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Pharmaceutical care in coronary heart disease
Linnaeus University, Faculty of Health and Life Sciences, Department of Medicine and Optometry. Linnaeus University, Linnaeus Knowledge Environments, Sustainable Health. Region Kalmar County, Sweden.ORCID iD: 0000-0001-7550-5706
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att stödja patienter med kranskärlssjukdom till bättre läkemedelsanvändning (Swedish)
Abstract [en]

Background: In coronary heart disease (CHD), pharmaceutical care implies that health care professionals cooperate with the patient to optimize drug therapy primarily for secondary prevention. Low adherence and discontinuation of drugs are common among patients with CHD, and this is associated with increased morbidity and mortality. The achievement of guidelines-recommended treatment goals for risk factors is disappointingly low in secondary prevention.

Aim: To study clinical and patient related aspects of pharmaceutical care for secondary prevention in patients with CHD.

Method: A pharmacist used medication review and motivational interviewing to impact patients’ beliefs about medicines and adherence in a pilot study. This intervention was further developed and tested in a randomized controlled trial (RCT) in 316 patients with verified CHD who were planned for follow-up at the cardiology clinic in Kalmar. The primary study outcome was the proportion ofpatients who reached the treatment goal for low-density lipoprotein (LDL)cholesterol. Patients’ adherence to cholesterol-lowering drugs according to a combination of refilled prescriptions and self-report was the key secondary outcome. In the RCT, pharmacists individualized both the dose and the content of thesupport based on the patient’s need. A process evaluation was planned alongside the trial to investigate implementation and mechanisms of impact such as pharmacists’ actions and effects on patients’ medication beliefs. In a separate qualitative study, we interviewed patients with CHD who had used their medicines for at least 12 months.

Results: At 15 months follow-up of the RCT, the primary outcome measure did not differ between groups. The intervention improved patient adherence to cholesterol-lowering medicines; 88% vs 77% of the patients were adherent, possibly because the intervention lowered patients’ concerns about medicines. In 84% of the intervention patients at least one actual drug-related problem (DRP) was identified, and for 90% of those DRPs actions were taken to resolve the problems. Analyses of the interviews with patients revealed that patients´ experiences with medicines varied greatly - from trivial to troublesome – and these were classified into one of seven categories: a sense of security, unproblematic, learning to live with it, taking responsibility for it, somewhat uncertain, troublesome, or distressing.

Conclusion: Pharmaceutical care improved the patients’ use of medicines in CHD but did not increase treatment goal achievement for LDL-cholesterol. Overall, the findings of this thesis emphasize that when support in managing medications is offered to patients, it should encompass various aspects of medicine-taking: safety, knowledge, beliefs, practical handling, impact on day-to-day life, and the patient’s medication experience.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press, 2021. , p. 200
Series
Linnaeus University Dissertations ; 409/2021
Keywords [en]
pharmaceutical care, patient experience, medication adherence, medicine management, medication review, motivational interviewing, coronary heart disease, secondary prevention, low-density lipoprotein cholesterol, cardiac rehabilitation, multi-professional collaboration, drug-related problems, pragmatic clinical trial, randomized controlled trial, qualitative analysis, process evaluation
National Category
Social and Clinical Pharmacy
Research subject
Natural Science, Biomedical Sciences; Health and Caring Sciences
Identifiers
URN: urn:nbn:se:lnu:diva-101643ISBN: 9789189283558 (print)ISBN: 9789189283565 (electronic)OAI: oai:DiVA.org:lnu-101643DiVA, id: diva2:1537931
Public defence
2021-04-16, Hjärnan, Länssjukhuset Kalmar, Kalmar, 09:00 (English)
Opponent
Supervisors
Available from: 2021-03-17 Created: 2021-03-17 Last updated: 2023-04-17Bibliographically approved
List of papers
1. Medication beliefs and self-reported adherence - results of a pharmacist’s consultation: A pilot study
Open this publication in new window or tab >>Medication beliefs and self-reported adherence - results of a pharmacist’s consultation: A pilot study
2014 (English)In: European Journal of Hospital Pharmacy: Science and Practice, ISSN 2047-9956, Vol. 21, no 2, p. 102-107Article in journal (Refereed) Published
Abstract [en]

ObjectivesClinical outcomes in the secondary prevention of cardiovascular disease depend on the patients’ adherence to prescribed medicines. Motivational interviewing (MI) is a patient-centered approach used to change different health behaviors. The objective of this pilot study was to explore the impact of a clinical pharmacist’s consultation on beliefs about medicines and self-reported medication adherence among patients with coronary heart disease (CHD).

MethodsCHD-patients participating in a prevention program at the Kalmar County Hospital were randomized to control or intervention. The intervention consisted of a medication review focused on cardiovascular drugs, and a semi-structured interview based on MI-approach, with a follow-up phone call two weeks later. The intervention was conducted by a clinical pharmacist at the cardiology unit three months post-discharge.

Primary outcome measures were the results from the Beliefs about medicines-Specific (BMQ-S) and the 8-Item Morisky Medication Adherence Scale (MMAS-8) two weeks after intervention.

Results21 enrolled patients (11 intervention) all completed to follow-up. MMAS-8 was very similar in the intervention and control groups. In BMQ-S the intervention group had a mean (SD) necessity score of 21 (4) and a concern score of 12 (6), corresponding results in the control group were 21 (3) and 10 (5). However, since there was a difference in BMQ-S at baseline, seven intervention patients shifted towards more positive beliefs compared to two control patients.

ConclusionNo difference was found in adherence and beliefs at follow-up. However, after consultation a larger proportion of patients changed towards more positive beliefs compared to control.

National Category
Pharmaceutical Sciences
Research subject
Biomedical Sciences, Pharmacology
Identifiers
urn:nbn:se:lnu:diva-31179 (URN)10.1136/ejhpharm-2013-000402 (DOI)000336518600010 ()2-s2.0-84895447658 (Scopus ID)
Available from: 2013-12-11 Created: 2013-12-11 Last updated: 2021-03-31Bibliographically approved
2. Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life
Open this publication in new window or tab >>Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life
2018 (English)In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 7, no 2, p. 1-15, article id e57Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients' adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes.

OBJECTIVE: This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately.

METHODS: The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient's medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use.

RESULTS: The protocol for this study was approved by the Regional Ethics Committee, Linköping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019.

CONCLUSIONS: The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol.

TRIAL REGISTRATION: ClinicalTrials.gov NCT02102503; https://clinicaltrials.gov/ct2/show/NCT02102503 (Archived by WebCite at http://www.webcitation.org/6x7iUDohy).

Place, publisher, year, edition, pages
JMIR Publications, 2018
Keywords
coronary artery disease, medication adherence, medication therapy management, pharmacist, randomized controlled trial
National Category
Social and Clinical Pharmacy
Research subject
Biomedical Sciences, Pharmacology
Identifiers
urn:nbn:se:lnu:diva-71385 (URN)10.2196/resprot.8659 (DOI)000432916000005 ()29463490 (PubMedID)2-s2.0-85083208653 (Scopus ID)
Funder
The Kamprad Family Foundation
Available from: 2018-03-06 Created: 2018-03-06 Last updated: 2021-05-07Bibliographically approved
3. Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Intervention Development and Protocol for the Process Evaluation
Open this publication in new window or tab >>Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Intervention Development and Protocol for the Process Evaluation
2018 (English)In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 7, no 1, p. 1-12, article id e21Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Trials of complex interventions are often criticized for being difficult to interpret because the effects of apparently similar interventions vary across studies dependent on context, targeted groups, and the delivery of the intervention. The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a randomized controlled trial (RCT) of an intervention aimed at improving pharmacological secondary prevention. Guidelines for the development and evaluation of complex interventions have recently highlighted the need for better reporting of the development of interventions, including descriptions of how the intervention is assumed to work, how this theory informed the process evaluation, and how the process evaluation relates to the outcome evaluation.

OBJECTIVE: This paper aims to describe how the intervention was designed and developed. The aim of the process evaluation is to better understand how and why the intervention in the MIMeRiC trial was effective or not effective.

METHODS: The research questions for evaluating the process are based on the conceptual model of change processes assumed in the intervention and will be analyzed by qualitative and quantitative methods. Quantitative data are used to evaluate the medication review in terms of drug-related problems, to describe how patients' beliefs about medicines are affected by the intervention, and to evaluate the quality of motivational interviewing. Qualitative data will be used to analyze whether patients experienced the intervention as intended, how cardiologists experienced the collaboration and intervention, and how the intervention affected patients' overall experience of care after coronary heart disease.

RESULTS: The development and piloting of the intervention are described in relation to the theoretical framework. Data for the process evaluation will be collected until March 2018. Some process evaluation questions will be analyzed before, and others will be analyzed after the outcomes of the MIMeRiC RCT are known.

CONCLUSIONS: This paper describes the framework for the design of the intervention tested in the MIMeRiC trial, development of the intervention from the pilot stage to the complete trial intervention, and the framework and methods for the process evaluation. Providing the protocol of the process evaluation allows prespecification of the processes that will be evaluated, because we hypothesize that they will determine the outcomes of the MIMeRiC trial. This protocol also constitutes a contribution to the new field of process evaluations as made explicit in health services research and clinical trials of complex interventions.

Place, publisher, year, edition, pages
JMIR Publications, 2018
Keywords
coronary artery disease, quality of health care, medication adherence, medication therapy management, pharmacist
National Category
Social and Clinical Pharmacy
Research subject
Biomedical Sciences, Pharmacology
Identifiers
urn:nbn:se:lnu:diva-71384 (URN)10.2196/resprot.8660 (DOI)000432915700019 ()29382630 (PubMedID)2-s2.0-85102335706 (Scopus ID)
Available from: 2018-03-06 Created: 2018-03-06 Last updated: 2022-06-13Bibliographically approved
4. Trivial or Troublesome: Experience with Coronary Heart Disease Medication from the Patient's Perspective
Open this publication in new window or tab >>Trivial or Troublesome: Experience with Coronary Heart Disease Medication from the Patient's Perspective
2020 (English)In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 14, p. 411-424Article in journal (Refereed) Published
Abstract [en]

Background: Living with coronary heart disease (CHD) usually means being prescribed several medications to help prevent new cardiac events. Using medicines for long-term conditions impacts on day-to-day life, and coping with medicines can be burdensome and can affect the quality of life. To enable better support of these patients, we need to understand their collective medicine-related experience. Purpose: The purpose of this study was to describe patients' medicine-related experience 1 year after the diagnosis of CHD. Patients and Methods: A qualitative, descriptive study using semi-structured interviews was conducted in 19 patients in their homes or at Linnaeus University, Sweden. Interviews were recorded and transcribed verbatim. Qualitative content analysis with an inductive approach was used. Results: Patients' experiences with using their medicines after diagnosis of CHD differed considerably. Some patients found handling the medicines and administering their treatment very easy, natural and straightforward, while others found that it was distressing or trouble-some, and influenced their lives extensively. There was a varied sense of personal responsibility about the treatment and use of medicines. The patients' experiences were classified into one of seven categories: a sense of security, unproblematic, learning to live with it, taking responsibility for it, somewhat uncertain, troublesome, or distressing. Participants in the study who expressed an unproblematic view of medicine taking also often revealed that they had dilemmas or uncertainties. Conclusion: Patients' medicine-related experiences after CHD vary greatly. The findings of this study highlight a need for more individualized support for patients using medicines for secondary prevention. The patients often needed better dialogue with healthcare providers to optimally manage their medicines. Medicine-related support for these patients should encompass various aspects of medicine-taking.

Place, publisher, year, edition, pages
Dove Medical Press Ltd, 2020
Keywords
coronary artery disease, qualitative research, patient experience, medicine management
National Category
Social and Clinical Pharmacy
Research subject
Biomedical Sciences, Pharmacology
Identifiers
urn:nbn:se:lnu:diva-93691 (URN)10.2147/PPA.S230120 (DOI)000520444100001 ()32184571 (PubMedID)2-s2.0-85081071462 (Scopus ID)
Available from: 2020-04-23 Created: 2020-04-23 Last updated: 2023-04-17Bibliographically approved
5. Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease - the MIMeRiC randomized controlled trial
Open this publication in new window or tab >>Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease - the MIMeRiC randomized controlled trial
2021 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 21, no 1, article id 367Article in journal (Refereed) Published
Abstract [en]

Background: In the treatment of coronary heart disease, secondary prevention goals are still often unmet and pooradherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomesand patient adherence.

Methods: This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the interventiongroup were seen by a clinical pharmacist two to fve times as required over seven months. Pharmacists were trainedto use motivational interviewing in the consultations and they tailored their support to each patient’s clinical needsand beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatmentgoal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patientadherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the efectson patient adherence to other preventive drugs, systolic blood pressure, disease-specifc quality of life, and healthcareuse.

Results: 316 patients were included. The proportion of patients who reached the target for low-density lipoproteincholesterol were 37.0% in the intervention group and 44.2% in the control group (P=.263). More intervention thancontrol patients were adherent to cholesterol-lowering drugs (88 vs 77%; P=.033) and aspirin (97 vs 91%; P=.036)but not to beta-blocking agents or renin–angiotensin–aldosterone system inhibitors.

Conclusions: Our intervention had no positive efects on risk factors for CHD, but it increased patient adherence.Further investigation of the intervention process is needed to explore the diference in results between patient adherence and medication efects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful efect on patient health

Place, publisher, year, edition, pages
BioMed Central (BMC), 2021
National Category
Social and Clinical Pharmacy
Research subject
Biomedical Sciences, Pharmacology
Identifiers
urn:nbn:se:lnu:diva-101984 (URN)10.1186/s12872-021-02178-0 (DOI)000679833300001 ()34334142 (PubMedID)2-s2.0-85111998744 (Scopus ID)2021 (Local ID)2021 (Archive number)2021 (OAI)
Available from: 2021-04-07 Created: 2021-04-07 Last updated: 2023-04-17Bibliographically approved

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