Effect of an in-hospital medication self-management intervention (SelfMED) on medication adherence in polypharmacy patients postdischarge: protocol of a pre-post intervention study.

INTRODUCTION: Healthcare providers usually manage medication for patients during hospitalisation, although patients are expected to self-manage their medication after discharge. A lack of self-management competencies is found to be associated with low adherence levels and medication errors harming patients' health. Currently, patients seldom receive support or education in medication self-management. When self-management is allowed during hospitalisation, it is rarely provided using a structured, evidence-based format. Therefore, an in-hospital medication self-management intervention (ie, SelfMED) was developed based on current evidence. To date, empirical data demonstrating the effect of SelfMED on medication adherence are lacking. This study primarily aims to evaluate the effect of the SelfMED intervention on medication adherence 2 months postdischarge in polypharmacy patients, as compared with usual care. METHODS AND ANALYSIS: A multicentre pre-post intervention study will be conducted. The study will start with a control phase investigating usual care (ie, medication management entirely provided by healthcare providers), followed by an intervention period, investigating the effects of the SelfMED intervention. SelfMED consists of multiple components: (1) a stepped assessment evaluating patients' eligibility for in-hospital medication self-management, (2) a monitoring system allowing healthcare providers to follow up medication management and detect problems and (3) a supportive tool providing healthcare providers with a resource to act on observed problems with medication self-management. Polymedicated patients recruited during the control and intervention periods will be monitored for 2 months postdischarge. A total of 225 participants with polypharmacy should be included in each group. Medication adherence 2 months postdischarge, measured by pill counts, will be the primary outcome. Secondary outcomes include self-management, medication knowledge, patient and staff satisfaction, perceived workload and healthcare service utilisation. ETHICS AND DISSEMINATION: The ethics committee of the Antwerp University Hospital approved the study (reference no: B3002023000176). Study findings will be disseminated through peer-reviewed publications, conference presentations and summaries in layman's terms. TRIAL REGISTRATION NUMBER: ISRCTN15132085.

Evaluation of methods measuring medication adherence in patients with polypharmacy: a longitudinal and patient perspective.

PURPOSE: To explore patients' willingness to have medication adherence measured using different methods and evaluate the feasibility and validity of their combination (i.e., pill counts, a medication diary and a questionnaire assessing adherence two months post-discharge). METHODS: (1) A cross-sectional evaluation of the willingness of patients with polypharmacy to have their medication adherence measured post-discharge. (2) Medication adherence was monitored during two months using pill counts based on preserved medication packages and a diary in which patients registered their adherence-related problems. During a home visit, the Probabilistic Medication Adherence Scale (ProMAS) and a questionnaire on feasibility were administered. RESULTS: A total of 144 participants completed the questionnaire at discharge. The majority was willing to communicate truthfully about their adherence (97%) and to share adherence-related information with healthcare providers (99%). More participants were willing to preserve medication packages (76%) than to complete a medication diary (67%) during two months. Most participants reported that preserving medication packages (91%), completing the diary (99%) and the ProMAS (99%) were no effort to them. According to the majority of participants (60%), pill counts most accurately reflected medication adherence, followed by the diary (39%) and ProMAS (1%). Medication adherence measured by pill counts correlated significantly with ProMAS scores, but not with the number of diary-reported problems. However, adherence measured by the medication diary and ProMAS correlated significantly. CONCLUSION: Combining tools for measuring adherence seems feasible and can provide insight into the accordance of patients' actual medication use with their prescribed regimen, but also into problems contributing to non-adherence.

The development and evaluation of a medication diary to report problems with medication use.

Purpose: The study aimed to develop and evaluate a medication diary for patients to report problems with medication use to enable shared-decision making and improve medication adherence. Methods: Based on a search for existing diaries, a review of the content, and a list of medication self-management problems compiled from previous research, a paper and pencil version of a medication diary was developed. The diary was reviewed for clarity and overall presentation by five healthcare providers and nine patients. Afterwards, user-friendliness was evaluated by 69 patients with polypharmacy discharged from hospital during a quantitative prospective study. Results: The medication diary consists of several parts: (1) a medication schedule allowing patients to list their medicines, (2) information sheets allowing patients to write down specific medication-related information, (3) a monthly overview to indicate daily whether medication-related problems were experienced, (4) problem sheets elaborating on the problems encountered, (5) space for specific medication-related questions for healthcare providers to facilitate shared-decision making. The review phase resulted in minor textual adjustments and one extra problem in the problem sheet. Most participants, who tested the medication diary for two months, found the diary user-friendly (80%) and easy to fill in (89%). About 40% of participants reported problems with medication use. Half of the patients indicated that the diary can facilitate discussing problems with healthcare providers. Conclusion: The medication diary offers patients the opportunity to report problems regarding their medication use in a proven user-friendly manner and to discuss these problems with healthcare providers. Reporting and discussing problems with medication use can serve as a first step towards making shared decisions on how to address the problems encountered.

Prevalence, risk factors and diagnostic accuracy of non-invasive tests for NAFLD in people with type 1 diabetes.

Background & Aims: The epidemiology of non-alcoholic fatty liver disease (NAFLD) in people with type 1 diabetes (T1D) is not yet elucidated. This study aimed to assess the diagnostic accuracy of non-invasive tests for NAFLD, to investigate the prevalence and severity of NAFLD, and to search for factors contributing to NAFLD in people with T1D. Methods: In this prospective cohort study, we consecutively screened 530 adults with T1D from a tertiary care hospital, using ultrasound (US), vibration-controlled transient elastography equipped with liver stiffness measurement (LSM) and controlled attenuation parameter, and the fatty liver index. Magnetic resonance spectroscopy (MRS) was performed in a representative subgroup of 132 individuals to validate the diagnostic accuracy of the non-invasive tests. Results: Based on MRS as reference standard, US identified individuals with NAFLD with an AUROC of 0.98 (95% CI 0.95-1.00, sensitivity: 1.00, specificity: 0.96). The controlled attenuation parameter was also accurate with an AUROC of 0.85 (95% CI 0.77-0.93). Youden cut-off was ≥270 dB/m (sensitivity: 0.90, specificity: 0.74). The fatty liver index yielded a similar AUROC of 0.83 (95% CI 0.74-0.91), but the conventional cut-off used to rule in (≥60) had low sensitivity and specificity (0.62, 0.78). The prevalence of NAFLD in the overall cohort was 16.2% based on US. Metabolic syndrome was associated with NAFLD (OR: 2.35 [1.08-5.12], p = 0.031). The overall prevalence of LSM ≥8.0 kPa indicating significant fibrosis was 3.8%, but reached 13.2% in people with NAFLD. Conclusions: NAFLD prevalence in individuals with T1D is 16.2%, with approximately one in 10 featuring elevated LSM. US-based screening could be considered in people with T1D and metabolic syndrome. Impact and Implications: We aimed to report on the prevalence, disease severity, and risk factors of NAFLD in type 1 diabetes (T1D), while also tackling which non-invasive test for NAFLD is the most accurate. We found that ultrasound is the best test to diagnose NAFLD. NAFLD prevalence is 16.2%, and is associated with metabolic syndrome and BMI. Elevated liver stiffness indicating fibrosis is overall not prevalent in people with T1D (3.8%), but it reaches 13.2% in those with T1D and NAFLD.

The Development of Recommendations for Healthcare Providers to Support Patients Experiencing Medication Self-Management Problems.

Medication self-management problems such as the inability to correctly obtain, understand, organize, administer or monitor medication can result in negative patient outcomes. However, supportive tools for healthcare providers to assist patients with medication self-management problems are lacking. This study aimed to develop recommendations for healthcare providers to support patients with polypharmacy who experience medication self-management problems. A three-phase study was conducted starting with (1) the mapping of medication self-management problems, followed by (2) a scoping review providing a list of relevant interventions and actions for each respective problem and (3) a three-round modified e-Delphi study with experts to reach consensus on the relevance and clarity of the recommended interventions and actions. The cut-off for consensus on the relevance and clarity of the recommendations was set at 80% expert agreement. Experts could propose additional recommendations based on their professional experience and expertise. The experts (n = 23) involved were healthcare professionals (i.e., nurses, pharmacists, and physicians) with specific expertise in medication management of patients with polypharmacy. Simultaneous with the second e-Delphi round, a panel of patients with polypharmacy (n = 8) evaluated the usefulness of recommendations. Results obtained from the patient panel were fed back to the panel of healthcare providers in the third e-Delphi round. Descriptive statistics were used for data analysis. Twenty medication self-management problems were identified. Based on the scoping review, a list of 66 recommendations for healthcare providers to support patients with the identified medication self-management problems was composed. At the end of the three-round e-Delphi study, the expert panel reached consensus on the relevance and clarity of 67 recommendations, clustered according to the six phases of the medication self-management model by Bailey et al. In conclusion, this study resulted in a guidance document including recommendations that can serve as a resource for healthcare providers to support patients with polypharmacy in case of medication self-management problems. Future research should focus on the evaluation of the feasibility and user-friendliness of the guide with recommendations in clinical practice.

Shared decision making on medication use between nurses and patients in an oncology setting: A qualitative descriptive study.

PURPOSE: (i) To explore patients' and nurses' experiences with medication-related shared decision making (SDM) (i.e., familiarity with the concept, application of medication-related SDM, barriers and facilitators towards its application) and (ii) to explore their role perceptions, respectively. METHODS: A qualitative study was conducted in which seven interviews with oncological patients and a focus group interview with six nurses were performed. Prior to the interviews, observations of the application of shared decision making were conducted using the OPTION-12 scale. The observations were used exclusively to trigger the group discussion. Data were collected from November 2020 until March 2021. RESULTS: According to participants, the application of SDM regarding medication by nurses in oncology is limited. Barriers mentioned were health status, medication-related knowledge, the therapeutic nurse-patient relationship, time pressures and workload. Patients valued nurses' contribution to SDM regarding medication and perceived them as key persons because of their advocating, informative, facilitating and supportive role. Individual and contextual factors determined patients' desire for involvement in medication-related decisions. DISCUSSION: Participants solely concentrated on SDM concerning drug choice and management of therapeutic and adverse effects. The patients' and nurses' experiences and perceptions towards SDM in other domains of pharmaceutical care need further investigation.

People-centered care and patients' beliefs about medicines and adherence: A cross-sectional study.

Introduction: People-centered care (PCC) strategies are believed to improve overall health outcomes. Medicines use is essential for the treatment of many patients with chronic conditions. Non-adherence rates are high and result in poor health outcomes, and increased healthcare utilization and costs. This study aimed to explore the relationship between PCC and adherence to medicines for persons with chronic medicines use, as well as the extent to which patients' beliefs about medicines are influenced by their level of perceived PCC. Methods: A cross-sectional survey design was performed with adults using at least 3 chronic medicines per day. To measure the degree of medicines adherence, patients' ideas about medication, and PCC, four validated questionnaires were used: The Medication Adherence Report Scale (MARS-5), Beliefs about medicines questionnaire (BMQ), Client-Centered Care Questionnaire (CCCQ) and the Shared Decision Making Questionnaire (SDM-Q-9). Socio-demographics, health status, and drug-related burden were questioned as potential factors to impact the relationship between PCC and adherence. Results: A sample of 459 persons participated. The mean score on the CCCQ (adjusted to pharmacotherapy) was 52.7 on 75 (sd = 8.83, range [18-70]). The top 20% scored 60 or more, the 20% lowest scores were 46 or less. Adherence levels were high, with a mean score of 22.6 on 25 on the MARS-5, and 88% scoring 20 or more. An increase in PCC corresponded to a higher chance of medicines adherence (OR 1.07, 95%CI [1.02-1.12]), corrected for age, the burden due to chronic diseases, the impact of side effects on daily life, and participants' beliefs about medicines. PCC showed positive correlations with the necessity of medicines use (r = 0.1, p = 0.016) and the balance between necessity and concerns (r = 0.3, p < 0.001); and negative correlations with levels of concerns (r = -0.3, p < 0.001) and scores on harmfulness (r = -0.3, p < 0.001) and overuse of medicines (r = -0.4, p < 0.001). Conclusion: Patients with chronic medicine use perceived an average high level of people-centeredness in the pharmaceutical care they received. This PCC was weakly positively associated with adherence to their medicines. The higher PCC was evaluated, the more patients believed in the necessity of the medicines use and the better the balance between necessity and concerns. The people-centeredness of pharmaceutical care showed several shortcomings and can still be improved. As such, healthcare providers are advised to actively engage in PCC, and not to wait passively for information provided by the patient.

Self-Management of Medication on a Cardiology Ward: Feasibility and Safety of the SelfMED Intervention.

An intervention, SelfMED, was introduced to facilitate patient self-management of medication during hospitalization. This study aimed to evaluate the feasibility and safety of the SelfMED intervention. All patients in a cardiology ward in a Belgian regional hospital were assessed for suitability for inclusion, applying an evidence-based stepped assessment tool. Patients eligible for medication self-management and willing to participate were included in the study (i.e., consecutive sampling). Patients who self-managed their medication were closely monitored by nurses. The feasibility of medication self-management was evaluated by implementation and completion rates and the opinions of cardiologists. Safety was evaluated by medication administration errors and errors in patients' registration of intake. Of 159 patients assessed for eligibility to self-manage medication in-hospital, 61 were included. A total of 367 medicines were self-managed. Pill counts showed 3 administration errors (0.8%), and on 6 occasions (1.7%) the patient's registration of the intake was incorrect. SelfMED was deemed feasible within the hospital ward. In cardiologists' opinions, SelfMED requires substantial time investment. In summary, SelfMED facilitated patient medication self-management in-hospital. As an essential step in the preparation for a full trial, this study showed it is feasible and safe to implement the intervention and identified some possibilities for refinement.

Home care nurses' management of high-risk medications: a cross-sectional study.

BACKGROUND: High-risk medications use at home entails an increased risk of significant harm to the patient. While interventions and strategies to improve medications care have been implemented in hospitals, it remains unclear how this type of medications care is provided in the home care setting. The objective was to describe home care nurses' management of high-risk medications. METHODS: A cross-sectional, descriptive design was set up in home care nurses in Flanders, Belgium. Participants were recruited through convenience sampling and could be included in the study if they provided medications care and worked as a home care nurses. Participants completed an online structured questionnaire. Questions were asked about demographic information, work experience, nurses' general attitude regarding high-risk medications, contact with high-risk medications and the assessment of risk and severity of harm, specific initiatives undertaken to improve high-risk medications care and the use of additional measures when dealing with high-risk medications. Descriptive statistics were used. RESULTS: A total of 2283 home care nurses participated in this study. In our study, 98% of the nurses reported dealing high-risk medications. Home care nurses dealt the most with anticoagulants (96%), insulin (94%) and hypnotics and sedatives (87%). Most nurses took additional measures with high-risk medications in less than 25% of the cases, with the individual double check being the most performed measure for all high-risk medications except lithium. Nurses employed by an organization received support mostly in the form of a procedure while self-employed nurses mostly look for support through external organizations and information sources. CONCLUSIONS: The study shows several gaps regarding high-risk medications care, which can imply safety risks. Implementation and evaluation of more standardized high-risk medications care, developing and implementing procedures or guidelines and providing continuous training for home care nurses are advised.

Beliefs about medication after hospital discharge in geriatric patients with polypharmacy.

OBJECTIVES: To describe beliefs about medication in geriatric patients with polypharmacy post-discharge and to evaluate the impact of discharge management on patients' medication beliefs. METHODS: A cross-sectional study was conducted between November 2019 and March 2020 in twelve general hospitals in Belgium. Four hundred geriatric patients with polypharmacy were surveyed at hospital discharge and two to five days post-discharge using the Beliefs about Medicines Questionnaire and self-developed questionnaires. RESULTS: According to participants, the benefits of medication outweighed the disadvantages as the mean necessity score (19.4/25) outweighed the mean concern score (11.9/25). Patients receiving help with medication management post-discharge had stronger necessity-, concern- and overuse-related beliefs. No patient- or discharge management-related factors were significant predictors of medication beliefs. CONCLUSIONS: Assessing patients' medication beliefs and identifying and addressing patients' concerns, can be an opportunity to improve medication use, to prevent non-adherence and to enhance safe medication practices at home.

Nurses' responsibilities and tasks in pharmaceutical care: A scoping review.

AIM: To provide an overview of responsibilities and tasks of nurses in pharmaceutical care. DESIGN: Scoping review. METHODS: Two databases were systematically searched (MEDLINE and Scopus) for recent original research papers concerning nurses' responsibilities and tasks in pharmaceutical care. The definition of responsibility was based on literature, moral and ethical discussions. Existing responsibilities and tasks beyond preparation and administration of medication were collected and synthesized. This main study outcome was extracted from titles and abstracts only. Results were reported in accordance with PRISMA-ScR guidelines. RESULTS: Of the 3,805 titles and abstracts reviewed, 453 abstracts were included. A total of seven responsibilities were identified: (a) management of therapeutic and adverse effects of medication, (b) management of medication adherence, (c) management of patient medication self-management, (d) management of patient education and information about medication, (e) prescription management, (f) medication safety management and (g) (transition of) care coordination. Within these responsibilities, all tasks performed by nurses were described.

What Happens after Hospital Discharge? Deficiencies in Medication Management Encountered by Geriatric Patients with Polypharmacy.

This study aimed to describe post-discharge medication self-management by geriatric patients with polypharmacy, to describe the problems encountered and to determine the related factors. In a multicenter study from November 2019 to March 2020, data were collected at hospital discharge and two to five days post-discharge. Geriatric patients with polypharmacy were questioned about medication management using a combination of validated (MedMaIDE) and self-developed questionnaires. Of 400 participants, 70% did self-manage medication post-discharge. Patients had a mean of four different deficiencies in post-discharge medication management (SD 2.17, range 0-10). Knowledge-related deficiencies were most common. The number of medicines and the in-hospital provision of medication management by nurses were significant predictors of post-discharge medication management deficiencies. In addition to deficiencies in knowledge, medication-taking ability and obtaining medication, non-adherence and disrupted continuity of medication self-management were common in geriatric patients with polypharmacy post-discharge. Improvements in in-hospital preparation could avoid medication self-management problems at home.