Prevalence and Correlates of Cost-Related Medication Nonadherence to Immunosuppressive Drugs After Heart Transplantation: The International Multicenter Cross-sectional Bright Study

Cost-related medication nonadherence (CRMNA) refers to not taking medications as prescribed because of difficulties paying for them.; The aims of this study were (1) to assess the prevalence of CRMNA to immunosuppressants in heart transplant recipients internationally and (2) to determine multilevel correlates (patient, center, and healthcare system levels) of CRMNA.; Using data from the cross-sectional international BRIGHT study, applying multistaged sampling, CRMNA was assessed via 3 self-report items in 1365 patients from 36 heart transplant centers in 11 countries. Cost-related medication nonadherence was defined as any positive answer on any of the 3 items. Healthcare system-level (ie, insurance coverage, out-of-pocket expenditures) and patient-level (ie, intention, perceived financial burden, cost as a barrier, a health belief regarding medication benefits, cost-related self-efficacy, and demographic factors) CRMNA correlates were assessed. Correlates were examined using mixed logistic regression analysis.; Across all study countries, CRMNA had an average prevalence of 2.6% (range, 0% [Switzerland/Brazil] to 9.8% [Australia]) and was positively related to being single (odds ratio, 2.29; 95% confidence interval, 1.17-4.47), perceived financial burden (odds ratio, 2.15; 95% confidence interval, 1.55-2.99), and cost as a barrier (odds ratio, 2.60; 95% confidence interval, 1.66-4.07). Four protective factors were identified: white ethnicity (odds ratio, 0.37; 95% confidence interval, 0.19-0.74), intention to adhere (odds ratio, 0.44; 95% confidence interval, 0.31-0.63), self-efficacy (odds ratio, 0.54; 95% confidence interval, 0.43-0.67), and belief about medication benefit (odds ratio, 0.70; 95% confidence interval, 0.57-0.87). Regarding variability, 81.3% was explained at the patient level; 13.8%, at the center level; and 4.8%, at the country level.; In heart transplant recipients, the CRMNA prevalence varies across countries but is lower than in other chronically ill populations. Identified patient-level correlates are novel (ie, intention to adhere, cost-related barriers, and cost-related self-efficacy) and indicate patient-perceived medication cost burden

Taking a broader perspective on medication adherence : the importance of system factors

As behavior is influenced by the system in which the patient lives, it is crucial to investigate the role of system factors in explaining adherence. To-date system level factors have received limited attention as potential predictors of medication adherence. As a consequence, the magnitude of the effect of different system factors on adherence is not known, a clear gap in the growing adherence literature. A framework which can be used in explaining the influence of system factors on behavior is an ecological model. In an ecological model 3 levels of influence on patient behavior are identified: 1) the micro level (relationships with healthcare professionals, social support) 2) the meso level (healthcare organization) and 3) the macro level (healthcare system and policy). The overall purpose of this dissertation was to explore the role of system factors in chronic illness management, focusing on medication adherence. Five articles present the results of this work. First, a systematic review was conducted of quantitative studies addressing factors at the different levels of the healthcare system that are associated with medication adherence in individuals with HIV and transplant (Tx) recipients. A total of 64 studies were identified. The 2 factors that were most consistently related to adherence were trust in the healthcare provider and access to medications. Across the factors examined study findings about their relationships to adherence varied. One explanation for this variability may be the wide variability in the methodological approaches utilized in studies. The 2nd manuscript provides an overview of commonly used statistical measures for expressing the strength of the relationships between variables such as system factors and adherence. Formulas utilized to directly calculate common effect sizes from summary data reported in studies and examples of methods utilized to indirectly estimate the effect size from summary statistics are presented. Third, a study was conducted to describe the strategies cardiovascular health professionals utilize to assess patients' medication adherence and to enhance adherence. In this study, a questionnaire was distributed to all attendants of a conference in Switzerland (March 2010). A total of 137 professionals were included. Questioning patients about NA during follow-up visits was the method used most frequently to assess adherence. Providing reading materials was the strategy used most frequently to enhance patient medication adherence. The 4th study examined adherence assessment strategies and the interventions healthcare professionals report using to improve adherence in Tx patients. Furthermore this study examined the professionals' perceptions about the effectiveness the interventions they utilize. Data were collected at a Tx nurses symposium in Germany (June 2010). Eighty-six participants are included in this study. The most frequently used assessment strategy was questioning patients about NA during follow-up. Training patients to self-administer medications and providing printed adherence information were the most frequent interventions (79%). The intervention perceived as most effective by the professionals was medication self-administration training. The final study describes the development, the content validity testing and the inter-rater reliability testing of the Chronic Illness Management Implementation - Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (CIMI-BRIGHT) instrument. The development of the CIMI-BRIGHT instrument was based on the conceptual framework of WHO's Innovative Care for Chronic Conditions framework, as well as the clinical expertise of the research team. Initial psychometric testing (content validity and inter-rating reliability) were conducted. Content validity was evaluated by 7 experts in chronic illness management. They rated the relevance of each item in terms of the construct 'chronic illness management' on a 4-point Likert scale (1=not relevant, 4=highly relevant). Content validity indexes were calculated for each item and the survey as a whole. Of the 51 items, 42 were had good content validity. To evaluate inter-rater reliability, a pilot study was conducted in 2 Tx programs. The percentage agreement in the 2 centers for the total instrument scores was 84.6% and 74.8%. Synthesizing the findings of the studies yields the following 3 key results which contribute to the current state of knowledge. First, there remains a significant knowledge deficit in view of the influence of healthcare system factors on medication adherence calling for further research investment. Second, nurses' practice patterns in view of adherence-related interventions call for a change in curricula. Finally, The CIMI-BRIGHT instrument is the first and only tool developed to systematically assess the level of chronic illness management in Tx centers and thus provides a building block for further observational and intervention research in transplantation

Prevalence and correlates of influenza vaccination among kidney transplant patients

CONTEXT: Immunosuppressive regimens increase kidney transplant patients' risk of contracting life-threatening influenza. However, little information exists about the prevalence and correlates of influenza vaccinations in this population. OBJECTIVE: To determine the prevalence and explore correlates of influenza vaccination in kidney transplant recipients. DESIGN, SAMPLE, AND SETTING: This cross-sectional study used data from the Supporting Medication Adherence in Renal Transplantation study. The convenience sample consisted of 356 adult kidney transplant recipients (58.1% male; mean age, 52.9 [SD 13.53] years) recruited from 2 Swiss transplant outpatient clinics. Influenza vaccination status was assessed by self-report (yes/no). MAIN OUTCOME MEASURE: Known correlates of vaccination in chronically ill patients (older age, cohabitation, higher education, higher socioeconomic status, financial stability, more comorbid diseases, nonsmoking status, and clinical site where care is received) were entered into a multiple logistic regression model. RESULTS: Of the 356 patients, only 83 (23.3%) reported having been vaccinated against influenza in the previous year. Positive vaccination status was significantly related to older age (odds ratio, 1.04; 95% confidence interval, 1.02-1.06). CONCLUSION: Despite national and international guidelines recommending influenza vaccination in kidney transplant recipients, the prevalence of influenza vaccination in this sample was low. This study's results suggest that transplant centers need to implement policies to maximize influenza vaccination of their patients

An ecological perspective on medication adherence

Adherence to a prescribed medication regimen is influenced not only by characteristics of the individual patient, but also by factors within the patient's environment, or so-called system level factors. Until now, however, health care system factors have received relatively little attention in explaining medication nonadherence. Ecological models might serve as a framework to help explain the influence of health care system factors on patient behavior (e.g., adherence). In an ecological model, different levels of factors influence patients' behavior, i.e. factors at the patient-level, micro- (provider and social support), meso- (health care organization), and macro (health policy) -levels. In order to understand medication adherence and implement interventions to improve medication adherence, factors at these different levels should be taking into consideration. This paper describes an ecological model compromised of the most important factors at the patient-, micro-, meso- and macro-levels.status: publishe

Medication non-adherence as a critical factor in the management of presumed resistant hypertension: a narrative review

Medication non-adherence is a crucial behavioural risk factor in hypertension management. Forty-three to 65.5% of patients with presumed resistant hypertension are non-adherent. This narrative review focuses on the definition of adherence/non-adherence, measurement of medication adherence, and the management of medication non-adherence in resistant hypertension using multilevel intervention approaches to prevent or remediate non-adherence.; A review of adherence and resistant hypertension literature was conducted. Medication adherence consists of three different yet related dimensions: initiation, implementation, and discontinuation. To effectively measure medication non-adherence, a combination of direct and indirect methods is optimal. Interventions to tackle medication non-adherence must be integrated in multilevel approaches. Interventions at the patient level can combine educational/cognitive (e.g., patient education), behavioural/counselling (e.g., reducing complexity, cueing, tailoring to patient's lifestyle) and psychological/affective (e.g., social support) approaches. Improving provider competencies (e.g., reducing regimen complexity), implementing new care models inspired by principles of chronic illness management, and interventions at the healthcare system level can be combined.; Improvement of patient outcomes in presumed resistant hypertension will only be possible if the behavioural dimensions of patient management are fully integrated at all levels

An ecological perspective on medication adherence

Adherence to a prescribed medication regimen is influenced not only by characteristics of the individual patient, but also by factors within the patient's environment, or so-called system level factors. Until now, however, health care system factors have received relatively little attention in explaining medication nonadherence. Ecological models might serve as a framework to help explain the influence of health care system factors on patient behavior (e.g., adherence). In an ecological model, different levels of factors influence patients' behavior, i.e. factors at the patient-level, micro- (provider and social support), meso- (health care organization), and macro (health policy) -levels. In order to understand medication adherence and implement interventions to improve medication adherence, factors at these different levels should be taking into consideration. This paper describes an ecological model compromised of the most important factors at the patient-, micro-, meso- and macro-levels

Development, content validity and inter-rater reliability testing of the CIMI-BRIGHT: an instrument to assess the level of chronic illness management implemented in solid organ transplant programs

Introduction: In this article we report the item generation, validity and inter-rater reliability testing of the Chronic Illness Management Implementation – Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation instrument. Methods: The instrument was developed based on the World Health Organization’s Innovative Care for Chronic Conditions framework by the research team in consultation with a chronic illness management expert and a focus group of transplant nurses. Seven chronic illness management experts were used to assist in calculating the content validity index for each item and the total instrument. A pilot study was conducted in two transplant programmes to examine inter-rater reliability. Percent agreement by professionals working within the same centre was calculated by averaging the percent agreement on individual items. Results: The instrument content validity index was 87%. The percentage agreement in both transplant programmes was 84.6% and 74.8%, indicating good inter-rater reliability. The final instrument consists of 55 items. Discussion: The results are promising, suggesting its value as a tool to measure implementation of chronic illness management in transplant programmes

Validation of the patient assessment of chronic illness care (PACIC) short form scale in heart transplant recipients: the international cross-sectional bright study

Transplant recipients are chronically ill patients, who require lifelong follow-up to manage co-morbidities and prevent graft loss. This necessitates a system of care that is congruent with the Chronic Care Model. The eleven-item self-report Patient Assessment of Chronic Illness Care (PACIC) scale assesses whether chronic care is congruent with the Chronic Care Model, yet its validity for heart transplant patients has not been tested.; We tested the validity of the English version of the PACIC, and compared the similarity of the internal structure of the PACIC across English-speaking countries (USA, Canada, Australia and United Kingdom) and across six languages (French, German, Dutch, Spanish, Italian and Portuguese). This was done using data from the cross-sectional international BRIGHT study that included 1378 heart transplant patients from eleven countries across 4 continents. To test the validity of the instrument, confirmatory factor analyses to check the expected unidimensional internal structure, and relations to other variables, were performed.; Main analyses confirmed the validity of the English PACIC version for heart transplant patients. Exploratory analyses across English-speaking countries and languages also confirmed the single factorial dimension, except in Italian and Spanish.; This scale could help healthcare providers monitor level of chronic illness management and improve transplantation care.; Clinicaltrials.gov ID: NCT01608477, first patient enrolled in March 2012, registered retrospectively: May 30, 2012