEADI materials into their practice, using a team-based approach, to help protect their older patients.

Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department

BACKGROUND

Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events.

STUDY OBJECTIVES

To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events.

METHODS

Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE.

RESULTS

From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event.

CONCLUSION

Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.

The Role of Pharmacists in Preventing Falls among America's Older Adults

Falls are the leading cause of both fatal and non-fatal injuries in people aged 65 years and older and can lead to significant costs, injuries, functional decline, and reduced quality of life. While certain medications are known to increase fall risk, medication use is a modifiable risk factor. Pharmacists have specialized training in medication management and can play an important role in fall prevention. Working in a patient-centered team-based approach, pharmacists can collaborate with the primary care providers to reduce fall risk. They can screen for fall risk, review and optimize medication therapy, recommend vitamin D, and educate patients and caregivers about ways to prevent falls. To help health-care providers implement fall prevention, the Centers for Disease Control and Prevention developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. Based on the established clinical guidelines, STEADI provides members of the health-care team, including pharmacists, with the tools and resources they need to manage their older patients’ fall risk. These tools are being adapted to specifically advance the roles of pharmacists in reviewing medications, identifying those that increase fall risk, and communicating those risks with patients’ primary care providers. Through a multidisciplinary approach, pharmacists along with other members of the health-care team can better meet the needs of America’s growing older adult population and reduce falls.

[An integrative review of drug utilization by the elderly in primary health care]

OBJECTIVE

To identify knowledge produced about drug utilization by the elderly in the primary health care context from 2006 to 2014.

METHOD

An integrative review of the PubMed, LILACS, BDENF, and SCOPUS databases, including qualitative research papers in Portuguese, English, and Spanish. It excluded papers with insufficient information regarding the methodological description.

RESULTS

Search found 633 papers that, after being subjected to the inclusion and exclusion criteria, made up a corpusof 76 publications, mostly in English and produced in the United States, England, and Brazil. Results were pooled in eight thematic categories showing the current trend of drug use in the elderly, notably the use of psychotropics, polypharmacy, the prevention of adverse events, and adoption of technologies to facilitate drug management by the elderly. Studies point out the risks posed to the elderly as a consequence of changes in metabolism and simultaneous use of several drugs.

CONCLUSION

There is strong concern about improving communications between professionals and the elderly in order to promote an exchange of information about therapy, and in this way prevent major health complications in this population.

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial

Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office

OBJECTIVE

To describe the development and implementation of a pharmacist-delivered Medicare Annual Wellness Visit (MWV).

SETTING

Physician-owned, private family practice office.

PRACTICE INNOVATION

Pharmacist-delivered MWV.

MAIN OUTCOME MEASURES

Patient visits and practice income.

RESULTS

Because of time constraints in the practice, physicians, nurse practitioners, and a physician assistant had been unable to offer MWVs, a new service available to Medicare beneficiaries under the Affordable Care Act. A pharmacist who was previously providing patient care services 1 day/week at a fixed hourly rate was able to add an additional 1 day/week for provision of MWVs. These visits involve updating medical and medication histories; measuring weight, mass, and blood pressure; assessing cognitive and physical function; and screening the patient and recommending preventive services. From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWV. Pharmacist visits were billed using codes G0438 and G0439, and the practice realized a positive net income for the MWVs.

CONCLUSION

Pharmacist-delivered MWVs are financially viable and allow for greater pharmacist participation on the primary care team.

Patterns and predictors of medication discrepancies in primary care

RATIONALE, AIMS AND OBJECTIVES

Identifying medication discrepancies across transitions of care is a common patient safety problem. Research examining relations between medication discrepancies and adherence, however, is limited. The objective of this investigation is to explore the relations between adherence and patient-provider medication discrepancies, and to test the hypothesis that non-adherence would be associated with medication discrepancies.

METHODS

Three hundred twenty-eight outpatients completed a current medication list and measures of health literacy, adherence, perceived physical functioning and subjective well-being. Patient lists were compared with active medications in the electronic medical record. Multivariate analyses identified demographic, clinical and patient-reported variables associated with discrepancies involving prescribed daily medications.

RESULTS

Despite high rates of self-reported adherence, patients reported taking fewer medications than the number of active medications in their medical record (3.79 vs. 4.83, P < 0.001). We identified one or more discrepancies in most records (294/328 or 89.6%). Identified discrepancies were completely reconciled in only 21.1% of patients with discrepancies. Discrepancies were associated with lower health literacy, poorer physical health status and subjective well-being, and poorer adherence to the regimen patients believed they had been prescribed. Multivariate analysis indicated that the number of medical record-reported medications and subjective well-being independently predicted the presence of discrepancies.

CONCLUSIONS

Findings suggest a complex relation between treatment adherence and medication discrepancies in which patient well-being and regimen complexity work in tandem to create discordance between patient and provider medication plans. Simplifying regimens when possible and attending to patient life satisfaction may improve adherence to a regimen constructed jointly between patient and provider.

A Qualitative Study of Older Adults and Computer Use for Health Education: "It opens people's eyes"

Adults over the age of 60 struggle with achieving target blood pressure readings due to difficulties seeing, hearing and understanding medical information which can result in poor adherence and drug interactions that can be fatal. According to the Institute of Medicine (2000) approximately 10% of adverse drug events may be attributed to communication failure between the provider and patient. Informing patients of potential drug interactions with over-the-counter (OTC) medications, supplements and alcohol use can contribute to better blood pressure control. The Next Generation Personal Education Program (PEP-NG) was designed to improve patient care by educating both older adults and their providers about the dangers of adverse drug interactions arising from self-medication. This web based program analyzes information entered by the patient user (with a stylus on a tablet computer) and delivers tailored interactive educational content applicable to the user's reported medication behaviors. This qualitative study demonstrated that even amongst participants that may not feel computer literate (older-age generation) it can be a useful tool for information dissemination and also a successful way to improve communication between provider and patient.

An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial

Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient-provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable™ is an Electronic Medical Record (EMR)-integrated tool designed to support patient-provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable™ improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.

Provider views about responsibility for medication adherence and content of physician-older patient discussions

OBJECTIVES

To investigate provider opinions about responsibility for medication adherence and examine physician-patient interactions to illustrate how adherence discussions are initiated.

DESIGN

Focus group discussions with healthcare providers and audio taped outpatient office visits with a separate group of providers.

SETTING

Focus group participants were recruited from multispecialty practice groups in New Jersey and Washington, District of Columbia. Outpatient office visits were conducted in primary care offices in Northern California.

PARTICIPANTS

Twenty-two healthcare providers participated in focus group discussions. One hundred patients aged 65 and older and 28 primary care physicians had their visits audio taped.

MEASUREMENTS

Inductive content analysis of focus groups and audio taped encounters.

RESULTS

Focus group analyses indicated that providers feel responsible for assessing medication adherence during office visits and for addressing mutable factors underlying nonadherence, but they also believed that patients were ultimately responsible for taking medications and voiced reluctance about confronting patients about nonadherence. The 100 patients participating in audio taped encounters were taking a total of 410 medications. Of these, 254 (62%) were discussed in a way that might address adherence; physicians made simple inquiries about current patient medication use for 31.5%, but they made in-depth inquiries about adherence for only 4.3%. Of 39 identified instances of nonadherence, patients spontaneously disclosed 51%.

CONCLUSION

The lack of intrusive questions about medication taking during office visits may reflect poor provider recognition of the questions needed to assess adherence fully. Alternatively, provider beliefs about patient responsibility for adherence may hinder detailed queries. A paradigm of joint provider-patient responsibility may be needed to better guide discussions about medication adherence.

Reducing Adverse Self-Medication Behaviors in Older Adults with Hypertension: Results of an e-health Clinical Efficacy Trial

A randomized controlled efficacy trial targeting older adults with hypertension (age 60 and over) provided an e-health, tailored intervention with the "next generation" of the Personal Education Program (PEP-NG). Eleven primary care practices with advanced practice registered nurse (APRN) providers participated. Participants (N = 160) were randomly assigned by the PEP-NG (accessed via a wireless touchscreen tablet computer) to either control (entailing data collection and four routine APRN visits) or tailored intervention (involving PEP-NG intervention and four focused APRN visits) group. Compared to patients in the control group, patients receiving the PEP-NG e-health intervention achieved significant increases in both self-medication knowledge and self-efficacy measures, with large effect sizes. Among patients not at BP targets upon entry to the study, therapy intensification in controls (increased antihypertensive dose and/or an additional antihypertensive) was significant (p = .001) with an odds ratio of 21.27 in the control compared to the intervention group. Among patients not at BP targets on visit 1, there was a significant declining linear trend in proportion of the intervention group taking NSAIDs 21-31 days/month (p = 0.008). Satisfaction with the PEP-NG and the APRN provider relationship was high in both groups. These results suggest that the PEP-NG e-health intervention in primary care practices is effective in increasing knowledge and self-efficacy, as well as improving behavior regarding adverse self-medication practices among older adults with hypertension.