Elizabeth J. Unni

Unintentional non-adherence and belief in medicines in older adults

OBJECTIVE To determine whether beliefs in medicines are associated with forgetfulness and carelessness in taking medications. METHODS Using a survey research design, baseline data (N=1220) and follow-up data (N=1024) were collected through an Internet survey using a convenience sample from Medicare enrollees aged 65 and older and who were Internet users. Logistic regression models were used to determine if patients beliefs about the necessity of taking prescribed medications and their concern beliefs regarding the potential consequences of taking medications were significant in predicting forgetfulness and carelessness in taking medications. RESULTS Concern beliefs in medicines were a significant predictor of forgetfulness and carelessness in taking medications. CONCLUSION If all cases of forgetfulness and carelessness in taking medications are considered as unintentional non-adherence with no reference to the patients beliefs in medicines; using cue based interventions such as phone reminders or alarms are not likely to reduce non-adherence. There was a strong association between patient belief in medications and non-adherence in older adults who were Medicare enrollees. PRACTICAL IMPLICATIONS It is important that researchers consider the influence that patient medication beliefs have on patient adherence to develop better interventions to reduce non-adherence.

Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: A theoretical approach

OBJECTIVE To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach. METHODS Study design was online cross sectional survey. A conceptual framework was developed using Andersens Behavioral Model and Leventhals Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence. RESULTS The models based on Andersens Behavioral Model and Leventhals Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications. CONCLUSION Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence. PRACTICE IMPLICATIONS Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.

Development of a new scale to measure self-reported medication nonadherence.

BACKGROUND A major drawback in the medication adherence literature today is the absence of a gold standard for measuring medication adherence. Objective measures of nonadherence such as prescription claims and pill count, while quantifying nonadherence, do not provide the reasons for nonadherence, hence making it difficult to develop intervention strategies. Self-reported measures are helpful to determine reasons for nonadherence; however, widely used self-reported measures such as the Morisky scale are restricted to only few potential reasons. OBJECTIVES The objective of this study was to develop a new scale to measure self-reported nonadherence and to compare it with the existing Morisky scale. METHODS A cross-sectional study of adult U.S. population on cholesterol-lowering and asthma maintenance medications was used. Data on nonadherence were collected using (1) the newly developed Medication Adherence Reasons Scale (MARS), (2) Morisky scale, and (3) an objective self-reported measure. RESULTS A total of 840 responses were collected. Factor analysis of MARS resulted in 5 subscales in cholesterol-lowering medications and 3 subscales in asthma maintenance medications. The level of agreement between both scales in identifying adherents and nonadherents as measured by kappa coefficient was 0.381 in cholesterol-lowering medications and 0.545 in asthma medications. MARS was able to identify various other significant reasons for nonadherence than that identified by the Morisky scale. CONCLUSION A new subjective measure of medication nonadherence based on the frequently reported reasons of nonadherence was developed, and it showed adequate reliability when compared with the Morisky scale to warrant future study.

Clustering medication adherence behavior based on beliefs in medicines and illness perceptions in patients taking asthma maintenance medications

Abstract Objectives: The prevalence of medication non-adherence is 50% in chronic disease conditions and varies from 30% to 70% in asthma maintenance medications. A major drawback in addressing medication non-adherence is the short time available for patient consultations, which limits the ability of the clinician in identifying the problem. Thus, this study explores how medication adherence behavior can be clustered and identifies the unique characteristics of each cluster so that clinicians can recognize the cluster characteristics in patients to provide targeted interventions. The study objectives were to: (1) cluster patients’ medication adherence behavior with asthma maintenance medications based on their beliefs in medicines and illness perceptions, and (2) describe the characteristics of the patients in each cluster based on psychosocial, clinical, and demographic characteristics. Research design and methods: A cross-sectional online survey design on a convenience sample of adult individuals who were taking asthma maintenance medications. Main outcome measures: Self-reported medication adherence using Morisky scale, beliefs in medicines using Beliefs in Medicines Questionnaire, and illness perceptions using the Brief Illness Perceptions Questionnaire. Results: The cluster analysis with 392 subjects resulted in five clusters based on patients’ beliefs in medicines and their illness perceptions. The clusters formed had distinct characteristics that lend themselves to monitoring or for which targeted interventions can be framed to improve medication adherence. Limitations: The study only examined asthma maintenance medications limiting the generalizability of the study. Also, all the data collected including medication adherence were self-reported data from an online panel. This can cause selection bias and lack of generalizability. Conclusions: The study demonstrated how the concept of ‘non-adherence’ is different for different patients and the need for tailored interventions for each type of non-adherence. With the limited consultation time available for clinicians to communicate with the patients, identifying the characteristics of patients in different clusters can assist clinicians in providing appropriate targeted interventions.

Revision and validation of Medication Adherence Reasons Scale (MAR-Scale)

Abstract Background: Medication non-adherence is a complex phenomenon that requires tailored interventions to improve it. A new self-reported measure of medication non-adherence was previously reported based on the commonly reported reasons underlying non-adherence with the intention to match the items in the scale with tailored interventions. Objective: The objectives were to revise the original Medication Adherence Reasons Scale (MAR-Scale) based on expert opinion and cognitive interviewing, and establish the psychometric properties of the revised scale. Methods: A cross-sectional design was used in cholesterol lowering and asthma maintenance medications in collaboration with an integrated medical center in the Mountain West. In the first phase, the original MAR-Scale was revised based on expert opinion and cognitive interviewing. In the second phase, the revised MAR-Scale was tested for psychometric properties in a random sample of 350 subjects on each medication. Results: Revisions based on expert opinion included asking a global question about adherence in the past 7 days, simplifying the items and converting them into first person sentences, objective anchoring of the scale, and expanding the ‘forgetfulness’ item. Cognitive interviewing added one additional item to the survey. The revised MAR- Scale identified 50% of the cholesterol lowering respondents and 68% of the asthma maintenance respondents as non-adherents. An exploratory factor analysis identified four domains in the scale, with Cronbach’s alpha ranging from 0.848–0.953 in cholesterol lowering and 0.827–0.891 in asthma maintenance medications. The scale also exhibited significant correlations with few other self-reported measures, consistent with hypotheses. A key limitation of the study was the moderate response rate to the survey for both medications. Conclusion: The revised MAR-Scale demonstrates better psychometric properties than the original.

Change in Medication Adherence and Beliefs in Medicines Over Time in Older Adults

Objective: The temporal component of medication adherence is important while designing interventions to improve medication adherence. Thus, the objective of this study was to determine how medication adherence and beliefs in medicines change over time in older adults. Methods: A two-year longitudinal internet-based survey among adults 65+ years was used to collect data on medication adherence (Morisky 4-item scale) and beliefs in medicines (Beliefs about Medicines Questionnaire). Paired t-test and one-way ANOVA determined if a change in beliefs in medicines and medication adherence over time was significant. A multiple linear regression was used to determine the significant predictors of change in medication adherence over time. Results: 436 respondents answered both baseline and follow-up surveys. Among all respondents, there was no significant change in adherence (0.58 ± 0.84 vs. 0.59 ± 0.84; p > 0.05), necessity beliefs (17.13 ± 4.31 vs. 17.10 ± 4.29; p > 0.05), or concern beliefs (11.70 ± 3.73 vs. 11.68 ± 3.77; p > 0.05) over time. For older adults with lower baseline adherence, there was a statistically significant improvement in adherence (1.45 ± 0.70 vs. 0.99 ± 0.97; p < 0.05); but no change in beliefs in medicines over time. The significant predictors of change in medication adherence over time were baseline adherence and baseline concern beliefs in medicines. Conclusion: With baseline adherence and baseline concern beliefs in medicines playing a significant role in determining change in adherence behavior over time, especially in individuals with lower adherence, it is important to alleviate medication concerns at the beginning of therapy for better adherence.

An Integrated Course in Pain Management and Palliative Care Bridging the Basic Sciences and Pharmacy Practice

Objective. To describe the development of an integrated pain and palliative care course and to investigate the long-term effectiveness of the course during doctor of pharmacy (PharmD) students’ advanced pharmacy practice experiences (APPEs) and in their practice after graduation. Design. Roseman University College of Pharmacy faculty developed a 3-week elective course in pain and palliative care by integrating relevant clinical and pharmaceutical sciences. Instructional strategies included lectures, team and individual activities, case studies, and student presentations. Assessment. Students who participated in the course in 2010 and 2011 were surveyed anonymously to gain their perception about the class as well as the utility of the course during their APPEs and in their everyday practice. Traditional and nontraditional assessment of students confirmed that the learning outcomes objectives were achieved. Conclusions. Students taking the integrated course on pain management and palliative care achieved mastery of the learning outcome objectives. Surveys of students and practicing pharmacists who completed the course showed that the learning experience as well as retention was improved with the integrated mode of teaching. Integrating basic and clinical sciences in therapeutic courses is an effective learning strategy.

Publication Rates of Social and Administrative Sciences Pharmacy Faculty in Non-Research Intensive Pharmacy Schools

Objective. To assess the level of publication rates from 2011 through 2015 by Social and Administrative Sciences (SAS) faculty at non-research intensive pharmacy schools. Methods. The Web of Science database was searched using faculty names identified from the American Association of Colleges of Pharmacy (AACP) faculty and professional staff roster. Publication rates of SAS faculty were calculated and compared using several demographic subcategories such as public/private school, part of an academic health center, schools with PhD program, funding status, etc. Results. The 208 SAS faculty members from 59 colleges contributed to 478 publications with a mean of 95.6 publications per year and 1.62 publications per institution per year. The number of publications increased 45% over the five years from 67 publications in 2011 to 122 in 2015.The average number of publications was 0.92 per year per SAS faculty compared to 0.82 publications per year per faculty from other basic pharmaceutical sciences divisions. The most commonly published research was research articles in the area of scholarship of teaching and learning. The significant predictors of publications were being part of an academic health center, having a PhD program, and higher percent of faculty members who are SAS faculty. Conclusion. Despite being affiliated with institutions with missions less targeted on research, this study showed SAS faculty members at non-research intensive institutions consistently contribute to published literature. Further studies are needed to examine reasons for the lack of publishing by almost half of the SAS faculty and ways to increase research and publication in the field of SAS.

Prevalence of insulin glargine vial use beyond 28 days in a Medicaid population

OBJECTIVES Insulin glargine, one of the most commonly prescribed drugs for diabetes, has a 28-day limit on the use of a 10-mL (1000 units) multiple-dose vial once the bottle is punctured. If patients who are using smaller doses or are not adherent continue to use insulin glargine beyond the 28-day window, it can result in questionable stability and sterility of the product. The aim of this study was to determine the proportion of patients who used each insulin glargine vial for more than 28 days, the mean number of days the vial was used after 28 days, the reason for the extended use, and whether that use had any association with diabetes control and injection site infection. METHODS The study was conducted in 2 phases. Phase I was a retrospective database analysis of insulin glargine 10-mL vial use by the adult Medicaid population with type 2 diabetes served by Molina Healthcare to determine the proportion of patients who used each vial beyond 28 days. Phase II was a cross-sectional telephone interview to identify the reasons for the extended use. RESULTS Of the 269 patients identified, 81% used it for more than 28 days, with a mean of 43 days. Of the interviewed patients, 60% did not discard the vials after 28 days because of a lack of awareness. Patients who were aware of the 28-day limit were informed by a pharmacist or diabetes educator. CONCLUSION A large proportion of Medicaid patients were found to use insulin glargine past the recommended 28-day limit. More work is needed with a larger sample size to determine whether reasons besides lack of awareness affect the use of insulin glargine beyond its expiration and the role of pharmacists and diabetes educators in improving adherence to disposing of the drug after 28 days.

Community pharmacist-led clinical services: physician's understanding, perceptions and readiness to collaborate in a Midwestern state in the United States

Many pharmacists are actively enhancing their role in the delivery of health care by offering a variety of pharmacist‐led clinical services. The delivery of these services within community pharmacies can contribute to overcoming the cost and accessibility challenges currently facing U.S. health care, especially when pharmacist–physician collaborative efforts are utilized. The study purpose was to identify general and family practice physicians’ awareness of pharmacists’ delivery of clinical services, uncover their perceived barriers to collaboration with community pharmacists, and collect their input on how to overcome such barriers in order to better understand how pharmacist‐led clinical services can be integrated, improved and more widely utilized as a healthcare delivery mechanism.