Yu Heng Kwan

Systematic review of the barriers affecting medication adherence in older adults.

Medication adherence is a crucial part in the management of chronic diseases. As older adults form a greater proportion of the population with chronic diseases and multiple morbidities, understanding medication adherence in older adults becomes important. In the present article, we aimed to systematically review the literature for the factors associated with medication adherence in the geriatric population. We carried out a literature search using electronic databases and related keywords. 17 391 articles were reviewed in total. 65 articles were found to be relevant to our objective. A total of 80 factors of five different categories were found to be associated with medication adherence in older adults. The factors, the types of studies and the number of studies that agreed or disagreed were presented. A flower model for medication adherence was also presented to allow clinicians to better understand the complex nature of medication adherence in this population. The 80 factors reviewed were categorized into five main categories; namely, patient factors, medication factors, physician factors, system‐based factors and other factors as factors affecting poor medication adherence in older adults. Clinicians need to be mindful of the complex nature of factors affecting medication adherence in this population to optimize therapeutic outcomes. Clinicians have to be more skillful to discover and to optimize the medication adherence factors in geriatric patients. The flower model is presented as a framework for clinicians to better understand the various factors affecting medication adherence in older adults. Geriatr Gerontol Int 2016; 16: 1093–1101.

Association between number of doses per day, number of medications and patient's non-compliance, and frequency of readmissions in a multi-ethnic Asian population.

Objective To investigate whether number of doses per day and number of medications are significantly associated with the number of readmissions and to study the association of readmission frequency with other medical and socio-demographic variables. Methods Retrospective cross-sectional study involving 432 patients who were readmitted within 15 days of previous hospital discharge between January 1, 2013 and March 31, 2013. Relevant medical records were collected from the national electronic databases of every public tertiary hospital in Singapore. Significant variables (p < 0.05) were identified using forward selection and modeled using generalized linear mixed models. Results A total of 649 unplanned readmissions were reviewed. At a multivariable level, number of readmission was significantly associated with the number of medications (p = 0.002) and number of doses per day (p = 0.003) after adjusting for race, liver disease, schizophrenia and non-compliance. Conclusion Complex medication regimen (i.e. multiple medications and multiple doses per day) is a statistically significant predictor of number of readmissions. Simplifying therapeutic regimens with alternatives such as longer-acting or fixed-dose combination drugs may facilitate better patient adherence and reduce costly readmissions.

Heart Wellness Programme: a pilot community-based cardiac rehabilitation programme in a multiethnic society.

INTRODUCTION Community-based exercise programmes have been shown to be effective in the Western world. However, there is a dearth of literature on their effectiveness in Asia. This pilot study aims to assess the effectiveness of the Asian community-based Health Wellness Programme (HWP) in Singapore. The HWP provides community cardiac rehabilitation services. METHODS A retrospective database analysis was conducted on cardiac rehabilitation patients who had completed the one-year wellness programme from 2010 to 2011. Patients were included in the programme if they had an underlying cardiac disease such as ischaemic heart disease and were deemed as stable by their cardiologist. Patients with New York Heart Association Class III or IV heart failure were excluded from this programme. Sociodemographic, anthropometric, clinical and laboratory data was recorded. Changes between the baseline and final measurements were analysed. RESULTS Complete data from a total of 136 patients was analysed. Improvements were noted in body fat percentage (change [Δ] -1.3%, p < 0.01), distance walked (Δ 9.7 m, p = 0.01), total cholesterol (Δ -7.8 mg/dL, p = 0.03), low-density lipoprotein (Δ -7.8 mg/dL, p = 0.03) and triglyceride (Δ -17.8 mg/dL, p < 0.01). CONCLUSION The low-to-moderate intensity HWP seems to be effective in a multiethnic community setting. To confirm the quality and effectiveness of such a programme in secondary cardiovascular prevention, more evidence from prospective controlled trials with suitable controls is needed.

Validity and reliability of the Health Assessment Questionnaire among patients with spondyloarthritis in Singapore

The Health Assessment Questionnaire (HAQ) is a popular tool used to measure disability. Few studies have assessed its psychometric properties in patients with spondyloarthritis (SpA). We therefore aimed to assess the reliability and validity of the HAQ in patients with SpA in Singapore.

A systematic review of quality-of-life domains and items relevant to patients with spondyloarthritis

OBJECTIVES To summarize, from the literature, quality-of-life (QoL) domains and items relevant to patients with spondyloarthritis (SpA), and to determine if commonly used SpA patient-reported outcome (PRO) instruments include the identified domains. METHODS We used PRISMA statement for systematic review and searched Medline® , Embase®, and PsycInfo® using relevant keywords. In addition, hand searches of references of the included articles were conducted. All articles were reviewed for inclusion by 2 independent reviewers. QoL domains and items relevant to patients with axial or peripheral SpA were extracted and presented using the adapted World Health Organization Quality-of-Life (WHOQOL) domain framework. SpA PROs were assessed to determine if they included the domains identified. RESULTS We retrieved 14,343 articles, of which 34 articles fulfilled inclusion criteria for review. Twenty-five articles were conducted in the European population. Domains such as negative feelings and activities of daily living were found to be present in 28 and 27 articles, respectively. SpA impacted QoL in all domains of the adapted WHOQOL framework. Domains that differed between types of SpA were financial resources, general levels of independence and medication side effects. Embarrassment, self-image, and premature ageing were items that differed by geographical setting. PROs to capture domains for peripheral SpA were similar for axial SpA. CONCLUSIONS We found that a wide range of domains and items of QoL were relevant to patients with SpA with minimal differences between patients with axial and peripheral SpA. Clinicians may consider using peripheral SpA PROs to measure QoL of patients with axial SpA.

A systematic review of the barriers affecting medication adherence in patients with rheumatic diseases

Medication adherence is a crucial part in the management of rheumatic diseases, especially with many such patients requiring long-term medications. In this paper, we aim to systematically review the literature for the factors associated with medication adherence in the rheumatic patient population. We carried out a systematic literature search using PubMed®, PsychInfo® and Embase ® with relevant keywords and employed the PRISMA® criteria. We included English peer-reviewed articles that studied the factors affecting medication adherence in patients with rheumatic diseases, which were assessed by two independent reviewers. Hand searches were conducted and relevant factors were extracted and classified using the World Health Organization (WHO)’s five dimensions of medication adherence. A simple diagram was drawn to summarise the factors extracted. 1977 articles were identified and reviewed and 90 articles were found to be relevant. A total of 17 factors and 38 sub-factors were identified and categorized based on the WHO’s five dimensions of medication adherence. A hand model for medication adherence was developed to succinctly summarise these dimension to remind clinicians the importance of medication adherence in daily practice. We conducted a systematic review on the various factors including patient, therapy, condition, health system and socioeconomic-related factors that affected medication adherence in rheumatic patients. We found 17 factors and 38 sub-factors that affected medication adherence in this population. This systematic review can facilitate future focused research in unexplored dimensions.

Stability of chronic medicines in dosage administration aids. How much have been done

Background The prevalence of chronic diseases is increasing in Asia, therefore compliance to the medications is of utmost importance to slow disease progression and improve outcomes. Dosage administration aids (DAAs) serve as important tool to improve the compliance of patients. However, there is a dearth of data on the stability of chronic medications in DAAs. Furthermore, data presented by our Western counterparts may not be applicable to us because of our extreme humidity and temperature. In this study, we aim to summarize the data available in the literature on the stability of chronic medications in DAA. Methods We performed a literature search using electronic databases and related keywords. Results In total, 24,336 articles were retrieved and 21 articles were found to be relevant to our topic. This commentary stratified drugs according to their treatment categories and key stability conclusions, DAA and conditions used and recommendations were presented. Conclusion Due to the lack of specific data, pharmacists have to exercise their professional judgment with the help from professional guidelines when using DAA in repackaging medication. Manufacturers and regulators can play a greater role in filling the gap needed to provide pharmacists with necessary information to fulfill their function.

Impact of Community-Based Cardiac Rehabilitation on Clinical Parameters of Patients with Cardiovascular Diseases

Background:Cardiac rehabilitation (CR) programmes have been shown to improve patient outcomes, but vary widely in their components. The impact of Singapore’s CR programme on clinical outcomes is currently not known.Objective:To evaluate the effects of a community-based CR programme on important clinical parameters in patients with cardiovascular disease in Singapore.Method:A retrospective cohort study was conducted. Cardiovascular patients who had completed a hospital-based CR programme were included. Patients who continued with community-based CR (n = 94) during the period of 2009-2013 were compared with patients who received regular care (n = 157). Changes in clinical and physical examination parameters between baseline and one-year post follow-up were analyzed. Within-group differences were compared using the paired t-test, while multivariate linear regression was used to compare the changes in the various parameters between the intervention and control groups. The primary outcome measure was low density lipoprotein (LDL) levels.Results:Patients in the intervention group had significant lowering of LDL (2.5 to 2.2 mmol/L, p<0.01), while the control group’s LDL increased (2.2 to 2.4 mmol/L, p<0.01). The intervention group had greater improvements in LDL (-0.3 vs. +0.2 mmol/L, p<0.01), triglycerides (-0.1 vs. +0.1 mmol/L, p=0.01), total cholesterol (-0.3 vs. +0.3 mmol/L, p<0.01), fasting blood glucose (-0.5 vs. +0.3 mmol/L, p<0.01), systolic blood pressure (-3.2 vs. +5 mmHg, p<0.01) and diastolic blood pressure (-2.6 vs. +2.8 mmHg, p<0.01).Conclusion:The community-based CR programme in Singapore is associated with improvements in several cardiovascular clinical parameters and may be of benefit to cardiovascular patients.

Prevalence of dysglycaemic events among inpatients with diabetes mellitus: a Singaporean perspective.

INTRODUCTION As the effectiveness of intensive glycaemic control is unclear and recommended glycaemic targets are inconsistent, this study aimed to ascertain the prevalence of dysglycaemia among hospitalised patients with diabetes mellitus in an Asian population and evaluate the current standards of inpatient glycaemic control. METHODS A retrospective observational study was conducted at a secondary hospital. Point-of-care blood glucose (BG) values, demographic data, medical history, glycaemic therapy and clinical characteristics were recorded. Dysglycaemia prevalence was calculated as proportions of BG-monitored days with at least one reading exceeding the cut points of 8, 10 and 15 mmol/L for hyperglycaemia, and below the cut point of 4 mmol/L for hypoglycaemia. RESULTS Among the 288 patients recruited, hyperglycaemia was highly prevalent (90.3%, 81.3% and 47.6% for the respective cut points), while hypoglycaemia was the least prevalent (18.8%). Dysglycaemic patients were more likely than normoglycaemic patients to have poorer glycated haemoglobin (HbA1c) levels (8.4% ± 2.6% vs. 7.3% ± 1.9%; p = 0.002 for BG > 10 mmol/L) and longer lengths of stay (10.1 ± 8.2 days vs. 6.8 ± 4.7 days; p = 0.007 for BG < 4 mmol/L). Hyperglycaemia was more prevalent in patients on more intensive treatment regimens, such as basal-bolus combination therapy and the use of both insulin and oral hypoglycaemic agents (100.0% and 96.0%, respectively; p < 0.001 for BG > 10 mmol/L). CONCLUSION Inpatient glycaemic control is suboptimal. Factors (e.g. type of treatment regimen, discipline and baseline HbA1c) associated with greater prevalence of dysglycaemia should be given due consideration in patient management.

Exploring Product-Specific Attributes of a Community Cardiac Rehabilitation Program in an Asian Urban City

BACKGROUND Cardiac rehabilitation (CR) has been proven to improve long-term outcomes for patients. Despite its benefits, its uptake throughout the world is poor. Factors affecting the motivation and barriers impeding an individual from participating in a CR program have been extensively studied. Nevertheless, knowledge of product-specific factors in affecting participation is lacking. OBJECTIVES To find out cultural-specific product attributes that are important to those contemplating participation in a community-based CR program using Consolidated criteria for Reporting Qualitative research (COREQ) as an anchor. METHODS Participants were recruited from attendees of the CR program at the Singapore Heart Foundation. A literature review was done to identify product-specific attributes that affected participation in CR programs. An interview guide was developed on the basis of the list of product attributes. The analysis was done by two independent analysts using NVivo version 11 (QSR International, Melbourne, Australia) via an inductive approach. Data analysis was carried out with recruitment and interviews ongoing until thematic saturation was reached. RESULTS In total, 13 male and 9 female participants (16 Chinese, 4 Indian, 1 Malay, and 1 Eurasian) aged between 47 and 89 years were interviewed. A total of 8 categories (System, Infrastructure, Environment, Monitoring, Activity, Program, Staff, and Companionship) with 30 subcategories were identified. New themes that have not been explored by previous studies were discovered under five different categories: System, Infrastructure, Environment, Program, and Companionship. CONCLUSIONS This study allows a better understanding of product-specific factors affecting participation in CR programs and serves as a springboard for further research to improve participation in community-based CR programs.