Integrated care for the management of ageing-related non-communicable diseases: current gaps and future directions

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Clinical Pharmacist Involvement in Mental Health Hospital in the Home

While the benefits of clinical pharmacist (CP) services have been comprehensively described in other healthcare settings, there is a paucity of evidence describing the role of the CP within the mental health (MH) Hospital-in-the-Home (HiTH). This suite of studies – a scoping review, an autoethnography, a quantitative medication safety study and a qualitative study – has comprehensively described the integration and evolution of the CP role, and provided preliminary evidence of the value of the MH-HiTH CP

An investigation into working alliance, compliance and congruence of beliefs among clients with a diagnosis of schizophrenia and their case managers

The therapeutic relationship is central to any intervention, and although relatively neglected in clients with psychosis, there is evidence of its importance in both case management and pharmacotherapy, the two cornerstones of the care of such clients. A therapeutic relationship might have a direct beneficial effect, as well as influencing compliance with treatment. A useful model of the alliance in the case management of clients with psychosis is the working alliance as it is applicable across treatments. Central to the working alliance is a sense of agreement, or congruence between client and clinician. Achieving congruence can be especially difficult in clients diagnosed with schizophrenia, due to disagreement among clinicians and clients over understanding the disorder, the severity of the phenomena under consideration, and aspects of the interventions used. The idea that some clients lack insight into their condition both reflects and exacerbates difficulties in establishing agreement. The concept of concordance draws together congruence of beliefs about the disorder and its treatment, adherence to treatment, and the alliance between clinician and client. In the present study, the associations between alliance, adherence and congruence of beliefs were examined in a cross-sectional, correlational study. The participants were 40 clients with a diagnosis of schizophrenia, and the 10 case managers who cared for them in an inner-city multi-disciplinary community mental health team. All clients were receiving anti-psychotic medications. Measures used included the Working Alliance Inventory; the Causal Belief Questionnaire; the Insight Scale; the Manchester scale for assessing symptoms and side effects; and indirect measures of adherence with treatment, rated by the case managers. The participants were also asked open questions about helpful and unhelpful aspects of treatment. Multivariate techniques were used to analyse the data. Case manager-rated alliance was positively associated with compliance with treatments. Client-rated alliance was negatively associated with compliance with medication, and positively associated with insight. A content analysis of the open questions suggested that clients and case managers had similar views over the helpful aspects of treatment, but differed over the unhelpful. The links between alliance and compliance are complex, perhaps reflecting the rating source, and judgements and expectation of treatment. The notion of concordance as defined was not supported, but the alliance seems to be an important factor in case management

Lääkehoitoon sitoutuminen kroonista myelooista leukemiaa sairastavilla : 86 suomalaisen potilaan tarina

The establishment of tyrosine kinase inhibitors (TKIs) has revolutionized the treatment of chronic myeloid leukemia (CML) during the last fifteen years. This study explored the journey of 86 patients with CML using oral TKI treatment in Finland. The aim was to assess their adherence to TKIs and how the adherence, which is crucial for treatment outcomes, could be improved. This study applied quantitative and qualitative methods and a randomized controlled study design during 2012-2014. All patients participated in the in-person interview, which followed the idea of the patient s journey with CML from the time before diagnosis to the study point. Patient-reported adherence was evaluated using Morisky s 8-Item Medication Adherence Scale (MMAS) (I-IV). Physicians were also asked to assess their patients adherence. Patient-reported adverse drug reactions (ADRs) and quality of life (QoL) were assessed during the interview using a structured questionnaire (II, III). The patient s knowledge of the disease and TKI treatment was evaluated by asking five key questions (I, III, IV). The intervention with 9-month follow-up in Study IV was based on tailored patient education combining nurse-conducted face-to-face counseling, educational video, patient booklet, website and text message reminders. The intervention material had the following learning objectives: CML as a disease, goals for TKI treatment, the importance of taking TKI medication as prescribed, and self-management of ADRs. A total of 86 patients participated in the study (approximately 20% of all Finnish CML patients). Of the patients enrolled, 43 were randomized into the intervention group and 43 into the control group (IV). A total of 68 patients completed the study. The results show that the response to TKI treatment was high (I), with 81% of the patients showing an optimal response to their treatment according to European LeukemiaNet 2013 recommendations. The CML patients knowledge of the disease and its treatment was poor (I). Despite the high molecular response rates to TKIs, adherence was not good in most of the patients: less than a quarter (23%) showed high adherence, 56% medium adherence, and 21% low adherence (I). Adherence was not influenced by patients gender, age, education, knowledge, time from diagnosis, ADRs, number of comorbidities or number of other medications. There was a considerable difference between observed and experienced adherence: 94% of the patients were highly adherent according to the physicians assessment, compared to 23% (I). The most common reason for unintentional non-adherence was forgetting to take the medication (I, III, IV). In the interviews patients reported self-regulation of medication taking, particularly on those occasions where patients wanted to avoid ADRs (III). The incidence of patient-reported ADRs was high (II). At the time of the study 97% of the patients reported suffering from at least one ADR, most commonly muscle soreness or cramp (80%), swelling of hands, legs, feet, or around the eyes (69%), and fatigue (50%). Patient interviews indicated that ADRs were the most common barriers to adherence (III). More than half of the patients felt the ADRs had a negative influence on their daily QoL (II). Compared with the total study group, the incidences of almost all symptoms were higher among patients whose symptoms negatively affected their daily life than those who reported no such influence (II). The patient journey model developed in the study (III) identified the following critical phases in the CML patient s journey: getting the diagnosis, starting the treatment, getting continuous support for treatment self-management, and managing fear caused by perceived severity of the disease. Even though only 44% of the low-adherent patients in the study experienced the TKI treatment as inconvenient, most of the patients (94%) were willing to stop taking the medication in the future if possible (III). All CML patients in the study were lacking a treatment plan and only a few had a medication list (I, III). The knowledge test (I, III) showed that patients had a poor understanding of their disease and its treatment, while low-adherent patients indicated that understanding the consequences of not taking the medication and the goal for the treatment would be motivating factors to adhere to the medication (III). The intervention significantly improved adherence (IV). In the intervention group the MMAS score increased more often than in the control group (p=0.001). The MMAS score declined in almost half of the patients in the control group, but only in 9% of those in the intervention group (p=0.001). A majority of the patients found the intervention useful, the most useful parts being face-to-face counseling and the educational booklet. Text messages were least valued. The findings of this study suggest that non-adherence is common among Finnish CML patients and that physicians seem to be too optimistic in assessing their patients adherence. The complex interplay between symptom burden, adherence, self-regulation, managing with ADRs, response to TKI therapy, and healthcare utilization highlights the need for regular symptom burden assessment in CML as a means to identify potential adherence problems before they affect the patients response to TKI treatment. Tailored patient education improved the adherence of patients with CML after a 9-month follow-up. Without the additional support, adherence behavior tended to decline. Patients were most satisfied with face-to-face counseling by the nurse, which means they need personal support and practical aids to help them manage their medication in everyday life. Access to personal counseling and information should be systematically planned as an essential part of CML care. Appropriate and updated information in printed and electronic formats should be available for nurses and other healthcare personnel to enable them to support their patients. The findings of this study suggest that patients perceptions and preferences should be understood and taken into account when designing patient education interventions for real-life clinical practice. The findings also highlight the need to further evaluate the interventions to enhance adherence. There is a need for communication to increase patients abilities to follow their treatment plan throughout their journey, which requires real partnership between healthcare professionals and patients.Krooninen myelooinen leukemia (KML) on pääosin aikuisilla esiintyvä verisyöpä, jonka hoito ja ennuste ovat muuttuneet dramaattisesti täsmälääkkeiden (tyrosiinikinaasin estäjät, TKI) tultua käyttöön. Hyvän hoitovasteen saamiseksi on tärkeää, että lääkkeet otetaan säännöllisesti ohjeen mukaisesti. TKI-lääkkeiden käyttöä suomalaisilla KML-potilailla ei ole aiemmin tutkittu. Tutkimuksen tarkoituksena oli 1) arvioida suomalaisten KML-potilaiden sitoutumista TKI-lääkehoitoon, 2) verrata potilaiden itsensä ilmoittamaa hoitoon sitoutuneisuutta hoitavien lääkäreiden arvioon siitä, 3) tutkia TKI-lääkityksen aiheuttamia haittavaikutuksia ja niiden yhteyttä hoitoon sitoutumiseen sekä koettuun elämänlaatuun, 4) tutkia kaikkein heikoimmin hoitoon sitoutuneiden kokemuksia sairaudesta ja sen hoidosta sekä 5) arvioida räätälöidyn neuvonta- ja tukiohjelman vaikuttavuutta lääkehoitoon sitoutumiseen. Tutkimukseen osallistui 86 aikuista KML-potilasta ja 13 hoitavaa lääkäriä kahdeksasta sairaalasta. Potilaat olivat käyttäneet TKI-lääkitystä vähintään kuuden kuukauden ajan. Potilaat haastateltiin tutkimuksen alussa ja 9 kuukauden kuluttua neuvonta- ja tukiohjelman aloittamisesta. Hoitovastetta seurattiin kliinisen normaalikäytännön mukaan. Neuvonta- ja tukiohjelma (interventio) koostui opetusvideosta, henkilökohtaisesta tapaamisesta hematologisen hoitajan kanssa, kirjallisesta tietopaketista, ohjeistuksesta nettisivujen kautta sekä vapaaehtoisesta lääkkeenoton muistutusviestistä matkapuhelimella. Potilaiden itse raportoima lääkehoitoon sitoutuneisuus arvioitiin Moriskyn 8-kohdan mittarilla (MMAS). Lääkärit tekivät vastaavan arvion potilaistaan 3-portaisen asteikon avulla. Potilaiden kokemat lääkehoidon aiheuttamat haittavaikutukset, koettu elämänlaatu ja tietämys sairaudesta ja sen lääkehoidosta arvioitiin strukturoiduilla kysymyksillä haastattelun yhteydessä. Potilaista alle neljännes (23 %) oli erinomaisesti, 56 % keskinkertaisesti ja 21 % heikosti sitoutunut TKI-lääkehoitoonsa. Lääkäreillä oli vääränlainen käsitys potilaidensa hoitoon sitoutumisesta: lääkärit arvioivat, että 94 % potilaista oli erinomaisesti hoitoon sitoutuneita eikä heillä ollut ongelmia lääkityksen kanssa. Hoitoon sitoutumisen yliarviointiin vaikuttanee hyvä hoitovaste. Potilaiden tietämys omasta sairaudestaan ja TKI-hoidosta oli varsin huono. Kaikilta potilailta puuttui kirjallinen hoitosuunnitelma ja lähes kaikilta lääkelista. Lähes kaikki potilaat ilmoittivat TKI-lääkkeen aiheuttavan haittavaikutuksia, yleisimmin lihaskipuja ja kramppeja (80 % potilaista), turvotusta silmien ympärillä, käsissä tai jaloissa (69 %) ja väsymystä (50 %). Yli puolet potilaista koki haittavaikutusten alentavan elämänlaatua. Näillä potilailla oli lukumääräisesti enemmän haittoja kuin niillä, jotka eivät kokeneet haittojen huonontavan elämänlaatua. Keskeisin hoitoon sitoutumiseen vaikuttava tekijä oli tahaton lääkkeen oton unohtaminen (puolella potilaista). Potilailla oli myös tarve tarkoituksellisesti muunnella lääkkeen ottoa, muun muassa välttääkseen haittavaikutuksia sosiaalisissa tilanteissa ja lomamatkoilla. Tutkimuksessa luodussa potilaan hoitopolun mallissa tunnistettiin haastattelujen perusteella seuraavat sairauteen liittyvät kriittiset vaiheet: diagnoosin saaminen, lääkehoidon aloittaminen, terveydenhuoltohenkilön antama jatkuva tuki omahoitoon sekä sairauden vakavuuden aiheuttaman pelon hallinta. KML-diagnoosi koettiin lähes aina kriisinä. Terveydenhuoltohenkilöstön tulisikin kiinnittää erityistä huomiota diagnoosin kertomistapaan. Diagnoosivaiheessa potilaat kokivat tiedonsaannissa puutteita ja valtaosa potilaista jäi sairastumisen jälkeen vaille psykologista tukea. He olivat kuitenkin varsin tyytyväisiä saamaansa hoitoon. Potilaat toivoivat ohjausta laboratoriotulosten ymmärtämiseen ja haittavaikutusten hallintaan. Lääkehoidon tavoitteiden ymmärtäminen koettiin motivoivana ja lääkehoitoon sitoutumista parantavana tekijänä. Tutkimuksessa käytetyllä koulutus- ja tukiohjelmalla pystyttiin parantamaan potilaiden lääkehoitoon sitoutumista. Tutkimus antoi viitteitä siitä, että ilman jatkuvaa omahoidon tukea hoitoon sitoutuminen heikkenee entisestään. Tärkeimpänä potilaat pitivät hoitajalta saatua henkilökohtaista neuvontaa ja vähiten hyödyllisenä muistutustekstiviestejä matkapuhelimella. Tutkimus tuo esille puutteita KML-potilaiden hoidossa ja omahoidon tukemisessa. Potilaan kokemukset ja toiveet sekä elämänlaatunäkökulma tulisi ottaa paremmin huomioon lääkehoidon aloituksessa ja seurannassa. Terveydenhuoltohenkilökunnan antama tuki ja neuvonta tulisi systemaattisesti suunnitella osaksi KML-potilaiden hoitoa. Muistutusviestit ja kirjeet eivät korvaa henkilökohtaista kontaktia. Hoitohenkilökunnalla tulisi olla saatavilla riittävät tiedot ja apuvälineitä potilaiden ohjaamiseen. Tutkimuksen tulosten perusteella varsin yksinkertaisilla toimenpiteillä pystytään suomalaisten KML-potilaiden hoitoon sitoutumista parantamaan, haittavaikutuksia lievittämään ja mahdollisesti vielä entisestään hoidon vaikuttavuutta lisäämään. Potilaan, terveydenhuoltohenkilöstön sekä apteekkien yhteistyö ja kommunikaatio keinojen löytämiseksi on avainasemassa

What are the basic self-monitoring components for cardiovascular risk management?

<p>Abstract</p> <p>Background</p> <p>Self-monitoring is increasingly recommended as a method of managing cardiovascular disease. However, the design, implementation and reproducibility of the self-monitoring interventions appear to vary considerably. We examined the interventions included in systematic reviews of self-monitoring for four clinical problems that increase cardiovascular disease risk.</p> <p>Methods</p> <p>We searched Medline and Cochrane databases for systematic reviews of self-monitoring for: heart failure, oral anticoagulation therapy, hypertension and type 2 diabetes. We extracted data using a pre-specified template for the identifiable components of the interventions for each disease. Data was also extracted on the theoretical basis of the education provided, the rationale given for the self-monitoring regime adopted and the compliance with the self-monitoring regime by the patients.</p> <p>Results</p> <p>From 52 randomized controlled trials (10,388 patients) we identified four main components in self-monitoring interventions: education, self-measurement, adjustment/adherence and contact with health professionals. Considerable variation in these components occurred across trials and conditions, and often components were poorly described. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted.</p> <p>Conclusions</p> <p>The components of self-monitoring interventions are not well defined despite current guidelines for self-monitoring in cardiovascular disease management. Few trials gave evidence-based rationales for the components included and self-measurement regimes adopted. We propose a checklist of factors to be considered in the design of self-monitoring interventions which may aid in the provision of an evidence-based rationale for each component as well as increase the reproducibility of effective interventions for clinicians and researchers.</p

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care

Hypertension Knowledge, Expectation of Care, Social Support, and Adherence to Prescribed Medications of African Americans with Hypertension Framed by the Roy Adaptation Model

Hypertension (HTN) prevalence in African Americans contribute to higher rates of disabilities and deaths from stroke, myocardial infarction, and end stage renal disease than all other racial groups in the United States. The major reason documented for these poor health outcomes is related to lower HTN control rates among African Americans compared to other racial/ethnic groups. Though overall HTN awareness, pharmacological treatments and control have significantly improved for all populations, studies found that rates of HTN control and adherence with anti-hypertensive medications are lower for African Americans compared to other subgroups. Study Aims The primary aim was to determine whether hypertension knowledge, expectation of care, and social support are predictors of adherence to prescribed medications while controlling for socioeconomic factors in the context of hypertension among African Americans. Methods A cross sectional quantitative approach was used. A secondary data analysis was conducted with 387 hypertensive African Americans. The Morisky Medication Adherence scale was used to measure adherence, internal consistency was established, (r=.61). The Roy Adaptation Model (RAM) was used to link HTN knowledge, expectations of care, social support, and socioeconomic factors with adherence to medications to provide an understanding of the process of adaptation. Logistic regressions were used to determine the relationships among the variables. Results The sample (N=387) was primarily female (76%) and men (24%). On average, participants scored high in knowledge about hypertension; mean knowledge score was .91 (SD = .09). Controlling for patient covariates, hypertension knowledge was not found to be a predictor of adherence to prescribed medications (p=.469). Expectation of care was found to be a predictor of adherence to prescribed medications (p=.008); social support was found to be a predictor of adherence to medications (p=.006). Conclusion and Implications This study supports findings regarding expectations of care, social support, and adherence to medication in African American patients with hypertension. The findings are useful for planning patient management initiatives specific to chronic disease such as hypertension