Barriers and facilitators for improving oral anticoagulant medication adherence in lower extremity deep venous thrombosis patients after spinal surgery: A qualitative study using the COM-B model

Park L.G., Ng F., Handley M.A.

Among patients with coronary heart disease, we sought to address the research questions of: 1) What is the acceptability of applying a technology-enabled approach to support medication adherence?; and 2) What are barriers to medication adherence using the Capability-Opportunity-Motivation Behavior (COM-B) model as a guiding framework?Applying qualitative research methods, we employed a series of 3 focus groups per individual (total 9 sessions). Coded data from thematic analysis were mapped to the COM-B model components for meaningful associations.Fourteen participants were recruited (median age 69.5 ± 11, 50% female). Barriers to medication adherence were organized along these COM-B domains: psychological capability (forgetfulness, distractions, fear of side effects), physical opportunity (inaccessible medications, inability to renew prescriptions), reflective (burdening family members), and automatic motivation (medication fatigue, health decline).Tailored text messaging and mobile phone apps were perceived as helpful tools for medication adherence. The COM-B model was useful to provide a comprehensive, theory-driven evaluation of patients' beliefs and motivations on whether to engage in medication adherence.To date, text messaging and mobile applications have not been widely implemented in the clinical setting and provide a major opportunity to innovate on approaches to address medication adherence.

Chen Y., Gao J., Lu M.

AbstractAimsTo synthesize the published studies on medication adherence trajectories among patients with chronic diseases and identify the influencing factors.DesignSystematic review.Data SourcesMedline (Ovid), Embase (Ovid) and Web of Science core collection were searched from database inception to 1 July 2022.Review MethodsPotentially eligible articles were independently screened by three reviewers using set inclusion and exclusion criteria. The Joanna Briggs Institute critical appraisal checklist for cohort studies was used to appraise the quality of the included articles. Three reviewers independently evaluated the quality, extracted data and resolved differences by consensus. Results were presented using descriptive synthesis, and the prevalence of recategorised medication adherence trajectories was calculated from the published data.ResultsFifty studies were included. Medication adherence trajectories among patients with chronic diseases were synthesized into six categories: adherence, non‐adherence, decreasing adherence, increasing adherence, fluctuating adherence and moderate adherence. Low and moderate evidence showed that (1) patient‐related factors, including age, sex, race, marital status and mental status; (2) healthcare team and system‐related factors, including healthcare utilization, insurance and primary prescriber specialty; (3) socioeconomic factors including education, income and employment status; (4) condition‐related factors including complications and comorbidities and (5) therapy‐related factors including the number of medications, use of other medications, and prior medication adherence behaviours were factors influencing the medication adherence trajectory. Marital status and prior medication adherence behaviour were the only influencing factors with moderate evidence of an effect.ConclusionThe medication adherence trajectory among patients with chronic diseases varied widely. Further studies are warranted to determine contributory factors.Implications for the ProfessionHealthcare providers should be aware that patients' medication adherence has different trajectories and should take appropriate measures to improve patients' medication adherence patterns.Patient or Public ContributionNone. As a systematic review, patients and the public were not involved.

Mirzaei-Alavijeh M., Hamzeh B., Omrani H., Esmailli S., Khakzad S., Jalilian F.

Abstract Background Medication adherence is a key component of successful dialysis in end-stage renal disease (ESRD). The aim of this study was to use the Capability-Opportunity-Motivation and Behavior (COM-B) model in order to identify the most important determinants of medication adherence among ESRD patients. Methods This research was a cross-sectional design that was conducted in two steps in 2021. In the first step, COM-B components of patients undergoing hemodialysis (HD) therapy were extracted through literature review. The second step was a cross-sectional study among 260 ESRD patients referred to the dialysis unit from Kermanshah, in the west of Iran. Data was collected using a written questionnaire by interviews. The data was analyzed in SPSS version 16 software. Results The mean age of respondents was 50.52 years [95% CI: 48.71, 52.33], ranged from 20 to 75 years. The mean score of medication adherence was 11.95 [95% CI: 11.64, 12.26], ranged from 4 to 20. Medication adherence is higher among patients with higher education (P = 0.009) and those who were employed (P < 0.001) and was significantly related to income (r = 0.176), while it was inversely and significantly related to the medication duration (r=-0.250). Motivation (Beta: 0.373), self-efficacy (Beta: 0.244), and knowledge (Beta: 0.116) are stronger determinants of medication adherence. Conclusion COM-B model can be proposed as an integrated framework in predicting medication adherence among ESRD patients. Our findings provide theory-based recommendations that can help future clinical and research decision-making for the development, implementation, and evaluation of treatment adherence interventions in Iranian ESRD patients. The use of COM-B model can provide a comprehensive explanation about medication adherence in ESRD patients. Future research should be focus on increasing motivation, self-efficacy and knowledge of Iranian ESRD patients in order to increasing medication adherence.

Tabassum H., Chakraborty R., Chatterjee N.

Lai H., Fan J., Liu H., Wu X., Wang L., Gao L., Zhou L., Chen T., Zhang L., Chen J., Luo Z.

Fracture liaison service (FLS) is a management system for osteoporotic fractures, its difficulty lies in long-term management. Through this pilot single-center study, we found that FLS combined with an internet-based follow-up service (online home nursing care) can economically and conveniently monitor patients, reduce falls and refractures, and improve care and medication adherence. Among potential e-health platforms, mobile internet encompasses the largest user group of mobile instant messaging software in Asia and offers strong interaction, low cost, and fast speed. The online home nursing care model prevents unnecessary hospital admissions and readmissions. This study aims to explore the effects of a fracture liaison service (FLS) model combined with online home nursing care on patients with fragility hip fracture. Patients discharged after November 2020 received FLS care combined with online home nursing care. Patients discharged from May 2020 to November 2020 received only routine discharge guidance and were classified as the control group. The Parker Mobility Score (PMS), Medical Outcomes Study 36-item short-form health survey (MOS SF-36), general medication adherence scale (GMAS), complication rate, and fall/refracture rates were used to evaluate the efficacy of the FLS combined with online home nursing care during the 52-week follow-up period. Eighty-nine patients with complete follow-up information were included in the analysis at the 52-week follow-up. The FLS combined with online home nursing care was associated with improved osteoporosis patient care, including increased medication adherence (64.58% in the control group and 90.24% in the observation group), improved mental quality of life, reduced fall/refracture rate (12.5% and 4.88%, respectively), and reduced rates of bedsores and joint stiffness; however, there was no effect on functional recovery within 1 year. We recommend the combination of FLS with online home nursing care, considering the local environment, to economically and conveniently monitor patients, reduce falls and refractures, and improve care and medication adherence.

Duffett L.

Venous thromboembolism (VTE) is the third most common cardiovascular disorder, affecting up to 5% of the population. VTE commonly manifests as lower-extremity deep venous thrombosis (DVT) or pulmonary embolism. Half of these events are associated with a transient risk factor and may be preventable with prophylaxis. Direct oral anticoagulants are effective and safe and carry a lower risk for bleeding than vitamin K antagonists. Many patients with VTE will have a chronic disease requiring long-term anticoagulation. Postthrombotic syndrome affects 25% to 40% of patients with DVT and significantly impacts function and quality of life.

Connolly M.J., Weppner W.G., Fortuna R.J., Snyder E.D.

Navarrete S., Solar C., Tapia R., Pereira J., Fuentes E., Palomo I.

Deep venous thrombosis is a frequent, multifactorial disease and a leading cause of morbidity and mortality. Most of the time deep venous thrombosis is triggered by the interaction between acquired risk factors, such as hip fracture, pregnancy, and immobility, and hereditary risk factors such as thrombophilias. The mechanisms underlying deep venous thrombosis are not fully elucidated; however, in recent years, important advances have shed light on the role of venous flow, endothelium, platelets, leukocytes, and the interaction between inflammation and hemostasis. It has been described that the alteration of venous blood flow produces endothelial activation, favoring the adhesion of platelets and leukocytes, which, through tissue factor expression and neutrophil extracellular traps formation, contribute to the activation of coagulation, trapping more cells, such as red blood cells. Thus, the concerted interaction of these phenomena allows the formation and growth of the thrombus. In this work, the main mechanisms involved in the pathophysiology of deep vein thrombosis will be described.

Ding A., Dixon S.W., Ferries E.A., Shrank W.H.

Ageno W.

AbstractThe term unusual site thrombosis refers to the occurrence of venous thromboembolism outside of the lower limbs and the pulmonary arteries. Unusual site thrombosis can virtually affect any venous segment, with the most common and/or clinically relevant sites including the upper limbs veins, the retinal veins, the splanchnic veins and the cerebral veins. Clinical features are obviously heterogeneous, while many predisposing factors are common, though with different prevalence among the various disorders. Antithrombotic therapy is prescribed to most patients, but the type, intensity, and duration of treatment vary both within and among patient groups. Increasing evidence is supporting the use of the direct oral anticoagulants in patients with upper limb deep vein thrombosis, cerebral vein thrombosis, and with splanchnic vein thrombosis. This article will review available evidence on the treatment of venous thrombosis occurring in unusual sites.

Seah T.H., Almahmoud S., Coifman K.G.

Multiple Sclerosis (MS) is a debilitating chronic autoimmune disease of the central nervous system that results in lower quality of life. Medication adherence is important for reducing relapse, disease progression, and MS-related symptoms, particularly during the early stages of MS. However, adherence may be impacted by negative emotional states. Therefore, it is important to identify protective factors. Past research suggests that the ability to discriminate between negative emotional states, also known as negative emotion differentiation (NED), may be protective against enactment of maladaptive risk-related behaviors. However, less is known as to how NED may promote adaptive health behaviors such as medication adherence. Utilizing weekly diaries, we investigated whether NED moderates the association between negative affect and medication adherence rates across 58 weeks among patients (n = 27) newly diagnosed with MS (following McDonald criteria). Results revealed that NED significantly moderated the relationship between negative affect and medication adherence. Specifically, greater negative affect was associated with lower adherence only for individuals reporting low NED. However, this link disappeared for those reporting moderate to high NED. Building upon past research, our findings suggest that NED may promote adaptive health behaviors and have important clinical implications for the treatment and management of chronic illness.

Di Pino L., Francaviglia B., Frazzetto M., Valenti N., Capranzano P.

The effect of direct oral anticoagulants (DOACs) on evolution of a post-thrombotic syndrome (PTS) is unknown.This retrospective study included patients (n = 98) with a PTS occurring after a proximal deep-vein thrombosis (DVT). The PTS progression was assessed by the Villalta scale change over time from when patients were started on DOACs for the prevention of DVT recurrence according to current guidelines. The PTS evolution was compared between patients with good (n = 63) vs. poor (n = 35) DOACs adherence, defined by using a medication possession ratio cut point of 0.80. The mean follow-up was 41.7 ± 17.7 and 27.5 ± 10.5 months in patients with good or poor adherence, respectively. The primary endpoint of PTS improvement (defined when the Villalta score became

Park H.R., Kang H.S., Kim S.H., Singh-Carlson S.

Globally, breast cancer has been identified as the most common cancer among women. The clinical efficacy of adjuvant oral antiestrogen therapy-including tamoxifen and aromatase inhibitors-has been proven to be clinically efficacious for breast cancer survivors. However, medication adherence for these therapies remains suboptimal among breast cancer survivors.The aim of this study was to evaluate the effect of a reminder intervention-a smart pill bottle paired with the Pillsy mobile application-on medication adherence, medication self-efficacy, and depression, among breast cancer survivors who were undergoing oral antiestrogen therapy.This study is a randomized controlled trial. Sixty-one women were allocated to an experimental group (n = 31) and the control group (n = 30). The experimental group received the reminder intervention of a smart pill bottle for 4 weeks. Study outcomes were identified as medication adherence, medication self-efficacy, and depression.Fifty-seven women completed the follow-up measurement. Significant differences in favor of the experimental group were noted for medication adherence ( P = .004) and medication self-efficacy ( P = .004). There was no statistically significant difference between the 2 groups with regard to depression ( P = .057).Reminder intervention using smart pill bottles was effective in improving medication adherence and medication self-efficacy among breast cancer survivors undergoing oral antiestrogen therapy.A smart pill bottle method of intervention can be a useful reminder strategy to improve medication adherence among breast cancer survivors.

Bhandari B., Narasimhan P., Vaidya A., Subedi M., Jayasuriya R.

Nepal has a high prevalence of hypertension which is a major risk factor for cardiovascular diseases globally. It is inadequately controlled even after its diagnosis despite the availability of effective treatment of hypertension. There is a need for an in-depth understanding of the barriers and facilitators using theory to inform interventions to improve the control of hypertension. This formative study was conducted to address this gap by exploring the perceived facilitators and barriers to treatment and control of hypertension in Nepal. We conducted in-depth interviews (IDIs) among hypertensive patients, their family members, healthcare providers and key informants at primary (health posts and primary health care center) and tertiary level (Kathmandu Medical College) facilities in Kathmandu, Nepal. Additionally, data were collected using focus group discussions (FGDs) with hypertensive patients. Recordings of IDIs and FGDs were transcribed, coded both inductively and deductively, and subthemes generated. The emerging subthemes were mapped to the Capability, Opportunity, and Motivation-Behaviour (COM-B) model using a deductive approach. Major uncovered themes as capability barriers were misconceptions about hypertension, its treatment and difficulties in modifying behaviour. Faith in alternative medicine and fear of the consequences of established treatment were identified as motivation barriers. A lack of communication between patients and providers, stigma related to hypertension and fear of its disclosure, and socio-cultural factors shaping health behaviour were identified as opportunity barriers in the COM-B model. The perceived threat of the disease, a reflective motivator, was a facilitator in adhering to treatment. This formative study, using the COM-B model of behaviour change identified several known and unknown barriers and facilitators that influence poor control of blood pressure among people diagnosed with hypertension in Kathmandu, Nepal. These findings need to be considered when developing targeted interventions to improve treatment adherence and blood pressure control of hypertensive patients.

Khan F., Tritschler T., Kahn S.R., Rodger M.A.

Summary Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation–perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3–6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.