Suzan N. Kucukarslan

Evaluating medication-related services in a hospital setting using the disconfirmation of expectations model of satisfaction

BACKGROUND Patient satisfaction is considered an important outcome measure of services and associated with behavioral intentions. The appraisal process commonly used in satisfaction models is the disconfirmation of expectations. A patient compares his or her experience to preexisting expectations. The resulting satisfaction from this comparison is dependent on whether the patients expectations are superior, inferior, or just as expected. OBJECTIVES The aims of this study were to (1) determine the relationship between disconfirmation of expectations with medication-related services and patient satisfaction with medical care; and (2) determine if patient satisfaction is related to the likelihood to say good things about the medical care provided at the hospital to family and friends. METHODS A cross-sectional, nonexperimental study design was implemented to test the disconfirmation of expectations model. Patients on warfarin therapy and recently discharged from an acute care hospital to their homes were surveyed by mail. The survey asked about how well the hospital services related to medication therapy met patient expectations. Satisfaction with medical care and the likelihood of positive word of mouth regarding the medical care were also measured. Structural equation modeling (SEM) was used to test the model. RESULTS The survey response rate was 34% (n=187). Factor analysis of the 7 disconfirmation of expectation items resulted in a 2-factor solution: (1) medication counseling and (2) discharge medication services. The SEM demonstrated that the model was significant; however, the disconfirmation of expectation items did not significantly relate to the 1-item satisfaction measure. Patient satisfaction and the behavioral intentions measures were significantly related. A post hoc analysis using SEM demonstrated that the disconfirmation of expectations factors did significantly relate to a higher-order latent construct. This construct also related to patient satisfaction. CONCLUSION The disconfirmation of expectations has a role in a postservice experience response expressed by the patient, but not as a direct antecedent to patient satisfaction. Opportunities to improve the model are the use of a multi-item satisfaction measure and the inclusion of patient affect.

Integrating medication therapy management in the primary care medical home: A review of randomized controlled trials.

PURPOSE Randomized controlled trials (RCTs) that evaluated the effect of medication therapy management (MTM) on patient outcomes in the primary care medical home were reviewed to determine how these services may be integrated into the primary care medical home. METHODS A literature search was conducted to identify RCTS published between 1989 and 2009 that evaluated the impact of MTM services on patient outcomes. To qualify as MTM services, the interventions had to include both a review of medication therapy and patient interactions, including educating patients about drug therapy, identifying potential barriers to medication adherence, and helping patients manage their diseases. The internal validity of the studies was evaluated using previously published criteria. The description, specification, and appropriateness of study objectives, study population, intervention, randomization, blinding, outcome measures, statistical analysis, and conclusions were evaluated. RESULTS A total of 1795 publications were identified, but only 8 met the inclusion criteria. These studies targeted patients with specific medical conditions or patients with multiple medications without specifying a medical condition. The interventions varied in intensity (i.e., frequency and length of patient contact), ranging from a single patient contact in a community pharmacy setting to multiple visits with an ambulatory care pharmacist practicing in a collaborative care model. Two of the 8 studies obtained expected results. These studies targeted patients with unrealized therapeutic goals, and the interventions involved collaboration between pharmacists and physicians and extensive patient follow-up. CONCLUSION Of 1795 publications identified, 8 were RCTs meeting selection criteria for evaluation of the effect of MTM services on patient outcomes. Two service elements that benefit patient care were identified: (1) selecting patients with specific therapeutic problems and (2) implementing MTM services that involve timely communication with primary care providers to discuss therapeutic problems, along with routine patient follow-up to support medication adherence to changes in therapy.

Employer-based patient-centered medication therapy management program: Evidence and recommendations for future programs

OBJECTIVE To evaluate a patient-centered employer-based medication therapy management (MTM) program. DESIGN Randomized controlled study. SETTING Health promotion program at the University of Michigan from June 2009 to December 2011. PARTICIPANTS Employees, retirees, and their dependents taking seven or more prescription medications. INTERVENTION Focus on Medicines (FOM) was a two-visit, patient-centered service with a 4-month follow-up. A comprehensive medication review occurred during the first visit. Pharmacists provided recommendations and a medication action plan at the second visit. The MAP incorporated patient preferences for problem resolution. MAIN OUTCOME MEASURES Patient uptake, medication cost, medication adherence, patient satisfaction with treatment, patient reasons for participation, patient satisfaction with the FOM program, drug-related problems, pharmacist recommendations, implementation of recommendations. RESULTS The FOM program attracted 128 individuals wanting information about their medications and an individualized drug regimen assessment to ensure that their therapy was safe and effective and that all medications were necessary. On average, 3.3 medication therapy problems were identified per patient; most were safety related. Overall, 63% of pharmacist recommendations were implemented. When a prescriber was contacted, 83% of pharmacist recommendations were implemented. A reduction in drug cost for patients and the employer was shown. Patients reported improved convenience in taking medications and rated the program favorably. CONCLUSION A personalized dialogue about medication use appears to meet a need among individuals taking large numbers of medications. Understanding why patients participate in MTM programs and what program features patients appreciate is useful in designing quality MTM programs.

Satisfaction with current health status in patients with a history of acute coronary syndrome

ABSTRACT Objective: To describe satisfaction with current health status in patients with a recent history of an acute coronary syndrome (ACS) event and to determine the association between satisfaction and patient-specific variables. Research design and methods: Patients from an ACS registry who were discharged from a university affiliated hospital over a 3-year period were mailed the study questionnaire. Main outcomes measures: Data included demographics, cardiac-specific measures, and general health status (SF-8 PCS, MCS and the EQ-5D VAS) and health status preference weight (EQ-5D Health Index). Satisfaction with current health status was assessed by a single question derived for this study with a 5-point Likert scale from ‘not satisfied at all’ to ‘highly satisfied.’ ANOVA determined the association between levels of satisfaction and health status scores. A multivariate linear regression model determined the association of patient, disease, and treatment variables with satisfaction. Independent variables were determined to be significant if the p-value in the model was <0.05. Results: Respondents (490, 40.3% response rate) averaged 65.2 ± 11.3 years of age; 71% male; 92% Caucasian; 64% with MI history; and 17% had their most recent cardiac event within 6 months. 63% of respondents were either mostly satisfied or highly satisfied with there current health status. Based on level of satisfaction, the mean PCS ranged from 36.9 ± 8.9 to 63.0 ± 6.2; mean MCS from 38.3 ± 13.1 to 55.7 ± 5.7; mean EQ-5D VAS from 37.0 ± 21.7 to 90.8 ± 20.7, and mean EQ-5D Health Index from 0.38 ± 0.3 to 0.93 ± 0.14, all ANOVA models p < 0.001. Statistically significant independent variables in the multivariate linear regression model included the number of symptoms, DASI cardiac function score, perceived severity of disease, and age. Satisfaction with current health state was associated with older age, fewer symptoms, better DASI cardiac function scores, and lower perceived severity of illness. Conclusion: Health-related quality of life, or health status, and satisfaction with health status have a direct, positive association. Greater burden of illness and younger age were significantly associated with dissatisfaction with health status. Extrapolation of results is limited to determining association but not causation due to the cross sectional study design.

A simple and promising tool to improve self-monitoring of blood glucose in patients with diabetes

AIM To examine patient formation of implementation plans, a volitional strategy, and its influence on self-monitoring of blood glucose (SMBG). METHODS A randomized experimental-control design over a 2-week time period was used. The study population was diabetes patients with HbA1c >7% and requiring insulin therapy. Patients were recruited from a southeastern Michigan healthcare system. A self-administered intervention was designed to assist patients to formulate plans to perform SMBG. The primary outcome measure was SMBG rates. Three control groups were used to control for testing effects. Hypotheses were tested using ANOVA at a significance level of 0.05. SMBG was measured using a 2-week diary and two recall measures. RESULTS There were 402 patients with diabetes recruited for the study. Analyses indicated that making implementation plans increased SMBG rates as assessed by a diary and two recall measures. The patients in the experimental group checked their blood sugar up to 7.77 times more than the control groups (sig<0.05) over a 2-week time period as measured by the diary. CONCLUSIONS Patient behavior can be impacted by using an implementation planning tool. This technique can help improve patient self-monitoring behavior.

Using Self-Regulation Theory to Examine Patient Goals, Barriers, and Facilitators for Taking Medication

AbstractBackground: Self-regulation theory predicts that patient behavior is determined by the patient’s assessment of his/her condition (illness presentation) and related health goals. Patients will adapt their behavior to achieve those goals. However, there are multiple levels of goals. In such cases, those lower-level goals (health goals) that are strongly correlated with higher-level goals (i.e. quality of life [QOL]) are more likely to drive patient behavior. Medication non-compliance is a health behavior that challenges healthcare practitioners. Thus, the primary aim of this paper is to explore the relationship between the lower-level goals for taking medication with higher-level goals. This paper also identifies patient-perceived barriers and facilitators toward achieving goals as they may relate to patients’ illness representation. Objectives: To identify lower- and higher-level goals associated with medication use for chronic conditions. To determine if there is a relationship between higher-level (global) goals and lower-level (health-related) goals. To identify patient-perceived facilitators and barriers to achieving those goals. Methods: This was a prospective, observational study using a mailed survey. The setting was a US Midwestern state-wide survey. Participants were patients living in the community with hypertension, heart disease, diabetes mellitus, or arthritis, and taking prescription medication for any one of those conditions. The main outcome measures were lower- and higher-level goals related to medication use. The survey asked the participants if they had achieved their goals and to identify factors that may pose as barriers or facilitators to achieving them. Pearson correlation was used to test the relationship between the lower- and higher-level goals at p < 0.05. Results: Responses from 292 qualifying patients were obtained. A significant relationship between lower- and higher-level goals existed (p = 0.03). Preventing future health problems was the most important lower-level goal for almost half of the respondents. Approximately 43% of the respondents said ‘improving or maintaining quality of life’ was their most important higher-level goal. Elderly respondents (65 years or older) said that being able to carry out daily activities on their own was their most important higher-level goal. To achieve this goal, they identified ‘preventing future health problems’ as the associated lower-level goal. One-third of the respondents stated that they had not yet achieved their medication-related goals. Patients identified good communication with their physicians (35%), the effectiveness of the drug product (32%), and their ability to monitor their condition (20%) as important factors toward helping them achieve their goals. Medication costs (30%), drug adverse effects (25%), and the lack of drug effectiveness (22%) were factors that patients identified as barriers to achieving their goals. Conclusion: There is a significant and positive relationship between the lower- and higher-level goals. Healthcare providers can work with their patients to achieve their goals. Both good communication with the prescriber and the effectiveness of the drug product were identified as the most important facilitator by one-third of the respondents. Future research should study if relating the impact of good symptom control or the reduction of future health risks to QOL or longevity, as deemed relevant by the patient, influences medication adherence behavior.

Evaluation of a dedicated pharmacist staffing model in the medical intensive care unit.

Purpose Published studies have shown that pharmacists on medical rounds reduce the incidence of preventable adverse drug events (ADEs). However, the impact of a dedicated pharmacist who provides consistent patient care in a critical care unit remains to be evaluated. Objective To determine the impact of a pharmacist who is permanently assigned to the medical intensive care unit (MICU) on the incidence of preventable ADEs, drug charges, and length of stay (LOS) in the MICU. Design A randomized, experimental versus historical control group design was used. Preventable ADEs were identified and validated by 2 pharmacists and a critical care physician. Information about MICU drug charges and LOS were obtained from the hospital administrative database. Results The intervention group had fewer occurrences of ADEs (10 ADEs/1,000 patient days) when compared to the control group (28 ADEs/1,000 patient days) at a significance level of .03. No significant differences were found between the 2 groups in MICU drug charges and LOS. The vast majority of the 596 documented recommended interventions (99%) were accepted by the medical team. Nutrition monitoring, medication indicated but not prescribed, and dosage modification were the top 3 problems identified by the pharmacist. Conclusion The addition of a dedicated critical care pharmacist to the MICU medical team improves the safe use of medication. The services of a dedicated critical care pharmacist should be expanded to include weekend hours to ensure the benefits of improved medication safety.

Examining determinants of self management behaviors in patients with diabetes: An application of the Theoretical Model of Effortful Decision Making and Enactment

OBJECTIVE This study examined determinants of self-monitoring of blood glucose (SMBG) in patients with diabetes based on a theoretical model. The model focuses on two equally important components of the decision process within a single framework: (1) making a decision and (2) enacting the decision. METHODS Diabetes patients with HbA1c >7% and requiring insulin therapy were recruited from a southeastern Michigan healthcare system. Responses were elicited using a mail-in questionnaire. SMBG was measured using a two-week diary and two recall measures. The applicability of the theoretical model as it relates to SMBG was tested using structural equation modeling (SEM). RESULTS The SEM analysis demonstrated that goal desire is an antecedent to goal intentions and that implementation desire and implementation intentions mediate the path between goal intentions and SMBG. Further, implementation intentions are a significant predictor of SMBG. CONCLUSION Consistent with the theoretical model, results indicated that implementation desire and implementation intentions mediate the relationship between strength of goal intention and performing specific behaviors to achieve the goal. PRACTICE IMPLICATIONS It is evident that in order to be more effective, educational programs or interventions should consider incorporating implementation and action plans to help patients translate decisions and intentions into behavior.

Patient-perceived risk associated with epilepsy and its medication treatment

Regardless of the expert advice of health care practitioners, it is ultimately the patients decision how to best manage his or her condition. This decision can be influenced by the perceived risk of both the disease and its treatment. The objective of this study was to develop a survey to evaluate perceived risk associated with epilepsy and its medication treatment. Risk was evaluated in five domains: performance, financial, social, psychological, and physical. A 40-item patient-perceived risk questionnaire was developed and administered to patients at one university-affiliated epilepsy clinic. Pearson correlation and regression analysis was used to identify significant components of overall perceived risk. A total of 64 patients completed the survey. Performance and physical risk significantly explained 34% of the variance in overall perceived risk associated with epilepsy. The overall perceived risk associated with the treatment of epilepsy was explained by performance, physical, psychological, and social risks (r(2)=0.386). Thus, the treatment of epilepsy poses more challenges for patients to maintain their lifestyle than the disease itself.

An experiment using hypothetical patient scenarios in healthy subjects to evaluate the treatment satisfaction and medication adherence intention relationship

Treatment beliefs and illness consequence have been shown to impact medication adherence in patients with years of asthma experience. These relationships are unknown in patients with early experience.