Effective chronic disease management: Patients’ perspectives on medication-related problems

https://doi.org/10.1016/j.pec.2006.09.012Get rights and content

Abstract

Objective

To examine medication-related problems from the perspective of patients with a chronic condition and to identify how they may be supported in managing their medication.

Methods

Patients prescribed medication for cardiovascular disease were recruited through five general medical surgeries and four community pharmacies in south London. Data were collected in 98 face-to-face interviews in participants’ own homes. Interviews were designed to enable a detailed and holistic exploration of medication-related problems from participants’ perspectives. Data were audio-recorded and transcribed verbatim to allow qualitative analysis.

Results

Five broad categories of medication-related problem emerged which were examined in the context of patients’ perspectives on, and experiences of, the use of medicines and health services. These were concerns about and management of side effects; differing views regarding the use of medicines; cognitive, practical and sensory problems; lack of information or understanding; and problems with access to, and organisation of, services.

Conclusion

All categories of problem had potential implications for the success of therapy in that they created barriers to adherence, access to medication or informed decision-making. The study demonstrated how patients actively engage in decision-making about their medicines in the home, if not in the consultation.

Practice implications

The five categories of problem provide a focus for interventions by health professionals to support patients in achieving optimal theory outcomes. They demonstrate the need for a comprehensive approach, spanning patient education to the systems of delivery of care. Within the NHS in Britain, policy and practice initiatives are being designed to achieve this end. Further research should focus on the evaluation of professional practices and service developments in supporting patients in the self-management of their medicines.

Introduction

To provide more effective health care and efficiency its delivery, health policy in the United Kingdom (UK) has become increasingly explicitly patient-focused. Patient empowerment and patient choice are central to health service developments. The importance of patients’ perspectives are stressed in health policy initiatives to promote diversity in the delivery of care, ensure a ‘patient-led National Health Service (NHS)’ and service development responsive to patients’ needs [1], [2], [3]. The place of the ‘expert patient’, which acknowledges that patients assume an active role in the management of their conditions and the importance of assisting and empowering patients to take more responsibility for their health care and outcomes has also been emphasised as an important component of disease management [4].

Cardiovascular disease accounts for a high proportion of morbidity and mortality in the UK and its prevalence is increasing throughout the world. Chronic conditions are predicted by the World Health Organisation to become the greatest source of disability by 2020. As part of the NHS Plan and National Service Frameworks, the British Government has set national standards and targets, for reducing morbidity and mortality associated with chronic disease such as coronary heart disease and stroke [5]. Cardiovascular disease is usually managed with prescription medicines along with recommendations for lifestyle modifications. The medicines management strategy in the National Service Framework for older people [6] stresses the importance of effective use of medicines. In coronary heart disease in particular, optimal outcomes require the safe and effective use of therapeutic interventions. Poor management, including suboptimal use of medicines can lead to increased morbidity and mortality as well as lead to increased consumption of health care resources [6], [7], [8].

Many studies have found that patients may not manage their medicines effectively and experience a wide range of problems [9], [10], [11], [12]. The frequency of medication-related problems in primary care has been estimated to range from 2.5 to 65% [10], [11], [13], [14], [15], [16], [17]. Much of this variation can be attributed to factors related to study methodology, for example, patient groups included or definitions of medication-related problem which range from narrow clinical definitions to more holistic approaches addressing the contexts in which problems arise.

Studies of patients’ perspectives regarding the use of medicines commonly focus on medication adherence [18], [19], [20]. That the majority of patients do not take prescribed medicines as intended is widely documented. It has long been recognized that non-adherence with medication regimens is, at least in part, a consequence of active decision-making on the part of patients [21]. Patients have their own perspectives regarding the use of medicines and make decisions based on their beliefs and experiences. They consider the risk and benefits of medicines and make judgments regarding their perceived efficacy and appropriateness [8], [20], [21], [22], [23], [24], [25]. Cognitive, physical and visual abilities can also hinder the ability of, especially older people, to take their medicines correctly [26].

Research has identified that patients’ perspectives of their illnesses differ from those of health professionals [27]. Health professionals are often not effective in identifying patients who exercise notions regarding their medication and/or are at risk from medication-related problems, which lead to inappropriate or suboptimal use. It is acknowledged that health professionals fail to meet patients’ expectations for information or, within consultations provide an opportunity for them to raise issues they see as important [23]. They have been challenged to develop relationships with their patients, which foster and encourage openness [8] to empower them to share in decisions regarding their care. It has been recognised that involving patients in treatment decisions poses difficulties for doctors [28]. Nevertheless, self-care and self-management, which are seen as important components of the management of chronic conditions [3], require that patients’ perspectives and experiences regarding the use of medication are addressed in the context of wider disease management.

This paper aimed to examine medication-related problems from the perspective of patients with a chronic condition and to identify how they may be supported in managing their medicines. A broad definition of medication-related problem was employed: any problem experienced by a patient that may impact on their ability to manage or use their medicines effectively’. The study was conceived to enable a holistic examination of patients’ experiences and rationale regarding the use of medicines in the management of their condition, and allow a classification and description of problems generated from, and grounded in, patients’ notions and experiences.

Section snippets

Study setting and recruitment of participants

Participants were recruited in five general medical surgeries and four community pharmacies in Lambeth, Southwark and Lewisham health authority areas, in south London. This area has a diverse population in terms of age structure, socio-economic characteristics and presence of ethnic minority groups [29]. This was reflected in the location of the surgeries and pharmacies. The sample of surgeries included single-handed and group practices. Each of the four pharmacies was in the vicinity of one of

Response rates and characteristics of participants

Two hundred and fifty nine patients (of a total of 315 invited to do so) took part in the screening interviews (response rate: 82%). One hundred and ninety-six patients were invited to participate in a home interview, of which 98 agreed and were subsequently interviewed (response rate: 50%). Sixty-one (62%) of participants in the home interviews were recruited via GP surgeries and 37 (38%) from the pharmacies. Patients identified with a medication-related problem at the screening interview were

Discussion

Medicines for cardiovascular disease are given out daily to thousands of people, possibly with little thought regarding their perspectives on the use of medication, or the problems they might be experiencing. These factors are all important determinants of the ultimate effectiveness and value of medication for cardiovascular disease. By adopting a holistic approach and qualitative methodology, this study has enabled an examination of medication-related problems from the perspective of patients

Acknowledgements

We would like to thank the staff at the surgeries and pharmacies who participated in the study for their assistance, all patients who shared their views and experiences and the School of Pharmacy, University of London for funding the work.

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