Shared decision-making in maternity care in Saudi Arabia: A cross-sectional study.

BACKGROUND: Shared decision-making (SDM) in maternity care involves women actively in decisions, thereby reducing decisional conflicts and enhancing satisfaction with care. AIM: To investigate SDM and the factors associated with it, and its correlation with respect in maternity care in Saudi Arabia. METHODS: A comprehensive, nationwide online questionnaire-based study was conducted between January to May 2023, involving women aged 18 years and above who were either pregnant or had experienced pregnancy/childbirth in the past 12 months. The Mothers' Autonomy in Decision-Making (MADM) scale and the Mothers of Respect Index (MORi) were used. Low to very low SDM was defined as a score of ≤ 24 on the MADM and low to very low respected was defined as a score of ≤ 49 on the MORi. RESULTS: A total of 505 women completed the survey. Low to very low SDM was reported by 137 (34.1 %, 95 confidence interval (CI), 29.6 % - 38.9 %) women. Factors significantly associated with low to very low SDM included seeing different obstetricians of different gender at each visit (adjusted odds ratio (AOR) 2.0, 95 % CI, 1.0 - 3.9), not meeting the same obstetrician throughout the pregnancy (AOR 2.6, 95 % CI, 1.2 - 5.6) and having an instrumental vaginal birth (AOR 6.67, 95 % CI, 1.6 - 28.1). There was a positive association between low to very SDM and feeling of low to very low respect ((χ2 = 83.8173, p < 0.001). CONCLUSION: More than one-third of women experienced low to very low SDM in maternity care. This should alert healthcare providers to the importance of continuity of care in Saudi Arabia.

Factors Influencing Kidney Transplantation Experiences for Patients From Culturally and Linguistically Diverse Backgrounds: A Qualitative Study.

BACKGROUND: Disparities in aspects of chronic kidney disease progression and management exist for patients from culturally and linguistically diverse (CALD) backgrounds, including with treatment and outcomes for kidney transplantation. OBJECTIVE: This study aimed to explore factors that impact kidney transplant outcomes from the perspective of kidney transplant recipients (KTRs) from CALD backgrounds and their family caregivers. METHODS: A descriptive qualitative design was utilised. Participants were recruited from two tertiary hospitals in Victoria, Australia. Semi-structured interviews were conducted with KTRs who were born overseas in countries where English is not the primary language. Interviews were also conducted with family caregivers. Analysis was guided by the Framework Method, and emergent subcategories were mapped into the categories identified in Andersen's Health Service Utilisation Model. RESULTS: Data from 21 KTRs and five caregivers were grouped under the categories of Population Characteristics, Environment, Health Behaviour and Outcomes. KTRs believed that neither culture nor religious beliefs impacted how they managed their transplant or healthcare utilisation. KTRs expressed satisfaction with their care, felt no inequity with how they were treated by health professionals and expressed gratitude for the Australian healthcare system. Language did not necessarily impact transplant outcomes, but there was a reliance on interpreters for non-English-speaking patients as most written information was in English. Caregivers were instrumental in providing support but discussed the challenges involved. CONCLUSION: This study explored factors influencing kidney transplantation for KTRs from a CALD background. The study provided insight into how to deliver quality healthcare to these patients, highlighting the importance of health services providing information that is written in the patient's own language and respectively asking KTRs about their health beliefs or customs. Caregivers were instrumental in supporting KTRs, but there is a need to better prepare them for this role. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement was integrated into the design and delivery of the study. KTRs from CALD backgrounds assisted with framing the research questions and offering advice on the recruitment and data collection process.

Assessment of academic burnout and professional self-concept in undergraduate nursing students: A cross-sectional study.

BACKGROUND: Nursing turnover and shortage are an increasing phenomenon throughout the world; thus, it is critical to determine the factors that contribute to them. Nursing students' retention plans and turnover intentions are significantly influenced by academic burnout and professional self-concept. The COVID-19 pandemic could aggravate the study-associated stresses leading to burnout and jeopardize the nursing student's professional socialisation which is a key factor in their professional self-concept formation, it is important to investigate their relationship. PURPOSE: To examine the relationship between professional self-concept and academic burnout among undergraduate Bachelor of Nursing students and identify predictors related to academic burnout. METHOD: This cross-sectional study was conducted from May to June 2021. The participants were undergraduate Bachelor of Nursing students from two campuses of a large university in Victoria, Australia. Out of 1630 students, 198 participated in the study. The students were invited to complete an online survey through the university's online learning platform or flyers. Descriptive statistics, Pearson correlation, and Bootstrapping approaches were used to analyse the data. RESULTS: The analysis found a significant positive correlation between the nursing students' total professional self-concept and academic burnout professional efficacy (r = 0.48; p < 0.01). A significant negative correlation was also detected between the total professional self-concept and academic burnout cynicism (r = - 0.21; p < 0.01). Moreover, the total nurse professional self-concept was a significant predictor of both academic burnout subscales cynicism and professional efficacy (p < 0.01). CONCLUSIONS: Positive nursing professional self-concept may alleviate student's academic burnout, and it might contribute to the promotion of their professional efficacy.

Pregnant persons and birth partners' experiences of shared decision-making during pregnancy and childbirth: An umbrella review.

OBJECTIVES: This umbrella review aimed to summarize evidence on pregnant persons and/or their birth partners' experiences and expectations of SDM during pregnancy and childbirth. METHODS: We searched eight databases from 2011 to 2023. Quantitative, qualitative and mixed methods systematic reviews were included in this review. RESULTS: We have identified 26 reviews that report on 622 primary studies involving over 213,000 pregnant persons and 22,000 birth partners, examining a broad range of decision-making scenarios in maternity care. The three-talk model was used to categorise the themes which include communication, weighing options, and making a decision. Multiple reviews have reported that pregnant persons and birth partners have mixed experiences in several decision-making scenarios, with insufficient information and inadequate consideration or answers to their questions being common issues. Pregnant persons and birth partners prefer clear explanations, simple communication, and involvement in decision-making. Exclusion from the decision-making during pregnancy and childbirth may lead to negative experiences, whilst involvement improves satisfaction, reduces distress and fosters empowerment. CONCLUSIONS: The review highlights the importance of promoting SDM in maternity care, as it is fundamental to promoting maternal, newborn, and family well-being. PRACTICE IMPLICATIONS: Health systems should redesign antenatal classes and train healthcare providers to enhance communication skills and encourage informed decision-making by pregnant persons and birth partners.

The PNG Midwifery Leadership Buddy Program: An evaluation.

PROBLEM: Papua New Guinea (PNG) has a high rate of preventable maternal and neonatal deaths. BACKGROUND: Developing midwifery leadership is vital to addressing the current deficits in health outcomes for women and their babies. The PNG Midwifery Leadership Buddy Program responds to this need through leadership training and partnering of midwives across PNG and Australia. Participants in the program undertake a workshop in Port Moresby and commit to a 12-month peer support relationship with a midwife 'buddy'. AIM: To evaluate participants' experiences of the Buddy Program and the impact of the program on leadership skills. METHODS: All 23 midwives who had completed the program were invited to participate in the evaluation. The study used a concurrent mixed methods approach. Qualitative data were collected via interviews and then thematically analysed. Quantitative data were collected via a survey and analysed with descriptive statistics, then findings were triangulated. FINDINGS: Participants reported increased confidence for leadership, action and advocacy. Numerous quality improvement projects were implemented in health services in PNG. Challenges to the success of the program included technological limitations, cultural differences and the COVID-19 pandemic. DISCUSSION: Participants reported the PNG Midwifery Leadership Buddy Program was successful in increasing their leadership skills and collaborative opportunities, as well as strengthening midwifery more broadly. While there were barriers, most participants valued the experience and believed it benefited them professionally and personally CONCLUSION: The Buddy Program provides a practical model for building midwifery leadership capacity that may be transferrable to other contexts.

Knowledge, attitudes, and beliefs of cardiovascular disease prevention in young adults in the country of Georgia.

INTRODUCTION: Cardiovascular disease (CVD) accounts for 46% of all mortality in the country of Georgia (former Soviet Union). Young adults in that country have not been studied regarding CVD and a need exists to understand lifestyle modifications to promote cardiovascular health. DESIGN: An interpretive description qualitative design was used to explore Georgian young adults' knowledge, attitudes, and beliefs of CVD preventative practices and life experiences. METHODS: A convenience sample of 19 ethnic Georgian participants (18-40 years old) who were fluent in either English, Georgian, or Russian from a local private university was used. Semi-structured interviews were conducted via video conferencing utilizing an interpreter. RESULTS: Four themes were identified: (1) CVD and risk factor knowledge, (2) prevention attitudes, beliefs, and gender differences, (3) health literacy influences, and (4) culture and societal impacts. CVD knowledge was limited and influenced by health literacy and the current healthcare system in Georgia. CONCLUSION: Cultural and societal gender norms influence cardiovascular health behaviors. CLINICAL IMPLICATIONS: Georgian nurses can play a key role in CVD education and screening for young adults in Georgia.

Factors associated with readmission in chronic kidney disease: Systematic review and meta-analysis.

BACKGROUND: Risk factors associated with all-cause hospital readmission are poorly characterised in patients with chronic kidney disease. OBJECTIVE: A systematic review and meta-analysis were conducted to identify risk factors and protectors of hospital readmission in chronic kidney disease. DESIGN, PARTICIPANTS & MEASUREMENTS: Studies involving adult patients were identified from four databases from inception to 31/03/2020. Random-effects meta-analyses were conducted to determine factors associated with all-cause 30-day hospital readmission in general chronic kidney disease, in dialysis and in kidney transplant recipient groups. RESULTS: Eighty relevant studies (chronic kidney disease, n = 14 studies; dialysis, n = 34 studies; and transplant, n = 32 studies) were identified. Meta-analysis revealed that in both chronic kidney disease and transplant groups, increasing age in years and days spent at the hospital during the initial stay were associated with a higher risk of 30-day readmission. Other risk factors identified included increasing body mass index (kg/m2 ) in the transplant group, and functional impairment and discharge destination in the dialysis group. Within the chronic kidney disease ​​​​group, having an outpatient follow-up appointment with a nephrologist within 14 days of discharge was protective against readmission but this was not protective if provided by a primary care provider or a cardiologist. CONCLUSION: Risk-reduction interventions that can be implemented include a nephrologist appointment within 14 days of hospital discharge, rehabilitation programme for functional improvement in the dialysis group and meal plans in the transplant group. Future risk analysis should focus on modifiable factors to ensure that strategies can be tested and implemented in those who are more at risk.

Using telehealth consultations for healthcare provision to patients from non-Indigenous racial/ethnic minorities: a systematic review.

OBJECTIVE: The COVID-19 pandemic has seen a rapid adoption of telehealth consultations, potentially creating new barriers to healthcare access for racial/ethnic minorities. This systematic review explored the use of telehealth consultations for people from racial/ethnic minority populations in relation to health outcomes, access to care, implementation facilitators and barriers, and satisfaction with care. MATERIALS AND METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Joanna Briggs Institute Manual for Evidence Synthesis. Five major databases were searched to identify relevant studies. Screening, full-text review, quality appraisal, and data extraction were all completed independently and in duplicate. A convergent integrated approach to data synthesis was applied with findings reported narratively. RESULTS: A total of 28 studies met the inclusion criteria. Telehealth-delivered interventions were mostly effective for the treatment/management of physical and mental health conditions including depression, diabetes, and hypertension. In several studies, telehealth improved access to care by providing financial and time benefits to patients. Technological difficulties were the main barriers to effective telehealth consultation, although overall satisfaction with telehealth-delivered care was high. DISCUSSION: Telehealth-delivered care for racial/ethnic minorities offers promise across a range of conditions and outcomes, particularly when delivered in the patient's preferred language. However, telehealth may be problematic for some due to cost and limited digital and health literacy. CONCLUSION: The development and implementation of guidelines, policies, and practices in relation to telehealth consultations for racial/ethnic minorities should consider the barriers and facilitators identified in this review to ensure existing health disparities are not exacerbated.

Associations between hyper-polypharmacy and potentially inappropriate prescribing with clinical and functional outcomes in older adults.

BACKGROUND: Hyper-polypharmacy and potentially inappropriate prescribing (PIP) are common among older inpatients. This study investigated associations between hyper-polypharmacy and PIP with clinical and functional outcomes in older adults at 3-months after hospital discharge. RESEARCH DESIGN AND METHOD: At discharge, prescribed medications were collected and PIPs, comprising potentially inappropriate medications (PIM) and potential prescribing omissions (PPO), were retrospectively identified using STOPP/START version 2. Outcomes were collected prospectively via telephone follow-up and audit. RESULTS: Data for 232 patients (mean age 80 years) were analyzed. PIP prevalence at discharge was 73.7% (PIMs 62.5%, PPOs 36.6%). Exposure to at least 1 PIM was associated with an increased occurrence of unplanned hospital readmission (adjusted odds ratio (AOR) 5.09; 95% CI 2.38─10.85), emergency department presentation (AOR 4.69; 95% CI 1.55─14.21) and the composite outcome (AOR 6.83; 95% CI 3.20─14.57). The number rather than the presence of PIMs was significantly associated with increased dependency in at least 1 activity of daily living (ADL) (AOR 2.31; 95% CI 1.08─4.20). Increased PIP use was associated with mortality (AOR 1.45; 95% CI 1.05─1.99). CONCLUSION: PIPs overall, and PIMs specifically, were frequent in older adults at hospital discharge, and were associated with increased re-hospitalizations and dependence in ADLs at 3-months post-discharge.

Translation to practice of cultural safety education in nursing and midwifery: A realist review.

OBJECTIVES: Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives. DESIGN: A systematic review following realist review publication standards. DATA SOURCES: Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included. REVIEW METHODS: A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed. RESULTS: Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety. CONCLUSION: Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety.

Transition from a renal paediatric clinic to an adult clinic: Perspectives of adolescents and young adults, parents and health professionals.

The management of chronic kidney disease is complex. With disease management being the responsibility of parents in the paediatric renal clinic, the responsibility is gradually shifted to adolescents and young adults during the transition to adult care. This multi-perspective qualitative study aimed to explore the experiences of adolescents and young adults, their parents and health professionals to gain an insight into transitional care. Focussing on the transition process and transfer to adult care, 18 adolescents and young adults and eight mothers participated in individual semi-structured interviews. Additionally, three focus groups were conducted with 20 multidisciplinary health professionals. Data were transcribed verbatim and analysed thematically. Similar responses from adolescents and young adults and mothers included the reluctance to leave the paediatric health service. Mothers found the transition to adult care more challenging than the adolescents and young adults. While health professionals acknowledged that engaging adolescents and young adults in their own care was challenging, they believed parents had an important role in facilitating their child's independence. This study highlights that health professionals in both paediatric and adult health services need to work collaboratively. However, importantly, health professionals need to be mindful that parents require an equal amount of engagement as adolescents and young adults, if not more, to mitigate parental barriers in achieving a successful transfer.

Practice priorities for acute care nursing: A Delphi study.

AIMS AND OBJECTIVES: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus. BACKGROUND: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care. DESIGN: Delphi Method. METHOD: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist. RESULTS: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care. CONCLUSION: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise. RELEVANCE TO CLINICAL PRACTICE: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

Transitioning adolescents to adult nephrology care: a systematic review of the experiences of adolescents, parents, and health professionals.

A challenging phase for adolescents with chronic kidney disease (CKD) is the transition from a pediatric to an adult health service. Failure to adequately prepare adolescents for transfer to adult care can lead to a decline in attendance to the adult clinic and an increase in the rate of non-adherence to medical treatment. The aim of this systematic review was to analyze studies exploring the experiences of adolescents, parents, and health professionals regarding the transition process of adolescents with CKD. Six databases were searched from inception to October 2018 for primary research articles. Eleven articles met the inclusion criteria, with only one exploring the parents' experiences. The results indicated that up to 50% of adolescents did not feel prepared to transfer to adult care at the time of transfer, and the timing was not ideal for some adolescents. Health professionals acknowledged that adolescents and parents felt emotional attachment to the pediatric unit, which led to anxiety about transferring. Once in adult care, adolescents felt out of place among the older patients, overwhelmed by the environment and the lack of attention from health professionals. Initiatives that could support transfer include allowing adolescents to attend pediatric consultation independently and meeting with adult health professionals prior to transfer. This review found that the transition process must be more responsive to adolescents by tailoring the timing of transfer according to their ability to assume self-care responsibility. In addition, there is a need to focus on the parents and their role in the transition process.

Rheumatologists' insight into medication adherence in patients with rheumatoid arthritis: A qualitative study.

BACKGROUND: Medication non-adherence is prevalent among patients with rheumatoid arthritis (RA). Rheumatologists are specialists in medication prescribing and counselling for RA, but their insights regarding medication adherence have not been studied. OBJECTIVE: To explore rheumatologists' insights into medication adherence in patients with RA. METHODS: A qualitative study using semi-structured interviews with 10 rheumatologists in Iran was undertaken. Thematic analysis was conducted to identify how rheumatologists assess medication adherence and their perceived determinants of adherence. The identified determinants of adherence were mapped according to the Andersen's Behavioral Model of Health Service Use. RESULTS: Six participants were male, and the mean age was 47 years. The mean years of experience as a rheumatologist was 8.6 (SD = 7.1) years. Rheumatologists did not use a validated tool for medication adherence assessment. They assessed medication adherence either by asking their patients simple questions or using laboratory test results. The identified determinants of adherence were divided into 3 groups: patient-, rheumatologist- and healthcare organization-related determinants. The proposed suggestions to improve adherence were: (a) to understand a patient's financial situation before prescribing more expensive medications; (b) to employ a dose-reducing strategy; (c) to give hope to patients regarding remission; and (d) to arrange a session with the nurse educator. CONCLUSION: The findings of this study provide insight into rheumatologists' perspectives on medication adherence of patients with RA. The identified determinants of adherence could be considered when developing initiatives to improve medication adherence in this group of patients.

Improving medication adherence in adult kidney transplantation (IMAKT): A pilot randomised controlled trial.

Resources to support long-term medication adherence in kidney transplantation are limited. This study aimed to determine the efficacy of an intervention designed for kidney transplant recipients to enhance medication adherence. A single-blind, multi-site, 12-month pilot randomised controlled trial was conducted at all five public hospitals providing adult kidney transplantation in Victoria, Australia. Participants were recruited at 4 to 6 weeks post-transplantation. Thirty-five participants were randomly assigned to a 3-month intervention, involving a face-to-face meeting (a medication review and a consumer-centred video) and health coaching every two weeks. Thirty-six were randomised to receive usual care. All participants were followed for nine months post-intervention. There were no differences in adherence between groups measured by Medication Event Monitoring System (MEMS), however, it was underutilised by 42% of participants. Based on the self-reported Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS©) score, the percentage of adherent participants decreased significantly between baseline and 3 to 12 months in the control group (p-values < 0.001) whilst the percentage of adherent participants in the intervention group remained constant over time. No group differences were detected in other outcomes. Due to the complex medication regimen, developing and testing a medication adherence intervention is difficult in kidney transplantation.

Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study.

AIM: First, to assess the clinical characteristics and medication adherence to oral rheumatoid arthritis (RA) medications in patients with RA. Second, to examine adherence determinants with a focus on the effect of medication out-of-pocket (OOP) costs on medication adherence to oral RA medications. Lastly, to examine cost-related medication non-adherence (CRN) in patients with RA. METHODS: A cross-sectional study of patients with RA was conducted at rheumatology outpatient clinics in Shiraz, Iran. The data collection survey consisted of 5 sections including demographic questions, disease-related questions, Compliance Questionnaire Rheumatology (CQR), CRN questions and an open-ended question. SPSS version 24 was used for analysis. RESULTS: A total of 308 completed surveys were collected. Adherence to oral RA medications was 40.3%. Just under 20% of participants were biologic disease-modifying antirheumatic drugs (bDMARDs) users and these bDMARDs users were 0.82 times less likely to be adherent to their oral RA medications compared to non-bDMARDs users (P < 0.05). There was no statistically significant association between OOP costs and adherence to oral RA medications (P > 0.05). However, 28.7% of participants reported not refilling, delaying to refill, skipping doses or taking smaller doses due to cost. In findings of the open-ended question, medication costs and affordability were the most commonly mentioned barriers to medication adherence. CONCLUSION: Non-adherence to oral RA medications was prevalent among Iranian patients with RA and OOP costs were a barrier to medication adherence.

ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: A scoping review.

Clinical practice guidelines (CPGs) for venous leg ulcer (VLU) management recommend below-knee compression to improve healing outcomes after calculating the ankle-brachial pressure index (ABPI) to rule out significant arterial disease. This systematic scoping review aimed to complete a qualitative and quantitative content analysis of international CPGs for VLU management to determine if consensus existed in relation to recommendations for compression application based on an ABPI reading and clinical assessment. Our review shows that there is a lack of consensus across 13 VLU CPGs and a lack of clear guidance in relation to the specific ABPI range of compression therapy that can be safely applied. An area of uncertainty and disagreement exists in relation to an ABPI between 0.6 and 0.8, with some guidelines advocating that compression is contraindicated and others that there should be reduced compression. This has implications in clinical practice, including when it is safe to apply compression. In addition, the inconsistency in the levels of evidence and the grades of recommendation makes it difficult to compare across various guidelines.

Quantifying the medication burden of kidney transplant recipients in the first year post-transplantation.

Background Kidney transplantation is an effective treatment, but it is not a cure. Since the risk of graft rejection and the presence of comorbid conditions remain for a lifetime, medications are necessary. Objective To examine the prescription medication burden of adult kidney transplant recipients from 3- to 12-months post-transplantation. Setting All five adult kidney transplant units in Victoria, Australia. Method As part of a larger intervention study, we conducted a retrospective review of prescription refill records and medical records containing the history of medication changes of 64 participants who completed the study. The complexity of the medication management was studied, and we looked at the burden of maintaining the medications supply. Outcome measures Pill burden, administration frequency, dose changes frequency, immunosuppressive medication changes, the estimated out-of-pocket costs of medications and frequency of pharmacy visits. Results At 3 months, the average daily pill burden was 22 (SD = 9) whilst at 12 months, it was 23 (SD = 10). Some participants required long-term prophylaxis of fungal infections up to 4 times a day whilst those with diabetes had to manage up to 4 insulin doses a day. The average out-of-pocket cost per person and the frequency of pharmacy visits at 6, 9 and 12 months post-transplantation remained relatively unchanged. Conclusion The medication regimen prescribed for kidney transplant recipients is complex and for most patients, it did not simplify over time post transplantation. Strategies are needed to support patients in managing the complexity of their medication regimen following kidney transplantation.

Do out-of-pocket costs affect medication adherence in adults with rheumatoid arthritis? A systematic review.

INTRODUCTION: For individuals with a chronic condition, long-term management of their medication can be difficult and as a result non-adherence is common among this cohort. In patients with rheumatoid arthritis (RA), the introduction of biologic agents was a revolutionary treatment but the high costs of this medication might limit their utilisation. OBJECTIVE: This systematic review aimed to determine whether out-of-pocket (OOP) costs affect adherence to RA medications in adults with a diagnosis of RA. METHODS: Twelve databases were searched to identify primary peer-reviewed articles, written in English from inception to April 2016 that referred to the relationship between adherence to RA medication and OOP costs. The CASP check list was used to assess the quality rating of the included studies. RESULTS: Six articles were identified in the review and all were considered as high quality studies. Among them, three directly considered the association between OOP costs and medication adherence as their main objective. Although the population and the methods of the studies varied widely, there was an inverse relationship between OOP costs and medication adherence in patients with RA. CONCLUSION: The findings of this review suggest that OOP costs can contribute to non-adherence to RA medication in patients with RA. Therefore, health policy makers globally should identify the appropriate OOP amount so these costs do not affect adherence whilst simultaneously ensuring that costs are not an intolerable burden for governments, providers and insurers.