Search

Milou van Heuckelum,1,2 Cornelia HM van den Ende,1,3 Sandra van Dulmen,4– 6 Bart JF van den Bemt2,7,8 1Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands; 2Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands; 3Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands; 4Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands; 5Nivel (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; 6Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway; 7Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands; 8Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, the NetherlandsCorrespondence: Milou van HeuckelumDepartment of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 9500 GM, the NetherlandsTel +31 24 352 8123Email m.vanheuckelum@maartenskliniek.nlBackground: Non-adherence to medication (range 30– 107%) is a major issue in patients with rheumatoid arthritis (RA). Previous research has shown that electronic monitoring feedback (EMF) might be an effective strategy to improve medication adherence in chronic conditions. Therefore, this study investigated the effectiveness of electronic monitoring feedback in patients with early RA to improve medication adherence and clinical outcomes compared to usual care.Methods: An open-label randomized clinical trial was performed to compare EMF with standard care during a 12-month follow-up period on two sites of the Sint Maartenskliniek (Nijmegen and Boxmeer) in the Netherlands. Patients were eligible if they: (1) had a (working) diagnosis of early RA, (2) were currently using methotrexate, (3) were aged ≥ 18 years, and (4) had a life expectancy of ≥ 12 months. Primary outcome was the difference in proportion of non-adherent patients measured with the Compliance Questionnaire on Rheumatology after 12 months. Secondary outcomes were beliefs about medicines, medication adherence measured with the MMAS-8®, patients’ health status, prescription of biologic DMARDs, and disease activity after 12 months.Results: Of the 367 initially-invited patients, 93 patients with early RA agreed to participate in this study. No significant difference was found in the proportion of non-adherent patients between the intervention arm and the usual care arm after 12 months follow-up (60.0% and 61.3%, p=0.93, respectively). Patients in the intervention arm tended to discontinue methotrexate earlier than patients in the usual care arm (median time in weeks: 15.7 (9.1– 33.6) and 21.9 (19– 28.4), respectively, p=0.31), whereas patients in the usual care arm tended to initiate biologic DMARDs earlier than those in the intervention arm (median time in weeks: 11.9 (5.7– 22) and 17 (9.9– 40.9), respectively, p=0.55).Conclusion: This study illustrates the challenge of targeting non-adherence with EMF in patients with early RA and shares important lessons learned about designing adherence intervention trials with respect to study attrition, accounting for drug survival, intervention fidelity, intervention uptake, and technical aspects.Keywords: randomized clinical trial, rheumatoid arthritis, DMARDs, medication adherence, disease activity, clinical outcomes

Angelien Sieben,1 Hein AW van Onzenoort,2,3 Sandra van Dulmen,4–6 CJHM van Laarhoven,7 Sebastian JH Bredie81Department of Surgery, Division of Vascular Surgery, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands; 2Department of Clinical Pharmacy, Amphia Hospital, Breda, the Netherlands; 3Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, the Netherlands; 4Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands; 5NIVEL (Netherlands institute for health services research), Utrecht, the Netherlands; 6Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway; 7Department of General Surgery, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands; 8Department of General Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, the NetherlandsBackground: Poor medication adherence is a limitation in the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs.Purpose: To examine the process and effect of a nurse-led, web-based intervention based on behavioral change strategies to improve medication adherence in patients with CVD.Patients and methods: In this single-center, prospective, controlled clinical trial, cardiovascular patients were assigned to usual care, usual care plus a personalized website, or usual care plus a personalized website and personal consultations. Primary outcome was the level of adherence to cardiovascular medication. Data collection occurred between October 2011 and January 2015.Results: In total, 419 patients were randomized. Just 77 patients logged on the website and half of the invited patients attended the group consultation. Due to the limited use of the website, we combined the results of usual care and the usual care plus website group in one group (usual care) and compared these with the results of the group which received the nurse intervention (intervention group). No significant difference in adherence between the usual care group and the intervention group was observed. The adherence level in the usual care group was 93%, compared to 89% in the intervention group (p=0.08). 29% (usual care) and 31% (intervention group) of the patients showed a low adherence according to the Modified Morisky Scale® (p-value=0.94). The mean necessity concern differential was 3.8 with no differences between the two studied groups (mean 3.8 vs mean 3.9, p-value =0.86).Conclusion: Our intervention program did not show an effect. This could indicate that structured usual care provided to all cardiovascular patients already results in high medication adherence or that shortly after a cardiovascular event adherence is high. It could also indicate that the program did not have enough impact because there was not enough compliance with the intervention protocol.Trial registration: ID number NCT01449695, approved May 2011.Keywords: medication adherence, nurses, e-health, Health Belief Model, cardiovascular

Esther du Pon,1,2 Siham El Azzati,1 Ad van Dooren,1 Nanne Kleefstra,3,4 Eibert Heerdink,1,5 Sandra van Dulmen6–8 1Research Group Process Innovations in Pharmaceutical Care, Utrecht University of Applied Sciences, Utrecht, the Netherlands; 2Diabetes Centre, Isala Clinics, Zwolle, the Netherlands; 3Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; 4Medical Research Group, Langerhans, Ommen, the Netherlands; 5Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; 6NIVEL (Netherlands Institute for Health Services Research), Department of Communication in Healthcare, Utrecht, the Netherlands; 7Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community care, Nijmegen, the Netherlands; 8Faculty of Health and Social Sciences, University of Southeast Norway, Drammen, Norway Purpose: The present study aims to investigate the effect of the group-based Proactive Interdisciplinary Self-Management (PRISMA) training program on medication adherence in patients with type 2 diabetes (T2DM) treated in primary care.Patients and methods: The current study is a two-arm, parallel group, randomized, open label trial (1:1) of 6-month duration with a 6-month extension period in which both groups received the intervention (wait-list control). People 18 years old or older who were diagnosed with T2DM were included. The intervention consisted of two group meetings about T2DM guided by care providers. The control group received usual care only (visits at the general practice). The primary outcome was adherence based on pharmacy refill data and was measured using medication possession ratio (MPR). The secondary outcomes were the number of drug holidays and self-reported adherence, measured by the 5-item Medication Adherence Rating Scale (MARS-5).Results: Of the total sample (n=108), 66.6% were male. The mean age was 69.3 years (SD=9.1). In the 6-month period, patients were more adherent in the intervention group (n=56) (median MPR =100.0 [51.1–100.0]) than in the control group (n=52) (median MPR =97.7 [54.1–100.0]) (U=1,042, z=-2.783, P=0.005). The intervention group had less drug holidays than the control group (relative risk 0.55, 95% CI, 0.37–0.80). The sum scores of the MARS did not differ between the intervention group (median =23.98, SD=0.91) and the control group (median =24.00, SD=1.54).Conclusion: The PRISMA program resulted in a small improvement in MPR and fewer drug holidays, while no improvement has been found in self-reported adherence. However, health care providers and policy makers could take into account that adherence might be influenced by PRISMA. Keywords: MPR, refill data, drug holidays, MARS, group education

Jeanine A Driesenaar,1 Peter AGM De Smet,2,3 Rolf van Hulten,4,5 Litje Hu,1 Sandra van Dulmen1,6,7 1NIVEL, Netherlands institute for health services research, Utrecht, the Netherlands; 2Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands; 3IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands; 4Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands; 5Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, the Netherlands; 6Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands; 7Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway Background: Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist–patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist–patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions. Methods: Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider–patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting. Results: A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians. Conclusion: Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients. Keywords: community pharmacy, communication, inhaled corticosteroids, pharmacist–patient interaction, Roter interaction analysis system

Hanneke E Zwikker,1,2 Sandra van Dulmen,3–5 Alfons A den Broeder,1,2 Bart J van den Bemt,1,2,6 Cornelia H van den Ende1,2 1Department of Rheumatology, 2Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands; 3Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands; 4NIVEL (Netherlands Institute for Health Services Research), Utrecht, the Netherlands; 5Department of Health Science, Buskerud and Vestfold University College, Drammen, Norway; 6Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands Background: This is the first cross-sectional study that aims to examine associations between beliefs about medication and non-adherence in patients with rheumatoid arthritis (RA) using disease-modifying antirheumatic drugs, taking potential psychological confounders into account.Methods: Eligible patients (diagnosed with RA for ≥1 year or ≥18 years, using greater than or equal to one disease-modifying antirheumatic drug) were included by their rheumatologist during regular outpatient visits between September 2009 and September 2010. Included patients received questionnaires. The Beliefs about Medicines Questionnaire was used to measure the perceived need to take medication (necessity beliefs), the concerns about taking medication (concern beliefs), general medication beliefs, and attitudes toward taking medication. Medication non-adherence (no/yes) was measured using the Compliance Questionnaire Rheumatology (CQR). Associations between beliefs and non-adherence, and the influence of demographical, clinical, and psychological factors (symptoms of anxiety/depression, illness cognitions, self-efficacy) were assessed using logistic regression.Results: A total of 580 of the 820 eligible patients willing to participate were included in the analyses (68% female, mean age 63 years, 30% non-adherent to their medication). Weaker necessity beliefs (OR [odds ratio]: 0.8, 95% CI [confidence interval]: 0.8–0.9) and an unfavorable balance between necessity and concern beliefs (OR: 0.9, 95% CI: 0.9–1.0) were associated with CQR non-adherence. Also, having an indifferent attitude toward medication (no/yes) was associated with CQR non-adherence (OR: 5.3, 95% CI: 1.1–25.8), but the prevalence of patients with an indifferent attitude toward medication was low. The associations were barely confounded by demographical, clinical, and psychological factors.Conclusion: Increasing necessity beliefs about medication in clinical practice might be worthwhile in improving medication adherence in RA patients. Keywords: medication non-adherence, medication beliefs, psychological confounders, cross-sectional studies, rheumatoid arthritis

Hanneke E Zwikker,1 Bart J van den Bemt,1,2 Johanna E Vriezekolk,1 Cornelia H van den Ende,1 Sandra van Dulmen3–51Departments of Rheumatology and Pharmacy, 2Department of Pharmacy, Radboud University Medical Centre, 3Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, 4Netherlands Institute for Health Services Research, the Netherlands; 5Department of Health Science, Buskerud University College, Drammen, NorwayObjectives: Several cross-sectional studies suggest that psychosocial factors are associated with non-adherence to chronic preventive maintenance medication (CPMM); however, results from longitudinal associations have not yet been systematically summarized. Therefore, the objective of this study was to systematically synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.Materials and methods: PUBMED, EMBASE, CINAHL, and PsychINFO databases were searched for studies meeting our inclusion criteria. The reference lists and the ISI Web of Knowledge of the included studies were checked. Studies were included if they had an English abstract, involved adult populations using CPMM living in Western countries, and if they investigated associations between psychosocial predictors and medication non-adherence using longitudinal designs. Data were extracted according to a literature-based extraction form. Study quality was independently judged by two researchers using a framework comprising six bias domains. Studies were considered to be of high quality if ≥four domains were free of bias. Psychosocial predictors for non-adherence were categorized into five pre-defined categories: beliefs/cognitions; coping styles; social influences and social support; personality traits; and psychosocial well-being. A qualitative best evidence synthesis was performed to synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.Results: Of 4,732 initially-identified studies, 30 (low-quality) studies were included in the systematic review. The qualitative best evidence synthesis demonstrated limited evidence for absence of a longitudinal association between CPMM non-adherence and the psychosocial categories. The strength of evidence for the review's findings is limited by the low quality of included studies.Conclusion: The results do not provide psychosocial targets for the development of new interventions in clinical practice. This review clearly demonstrates the need for high-quality, longitudinal research to identify psychosocial predictors of medication non-adherence.Keywords: medication adherence, psychosocial factors, systematic review, longitudinal studies, somatic and chronic diseases

BACKGROUND/OBJECTIVE: To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles. In addition, relationships between PN/patient characteristics (including Five A's) and communication styles will be examined. SUBJECTS/METHODS: In this observational study, 100 videotaped real-life consultations, collected in 2010/2011, were viewed using an observational checklist. Selection of consultations was based on PNs' registration of patient's complaint. The quality of weight-loss counseling was assessed by the Five A's Model (sequence of evidence-based practice behaviors that are effective for helping patients to change health behaviors) and by PNs' communication styles. Moreover, several PN and patient characteristics were registered. Descriptive statistics and logistic regression analysis were conducted with significance set at P < 0.05. RESULTS: PNs most frequently arranged follow-up, assessed the risk and current behavior and advised. However, they rarely assisted in addressing barriers and securing support. For weight or physical activity, most PNs used a motivational communication style. In discussions of nutrition, they mostly used an informational communication style. Moreover, PNs used a combination of communication styles. PN characteristics, including their behavior concerning the Five A's, were stronger related to communication styles than patient characteristics. CONCLUSIONS: PNs reasonably complied with the Five A's Model. The quality of PNs' weight-loss counseling might be increased by routinely providing assistance in addressing barriers and securing support, and routinely reaching agreement with collaboratively set goals. European Journal of Clinical Nutrition (2015) 69, 73-78; doi: 10.1038/ejcn.2014.129; published online 2 July 2014, INTRODUCTION Overweight and obesity are increasing worlwide. (1) Overweight and obesity may cause different health problems, such as type 2 diabetes, cardiovascular disease and hypertension. (2) Reviews provide evidence that [...]

Arlene Mejino,1 Janneke Noordman,1 Sandra van Dulmen1–31Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands; 2Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, Nijmegen, The Netherlands; 3Department of Health Science, Buskerud University College, Drammen, NorwayAims: This study examined the perspectives and experiences of patients, parents, and health care providers with shared medical appointments (SMAs) for children and adolescents with type 1 diabetes. Specifically studied were reasons to attend SMAs, perceived differences between SMAs and individual medical appointments, patient-valued health care aspects, and providers' performance.Methods: Fifty-two patients, 8 parents, and 36 health care providers participated. Perspectives on SMAs were assessed with questionnaires and an online focus group. Data was analyzed using descriptive statistics.Results: Health care providers had work-related reasons to conduct SMAs. Patients and parents primarily valued the presence of other patients during SMAs. According to health care providers and patients, a higher or similar amount of information was discussed during SMAs as opposed to individual appointments, respectively. SMAs did contain more discussion about lifestyle. Most consultation aspects considered important by the patients were performed by their health care providers. Patient satisfaction with SMAs did tend to decrease after 3 months. Parents were somewhat more critical about SMAs.Conclusions: Health care providers, patients, and parents were generally positive about SMAs. Future studies should examine the impact of the presence of parents and different health care providers during SMAs, and that of differences in patient age, type of insulin treatment, and disease-related problems.Keywords: child, adolescent, diabetes mellitus type 1, pediatrics, shared medical appointment

BACKGROUND/OBJECTIVE: To examine the content of Dutch practice nurses' (PNs') advices about weight, nutrition and physical activity to overweight and obese patients. SUBJECTS/METHODS: A 100 videotaped real-life PN consultations (The Netherlands, 2010/2011) with overweight or obese patients were selected. An observational checklist was developed to assess frequency and content. Personalization of advices was scored, as also the guidelines on which PNs based their advices. Content analysis was used to identify different categories of advices. RESULTS: About one quarter of advices concerned weight, over two-thirds nutrition and one-third physical activity. Lose weight, eat less fat and be more physically active in general were the main categories for each type of advice. Despite high clarity of advices, lower scores were found for specificity and personalization. Very few nutrition advices were provided in combination with physical activity advices. CONCLUSIONS: Weight advices often related to the patient's complaint. PNs seldom set a concrete weight goal. Although benefits of physical activity were discussed, often no practical advices were provided about how to achieve this. Integrated lifestyle advice was not common: advices about nutrition and physical activity were fragmented throughout the consultation. Obesity prevention needs more emphasis in PNs' educational programs. European Journal of Clinical Nutrition (2014) 68, 50-56; doi:10.1038/ejcn.2013.219; published online 30 October 2013 Keywords: General practice; obesity; lifestyle; nurses; observation, INTRODUCTION Overweight (that is, body mass index greater than or equal to 25) and obesity (that is, body mass index greater than or equal to 30) are on the rise [...]