scholarly journals Process Evaluation of MAPS: A Highly Tailored Digital Intervention to Support Medication Adherence in Primary Care Setting

2021 ◽  
Vol 9 ◽  
Author(s):  
Aikaterini Kassavou ◽  
Charlotte A. Court ◽  
Venus Mirzaei ◽  
James Brimicombe ◽  
Simon Edwards ◽  
...  
Keyword(s):  
Primary Care ◽  
Medication Adherence ◽  
Process Evaluation ◽  
Behaviour Change ◽  
Qualitative Evidence Synthesis ◽  
Intervention Effectiveness ◽  
Trial Process ◽  
Digital Intervention ◽  
Underlying Mechanisms ◽  
Post Trial

Background: Medication adherence can prevent health risks, but many patients do not adhere to their prescribed treatment. Our recent trial found that a digital intervention was effective at improving medication adherence in non-adherent patients with Hypertension or Type 2 Diabetes; but we do not know how it brought about behavioural changes. This research is a post-trial process evaluation of the mechanism by which the intervention achieved its intended effects.Methods: A mixed methods design with quantitative and qualitative evidence synthesis was employed. Data was generated by two studies. Study 1 used questionnaires to measure the underlying mechanisms of and the medication adherence behaviour, and digital logfiles to objectively capture intervention effects on the process of behaviour change. Multilevel regression analysis on 57 complete intervention group cases tested the effects of the intervention at modifying the mechanism of behaviour change and in turn at improving medication adherence. Study 2 used in depth interviews with a subsample of 20 intervention patients, and eight practise nurses. Thematic analysis provided evidence about the overarching intervention functions and recommendations to improve intervention reach and impact in primary care.Results: Study 1 found that intervention effectiveness was significantly associated with positive changes in the underlying mechanisms of behaviour change (R2 = 0.26, SE = 0.98, P = 0.00); and this effect was heightened twofold when the tailored intervention content and reporting on medication taking (R2 = 0.59, SE = 0.74, P = 0.00) was interested into the regression model. Study 2 suggested that the intervention supported motivation and ability to adherence, although clinically meaningful effects would require very brief medication adherence risk appraisal and signposting to ongoing digitally delivered behavioural support during clinical consultations.Conclusion: This post trial process evaluation used objective methods to capture the intervention effect on the mechanisms of behaviour change to explain intervention effectiveness, and subjective accounts to explore the circumstances under which these effects were achieved. The results of this process evaluation will inform a large scale randomised controlled trial in primary care.

scholarly journals Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Kate Morton ◽  
Laura Dennison ◽  
Rebecca Band ◽  
Beth Stuart ◽  
Laura Wilde ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Decision Making ◽  
Mixed Methods ◽  
Process Evaluation ◽  
Contextual Factors ◽  
Clinical Inertia ◽  
Adherence To Medication ◽  
Factors Influencing ◽  
Digital Intervention

Abstract Background A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation. Methods One hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol. Results Mean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients. Conclusions This mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response. Trial registration (ISRCTN13790648). Registered 14 May 2015.

scholarly journals Feasibility study of a digitalized nurse practitioner-led intervention to improve medication adherence in type 2 diabetes patients in Dutch primary care

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Stijn Hogervorst ◽  
Marcel Adriaanse ◽  
Hella Brandt ◽  
Marcia Vervloet ◽  
Liset van Dijk ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Medication Adherence ◽  
Focus Groups ◽  
Process Evaluation ◽  
Nurse Practitioner ◽  
Phase 1 ◽  
Healthcare Providers ◽  
Phase 2

Abstract Purpose The purpose of this feasibility study was to improve and implement an intervention aimed at enhancing medication adherence in sub-optimally controlled and non-adherent type 2 diabetes (T2DM) patients in primary care. Methods Four phases were completed: (1) context analysis, (2) collaboration protocol development, (3) digitalization, and (4) process evaluation. Two community pharmacies and seven general practices participated. In phase 1, two focus groups were conducted, of which one with healthcare providers (HCP, N = 5) and one with patients (N = 11). In phase 4, four semi-structured interviews and one focus group (N = 6) were conducted with healthcare providers. The goal of these focus groups and interviews was to obtain insights into current care to support medication adherence (phase 1), opportunities for collaboration (phase 2) and process evaluation (phase 4). Data were analyzed in Atlas.ti using thematic analyses. Results Both T2DM patients and HCPs considered medication adherence vital. Suboptimal collaboration between HCPs and unreliable ways to monitor medication non-adherence appeared important barriers for adequate care to support medication adherence (phase 1). The nurse practitioner (NP) was chosen as the interventionist with supportive roles for other HCPs (phase 2). All components of the intervention were digitalized (phase 3). The implementation of the digitalized intervention was reported to be suboptimal (phase 4). Main reasons were that pharmacy refill data were unreliable, NPs experienced difficulties addressing medication non-adherence adequately and collaboration between HCPs was suboptimal. Conclusions The medication adherence enhancing intervention was successfully digitalized, but implementation of the digitalized intervention appeared not feasible as of yet.

scholarly journals Improving mobility and participation of older people with vertigo, dizziness and balance disorders in primary care using a care pathway: feasibility study and process evaluation

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Eva Seckler ◽  
Verena Regauer ◽  
Melanie Krüger ◽  
Anna Gabriel ◽  
Joachim Hermsdörfer ◽  
...  
Keyword(s):  
Primary Care ◽  
Data Collection ◽  
Older People ◽  
Process Evaluation ◽  
Feasibility Study ◽  
Health Professionals ◽  
Implementation Strategy ◽  
Care Pathway ◽  
Main Trial ◽  
Telephone Helpline

Abstract Background Community-dwelling older people are frequently affected by vertigo, dizziness and balance disorders (VDB). We previously developed a care pathway (CPW) to improve their mobility and participation by offering standardized approaches for general practitioners (GPs) and physical therapists (PTs). We aimed to assess the feasibility of the intervention, its implementation strategy and the study procedures in preparation for the subsequent main trial. Methods This 12-week prospective cohort feasibility study was accompanied by a process evaluation designed according to the UK Medical Research Council’s Guidance for developing and evaluating complex interventions. Patients with VDB (≥65 years), GPs and PTs in primary care were included. The intervention consisted of a diagnostic screening checklist for GPs and a guide for PTs. The implementation strategy included specific educational trainings and a telephone helpline. Data for mixed-method process evaluation were collected via standardized questionnaires, field notes and qualitative interviews. Quantitative data were analysed using descriptive statistics, qualitative data using content analysis. Results A total of five GP practices (seven single GPs), 10 PT practices and 22 patients were included in the study. The recruitment of GPs and patients was challenging (response rates: GP practices: 28%, PT practices: 39%). Ninety-one percent of the patients and all health professionals completed the study. The health professionals responded well to the educational trainings; the utilization of the telephone helpline was low (one call each from GPs and PTs). Familiarisation with the routine of application of the intervention and positive attitudes were emphasized as facilitators of the implementation of the intervention, whereas a lack of time was mentioned as a barrier. Despite difficulties in the GPs’ adherence to the intervention protocol, the GPs, PTs and patients saw benefit in the intervention. The patients’ treatment adherence to physical therapy was good. There were minor issues in data collection, but no unintended consequences. Conclusion Although the process evaluation provided good support for the feasibility of study procedures, the intervention and its implementation strategy, we identified a need for improvement in recruitment of participants, the GP intervention part and the data collection procedures. The findings will inform the main trial to test the interventions effectiveness in a cluster RCT. Trial registration Projektdatenbank Versorgungsforschung Deutschland (German registry Health Services Research) VfD_MobilE-PHY_17_003910, date of registration: 30.11.2017; Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00022918, date of registration: 03.09.2020 (retrospectively registered).

scholarly journals Optimal cut-off points for adherence measure among patients with type 2 diabetes in primary care clinics: a retrospective analysis

2021 ◽  
Vol 12 ◽  
pp. 204062232199026
Author(s):  
Ming Tsuey Lim ◽  
Norazida Ab Rahman ◽  
Xin Rou Teh ◽  
Chee Lee Chan ◽  
Shantini Thevendran ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Medication Adherence ◽  
Poor Adherence ◽  
Adherence Measure ◽  
Primary Care Clinics ◽  
Assessment Period ◽  
Hba1c Target ◽  
Optimal Adherence

Background: Medication adherence measures are often dichotomized to classify patients into those with good or poor adherence using a cut-off value ⩾80%, but this cut-off may not be universal across diseases or medication classes. This study aimed to examine the cut-off value that optimally distinguish good and poor adherence by using the medication possession ratio (MPR) and proportion of days covered (PDC) as adherence measures and glycated hemoglobin (HbA1c) as outcome measure among type 2 diabetes mellitus (T2DM) patients. Method: We used pharmacy dispensing data of 1461 eligible T2DM patients from public primary care clinics in Malaysia treated with oral antidiabetic drugs between January 2018 and May 2019. Adherence rates were calculated during the period preceding the HbA1c measurement. Adherence cut-off values for the following conditions were compared: adherence measure (MPR versus PDC), assessment period (90-day versus 180-day), and HbA1c target (⩽7.0% versus ⩽8.0%). Results: The optimal adherence cut-offs for MPR and PDC in predicting HbA1c ⩽7.0% ranged between 86.1% and 98.3% across the two assessment periods. In predicting HbA1c ⩽8.0%, the optimal adherence cut-offs ranged from 86.1% to 92.8%. The cut-off value was notably higher with PDC as the adherence measure, shorter assessment period, and a stricter HbA1c target (⩽7.0%) as outcome. Conclusion: We found that optimal adherence cut-off appeared to be slightly higher than the conventional value of 80%. The adherence thresholds may vary depending on the length of assessment period and outcome definition but a reasonably wise cut-off to distinguish good versus poor medication adherence to be clinically meaningful should be at 90%.

scholarly journals Effectiveness and cost-effectiveness of implementing HIV testing in primary care in East London: protocol for an interrupted time series analysis

BMJ Open ◽  
2017 ◽  
Vol 7 (12) ◽  
pp. e018163 ◽  
Author(s):  
Werner Leber ◽  
Lee Beresford ◽  
Claire Nightingale ◽  
Estela Capelas Barbosa ◽  
Stephen Morris ◽  
...  
Keyword(s):  
Primary Care ◽  
Time Series ◽  
General Practice ◽  
Cost Effectiveness ◽  
Hiv Testing ◽  
Cost Effective ◽  
Interrupted Time Series ◽  
Rapid Hiv Testing ◽  
Post Trial ◽  
Implementation Programme

IntroductionHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets).Methods and analysisService evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses.Ethics and disseminationThe chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

scholarly journals Critical aspects of the management of stable coronary artery disease in primary care practice or how to increase the efficacy of evidence-based pharmacological therapy?

2020 ◽  
Vol 6 (3) ◽  
pp. 15-20
Author(s):  
Sergey K. Zyryanov ◽  
Sergey B. Fitilev ◽  
Alexander V. Vozzhaev ◽  
Irina I. Shkrebniova ◽  
Dmitry A. Klyuev
Keyword(s):  
Primary Care ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Medication Adherence ◽  
Stable Coronary Artery Disease ◽  
Density Lipoprotein ◽  
Pharmacological Therapy ◽  
Care Practice ◽  
Cross Sectional ◽  
Artery Disease

Introduction: The publication describes a fragment of the pharmacoepidemiologic study conducted to review the quality of management of patients with stable coronary artery disease (SCAD) in primary care over a 12-year period. The aim of the study was to justify the application of standard operating procedures (SOPs). Such determinants of pharmacotherapy as non-pharmacological modification of cardiovascular risk factors (RFs) and medication adherence were analyzed. Material and methods: A retrospective, cross-sectional, 3-stage (2006, 2011, 2018) study was conducted in a primary care setting of Moscow. As many as 3027, 1834, 805 patients with verified diagnosis of SCAD were included. Demographics, medical history, data on modifiable RFs and prescribed drug therapies were collected. At the third stage, medication adherence was measured, using the 8-item Morisky scale. Results and discussion: Over a 7-year period, better control of modifiable RFs in coronary patients was revealed. The target levels of blood pressure were reached in 58.3% (+20.7%; p < 0.05) of the patients, total cholesterol – in 33.0% (+16.0%; p < 0.05), and low-density lipoprotein cholesterol – in 23.3% (+12.2%; p < 0.05). Two critical problems that determined still inadequate RFs control were identified. The attention of physicians to RFs and rates of non-pharmacological interventions remained low throughout the study. Information on lifestyle RFs was recorded in fewer than one-third of the subjects. The lipid profile was registered only in half of patients’ histories. Non-adherence to pharmacotherapy was identified in 51.3% of patients. Conclusion: Further increase in efficacy of pharmacotherapy might be provided by application of SOPs regarding the registration and correction of modifiable cardiovascular RFs, identification of non-adherent patients and promotion of medication adherence.

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