Przemyslaw Kardas

Determinants of patient adherence: a review of systematic reviews.

Purpose: A number of potential determinants of medication non-adherence have been described so far. However, the heterogenic quality of existing publications poses the need for the use of a rigorous methodology in building a list of such determinants. The purpose of this study was a systematic review of current research on determinants of patient adherence on the basis of a recently agreed European consensus taxonomy and terminology. Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library, IPA, and PsycINFO were systematically searched for systematic reviews published between 2000/01/01 and 2009/12/31 that provided determinants on non-adherence to medication. The searches were limited to reviews having adherence to medication prescribed by health professionals for outpatient as a major topic. Results: Fifty-one reviews were included in this review, covering 19 different disease categories. In these reviews, exclusively assessing non-adherence to chronic therapies, 771 individual factor items were identified, of which most were determinants of implementation, and only 47—determinants of persistence with medication. Factors with an unambiguous effect on adherence were further grouped into 8 clusters of socio-economic-related factors, 6 of healthcare team- and system-related factors, 6 of condition-related factors, 6 of therapy-related factors, and 14 of patient-related factors. The lack of standardized definitions and use of poor measurement methods resulted in many inconsistencies. Conclusions: This study provides clear evidence that medication non-adherence is affected by multiple determinants. Therefore, the prediction of non-adherence of individual patients is difficult, and suitable measurement and multifaceted interventions may be the most effective answer toward unsatisfactory adherence. The limited number of publications assessing determinants of persistence with medication, and lack of those providing determinants of adherence to short-term treatment identify areas for future research.

Multivariate relationships between international normalized ratio and vitamin K-dependent coagulation-derived parameters in normal healthy donors and oral anticoagulant therapy patients

Background and objectivesInternational Normalized Ratio (INR) is a world-wide routinely used factor in the monitoring of oral anticoagulation treatment (OAT). However, it was reported that other factors, e. g. factor II, may even better reflect therapeutic efficacy of OAT and, therefore, may be potentialy useful for OAT monitoring. The primary purpose of this study was to characterize the associations of INR with other vitamin K-dependent plasma proteins in a heterogenous group of individuals, including healthy donors, patients on OAT and patients not receiving OAT. The study aimed also at establishing the influence of co-morbid conditions (incl. accompanying diseases) and co-medications (incl. different intensity of OAT) on INR.Design and MethodsTwo hundred and three subjects were involved in the study. Of these, 35 were normal healthy donors (group I), 73 were patients on medication different than OAT (group II) and 95 were patients on stable oral anticoagulant (acenocoumarol) therapy lasting for at least half a year prior to the study. The values of INR and activated partial thromboplastin time (APTT) ratio, as well as activities of FII, FVII, FX, protein C, and concentration of prothrombin F1+2 fragments and fibrinogen were obtained for all subjects. In statistical evaluation, the uni- and multivariate analyses were employed and the regression equations describing the obtained associations were estimated.ResultsOf the studied parameters, three (factors II, VII and X) appeared as very strong modulators of INR, protein C and prothrombin fragments F1+2 had moderate influence, whereas both APTT ratio and fibrinogen had no significant impact on INR variability. Due to collinearity and low tolerance of independent variables included in the multiple regression models, we routinely employed a ridge multiple regression model which compromises the minimal number of independent variables with the maximal overall determination coefficient. The best-fitted two-component model included FII and FVII activities and explained 90% of INR variability (compared to 93% in the 5-component model including all vitamin K-dependent proteins). Neither the presence of accompanying diseases nor the use of OAT nor any other medication (acetylsalicylic acid, statins, steroids, thyroxin) biased significantly these associations.ConclusionAmong various vitamin K-dependent plasma proteins, the coagulation factors II, VII and X showed the most significant associations with INR. Of these variables, the two-component model, including factors II and VII, deserves special attention, as it largely explains the overall variability observed in INR estimates. The statistical power of this model is validated on virtue of the estimation that the revealed associations are rather universal and remain essentially unbiased by other compounding variables, including clinical status and medical treatment. Further, much broader population studies are needed to verify clinical usefulness of methods alternate or compounding to INR monitoring of OAT.

Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments.

ABSTRACT Introduction: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, ‘Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY’, which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter’s eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

Family physicians' perception of plastic surgery and its influence on referral. A survey from Poland.

Abstract Background: Inadequate family physicians’ knowledge of plastic surgery might be a barrier for patients to benefit from plastic surgery treatments reimbursed by the Polish National Health Service (NHS). Objectives: The aim of this study was to assess family physicians’ awareness of the indications for plastic surgery, and their knowledge of conditions that are treated without extra costs for the patient in plastic surgery outpatient clinics (OCs). Methods: An e-mail survey was carried out in a group of 100 out of 378 randomly selected primary care doctors currently practicing in Lodz, central Poland. Respondents were asked to fill in a questionnaire, which contained questions about conditions with reimbursed treatments in plastic surgery OCs. We also provided them with a list of diseases and asked them to which OC they would refer a patient in such case. Results: 58 primary care physicians responded: 30 specialists in family medicine and 28 residents in the final year of their specialization in family medicine. Respondents had good knowledge of the range of conditions managed in plastic surgery OCs. They were also aware of most of the medical procedures not being reimbursed by the Polish NHS. However, some indications for plastic surgery as well as the free availability of relevant medical procedures were known by less than half of the respondents (e.g. lipoma 47%, gynaecomastia 28%, and xanthelasma palpebrarum 16%). Conclusion: To improve collaboration between plastic surgeons and family physicians basic information regarding plastic surgery might be included in residency programmes in family medicine.

An acupuncture needle remaining in a lung for 17 years: case study and review

The case of a 67-year-old patient with an acupuncture needle remaining in his left lung is described. This foreign body was a remnant of a procedure performed by a doctor 17 years previously for osteoarthritic back pain. On the basis of this case, a review was performed of literature available in the PubMed database dealing with acupuncture needles remaining in a patients body. A total of 25 articles were found. The articles describe needles found in the bladder, shoulder girdle, spinal cord, right ventricle, L5 nerve root, medulla oblongata, skin, carpal tunnel, nuchal and occipital area, calf and paraspinal muscle. Migration of needle fragments to the liver, pancreas, stomach, colon, breast, kidney, muscles, and spinal cord has been reported in the literature. In cases where patients were operated on, the needles were removed without subsequent complications and the patients recovered fully.

Reasons for elderly patient hospitalization in departments of internal medicine in Lodz

Background and aims: The number of hospitalizations of elderly patients in Poland has been increasing rapidly in recent years. For Lodz, with the oldest population among big cities in Poland, this is an especially important problem. In order to reduce the number of elderly patient hospitalizations, it is first necessary to know the main reasons for these hospitalizations. This study aimed to determine the reasons for elderly patient hospitalizations in Lodz. Methods: Data related to elderly patients (65 and over) admitted to departments of internal medicine in three district hospitals in Lodz were collected. The reasons for hospital admission, coded according to the International Classification of Diseases — 10th Revision, were used for the calculations. Results: Elderly persons accounted for 53.6% of patients hospitalized at the departments studied. The most frequent reasons for hospital admission of the elderly were cardiovascular diseases (CVD) (54.7%) and respiratory tract diseases (19.9%). The most frequent specific diagnoses for hospitalization were coronary heart disease (CHD) (15.7%), pneumonia (11.5%), stroke (8.5%), hypertension (7.2%), heart failure (5A%), non-insulin-dependent diabetes (5.3%) and insufficiency of cerebral arteries (5.3%). Hypertension was nearly twice as frequent a reason for hospital admission in women as in men. Conclusions: Elderly persons account for more than half of patients in departments of internal medicine in Lodz. The most frequent reason for hospital admission of the elderly is CVD, particularly CHD.

Processing Diabetes Mellitus Composite Events in MAGPIE

The focus of this research is in the definition of programmable expert Personal Health Systems (PHS) to monitor patients affected by chronic diseases using agent oriented programming and mobile computing to represent the interactions happening amongst the components of the system. The paper also discusses issues of knowledge representation within the medical domain when dealing with temporal patterns concerning the physiological values of the patient. In the presented agent based PHS the doctors can personalize for each patient monitoring rules that can be defined in a graphical way. Furthermore, to achieve better scalability, the computations for monitoring the patients are distributed among their devices rather than being performed in a centralized server. The system is evaluated using data of 21 diabetic patients to detect temporal patterns according to a set of monitoring rules defined. The system’s scalability is evaluated by comparing it with a centralized approach. The evaluation concerning the detection of temporal patterns highlights the system’s ability to monitor chronic patients affected by diabetes. Regarding the scalability, the results show the fact that an approach exploiting the use of mobile computing is more scalable than a centralized approach. Therefore, more likely to satisfy the needs of next generation PHSs. PHSs are becoming an adopted technology to deal with the surge of patients affected by chronic illnesses. This paper discusses architectural choices to make an agent based PHS more scalable by using a distributed mobile computing approach. It also discusses how to model the medical knowledge in the PHS in such a way that it is modifiable at run time. The evaluation highlights the necessity of distributing the reasoning to the mobile part of the system and that modifiable rules are able to deal with the change in lifestyle of the patients affected by chronic illnesses.

Factors affecting the opinions of family physicians regarding generic drugs – a questionnaire based study

A range of factors are believed to exert a negative influence on opinions of physicians about generic drugs.The aim of this study was to survey the opinions of primary care doctors on generics, and determine the factors which may affect them. A questionnaire comprising thirty eight questions was distributed among primary care doctors working in seventy out-patient clinics of the Lodzkie province, Poland, during the period of January 1, 2010 - December 31, 2010. A total of 170 of 183 participants completed the survey (average age 48.5; 70.0% women): a 92.9% response rate. While 38.8% of physicians claimed that generics were worse than brand name drugs, 54.1% considered them to be better. However, 36.5% of the doctors did not choose generics for their own use. Two key opinions were identified among the responses concerning the effectiveness of generic drugs: use of generic drugs by the physician (p<0.001), and their opinion that pharmacists do inform patients about generic drugs (p<0.05). Although existing evidence confirms that generic and brand name drugs are equally effective, many physicians doubt this, which prevents them from being used as cost effective drug therapy. In order to increase healthcare savings through the use of generics, these factors should be addressed: for example, convincing a physician to adopt generics for personal use may be an efficient way to support more cost effective treatment of his patients.

A multinational cross-sectional survey of the management of patient medication adherence by European healthcare professionals

Objectives To examine which interventions healthcare professionals use to support patients with taking medicines and their perceptions about the effectiveness of those actions. Design Cross-sectional multinational study. Setting Online survey in Austria, Belgium, England, France, Germany, Hungary, The Netherlands, Poland, Portugal and Switzerland. Participants A total of 3196 healthcare professionals comprising doctors (855), nurses (1047) and pharmacists (1294) currently registered and practising in primary care and community settings. Main outcome measures Primary outcome: Responses to the question ‘I ask patients if they have missed any doses of their medication’ for each profession and in each country. Secondary outcome: Responses to 50 items concerning healthcare professional behaviour to support patients with medication-taking for each profession and in each country. Results Approximately half of the healthcare professionals in the survey ask patients with long-term conditions whether they have missed any doses of their medication on a regular basis. Pharmacists persistently report that they intervene less than the other two professions to support patients with medicines. No country effects were found for the primary outcome. Conclusions Healthcare professionals in Europe are limited in the extent to which they intervene to assist patients having long-term conditions with medication adherence. This represents a missed opportunity to support people with prescribed treatment. These conclusions are based on the largest international survey to date of healthcare professionals’ management of medication adherence.

An education-behavioural intervention improves adherence to statins

PurposeEffective treatment of hyperlipidemia is an important precondition for cardiovascular diseases. Unfortunately, adherence to lipid-lowering treatment is unsatisfactory. In order to improve adherence to statins, an intervention combining educational and behavioural components was tested in general practice settings.MethodsA total of 198 outpatients with untreated hyperlipidemia were enrolled in this open-label, prospective, randomised study. Patients were prescribed simvastatin, in initial dosage of 20 mg daily, and followed for 48 weeks. Intervention group received educational counseling at each visit (that is every 8 weeks); and were also asked to adopt a routine evening activity of their choice for a reminder. Control group obtained usual care. Primary outcome measure was patient adherence, expressed as medication possession ratio (MPR).ResultsPatients’ mean age was 59.6 +/- 9.1 years. Study arms differed in their level of adherence: mean ± SD MPR was 95.4±53.7% and 81.7±31.0%, for intervention and control group, respectively (P<0.05). Patients from intervention group found a reminder activity useful in over 90% of cases.ConclusionsSimple inexpensive educational-behavioural intervention proved to be effective in enhancing adherence to statins in hyperlipidemia. Given the health and economic consequences of non-adherence, these results may have high clinical, and practical usefulness.