Patients and Physicians Beliefs and Practices Regarding Adherence to Cardiovascular Medication.

IMPORTANCE: Nonadherence to medication is a salient cause of poor outcomes of health care and a primary driver of growing health care costs. Little is known about physician communication with patients regarding their adherence to cardioprotective medication. OBJECTIVE: To identify patients' and physicians' beliefs and practices regarding discussions of adherence to cardioprotective medication. DESIGN, SETTING, AND PARTICIPANTS: Paired patient and physician questionnaires were developed based on the 8-item Morisky Medication Adherence Scale and administered to 2 academic and 2 community-based cardiology practices in the Chicago, Illinois, metropolitan and suburban areas from June 2 to July 22, 2015. Twenty-one cardiologists and 66 of their outpatients 18 years and older participated. MAIN OUTCOMES AND MEASURES: Patient and physician beliefs about discussions of adherence to medication, the frequency of such discussions, and physician recognition of patients who are nonadherent to medication. RESULTS: A total of 21 physicians (5 [24%] women) and 66 patients (23 [35%] women; mean age, 71.6 years) participated in the study. Forty (61%) patients reported rarely or never discussing their adherence to medication with their physicians. Of these patients, 8 (13%) had poor adherence and 36 (55%) had moderate adherence. Only 1 of the physicians of the patients with the poorest adherence correctly identified a patient as being poorly adherent. Fourteen physicians (67%) disagreed with the statement, "I am aware of how often my patient misses a dose of medication." By contrast, all of the physicians agreed that it is important for them to discuss adherence to medication with their patients. CONCLUSIONS AND RELEVANCE: Physicians acknowledge the importance of discussing adherence to medication with their patients, yet for many reasons these discussions are uncommon. More important, our study found a notable failure by cardiologists to correctly recognize which of their patients were nonadherent. The novel design of our research identified an important yet neglected aspect of clinical practice. We recommend that physicians include a highly specific question about adherence to medication at every patient visit.

Emergency care and referral among isolated island populations in the Bahamas.

BACKGROUND: Isolated island populations face unique health challenges. In the Bahamas, the islands of Mayaguana, Inagua, Crooked Island, Acklins, and Long Cay-referred to as the MICAL Constituency-are among the most isolated. OBJECTIVES: Our objective was to better understand regional emergency care needs and capabilities, and determine how emergency care can be optimized among island populations. METHODS: During the summer of 2013, the project team conducted semi-structured key-informant interviews and small-group discussions among all health care teams in the MICAL region, as well as a community-based household survey on the island of Mayaguana. The interviews and small-group discussions consisted of open-response questions related to health care services, equipment, supplies, medications, and human resources. The community-based survey examined the prevalence of chronic noncommunicable diseases (CNCDs) and associated risk factors affecting the inhabitants of the region. RESULTS: The average number of annual emergency referrals from each of the MICAL islands was approximately 25-30, and reasons for referrals off-island included chest pain, abdominal pain, trauma, and dysfunctional uterine bleeding. Traditional prehospital care is not established in the MICAL Constituency. Providers reported feelings of isolation from the distant health system in Nassau. Whereas most clinics have a well-stocked pharmacy of oral medications, diagnostic capabilities are limited. The household survey showed a high prevalence of CNCDs and associated risk factors. CONCLUSION: Ongoing in-service emergency care training among MICAL providers is needed. Additional equipment could significantly improve emergency care capabilities, specifically, equipment to manage chest pain, fractures, and other trauma. Community-based preventive services and education could improve the overall health of the island populations.

Emergency and urgent care capacity in a resource-limited setting: an assessment of health facilities in western Kenya.

OBJECTIVE: Injuries, trauma and non-communicable diseases are responsible for a rising proportion of death and disability in low-income and middle-income countries. Delivering effective emergency and urgent healthcare for these and other conditions in resource-limited settings is challenging. In this study, we sought to examine and characterise emergency and urgent care capacity in a resource-limited setting. METHODS: We conducted an assessment within all 30 primary and secondary hospitals and within a stratified random sampling of 30 dispensaries and health centres in western Kenya. The key informants were the most senior facility healthcare provider and manager available. Emergency physician researchers utilised a semistructured assessment tool, and data were analysed using descriptive statistics and thematic coding. RESULTS: No lower level facilities and 30% of higher level facilities reported having a defined, organised approach to trauma. 43% of higher level facilities had access to an anaesthetist. The majority of lower level facilities had suture and wound care supplies and gloves but typically lacked other basic trauma supplies. For cardiac care, 50% of higher level facilities had morphine, but a minority had functioning ECG, sublingual nitroglycerine or a defibrillator. Only 20% of lower level facilities had glucometers, and only 33% of higher level facilities could care for diabetic emergencies. No facilities had sepsis clinical guidelines. CONCLUSIONS: Large gaps in essential emergency care capabilities were identified at all facility levels in western Kenya. There are great opportunities for a universally deployed basic emergency care package, an advanced emergency care package and facility designation scheme, and a reliable prehospital care transportation and communications system in resource-limited settings.