Cynthia L. Russell

Interventions to Improve Medication Adherence Among Older Adults: Meta-Analysis of Adherence Outcomes Among Randomized Controlled Trials

PURPOSE This study investigated the effectiveness of interventions to improve medication adherence (MA) in older adults. DESIGN AND METHODS Meta-analysis was used to synthesize results of 33 published and unpublished randomized controlled trials. Random-effects models were used to estimate overall mean effect sizes (ESs) for MA, knowledge, health outcomes, and health services utilization. RESULTS Data were synthesized across 11,827 participants. Interventions significantly improved MA (ES = 0.33), knowledge (ES = 0.48), and diastolic blood pressure (ES = 0.19). Nonsignificant effects were found for systolic blood pressure (ES = 0.21), other health outcomes (ES = 0.04), and health services utilization (ES = 0.16). Moderator analyses showed larger adherence ESs for interventions employing special medication packaging, dose modification, participant monitoring of medication effects and side effects, succinct written instructions, and standardized (not tailored) interventions. Larger effects were found when a moderate proportion of participants were women, for participants taking 3-5 medications, and when pill count adherence was measured. IMPLICATIONS The findings document that interventions increase MA in older adults. The considerable heterogeneity in the magnitude of effects across studies and results of the moderator analyses demonstrate the need for additional empirical research to optimize interventions.

Interventions to improve medication-adherence after transplantation: a systematic review

Reports of interventions to improve adherence to medical regimens in solid organ transplant recipients are scarce. A systematic review identified 12 intervention studies. These studies focused on renal, heart, and liver transplant recipients. Five reports used randomized controlled trial (RCT) designs. Sample sizes varied between 18 and 110 subjects. The interventions are difficult to evaluate and categorize because of brief descriptions of intervention details. Of the 12 studies identified in this review, only five studies found a statistically significant improvement in at least one medication‐adherence outcome with the intervention. In general, most included a combination of patient‐focused cognitive/educational, counseling/behavioral, and psychologic/affective dimensions. Eight studies intervened at the healthcare provider, healthcare setting or healthcare system level, but showed a limited improvement in adherence. No single intervention proved to be superior at increasing medication‐adherence in organ transplantation, but a combination of interventions in a team approach for the chronic disease management of organ transplant patients may be effective in a long‐term perspective. In conclusion, finding the most effective combination of interventions to enhance adherence is vital. Utilizing an RCT design and adhering to the CONSORT guidelines can lead to higher quality studies and possibly more effective intervention studies to enhance medication‐adherence.

An Overview of the Integrative Research Review

The integrative literature review has many benefits to the scholarly reviewer, including evaluating the strength of the scientific evidence, identifying gaps in current research, identifying the need for future research, bridging between related areas of work, identifying central issues in an area, generating a research question, identifying a theoretical or conceptual framework, and exploring which research methods have been used successfully. The 5-stage integrative review process includes (1) problem formulation, (2) data collection or literature search, (3) evaluation of data, (4) data analysis, and (5) interpretation and presentation of results. Maintaining scientific integrity while conducting an integrative research review involves careful consideration to threats to validity. Strategies to overcome these threats are reviewed. The integrative review methodology must involve detailed and thoughtful work, the outcome of which can be a significant contribution to a particular body of knowledge and, consequently, to practice and research.

Non-adherence in patients on chronic hemodialysis: an international comparison study

BACKGROUND Adherence to diet and fluid restrictions by adults on hemodialysis treatment is challenging. This study compared non-adherence (NA) to diet and fluid restrictions between adult US and German hemodialysis patients, and assessed potential predictors for NA. METHODS A cross-sectional multicenter comparative study of 456 adult hemodialysis patients was conducted in 12 outpatient-based hemodialysis centers in the United States and Germany. NA was based on self-report using the Dialysis Diet and Fluid Non-adherence Questionnaire (DDFQ). Laboratory marker, interdialytic weight gain (IDWG) and dialysis adequacy (Kt/V) information were obtained from medical records. Mean time on dialysis was 50 months (range 3-336); mean age was 62 years (range 19-91), with the majority of patients (89.7%) being white. RESULTS Self-reported frequency of NA to diet was 80.4% and to fluid 75.3% in the total sample. The degree of NA to diet and fluid differed significantly, with the US patients (68.1% vs. 61.1%) reporting less NA when compared with German (81.6% vs. 79.0%) patients (p<0.0001). Phosphorus, albumin, IDWG and Kt/V levels were higher in the US compared with the German subsample (all p<0.0001; IDWG p<0.003). Generalized regression models revealed that education (p<0.01) and smoking (p<0.01) predicted NA to diet, whereas single marital status (p<0.008) and male sex (p<0.04) were independent predictors for NA to fluid. CONCLUSIONS NA persists as one of the most challenging tasks in health care of patients with chronic conditions, including hemodialysis patients. Our findings suggest that patient, condition-related, socioeconomic and health care system-related factors may contribute to NA to diet and fluid restrictions.

Interventions to improve hemodialysis adherence: a systematic review of randomized-controlled trials.

Over 485,000 people in the United States have chronic kidney disease, a progressive kidney disease that may lead to hemodialysis. Hemodialysis involves a complex regimen of treatment, medication, fluid, and diet management. In 2005, over 312,000 patients were undergoing hemodialysis in the United States. Dialysis nonadherence rates range from 8.5% to 86%. Dialysis therapy treatment nonadherence, including treatment, medication, fluid, and diet nonadherence, significantly increases the risk of morbidity and mortality. The purpose of this paper is to systematically review randomized‐controlled trial intervention studies designed to increase treatment, medication, fluid, and diet adherence in adult hemodialysis patients. A search of Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982 to May 2008), MEDLINE (1950 to May 2008), PsycINFO (1806 to May 2008), and all Evidence‐Based Medicine (EBM) Reviews (Cochran DSR, ACP Journal Club, DARE, and CCTR) was conducted to identify randomized‐controlled studies that tested the efficacy of interventions to improve adherence in adult hemodialysis patients. Eight randomized‐controlled trials met criteria for inclusion. Six of the 8 studies found statistically significant improvement in adherence with the intervention. Of these 6 intervention studies, all studies had a cognitive component, with 3 studies utilizing cognitive/behavioral intervention strategies. Based on this systematic review, interventions utilizing a cognitive or cognitive/behavioral component appear to show the most promise for future study.

Searching for the Intervention in Intervention Research Reports

PURPOSE Precisely described interventions in nursing research reports are essential as a foundation for nursing practice and to facilitate future research. The purpose of this project was to characterize the intervention descriptions in nursing intervention research reports. DESIGN AND METHODS Quantitative content analysis was used to analyze intervention descriptions in reports published in English-language general nursing journals during 2005. Normative analysis was used to examine reports for details related to intervention content and delivery. Physical unit analysis was used to compare relative amounts of article space devoted to intervention description vs. other methodological details. FINDINGS Results were tabulated for 141 research articles published in 27 journals. Analysis indicated incomplete reporting of intervention details in many articles. Dose and dosing frequency were rarely completely defined. Delivery setting and interventionist were frequently not indicated, and the professional credentials of nurse interventionists were often unclear. While descriptions of interventions involving substances or devices were typically detailed, the specifics of psychological, educational, behavioral, and systems-level interventions were often lacking. Intervention descriptions averaged 7.27% of total article space, whereas nonintervention methodological descriptions averaged 20.74% of space. Of studies examined, only 38 (27.0%) reported enough detail to potentially replicate the study or translate the intervention into practice. CONCLUSIONS Intervention descriptions in general nursing journals lack sufficient detail to provide the evidence basis for practice.

Medication-taking beliefs of adult renal transplant recipients.

PURPOSE To describe the medication-taking beliefs of younger and older adult renal transplant recipients. METHOD A descriptive design was used to study 16 adult renal transplant recipients, 8 older and 8 younger, recruited from a renal transplant program in the midwest. A semistructured interview was conducted based on the theory of planned behavior. Data were examined using manifest content analyses. RESULTS Both groups had similar behavioral, normative, control, and problem-solving medication-taking beliefs. Planning ahead, organizing, using cues, involving a support person, and remembering the donor and life on dialysis were key control beliefs. Differences were found in beliefs regarding difficulties with taking immunosuppressive medications. The majority in both groups mentioned forgetting to take their immunosuppressive medications on at least one occasion. CONCLUSIONS/APPLICATION As empiric evidence in this area grows, the clinical nurse specialist is paramount in assisting both younger and older renal transplant recipients with immunosuppressive medication taking and, consequently, in fostering better outcomes.

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients.

Russell C, Conn V, Ashbaugh C, Madsen R, Wakefield M, Webb A, Coffey D, Peace L. Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients. 
Clin Transplant 2011: 25: 864–870.

Medication Adherence in Older Renal Transplant Recipients

This project examined patterns, predictors, and outcomes of medication adherence in a convenience sample of 37 renal transplant recipients aged 55 years or older in a Mid-Southern U.S. facility using an exploratory, descriptive, longitudinal design. Electronic monitoring was conducted for 12 months using the Medication Event Monitoring System. An alarming 86% of the participants were nonadherent with medications. Four clusters of medication taking and timing patterns were identified with evening doses presenting particular challenges. Depression, self-efficacy, social support, and medication side effects did not predict medication adherence. There was no significant difference in medication adherence scores between those with and without infections. Medication adherence pattern data from electronic monitoring provides an opportunity for health care professionals to move away from blaming the patient by attempting to identify predictors for medication nonadherence. Medication dose taking and timing patterns could be explored with patients so that medication adherence interventions could target specific patient patterns.

Medication adherence in successful kidney transplant recipients

OBJECTIVE To explore the medication-taking behavior of successful kidney transplant recipients and determine what behaviors were common among this group. METHODS Open-ended interviews were conducted by telephone with 19 individuals who had successfully maintained a transplanted kidney for 25 years or more. Data were coded by using a grounded theory approach to explore patterns of phenomena, common descriptions, and relationships. RESULTS Four themes emerged as participants described the behaviors they developed to adhere successfully to the immunosuppressive medication required for maintaining their transplanted kidneys. The themes were reminder methods, obtaining medications, maintaining routines, and problem-solving strategies. Kidney transplant recipients identified the importance of developing and maintaining medication-taking skills and routines on medication adherence. Problem-solving abilities were also valuable during times of disruption of normal routines. CONCLUSIONS Interventions focusing on medication-taking skills, habit formation, and resources for problem solving may improve immunosuppressive medication adherence and clinical outcomes in kidney transplant recipients.