Oſten, compliance is also used and the two can be used interchangeably in research and clinical practice . It describes “the extent to which the patients’ behavior (including medication-taking) coincides with medical or healthcare advice”, yet its meaning has become more negative regarding patient’s behaviors, since it implies patient’s passivity.
Nevertheless,measurement of medication adherence can be quite challenging since and parameters of acceptable adherence need to be carefully delineated and appropriated for individual situations. There are numerous tools available for these measurements, but these need to prove to be valid, reliable, and sensitive to change. The selection of a method to monitor adherence should be based on individual attributes and goals/resources of the study or the clinical setting. Currently none of the available methods can be considered as a gold standard and the combination of methods is recommended.
Objective measures include pill counts, electronic monitoring, secondary database analysis and biochemical measures and are thought to represent an improvement over subjective measures. As such, objective measures should be used to validate and correlate the subjective ones. However, a meta-analysis on adherence outcomes states that a multi-subjective-measure approach may have higher sensitivity, but not accuracy, over employing a single objective measure. In summary, subjective and objective measures have both advantages and disadvantages and should be used in combination.
The Medication Events Monitoring System (MEMS) is the most commonly used EMP device in medication adherence studies.
Although poor adherence is directly linked to patient behavior, there is no definitive data that has defined a ‘non-adherent’ personality or revealed a relationship between adherence and the ability to follow self-care or lifestyle recommendations.14 Likewise, medication adherence has not been shown to be correlated to demographic variables such as age, gender, or race, although there is a weak relationship with lower education and income levels. There are many variables that can be factored into adherence behavior outside of demographic variables that have greater utility as a predictor of medication adherence behavior. Table 1 categorizes the predictive strength of consumer-related variables (and their interaction within the health care system) as they are presented in the literature.
Moreover, the decision to be adherent is unique for each medication, and driven by three factors: (1) the perceived need for the medication (related to their understanding of the disease and therapy): (2) the perceived concerns about the medication (related to side-effects and safety); and (3) the perceived medication affordability.
National Consumers League’s Approach
The National Consumers League has launched a medication adherence awareness campaign entitled “Script Your Future”. The multiyear effort focuses primarily on patients affected by diabetes, respiratory disease, and cardiovascular disease. It is a powerful campaign that educates the consumer that poor medication adherence can lead to consequences that affect their ability to take care of themselves and their loved ones, places undue emotional and financial burden on family members, and jeopardizes the ability to experience future family events and milestones. The campaign also encourages patients and health care professionals to better communicate about ways to improve medication adherence.
Physicians, particularly primary care physicians (PCPs) and other specialists that write prescriptions for chronic diseases, can play a key role in addressing medication adherence given that they represent the initiation of the prescription process and have the opportunity to develop a trusting relationship with the patient.
This is a very important paper!
Although the term compliance has been in use for the longest period of time, nowadays it is considered that it is not entirely adequate and that changes in the relation between patients and healthcare professionals must be taken into consideration. Patients’ status is no longer submissive and passive and their role in accomplishing therapeutic objectives does not only imply compliance with medical instructions but active cooperation and agreement with a doctor and a pharmacist. Due to these reasons the term adherence has become more desirable in practice since the 90’s of the 20th century.
Differences between compliance and adherence are thus not only in the semantic sense but of essential nature. While in compliance the focus is on the healthcare provider who has a dominant status in relation to the patient, the concept of adherence is oriented to the patient and cooperation. In relation to this, the flow of information is one-way and the objective is to achieve obedience of the patient, while adherence implies a two-way information transfer and engagement of both subjects.[Top]
This is the external link to the e-book.
As Bhaskar puts it, ‘Theory without experiment is empty. Experiment without theory is blind’ (1978, 191).
Society is made by, but never under the control of, human intentions.
Evaluation has traditionally been asked to pronounce on whether a programme makes a difference ‘beyond that which would have happened anyway’. We always need to keep in mind that what would have happened anyway is change – unavoidable, unplanned, self-generated, morphogenetic change.
Realist evaluation is a form of theory-driven evaluation. But its theories are not the highfalutin’ theories of sociology, psychology and political science. Indeed, the term ‘realistic’ evaluation is sometimes substituted out of the desire to convey the idea that the fate of a programme lies in the everyday reasoning of its stakeholders. Good evaluations gain power for the simple reason that they capture the manner in which an awful lot of participants think. One might say that the basic currency is common-sense theory.
However, this should only be the starting point. The full explanatory sequence needs to be rooted in but not identical to everyday reasoning. In trying to describe the precise elbow room between social science and common sense one can do no better that to follow Elster’s thinking. He has much else to say on the nuts and bolts of social explanation, but here we concentrate on that vital distinction, as mooted in the following:
Much of science, including social science, tries to explain things we all know, but science can make a contribution by establishing that some of the things we all think we know simply are not so. In that case, social science may also explain why we think we know things that are not so, adding as it were a piece of knowledge to replace the one that has been taken away. (2007: 16)
Evidence-based policy has become associated with systematic review methods for the soundest of reasons. Social research is supremely difficult and prone to all kinds of error, mishap and bias. One consequence of this in the field of evaluation is the increasingly strident call for hierarchies of evidence, protocolised procedures, professional standards, quality appraisal systems and so forth. What this quest for technical purity forgets is that all scientific data is hedged with uncertainty, a point which is at the root of Popperian philosophy of science.
What is good enough for natural science is good enough for evidence-based policy, which comes with a frightening array of unanticipated swans – white, black and all shades of grey. Here too, ‘evidence’ does not come in finite chunks offering certainty and security to policy decisions. Programmes and interventions spring into life as ideas about how to change the world for the better. These ideas are complex and consist of whole chains of main and subsidiary propositions. The task of evaluation research is to articulate and refine those theories. The task of systematic review is to refine those refinements. But the process is continuous – for in a ‘self-transforming’ world there is always an emerging angle, a downturn in programme fortunes, a fresh policy challenge. Evidence-based policy will only mature when it is understood that it is a continuous, accumulative process in which the data pursues, but never quite draws level with, unfolding policy problems. Enlightened policies, like bridges over swampy waters, only hold ‘for the time being’.
It has always been stressed that realism is a general research strategy rather than a strict technical procedure (Pawson and Tilley, 1997b: Chapter 9). It has always been stressed that innovation in realist research design will be required to tackle a widening array of policies and programmes (Pawson, 2006a: 93–99). It has always been stressed that this version of realism is Popperian and Campbellian in its philosophy of science and thus relishes the use of the brave conjecture and the application of judgement (Pawson et al., 2011a).
a PHR was defined in the project specification as:
… a digital tool that helps people to maintain their health and manage their care. It may do this by enabling them to capture their own health and care data, to communicate with health and care services, and/or to have access to their care record.
The literature review found evidence of unmet needs. Patient expectations were not being met by PHRs; in particular limited content of the record was being made available to patients and there was an inability to bring together records from different care settings into one place.
Recommendations for further research:
Understand what patients require from PHRs – what information do they want to see and what do they want to use PHRs for, and why (ie gain or benefit)? This understanding needs to include people who do not currently use PHRs and the requirements of different groups (eg adults, older people, children, people who are ‘hard to reach’, those with sensory and other disabilities and those with mental health issues, etc). Any study needs to examine requirements in a person-centred way across care setting boundaries, rather than from the perspective of specific care providers.
The categories of services provided currently by PHRs:
- communicating with your care team through the PHR
- seeing your medication records and tools, to review them and remind you to take medication
- services to help you to plan and manage your own care
- information and support services.
In the systems that were connected to the care providers’ EHR (17/23), 76% showed a benefit in the use of the PHR. However in standalone PHRs, benefits were seen only in 50% of the studies (3/6)
Responses about PHR services indicate that they are at a relatively low level of maturity.
- Most of the PHRs are currently setting-specific (ie primary, hospital or social care), although some suppliers have aspirations for integrated implementation across more than one setting.
- PHRs mainly provide patients with a view of their records, rather than the ability to update or annotate them, let alone upload their own data.
- Linkage of PHRs to electronic health or care record systems was in some cases aspirational, particularly when compared with implementer responses about current linkage. Also, the links are generally unidirectional (from the electronic health or care record to the PHR, rather than vice versa).
- The main way in which users could communicate with their care teams was via email-type messaging rather than instant methods, such as video and instant messaging etc.
- While PHRs enable patients or citizens to view their medications, they are generally setting- specific, for example only their GP or hospital medication records. Patients are unable to interact electronically with their medication record, eg to point out errors or to remind themselves to take their medicines.
The main use of PHRs is currently access to blood test results. In patient online access to GP records, repeat prescriptions and appointment booking are also major uses. PHRs tend to be used before or after appointments, which indicates that preparation for and debriefing on consultations is important. These uses are quite limited and, in the case of blood results, are limited to specific patient groups. There is still little evidence about how PHRs are used, what they are used for and why.
Potential benefits for both patients (improved experience and outcomes) and organisations (time, effectiveness and cost savings) were identified in the survey responses, but the majority were aspirational and we were able to obtain little supporting evidence of objectively realised benefits. The literature review identified a number of studies that identified patient benefits, but these were largely qualitative, focusing on how patients felt about the PHRs, rather than any quantitative assessment of their impact on health outcomes (eg lifestyle improvements) derived from bias-free study designs.
Similarly, reports of disbenefits were mainly related to fears and anxieties, for example of increased burden on clinicians or patient confidentiality, with little supporting evidence.[Top]
This is an important paper
Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care.
The nature of the research question drives the choice of methods. Health services researchers use quantitative methodologies to address research questions about causality, generalizability, or magnitude of effects. Qualitative methodologies are applied to research questions to explore why or how a phenomenon occurs, to develop a theory, or to describe the nature of an individual’s experience. Mixed methods research studies draw upon the strengths of both quantitative and qualitative approaches and provides an innovative approach for addressing contemporary issues in health services.
Method level integration commonly relates to the type of design used in a study. For example, connecting follows naturally in sequential designs, while merging can occur in any design. Embedding generally occurs in an interventional design. Thus, the design sets parameters for what methodological integration choices can be made. Integration of qualitative and quantitative data at the interpretation and reporting level occurs through three approaches:
- integrating through narrative;
- integrating through data transformation;
- integrating through joint displays.