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PubMed2006

Changes in antihypertensive prescribing during US outpatient visits for uncomplicated hypertension between 1993 and 2004.

Monitoring national patterns of antihypertensive drug therapy is essential to assessing adherence to treatment guidelines and the impact of major scientific publications on physician prescribing. We analyzed data from 2 US National Ambulatory Care Surveys to examine trends between 1993 and 2004 in the prescription of antihypertensive drug classes for uncomplicated hypertension and the association between thiazide and beta-blocker prescribing and physician and patient characteristics. Diuretic prescriptions remained level through 2001 (39%; 95% CI: 34% to 44%) but increased to 53% (48% to 58%) in 2003, largely because of a 72% increase in thiazide prescriptions in the first quarter of 2003 (50%; 95% CI: 40% to 59%). However, these increases did not sustain in 2004. Beta-blocker prescriptions increased modestly from 1993 (24%; 95% CI: 19% to 29%) to 2004 (33%; 95% CI: 28% to 39%). Prescription of calcium channel blockers and angiotensin-converting enzyme inhibitors declined significantly following the sixth Joint National Committee report, but both subsequently rebounded to prereport levels. Prescription of angiotensin II receptor blockers increased continuously from 1% in 1995 to 23% by 2004. Polytherapy prescriptions, particularly those involving > or = 3 drug classes, became increasingly prevalent, accounting for 60% of antihypertensive drug visits by 2004. Prescriptions of thiazides and beta-blockers were both more likely in 1998-2004 (versus 1993-1997). Blacks, women, and hospital outpatients were more likely to receive thiazides. Also, cardiologists were more likely to prescribe beta-blockers. Evidence-based guidelines for antihypertensive drug therapy do impact physician prescribing, but the impact seems to be short lived. Future interventions are imperative for promoting long-term adherence to published guidelines.

Adult↗

PubMed2006

Use of depression education materials to improve treatment compliance of primary care patients.

In a collaborative effort between a managed behavioral health organization, a health maintenance organization, and a state employer, this pilot study tested the value of mailing a depression education flyer to primary care patients who were recently prescribed antidepressant medications and an informational letter to their physician. The intervention, designed to improve use of behavioral healthcare services and antidepressant medication adherence, had a moderate impact on consistency of antidepressant medication use and on use of psychotherapy in combination with antidepressant medications. Additionally, intervention patients on combination treatment were more likely to stay on antidepressant medications into the continuation phase of treatment.

Adult↗

PubMed2005

Does a pre-hospital emergency pathway improve early diagnosis and referral in suspected stroke patients?--Study protocol of a cluster randomised trial [ISRCTN41456865].

BACKGROUND: Early interventions proved to be able to improve prognosis in acute stroke patients. Prompt identification of symptoms, organised timely and efficient transportation towards appropriate facilities, become essential part of effective treatment. The implementation of an evidence based pre-hospital stroke care pathway may be a method for achieving the organizational standards required to grant appropriate care. We performed a systematic search for studies evaluating the effect of pre-hospital and emergency interventions for suspected stroke patients and we found that there seems to be only a few studies on the emergency field and none about implementation of clinical pathways. We will test the hypothesis that the adoption of emergency clinical pathway improves early diagnosis and referral in suspected stroke patients. We designed a cluster randomised controlled trial (C-RCT), the most powerful study design to assess the impact of complex interventions. The study was registered in the Current Controlled Trials Register: ISRCTN41456865--implementation of pre-hospital emergency pathway for stroke--a cluster randomised trial. METHODS/DESIGN: Two-arm cluster-randomised trial (C-RCT). 16 emergency services and 14 emergency rooms were randomised either to arm 1 (comprising a training module and administration of the guideline), or to arm 2 (no intervention, current practice). Arm 1 participants (152 physicians, 280 nurses, 50 drivers) attended an interactive two sessions course with continuous medical education CME credits on the contents of the clinical pathway. We estimated that around 750 patients will be met by the services in the 6 months of observation. This duration allows recruiting a sample of patients sufficient to observe a 30% improvement in the proportion of appropriate diagnoses. Data collection will be performed using current information systems. Process outcomes will be measured at the cluster level six months after the intervention. We will assess the guideline recommendations for emergency and pre-hospital stroke management relative to: 1) promptness of interventions for hyperacute ischaemic stroke; 2) promptness of interventions for hyperacute haemorrhagic stroke 3) appropriate diagnosis. Outcomes will be expressed as proportions of patients with a positive CT for ischaemic stroke and symptoms onset < or = 6 hour admitted to the stroke unit. DISCUSSION: The fields in which this trial will play are usually neglected by randomised controlled trial (RCT). We have chosen the cluster-randomised controlled trial (C-RCT) to address the issues of contamination, adherence to real practice, and community dimension of the intervention, with a complex definition of clusters and an extensive use of routine data to collect the outcomes.

Brain Ischemia↗

PubMedDate not supplied

Testing a theoretical model of exercise behavior for older adults.

BACKGROUND: Although there are many known benefits to exercise, only 10-30% of older adults report regular exercise. Understanding the factors that explain exercise behavior in older adults will help structure interventions that motivate these individuals to initiate and adhere to regular exercise. OBJECTIVE: The purpose of this study was to test the impact of components from two theoretical perspectives that explain exercise behavior, social cognitive theory, and the transtheoretical model. METHODS: This was a descriptive study using a sample of 179 older adults living independently in an East Coast continuing care retirement community (CCRC). A single one-time interview was completed and included: (a) stage of change for exercise, (b) self-efficacy and outcome expectations, (c) health status, (d) fear of falling, and (e) exercise activity. Model testing used structural equation modeling. RESULTS: Testing of the hypothesized model showed that 11 of the 22 paths were statistically significant. Health status and social support influenced self-efficacy and outcome expectations which directly influenced stage of change and exercise. Social support likewise directly influenced stage of change. Together the variables in the model explained 64% of exercise behavior in older adults. There was a poor fit of the hypothesized model to the data with a chi2 of 144.7, degrees of freedom (df) of 23 and a ratio of 6.3. The revised model fit the data better chi2 = 80.5, df = 19, p <.05, chi2/df = 4.2) and there was improved fit when compared to the hypothesized model (chi2 difference of 64.0, df difference of 4, p < or = l. DISCUSSION: The combined testing of the mediating components of the theory of self-efficacy as well as the incorporation of the stage of change to explain exercise behavior in older adults suggests that both of these approaches are useful. Stage of change may be particularly useful to help determine the most appropriate intervention to increase activity and exercise in older adults.

Aged↗

PubMedDate not supplied

Description of a clinical pharmacist intervention administered to primary care patients with depression.

The objective of this article is to provide a detailed description of interactions between patients with depression and pharmacists. Analysis was conducted on patients from the intervention arm (n=268) of an randomized controlled trial that evaluated the impact of a clinical pharmacist on the outcomes for depressed primary care patients from nine metropolitan Boston practices. The main outcome measure was the amount of intervention time spent with patients, physicians, and other activities. Details of the behavioral intervention and a categorization of the activities are offered. Pharmacists reported 978 encounters with 268 patients in 6 months. Eighty percent of patient encounters occurred by telephone. Initial encounters took 45 min if in person and 13.3 min if by telephone. Subsequent encounters followed a similar pattern. Follow-up visits occurred 2.3 times per patient. Physician contact took considerably less time. In total, the pharmacist intervention took 70.3 min per patient over 6 months; 42.2% of encounters involved an activity related to non-antidepressant medication and 85% of encounters involved general support. Other activities (education, advocating antidepressants, and motivating adherence) occurred in at least 50% of encounters. Pharmacists repeated intervention activities in the same category approximately two to three times. Interventions to improve the care of depression in primary care patients must anticipate encountering intense needs for information, personal support, and help negotiating the healthcare system. Research that identifies relationships between the components (active ingredients) of an intervention and the outcomes of care will benefit future intervention strategies and contribute to improved and efficient care.

Adult↗

PubMed2004

Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes.

BACKGROUND: Adherence difficulties and psychological problems are associated with poor glycaemic control in diabetes. We undertook a systematic review and meta-analysis of psychological therapies to assess their effectiveness in improving glycaemic control in type 2 diabetes. METHODS: We searched MEDLINE, PsychINFO, EMBASE, and the Cochrane Central Register of Controlled Trials up to January, 2003. Eligible studies were randomised controlled trials that involved people with type 2 diabetes and evaluated a psychological therapy (counselling, cognitive behaviour therapy, or psychodynamic therapy) to improve diabetes control. We extracted the number of participants, their age, duration of diabetes, glycaemic control, type of psychological therapy, its mode of delivery, and type of intervention in the control group. The main outcome was long-term glycaemic control measured by percentage of glycated haemoglobin. Blood glucose concentration, weight, and psychological distress were also measured. Pooled standardised effect sizes were calculated. FINDINGS: 25 trials were eligible for the review. In 12 trials, the mean percentage glycated haemoglobin was lower in people assigned a psychological intervention than in the control group (usual care, education, waiting list, or attention control); the pooled mean difference was -0.32 (95% CI -0.57 to -0.07) equivalent to an absolute difference of -0.76%. There were non-significant differences in blood glucose concentration (eight trials; -0.11 [-0.65 to 0.42]) and weight gain (nine trials; 0.37 [-0.18 to 0.93]). Psychological distress was significantly lower in the intervention groups (five trials; -0.58 [-0.95 to -0.20]). INTERPRETATION: In type 2 diabetes, there are improvements in long-term glycaemic control and psychological distress but not in weight control or blood glucose concentration in people who receive psychological therapies.

Blood Glucose↗

PubMed2004

Dietary adherence in the Women's Health Initiative Dietary Modification Trial.

This article describes adherence to a low-fat dietary pattern (less than 20% energy from fat, five or more fruit/vegetable and six or more grain servings daily) in Years 1 and 5 of the Women's Health Initiative Dietary Modification Trial, which was designed to examine the effects of a low-fat dietary pattern on risk of breast and colorectal cancers and other chronic diseases in postmenopausal women. Participants were randomly assigned to a low-fat dietary intervention arm (40%, n=19,542) or a usual diet control arm (60%, n=29,294). Women in the intervention arm completed 18 group sessions during the first year, followed by quarterly annual maintenance sessions. Adherence was assessed as control minus intervention (C-I) group differences in percent total energy from fat as estimated by a food frequency questionnaire. Based on these self-reported dietary data, mean C-I was 10.9 percentage points of energy from fat at Year 1, decreasing to 9.0 at Year 5. Factors associated with poorer adherence were being older, being African American or Hispanic (compared with white), having low income, and being obese. Group session attendance was strongly associated with better dietary adherence. There are many limitations of self-reported dietary data, particularly related to social desirability and intervention-associated bias. Nonetheless, these data indicate that long-term dietary change was achieved in this clinical trial setting and reinforce the potential of the ongoing trial to answer questions of public health importance.

Aged↗

PubMed2006

Agreement between patients with schizophrenia and providers on factors of antipsychotic medication adherence.

OBJECTIVE: Medication adherence continues to be a challenge for patients with schizophrenia. Many interventions have been tested but not widely adopted. To fill this gap, this qualitative study examined patient and provider perspectives on barriers, facilitators, and motivators related to adherence. METHODS: Twenty-six patients (15 veterans and 11 nonveterans) diagnosed as having schizophrenia or schizoaffective disorder completed in-depth qualitative interviews. Each patient's mental health provider completed an open-ended paper-and-pencil questionnaire that followed the format of the patient qualitative interview. Patients and their providers were asked about seven domains of an explanatory model for schizophrenia and about barriers to, facilitators for, and motivators to taking antipsychotic medication. Patients and providers responded from the perspective of the patient. Patient interviews were audiotaped and transcribed. The data were analyzed with content analysis and constant comparison methods. RESULTS: Explanatory model agreement between patients and their providers ranged from 40 to 100 percent, depending on the explanatory model domain. Patients identified 214 unique barriers, facilitators, and motivators, and agreement between patients and their providers ranged from 54 to 65 percent. Sample patient quotes are provided. CONCLUSIONS: Substantial disagreement arose between patients and their providers with regard to their explanatory models for schizophrenia and the barriers, facilitators, and motivators thought to affect patients' medication adherence decisions. These findings will be used to develop and test a patient-centered strategy to enhance medication adherence.

Adult↗

PubMed1999

Impact of same-day screening mammography availability: results of a controlled clinical trial.

BACKGROUND: We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations. PATIENTS AND METHODS: Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group). MAIN OUTCOME MEASURES: Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography. RESULT: Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P<.001), increasing to 61% and 49% at 6 months (P<.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P<.001), women who were not employed (54% vs 36%; P<.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P<.001) within the last 5 years. CONCLUSIONS: Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.

Academic Medical Centers↗

PubMed1994

Measuring adherence to asthma medication regimens.

The failure of patients to adhere to physician-prescribed regimens, either pharmacologic or behavioral, has been well documented in medical literature. Poor adherence to asthma medication regimens has been repeatedly demonstrated in both children and adults, with rates of nonadherence commonly reported from 30 to 70%. Medication regimens for asthma care are particularly vulnerable to adherence problems because of their duration, the use of multiple medications, and the periods of symptom remission. The clinical effects of this nonadherence by asthmatic patients can include treatment failure, unnecessary and dangerous intensification of therapy, and costly diagnostic procedures, complications, and hospitalizations. Although the measurement of adherence is an important component of both medical and behavioral interventions to control asthma, relatively little research has directly addressed the reliability and validity of the measures most widely used to assess asthma medication compliance. This review will discuss methods and issues in the measurement of adherence in general, and where available, measures that have been specifically used in evaluating adherence to asthma medication. Common measures used to assess compliance with asthma medications include direct measures, which confirm the use of medication by assaying it in blood, urine, or saliva, or which confirm the to use a medication, such as observed skill in using a metered dose inhaler. Indirect measures infer use with varying degrees of reliability, by use of clinical judgment, self-report/asthma diaries, medication measurement, and electronic medication monitors. The uses and limitations of these measures will be discussed.

Adult↗

PubMed2002

Overcoming patient-related barriers to cancer pain management for home care patients. A pilot study.

The purpose of this pilot study was to explore the effectiveness of a pain education program to overcome patient-related barriers in managing cancer pain for Taiwanese home care patients with cancer. The pain education program was developed based on previous studies of Taiwanese patient-related barriers to cancer pain management. The Barriers Questionnaire-Taiwan form, the Brief Pain Inventory, the Medication Adherence Questionnaire, and a demographic questionnaire were used for data collection. The sample consisted of 18 patients in the experimental group and 19 patients in the control group. Descriptive statistics, tests, and paired tests were used to analyze the data. Results of this study revealed that patients who received the pain educational program had significantly greater reduction in Barriers Questionnaire-Taiwan form scores and more improvement in medication adherence compared with patients who did not participate in the program. When compared to pretest scores, patients scores after receiving the pain education intervention showed significant improvement on the Barriers Questionnaire-Taiwan form, medication adherence, pain intensity, and pain interference. The results of this study support the effectiveness of the pain education program on overcoming the barriers to cancer pain management for Taiwanese home care patients with cancer.

Adolescent↗

PubMed2005

Physicians' attitudes to the pharmacological treatment of patients with stable angina pectoris.

BACKGROUND: Little is known about how physicians' knowledge of and attitudes to practice guidelines for stable angina may influence their implementation. AIM: To explore the association between physicians' demographics, their knowledge, and opinions about stable angina and their self-reported adherence to guideline recommendations. DESIGN: Questionnaire-based survey. METHODS: We surveyed 1228 Quebec physicians using a questionnaire based on the 'awareness-to-adherence' conceptual framework to measure their adherence with recommendations for the pharmacological treatment of stable angina. Independent predictors of adherence with the targeted recommendations were determined by stepwise linear regression analysis. RESULTS: We received 877 (71.4%) responses from the 1228 eligible physicians. More than 90% of respondents were aware of and agreed with the targeted recommendations. However, the adoption rate varied, even among physicians who generally agreed with the guidelines. Factor analysis indicated that most physicians agreed with recommendations concerning ASA. More negative attitudes were expressed toward beta-blockers and hypolipaemic drugs. Respondents trusted the recommendations of a variety of scientific and professional organizations. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations. Physician demographics and practice characteristics did not predict adherence. DISCUSSION: Physicians were aware of and agreed with the recommendations, so additional large-scale dissemination of the guidelines would be unlikely to improve prescription patterns. However, negative attitudes about beta-blockers and hypolipaemic therapy affected adherence to recommendations for these drugs. Continuing medical education interventions involving local opinion leaders might address some of the obstacles identified.

Adrenergic beta-Antagonists↗

PubMed2006

Developing an in-house resource for clinical social work services in the dialysis setting: a pilot program.

In 2005, the Renal Care Group's social work department in Arizona launched a pilot program to show the viability of an in-house resource for clinical social work services to address depression and treatment adherence among hemodialysis patients. Sixty-three participants were divided into an intervention group that was counseled by a licensed clinical social worker over a span of 3 months and a comparison group that received no additional services. Quantitative data were collected by using the Center for Epidemiological Studies-Depression scale, the short form of the Kidney Disease Quality of Life survey, and attendance records. Qualitative data were collected as narrative descriptions of patients' reasons for missing treatment time, their readiness for change, and the benefits they observed with improved adherence. Although no significant differences in outcomes were found between the intervention and comparison groups, women and patients with catheters were significantly more depressed than men and patients with fistulas. The qualitative data indicated that loss of confidence in the healthcare team undermined adherence even though patients described the potential benefits of dialysis in terms of increased energy, emotional well-being, and the ability to resume familiar activities. The findings supported the feasibility of establishing a clinical role within the social work department that would be dedicated to clinical social work practice in the dialysis setting.

Adult↗

PubMed2006

Quality assessment of sedation in intensive care.

BACKGROUND: In the intensive care unit (ICU), analgesia and sedation are used to improve the comfort and safety of patients undergoing intensive care therapies. However, continuous administration of sedatives prolongs the time on mechanical ventilation and ICU stay. These adverse effects can be reduced by clear definition of the goals of sedation combined with a sedation protocol. METHODS: The adherence to the local sedation guideline of a university affiliated ICU was monitored prospectively before and after intervention: reinforcement of the guideline. The primary endpoints of the study were the occurrence of daily interruption or tapering of sedation and achievement of the target Ramsay scale level (days: 2-3, nights: 3-4) according to the guideline. RESULTS: Comparing sedation before and after the intervention (166 and 170 ICU days), no significant differences were observed in the occurrence of daily interruption or tapering of sedatives, 94/129 (73%) vs. 109/139 (78%) of sedation days, nor in the Ramsay scale level during the day, 4 (3-5) vs. 4 (3-5), or in the night, 5 (4-5) vs. 5 (4-5), respectively. After the intervention, Ramsay scale recordings were made more frequently, 280/398 (70%) vs. 234/380 (62%) of the nurses' shifts (P < 0.01). CONCLUSION: Adherence to the local sedation guideline was not high, and no significant change was seen after this simple intervention. Continuous education and discussion on the desirable and undesirable effects of sedation, followed by multidisciplinary re-evaluation of the current guideline, are due in our unit.

Aged↗

PubMed2005

Medication non-adherence in the adolescent renal transplant recipient: a clinician's viewpoint.

Recent advancements in immunosuppression and surgical techniques have significantly improved the outcome of kidney transplantation in the pediatric population. Adolescents enjoy the best 1-year graft survival of any age group. However, the long-term transplant outcome in adolescents is disappointing. Non-adherence with immunosuppressive medications is one of the most important contributing factors for graft rejection and loss in teenagers. The impact of non-adherence is perceived to be far more powerful in adolescent transplant recipients than in the transplant population as a whole. To better understand adolescent non-adherence, the process of transplantation must be placed in the context of adolescent development. Adolescents try to establish their identity and autonomy separately from the parents; however at the same time, adolescents with chronic illness require help, support and guidance from adults, including parents and medical personnel. Adolescents have limited ability to anticipate abstractly the long-term consequences of their immediate actions. This inconsistency can create frustration in both adolescents and in the supporting systems around them. Despite the significant consequences of adolescent non-adherence, research in this area is scarce. There are still no established definitions, standardized diagnostic methods and effective interventions to treat and prevent this problem. We propose the recommendations to approach the problems of adolescent transplant non-adherence from the transplant clinician's viewpoint. With early identification and appropriate interventions, significant improvement in adolescent graft survival is possible.

Adolescent↗

PubMed2002

Psychological factors in end-stage renal disease: an emerging context for behavioral medicine research.

End-stage renal disease (ESRD) is a chronic, life-threatening condition afflicting over 300,000 Americans. Patient nonadherence and psychological distress are highly prevalent among ESRD patients, and both have been found to contribute to greater morbidity and earlier mortality in this population. A range of factors have been examined as potential determinants of adherence and adjustment. Evidence suggests that adherence and adjustment are maximized when a patient's preferred style of coping is consistent with the contextual features or demands of the renal intervention the patient is undergoing. Challenges for future clinical research include refining methodologies for the assessment of depression and adherence, more clearly evaluating the efficacy of psychological interventions, and clarifying the role that depression and social support play in influencing patient mortality.

Adaptation, Psychological↗

PubMed2000

Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes?

PURPOSE: We sought to evaluate the effect of automated telephone assessment and self-care education calls with nurse follow-up on the management of diabetes. SUBJECTS AND METHODS: We enrolled 280 English- or Spanish-speaking adults with diabetes who were using hypoglycemic medications and who were treated in a county health care system. Patients were randomly assigned to usual care or to receive an intervention that consisted of usual care plus bi-weekly automated assessment and self-care education calls with telephone follow-up by a nurse educator. Outcomes measured at 12 months included survey-reported self-care, perceived glycemic control, and symptoms, as well as glycosylated hemoglobin (Hb A1c) and serum glucose levels. RESULTS: We collected follow-up data for 89% of enrollees (248 patients). Compared with usual care patients, intervention patients reported more frequent glucose monitoring, foot inspection, and weight monitoring, and fewer problems with medication adherence (all P -0.03). Follow-up Hb A,, levels were 0.3% lower in the intervention group (P = 0.1), and about twice as many intervention patients had Hb A1c levels within the normal range (P = 0.04). Serum glucose levels were 41 mg/dL lower among intervention patients than usual care patients (P = 0.002). Intervention patients also reported better glycemic control (P = 0.005) and fewer diabetic symptoms (P <0.0001 ), including fewer symptoms of hyperglycemia and hypoglycemia. CONCLUSIONS: Automated calls with telephone nurse follow-up may be an effective strategy for improving self-care behavior and glycemic control, and for decreasing symptoms among vulnerable patients with diabetes.

Adult↗

PubMed1984

Survival following aggressive treatment of secondary aortocolonic fistula.

Secondary aortocolonic fistula is an uncommon complication of prosthetic aortic grafts; apparently there have been only two previously described long-term survivors. We describe a long-term survivor with this complication in which preoperative computed tomographic scanning and percutaneous abscess drainage allowed early diagnosis and intervention and contributed to optimal treatment and survival. Adherence to time-honored principles of abscess drainage and graft removal, followed by extra-anatomic bypass when indicated, are essential to successful treatment.

Abscess↗