How effective is a professionally led, group based

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How effective is a professionally led,
group based intervention in improving
medication adherence in individuals with a
chronic (long term) condition?
Author: Alex Johnston
Date: January 2013
Introduction
Non adherence to prescription medication has received increased
attention particularly in the setting of chronic medical conditions. The
incidence of reported medication non adherence varies greatly however,
most reviews agree that between one third and a half of medicines
prescribed for long-term medical conditions are not taken as directed
(World Health Organisation, 2003). In chronic, asymptomatic diseases
such as glaucoma and hypertension non
adherence has significant effects on treatment outcomes often leading to
increased resource utilisation, more frequent hospital appointments and
diagnostic tests, increases in doses or changes in medications and risk
to the patients if subsequent surgical intervention is required (Gray et al,
2010).
Barriers to treatment adherence include situational and environmental
factors (major life events, travel, competing activities); medication
regimen factors (refill, complexity, adverse events, cost); patient related
factors (age, knowledge, memory, motivation, comorbidity, health
beliefs) and provider related factors (satisfaction with and
communication by clinicians) (Taylor et al, 2002; Noecker, 2009)
Recent reviews of studies in patients with many different chronic
conditions reveal familiar themes in strategies to address non
adherence: social support (DiMatteo, 2004); simplification of treatment
regimes (Tsai, 2009; Gupta et al, 2009); multidisciplinary efforts at
patient support and education and structural support such as patient
reminders, more frequent clinic visits or telephone phone calls from staff
(Handley et al 2006). However, few significantly affected long term
clinical outcomes (Kripalani et al 2007; McDonald et al, 2002)
Therefore the aim of this rapid review is to better understand the
strengths and limitations of a professionally led, group based
intervention in improving medication adherence in individuals with a
chronic (long term) condition.
Please note, given the lack of empirical studies on professionally
led, group based interventions to improve medication adherence in
patients with glaucoma this review has expanded its search
strategy to include a range of chronic diseases.
1
Search Strategy
A thorough search of the literature was performed in order to identify
available literature relating to the effect of a professionally led, group
based intervention to improve medication adherence in individuals with a
chronic (long term) condition.
Inclusion Criteria
Study type
 Randomised Controlled Trials (RCT)
 Non-experimental design
 Pilot
 Phenomenological
Exclusion Criteria
 Studies that do not focus on professionally led, group based
interventions to improve medication adherence in individuals with a
chronic condition.
 Studies which focused on mental health conditions.
 Non English studies
Participants
 Adults
Outcomes
The primary outcome measure was improved adherence, however all
studies with various primary and secondary outcome measures were
included.
Language of population
English Language - 1990 to 2012
Search terms
A thorough search of electronic databases and journals was implored
using the keywords:
Condition
 Glaucoma
2
 Chronic open-angle glaucoma (GOAG)
 Chronic disease
 Long term condition
Intervention
 Group based intervention professionally led
 Health education
Outcomes
 Improved adherence
 Improved compliance
 Improved concordance
 Improved clinical outcomes
3
Databases/Resources Searched
A literature search of studies published between 1990 and 2012 was
performed. Databases and search engines used included: OVID,
MEDLINE, AMED, Cochrane Library, Web of Knowledge and Google
Scholar.
Due to time restraints only electronic journals were appraised. Ancestral
searching of reference lists to identify all relevant empirical studies also
took place. All the included studies were published in English.
Critical Appraisal
Nine studies were identified for appraisal: Zwikker et al 2012, Nielsen et
al 2010, Chen et al 2009, Lacey et al 2009, Okeke et al 2009, Blondeau
et al 2007, Jiang et al 1999, Windsor et al 1990, Dunn et al 1990
(Appendix 1).
Study purpose
These studies all shared a common purpose to examine if a
professionally led, education intervention improved medication
adherence in individuals with a chronic (long term) condition. However,
the studies were delivered in different settings and used multifaceted
interventions.
 Zwikker (2012) described the systematic development and content of
a short intervention to improve medication adherence to diseasemodifying anti-rheumatic drugs in non-adherent patients with
rheumatoid arthritis (RA).
 Nielsen (2010) evaluated a group based educational programme to
increase patients’ knowledge of osteoporosis and level of adherence
with medical treatment.
 Chen (2009) compared patients understanding of glaucoma
 Lacey (2009) obtained narratives from participants who described
satisfying and dissatisfying therapy experiences.
 Okeke (2009) investigated the impact of an intervention programme
to improve adherence with topical therapy for glaucoma.
 Blondeau (2007) investigated if a two hour information session
improved glaucoma patients’ understanding and compliance.
 Jiang (2008) evaluated the impact of diabetic education programmes
on diabetic control.
4
 Windsor (1990) evaluated the efficacy and cost effectiveness of
health education methods to increase medication adherence among
adults with asthma.
 Dunn (1990) examined the impact of a formal diabetes education
programme on diabetes specific knowledge and attitude and the
relationship between these characteristics and metabolic control of
the disease.
5
Literature Review
All nine studies provided detailed discussions on the background to each
study/paper, succeeded in aggregating relevant information (previous
research etc.) and commented on the clinical importance of the subject.
Design
Using a phenomenology approach Lacey (2009) sought to capture
patients’ subjective experiences with glaucoma therapy. Three of the
studies adopted randomized designs (Nielsen 2010, Okeke 2009,
Windsor 1990). Chen 2009, Jiang 1999 and Dunn 1990 chose non
experimental designs. Blondeau (2007) presented findings from an
information session which aimed to improve patients understanding and
compliance on glaucoma. Whilst Zwikker (2012) described the
development of a short intervention to improve medication adherence in
patients with RA, the intervention was then piloted twice.
Chronic conditions
The nine included studies recruited participants with a wide range of
conditions including: glaucoma, osteoporosis, asthma, RA and diabetes.
Settings
Studies were conducted in the UK (Lacey 2009), Taiwan (Jiang 1999),
Australia (Dunn 1990), Netherlands (Zwikker 2012), Denmark (Nielsen,
2010), China (Chen 2009) and three studies took place in North America
(Windsor 1990, Blondeau, 2007, Okeke 2009).
Sample sizes
A total of 1803 participants were recruited across all the studies, with
individual studies having between 24 and 309 participants. Participants
were recruited from either primary or secondary care settings.
According to Aveyard (2007) researchers should demonstrate how they
determined the sample size, also known as power calculation and
should be clearly documented in the paper only Nielsen (2010), and
Okeke (2009) did so, (not applicable to Zwikker 2012 or Lacey 2009).
Zwikker (2012) Chen (2009) and Dunn (1990) did not provide inclusion
and exclusion criteria. All studies referenced previously published study
methodology.
6
Okeke (2009) and Jiang (1999) incorporated the use of multi site trials
increasing sample size and improving external validity of the study.
According to Aveyard (2007) qualitative samples are often small and this
was recognised by Lacey (2009) who recruited twenty four participants.
Ethical Approval
The following authors, provided details on obtaining ethical approval
from committees and informed consent from participants, thus
reassuring the reader that research was conducted in accordance with
accepted community principles (Nielsen 2010, Lacey 2009, Okeke 2009,
Windsor 1990).
Follow-up
Six studies reported information on follow-up rates.
 3, 12 and 24 month Nielsen (2010)
 12 month Windsor (1990)
 1, 4 and 10 month Blondeau (2007)
 3 and 6 month Okeke (2009)
 4 month Jiang (1999)
 3 month Dunn (1990)
Brief summary of the interventions
 Zwikker (2012) evaluated a short intervention programme consisting
of two motivational interviewing guided group sessions led by a
pharmacist.
 Nielsen (2010) assessed a multi disciplinary team led group based
programme (four classes over four weeks) to improve patient
knowledge and adherence on osteoporosis.
 Okeke (2009) assessed a multifaceted intervention administered by
study staff, involving, a ten minute education video stressing the
importance of regular drop taking, structured discussion with the
study coordinator, use of a diary, reminder telephone calls and
administration of a questionnaire about drop taking behaviour.
 Lacey (2009) used information gathered from focus groups to inform
ten, one-to-one, home based, semi-structured in depth interviews.
 Chen (2009) used group based interventions to compare compliance,
life style, habits and knowledge of glaucoma with an intervention and
control group.
 Blondeau (2007) assessed a nurse led, two hour group education
session to improve patient understanding and compliance.
7
 Based on recommendations from the American Diabetes Association
Jiang (1999) evaluated a diabetes education programme provided by
a team of diabetes physicians, dieticians and nurse educators.
 Windsor (1990) offered a 30 minute one to one session with
instructions on the use if a peak flow meter, a 60 minute asthma
support group session and two brief telephone reinforcement calls
within one month of group session.
 Dunn (1990) assessed a two day diabetic education programme in
which 6 to 8 patients some accompanied by a relative or friend
attended a two day programme.
Below is a table consisting of two columns and 10 rows, including a
header row.
Study
Zwikker (2012)
Nielsen (2010)
Okeke (2009)
Lacey (2009)
Chen (2009)
Blondeau (2007)
Jiang (1999)
Windsor (1990)
Dunn (1990)
Outcome measures
Improved medication adherence.
Improved medication adherence and
increased knowledge.
Improved adherence with topical once daily
therapy for glaucoma.
A better understanding of the obstacles to and
motivations for adherence with glaucoma
medication.
Improved medication adherence and
increased knowledge.
Improved medication adherence and
increased knowledge.
Improved diabetes self care techniques and
metabolic outcome.
Increased medication adherence
Improved metabolic improvement in diabetes
control.
8
Results
Medication adherence
The following authors demonstrated improved adherence to glaucoma
therapies: Okeke (2009) (p = <0.001) effect was sustained during the
follow up observation period and Blondeau (2007) (following session
19% of respondents reported improved adherence at 1 and 4 months
but increased to 37% after 10 months). Chen (2009) demonstrated a
positive trend. Whilst Lacey (2009) identified multiple obstacles to
adherence and suggested emphasis should be placed on identification
of the stage(s) where adherence is breaking down.
Zwikker (2012) demonstrated that adherent patients had higher
‘necessity’ belief scores about medications than non adherent patients
(p = 0.02), patients with recent onset RA were more adherent than
patients with a longer RA duration (p = 0.05) and adherent patients
reported fewer adverse medication effects than non adherent patients.
Nielsen (2010) reported that self reported adherence to medication for
osteoporosis was significantly higher in the intervention group (p =
0.001). Likewise, Windsor (1990) found that the experimental group
exhibited a significantly higher level of improvement in adherence
among adults with asthma (44% compared to 2% in control group).
There were contrasting results in the two studies investigating diabetic
metabolic outcomes. Jiang (1999) concluded that an intensive diabetes
educational programme provides an effective method for improving both
self care techniques and metabolic outcomes (p < 0.001) whilst Dunn
(1990) reported that diabetes knowledge did not predict improvement in
the control of diabetes.
Cost effectiveness
The actual or estimated cost of delivering the programme per participant
were reported in two studies: Blondeau (2007) Can$16-18 per patient
and Windsor (1990) $32.03 per patient.
Harms
None of the studies reported that they had received any complaints. No
adverse outcomes were reported in any of the included studies.
9
Discussion
In this rapid review of studies designed to improve medication
adherence in chronic medical conditions, eight of the nine studies (Dunn,
1990 was the exception) reported significant improvement in adherence.
However, the paucity of studies which examined outcomes beyond
twelve months, (Nielsen, 2010 and Windsor 1990 were the exceptions)
make it difficult to speculate whether benefits would be maintained long
term, or indeed if there are benefits which only become apparent over
time.
Through the use of a questionnaire Chen (2009) illustrated that the
Glaucoma Club (educational lectures using a holistic approach) is an
effective platform to improve patient’s knowledge and self management
of glaucoma. A contributing factor to study scores was patient
educational attainment; more patients from the Glaucoma club had
attended university.
To ensure effective therapeutic outcomes, the study emphasises an
‘open and honest’ approach to communication techniques. It is worth
noting that although the subjective measure of self report is the most
utilised method for assessing adherence (Chang, 1991, Nelson 2006) it
is said to be unreliable as patients tend to over-estimate their adherence
level. This was indeed acknowledged by Nielsen (2010) and Windsor
(1990) however, Windsor’s reported use of psychometric analysis
increases the studies internal validity.
In Okeke’s (2009) multifaceted intervention, the monitoring device used
could only provide data on one type of medication (travoprost) therefore,
self report results were also used as a measure of adherence. The use
of IOP as a clinical outcome identified that improvement in adherence
was not matched by lower IOP levels. In addition, data showed that
poorly adherent patients increase drop taking two weeks prior to their
appointment suggesting that IOP measurements are not an accurate
measure of adherence. Small sample size and a low baseline adherence
rate may have also influenced results.
As in other studies, (Domino, 2005, Hoeveaars, 2008, Budenz, 2009),
Jiang (1999), reported that when used alone, patient education has been
found to be ineffective in improving adherence. Again the use of self
reporting as a measure of adherence may affect study outcomes.
The use of questionnaires (non-standardised) was used by Blondeau
(2007) and Nielsen (2010) both of whom assessed participants’
knowledge and level of adherence. Only Dunn (1990) discussed the use
of a previously validated adherence tool, a five point Likert scale.
10
An attitudinal change specifically ‘necessity’ beliefs and how they may
be predictive of subsequent improvements in adherence were discussed
by Dunn (1990) and Zwikker (2012).
Motivational interviewing (MI) delivered by a multidisciplinary team and
targeting only non adherent patients was investigated by Zwikker (2012).
He acknowledges that the group format might compromise MI
effectiveness as it could prevent individual needs from being met. This
was also identified by Windsor (1990) who complemented group
sessions with one to one sessions; Zwikker (2012) addresses individual
patient needs through the discussion of individual beliefs and barriers.
Whilst Nielsen (2010), who reported significant improvement in
adherence, concludes, that group based patient educational
programmes can not be a substitute for individual face to face
discussion with clinical staff.
Lacey (2009) reported that age related issues identified by younger
participants only emerged during one to one interviews and not in the
focus groups. She suggests that as a taboo subject, age may not have
been discussed in the focus groups to avoid offence. The introduction of
an education assistant is recommended and results suggest that
intervention should be focused at diagnosis and be tailored to the
individual. Member checking, a strategy to ensure the trustworthiness of
research was used with all participants to clarify and elaborate further on
their earlier responses. This shows a degree of collaboration between
the researchers and the participants and contributes to the
trustworthiness of the study (Curtin and Fossey, 2007).
11
Conclusion
It is not possible to draw definitive conclusions about which features of
the included interventions are most beneficial. However, educating
patients about their condition in a group setting, complemented with one
to one sessions and multifaceted interventions have all contributed to
positive findings for improving adherence levels.
It is important to recognise that there is a large amount of research on
interventions for improving adherence to glaucoma therapy. However
due to time restrictions and the restrictive inclusion criteria a substantial
body of relevant evidence has not been discussed in this report.
12
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