Assessment of Patient Medication Adherence, Medical Record Accuracy, and Medication Blood Concentrations for Prescription and Over-the-Counter Medications.
ABSTRACT: Importance:Inaccurate medication records and poor medication adherence result in incomplete knowledge of therapy for patients. Objective:To study accuracy of medical records and patient adherence by measuring blood concentrations of medications. Design, Setting, and Participants:This cross-sectional study validated a serum-based liquid chromatography-tandem mass spectrometry assay to simultaneously quantify 263 medications used for acute and chronic conditions. The assay panel was applied to 3 clinical patient cohorts: residual serum from 1000 randomly selected samples sent for routine clinical chemistry testing between April 8 and October 6, 2015 (residuals cohort), 50 prospectively enrolled patients in a gastroenterology clinic between March 1 and March 15, 2016, who were prescribed more than 5 medications (gastroenterology care cohort), and a convenience cohort of 296 patients with hypertension who sought care in an emergency department (ED care cohort) between July 1, 2012, and April 25, 2013. Integrated data analysis of the cohorts was performed from August 22 to November 29, 2017. Main Outcomes and Measures:Medication serum concentrations, electronic health record medication lists, and predicted drug interactions. Results:Of the 1346 total samples, 1000 came from the residuals cohort (640 women and 360 men; median age, 60 years [interquartile range (IQR), 44-71 years]), 50 from the gastroenterology care cohort (30 women and 20 men; median age, 66 years [IQR, 62-70 years]), and 296 from the ED care cohort (160 women and 136 men; median age, 59 years [IQR, 52-66 years]). Median medication adherence, defined as the subset of detected medications from the prescription record, was 83% (IQR, 50%-100%) in the residuals cohort, 100% (IQR, 84%-100%) in the gastroenterology care cohort, and 78% (IQR, 57%-100%) in the ED care cohort. Patients adherent to 1 medication were more often adherent to other medications. Among patients prescribed 3 medications or more, there were no significant associations between medication adherence and sex or number of prescribed medications, and there was a modest association between adherence and age. By comparing detected vs prescribed medications, we detected a median of 0 (IQR, 0-2) medications per patient that were not listed in the electronic health record in the residuals cohort, 1 (IQR, 0-2) medication per patient that was not listed in the electronic health record in the gastroenterology care cohort, and 1 (IQR, 0-2) medication per patient that was not listed in the electronic health record in the ED care cohort. A total of 435 patients (43.5%) in the residuals cohort had no discrepancy between the electronic health record and detected medication lists, 22 patients (44.0%) in the gastroenterology care cohort had no discrepancy between the electronic health record and detected medication lists, and 41 patients (13.9%) in the ED care cohort had no discrepancy between the electronic health record and detected medication lists. Half of adverse drug reaction alerts occurred among medications detected without prescription. Conclusions and Relevance:Comprehensive medication monitoring offers promise to improve adherence, the accuracy of medical records, and the safety for patients with polypharmacy.
Project description:Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.
Project description:The Northwestern University Center for Education and Research on Therapeutics (CERT), funded by the Agency for Healthcare Research and Quality, is one of seven such centers in the USA. The thematic focus of the Northwestern CERT is 'Tools for Optimizing Medication Safety.' Ensuring drug safety is essential, as many adults struggle to take medications, with estimates indicating that only half of adults take drugs as prescribed. This report describes the methods and rationale for one innovative project within the CERT: the 'Primary Care, Electronic Health Record-Based Strategy to Promote Safe and Appropriate Drug Use'.The overall objective of this 5-year study is to evaluate a health literacy-informed, electronic health record-based strategy for promoting safe and effective prescription medication use in a primary care setting. A total of 600 English and Spanish-speaking patients with diabetes will be consecutively recruited to participate in the study. Patients will be randomized to receive either usual care or the intervention; those in the intervention arm will receive a set of print materials designed to support medication use and prompt provider counseling and medication reconciliation. Participants will be interviewed in person after their index clinic visit and again one month later. Process outcomes related to intervention delivery will be recorded. A medical chart review will be performed at 6 months. Patient outcome measures include medication understanding, adherence and clinical measures (hemoglobin A1c, blood pressure, and cholesterol; exploratory outcomes only).Through this study, we will be able to examine the impact of a health literacy-informed, electronic health record-based strategy on medication understanding and adherence among diabetic primary care patients. The measurement of process outcomes will help inform how the strategy might ultimately be refined and disseminated to other sites. Strategies such as these are needed to address the multifaceted challenges related to medication self-management among patients with chronic conditions.Clinicaltrials.gov NCT01669473.
Project description:Poor adherence to medication regimens and medical record inconsistencies result in incomplete knowledge of medication therapy in polypharmacy patients. By quantitatively identifying medications in the blood of patients and reconciling detected medications with the medical record, we have defined the severity of this knowledge gap and created a path toward optimizing medication therapy.We validated a liquid chromatography-tandem mass spectrometry assay to detect and/or quantify 38 medications across a broad range of chronic diseases to obtain a comprehensive survey of patient adherence, medical record accuracy, and exposure variability in two patient populations. In a retrospectively tested 821-patient cohort representing U.S. adults, we found that 46% of medications assessed were detected in patients as prescribed in the medical record. Of the remaining medications, 23% were detected, but not listed in the medical record while 30% were prescribed to patients, but not detected in blood. To determine how often each detected medication fell within literature-derived reference ranges when taken as prescribed, we prospectively enrolled a cohort of 151 treatment-regimen adherent patients. In this cohort, we found that 53% of medications that were taken as prescribed, as determined using patient self-reporting, were not within the blood reference range. Of the medications not in range, 83% were below and 17% above the lower and upper range limits, respectively. Only 32% of out-of-range medications could be attributed to short oral half-lives, leaving extensive exposure variability to result from patient behavior, undefined drug interactions, genetics, and other characteristics that can affect medication exposure.This is the first study to assess compliance, medical record accuracy, and exposure as determinants of real-world treatment and response. Variation in medication detection and exposure is greater than previously demonstrated, illustrating the scope of current therapy issues and opening avenues that warrant further investigation to optimize medication therapy.
Project description:Importance:Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy. Objective:To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention. Design, Setting, and Participants:This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat. Interventions:Clinics were randomly assigned to to groups: electronic health record-based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care. Main Outcomes and Measures:Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications. Results:Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, -2.0 mm Hg; 95% CI, -5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (-5.6 mm Hg; 95% CI, -8.8 to -2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]). Conclusions and Relevance:The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care. Trial Registration:ClinicalTrials.gov identifier: NCT01578577.
Project description:Objective:Medication adherence is an important aspect of chronic disease management. Electronic health record (EHR) data are often not linked to dispensing data, limiting clinicians' understanding of which of their patients fill their medications, and how to tailor care appropriately. We aimed to develop an algorithm to link EHR prescribing to claims-based dispensing data and use the results to quantify how often patients with diabetes filled prescribed chronic disease medications. Materials and Methods:We developed an algorithm linking EHR prescribing data (RxNorm terminology) to claims-based dispensing data (NDC terminology), within sample of adult (19-64) community health center (CHC) patients with diabetes from a network of CHCs across 12 states. We demonstrate an application of the method by calculating dispense rates for a set of commonly prescribed diabetes and cardio-protective medications. To further inform clinical care, we computed adjusted odds ratios of dispense by patient-, encounter-, and clinic-level characteristics. Results:Seventy-six percent of cardio-protective medication prescriptions and 74% of diabetes medications were linked to a dispensing record. Age, income, ethnicity, insurance, assigned primary care provider, comorbidity, time on EHR, and clinic size were significantly associated with odds of dispensing. Discussion:EHR prescriptions and pharmacy dispense data can be linked at the record level across different terminologies. Dispensing rates in this low-income population with diabetes were similar to other populations. Conclusion:Record linkage resulted in the finding that CHC patients with diabetes largely had their chronic disease medications dispensed. Understanding factors associated with dispensing rates highlight barriers and opportunities for optimal disease management.
Project description:Latinos experience disproportionately higher rates of uncontrolled hypertension as compared to Blacks and Whites. While poor adherence is a major contributor to disparities in blood pressure control, data in Latino patients are scant. More importantly, translation of interventions to improve medication adherence in community-based primary care practices, where the majority of Latino patients receive their care is non-existent.Using a randomized controlled design, this study evaluates the effectiveness of a culturally tailored, practice-based intervention compared to usual care on medication adherence, among 148 Latino patients with uncontrolled hypertension who are non-adherent to their antihypertensive medications. Bilingual medical assistants trained as Health Coaches deliver the intervention using an electronic medical record system-embedded adherence script. Patients randomized to the intervention group receive patient-centered counseling with a Health Coach to develop individualized self-monitoring strategies to overcome barriers and improve adherence behaviors. Health Coach sessions are held biweekly for the first 3 months (6 sessions total) and then monthly for the remaining 3 months (3 sessions total). Patients randomized to the usual care group receive standard hypertension treatment recommendations as determined by their primary care providers. The primary outcome is the rate of medication adherence at 6 months. The secondary outcome is reduction in systolic and diastolic blood pressure at 6 months.If successful, findings from this study will provide salient information on the translation of culturally tailored, evidence-based interventions targeted at medication adherence and blood pressure control into practice-based settings for this high-risk population.NCT01643473 on 16 July 2012.
Project description:Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient-provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable™ is an Electronic Medical Record (EMR)-integrated tool designed to support patient-provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable™ improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.
Project description:OBJECTIVE:To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. DATA SOURCES/SETTING:Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012. STUDY DESIGN:Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. DATA COLLECTION:Adherence and OOP costs were based on pharmacy dispensing records and benefits. PRINCIPAL FINDINGS:Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months). CONCLUSIONS:Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.
Project description:We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3?percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events.
Project description:BACKGROUND:Poor medication adherence is a pervasive problem in patients with hypertension. Despite research documenting an association between patient-provider communication and medication adherence, there are no empirical data on how the informational and relational aspects of communication affect patient's actual medication-taking behaviors. The aim of this study was to evaluate the impact of patient-provider communication on medication adherence among a sample of primary care providers and their black and white hypertensive patients. METHODS AND RESULTS:Cohort study included 92 hypertensive patients and 27 providers in 3 safety-net primary care practices in New York City. Patient-provider encounters were audiotaped at baseline and coded using the Medical Interaction Process System. Medication adherence data were collected continuously during the 3-month study with an electronic monitoring device. The majority of patients were black, 58% women, and most were seeing the same provider for at least 1 year. Approximately half of providers were white (56%), 67% women, and have been in practice for an average of 5.8 years. Fifty-eight percent of patients exhibited poor adherence to prescribed antihypertensive medications. Three categories of patient-provider communication predicted poor medication adherence: lower patient centeredness (odds ratio: 3.08; 95% confidence interval: 1.04-9.12), less discussion about patients' sociodemographic circumstances (living situation, relationship with partner; odds ratio: 6.03; 95% confidence interval: 2.15-17), and about their antihypertensive medications (odds ratio: 6.48; 95% confidence interval: 1.83-23.0). The effect of having less discussion about patients' sociodemographic circumstances on medication adherence was heightened in black patients (odds ratio: 8.01; 95% confidence interval: 2.80-22.9). CONCLUSIONS:The odds of poor medication adherence are greater when patient-provider interactions are low in patient centeredness and do not address patients' sociodemographic circumstances or their medication regimen.