Assessment of patient and provider attitudes towards therapeutic drug monitoring to improve medication adherence in low-income patients with hypertension: a qualitative study.

OBJECTIVES: Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM. DESIGN: Prospective analysis of responses to a set of questions during semistructured interviews. SETTING: Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population. PARTICIPANTS: Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics. PRIMARY AND SECONDARY OUTCOME MEASURES: Attitudes towards TDM and the potential impact on physician-patient relationship. RESULTS: We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician-patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks. CONCLUSION: The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient-physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.

Patient Preparation for Outpatient Blood Work and the Impact of Surreptitious Fasting on Diagnoses of Diabetes and Prediabetes.

OBJECTIVE: To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results. PATIENTS AND METHODS: We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes. RESULTS: Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes. CONCLUSION: Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

Understanding Underuse of Advance Care Planning Among a Cohort of African American Patients With Advanced Cancer: Formative Research That Examines Gaps in Intent to Discuss Options for Care.

BACKGROUND: Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans (AAs). This study assessed the impact of stage of intent to discuss ACP options as key potential barriers. METHODS: We examined intent to discuss completion of ACP, PC, and hospice among 22 AA patients with cancer admitted to a local safety net hospital. Participants were asked about intent to discuss an advanced directive or living will (AD/LW), medical power of attorney (MPOA), PC, and hospice with their doctors. Intent to discuss these ACP components was based on the transtheoretical model. Electronic health records were reviewed at various intervals to assess completion of ACP behaviors and survival. RESULTS: Participants had colorectal (33%), breast (44%), and lung (23%) cancer, and 82% had stage III/IV disease. Low percentages of patients were in the precontemplation stage for AD/LW completion (4.6%), MPOA completion (13.6%), and PC discussions (27.2%), but 77.2% were in the precontemplation stage for hospice discussions. At 1 year, only 5% completed an AD/LW, 36.4% appointed an MPOA, 42.9% were referred to PC, and 12.5% were referred to hospice. More than half (54.6%) were deceased by the study's conclusion. Most (81%) of these died within 6 months of their baseline study assessment. CONCLUSIONS: Despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low. This formative research is needed to develop education and counseling interventions for this high-risk, vulnerable population.

The Desires of Their Hearts: The Multidisciplinary Perspectives of African Americans on End-of-Life Care in the African American Community.

BACKGROUND: Studies have identified racial differences in advance care planning and use of hospice for care at the end of life. Multiple reasons for underuse among African American patients and their families have been proposed and deserve further exploration. OBJECTIVE: The goal of this study was to examine perceptions of advance care planning, palliative care, and hospice among a diverse sample of African Americans with varying degrees of personal and professional experience with end-of-life care and use these responses to inform a culturally sensitive intervention to promote awareness of these options. METHODS: Semistructured interviews and focus groups were conducted with African Americans who had varying degrees of experience and exposure to end-of-life care both personally and professionally. We conducted in-depth qualitative analyses of these interviews and focus group transcripts and determined that thematic saturation had been achieved. RESULTS: Several themes emerged. Participants felt that advance care planning, palliative care, and hospice can be beneficial to African American patients and their families but identified specific barriers to completion of advance directives and hospice enrollment, including lack of knowledge, fear that these measures may hasten death or cause providers to deliver inadequate care, and perceived conflict with patients' faith and religious beliefs. Providers described approaches they use to address these barriers in their practices. CONCLUSION: Findings, which are consistent with and further elucidate those identified from previous research, will inform design of a culturally sensitive intervention to increase awareness and understanding of advance care planning, palliative care, and hospice among members of the African American community.