Reducing cardiovascular medication complexity in a German university hospital: effects of a structured pharmaceutical management intervention on adherence.

BACKGROUND: Patient adherence is necessary for successful medication therapy. However, highly complex medication regimens may lead to poor adherence, which decreases the effectiveness of treatment and often results in treatment failure, excessive morbidity and mortality, and higher costs.  OBJECTIVE: To examine whether patient adherence can be increased indirectly through reducing medication complexity by (a) pharmaceutical counseling of hospital medical staff and (b) additional information in the discharge letter for the primary care provider (PCP) about the simplified discharge medication.  METHODS: At the Medical Center Hamburg-Eppendorf, a tertiary care university hospital in Germany, 240 chronically ill inpatients with hypertension, diabetes, and/or dyslipidemia were enrolled in this prospective, semirandomized study. For the intervention group, hospital doctors were counseled by a clinical pharmacist on feasible simplifications of cardiovascular and antidiabetic medications. In 1 randomized subgroup, the PCP received additional explanatory information in the discharge letter. Adherence (self-reporting using the Medication Adherence Rating Scale [MARS-D]) and medication complexity (using the Medication Regimen Complexity Index [MRCI-D]) were recorded at admission to the hospital, discharge from the hospital, and 6 weeks after discharge. Patient quality of life (QoL) and satisfaction with information about medications were assessed at admission and after discharge.   RESULTS: At discharge, the medication regimen in the intervention group was significantly less complex than in the comparison group. Yet, 6 weeks  after discharge, the complexity of the outpatient medication had increased to values similar to the comparison group, unless the PCP received additional information in the discharge letter. Propensity adjusted complete adherence rates at discharge were slightly, but not significantly, higher in the intervention group than in the comparison group. Within the intervention group, complete adherence was more frequent in the subgroup with additional information for the PCP. Patient QoL and satisfaction with information were comparable in both groups.   CONCLUSION: The complexity of cardiovascular and antidiabetic hospital medications can be reduced by counseling the hospital doctors. However, for a sustainable simplification of outpatient medication, the PCPs must receive explicit information about the modifications. Patient adherence was not significantly influenced by this intervention. To verify these results, further research with objective measures of adherence and in patients with other diseases is needed. 

Incomplete medication adherence of chronically ill patients in German primary care.

BACKGROUND: Incomplete medication adherence is a major problem in health care worldwide. Patients who adhere to medical treatment have a better prognosis and create fewer costs. OBJECTIVE: To assess the degree of incomplete adherence of chronically ill routine primary care patients in a German setting and analyze the association between incomplete medication adherence, as well as clinical and sociodemographic patient characteristics. METHODS: In a cross-sectional survey, chronically ill patients were asked to assess their adherence in primary care retrospectively using the Medication Adherence Report Scale (MARS-D) questionnaire. To investigate the association of incomplete adherence with sociodemographic and clinical data, univariate and multivariate analyses were conducted. RESULTS: In total, 62.1% of 190 patients were categorized as incompletely adherent. The mean MARS-D score was 23.5 (standard deviation = 2.7). Analyses revealed no statistically significant associations at P < 0.05 between degree of adherence and patient characteristics. The total explained variance amounted to 11.8% (Nagelkerke's R(2) = 0.118) in the multivariate analysis. CONCLUSION: Previously reported results regarding associations of sociodemographic and clinical data with incomplete medication adherence could not be confirmed for this sample of chronically ill patients. In order to be able to provide guidelines for the reduction of incomplete medication adherence in German primary care, further research is needed.

Medication complexity, prescription behaviour and patient adherence at the interface between ambulatory and stationary medical care.

PURPOSE: A hospital stay is often accompanied by changes in medication therapy. The purpose of this study was to investigate the impact of a transfer across the interfaces on the complexity of therapeutic regimens and patient adherence as well as the attitudes of patients and general practitioners (GPs) towards pharmacotherapies. METHODS: This was a prospective observational study that analysed the complexity of medication therapies and the adherence and attitudes of internal medicine and urology patients towards their medication(s) at three time points (hospital admission, discharge and 6 weeks after discharge). GPs of the patients recruited to the study were questioned about the follow-up medication therapy and their opinion on the medication prescribed in hospital. RESULTS: At the time of hospital admission, 60.2 % of the study population were nonadherent. During hospitalization, the number decreased to 37.6 %, but increased to 61.2 % 6 weeks after discharge. Changes in the overall complexity of the therapy regimens were marginal and not statistically significant. Of the long-term medication regimens, 48.6 % were modified during hospital stay. The patients preferred regimens with a minimum of drug administrations. GPs stated to be willing to continue hospital prescriptions but were restricted by financial budgets. CONCLUSION: The results of this study confirm that an increase in adherence during a hospital stay is only transient, underlining the need for interventions to ameliorate medication adherence. They also suggest that patients prefer simple regimens. Although GPs are willing to consider their patient's preferences on pharmacotherapy, they state limitations due to financial budgets. Further studies are needed that investigate the extent to which medication therapies can be simplified and the effect of simplification on adherence.

Development and psychometric evaluation of the German version of the Medication Regimen Complexity Index (MRCI-D).

BACKGROUND: Several factors contribute to the complexity of pharmacotherapeutic regimens, like the total number of medications to be taken, the number of dosage units to take at a time, dosage frequency, as well as specific directions concerning the administration. The Medication Regimen Complexity Index (MRCI) is a validated instrument developed in English for the measurement of the complexity of a given pharmacotherapeutic regimen. OBJECTIVES: Translation of the MRCI into German and evaluation of the translated instrument (MRCI-D) in order to make it more easily accessible for use in German practice and research. METHODS: The process of validation included the translation of the English version to German, back-translation into English, comparison of the back-translated and the original versions, pre-tests, and pilot-testing of the German version by three raters using 20 medication regimens for inpatients. The subsequent psychometric evaluation included the calculation of inter-rater and test-retest reliability, as well as the assessment of convergent validity. RESULTS: The number of medications correlated highly and statistically significantly with the MRCI-D score (0.91, P < 0.001), indicating sufficient convergent validity of the instrument. Both inter-rater and test-retest reliability were very high (intraclass correlation coefficients above 0.80 in all cases). CONCLUSION: Our results demonstrate that the German version of the MRCI reflects the complexity of therapeutic regimens with similar validity and reliability as the established English version. Thus, it may be a valuable tool to analyse therapeutic regimens in both clinical practice and science.

Stressful encounters with social work clients: a descriptive account based on critical incidents.

This article presents the findings of an analysis of 130 critical incidents reported by social workers in Israel. Almost all the incidents turned out to be upsetting events that caused the writers a great deal of pain, frustration, and self-doubt. Content analysis yielded four main categories of incidents or events: (1) client hostility and aggression toward the worker, (2) client behaviors that violated the unwritten rules of the profession or the workers' expectations, (3) inherent professional dilemmas, and (4) workers' personal issues. Although the events may not be typical of worker-client interactions, they tend to undermine the workers' professional confidence and color their entire work experience. Recommendations are made for training that better prepares social workers for the difficult situations they may encounter and for supervision that helps them to deal with such situations more effectively.