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Nurse interventions to improve medication adherence among discharged older adults: a systematic review
HENK VERLOO1,4, ARNAUD CHIOLERO2,3, BLANCHE KISZIO4, THOMAS KAMPEL4, VALÉRIE SANTSCHI4,5
1School of Health sciences, HES-SO Valais — Wallis, University of Applied sciences Western Switzerland, Chémin de l’Agasse 6, Sion, Switzerland 2IUMSP, Lausanne University Hospital, Lausanne, Switzerland 3Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland 4La Source, School of Nursing Sciences, University of Applied Sciences Western Switzerland, Lausanne, Switzerland 5Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
Address correspondence to: H. Verloo. Tel: +41 27 606 84 24; Fax +41 27 606 84 01. Email: henk.verloo@unil.ch
Abstract
Background: discharged older adult inpatients are often prescribed numerous medications. However, they only take about half of their medications and many stop treatments entirely. Nurse interventions could improve medication adherence among this population. Objective: to conduct a systematic review of trials that assessed the effects of nursing interventions to improve medication adherence among discharged, home-dwelling and older adults. Method: we conducted a systematic review according to the methods in the Cochrane Collaboration Handbook and reported results according to the PRISMA statement. We searched for controlled clinical trials (CCTs) and randomised CCTs (RCTs), published up to 8 November 2016 (using electronic databases, grey literature and hand searching), that evalu- ated the effects of nurse interventions conducted alone or in collaboration with other health professionals to improve medi- cation adherence among discharged older adults. Medication adherence was defined as the extent to which a patient takes medication as prescribed. Results: out of 1,546 records identified, 82 full-text papers were evaluated and 14 studies were included—11 RCTs and 2 CCTs. Overall, 2,028 patients were included (995 in intervention groups; 1,033 in usual-care groups). Interventions were nurse-led in seven studies and nurse-collaborative in seven more. In nine studies, adherence was higher in the intervention group than in the usual-care group, with the difference reaching statistical significance in eight studies. There was no sub- stantial difference in increased medication adherence whether interventions were nurse-led or nurse-collaborative. Four of the 14 studies were of relatively high quality. Conclusion: nurse-led and nurse-collaborative interventions moderately improved adherence among discharged older adults. There is a need for large, well-designed studies using highly reliable tools for measuring medication adherence.
Keywords: medication adherence, nurse intervention, nurse-led interventions, nurse-collaborative interventions, systematic review, older people
Background
Medication adherence—defined as the extent to which patients take medication as prescribed by their healthcare professionals—is an important aspect of treatment efficacy, healthcare costs and patient safety [1, 2]. Medication
adherence also implies the notion of concordance, i.e. a process of shared decision-making between patients and healthcare professionals [3]. According to a WHO report, inadequate medication adherence averaged 50% among patients with a chronic disease [4] and represented a signi- ficant problem that led to increased morbidity and
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mortality, as well as increased healthcare costs [5, 6]. Many older adults suffer from multiple chronic diseases and are treated with numerous medications. They are, therefore, at a high risk of poor adherence, e.g. missing doses, discontinu- ation, alteration of schedules and doses or overuse [7]. Non- adherence can result in worsening clinical outcomes, including re-hospitalisation, exacerbation of chronic medical conditions and greater healthcare costs [8, 9]. Up to 10% of hospital readmissions have been attributed to non-adherence [6].
Several studies have demonstrated that insufficient medica- tion adherence is common among discharged older adults [9, 10]. Older adults experienced changes in their medication regi- men during hospitalisation [11] and in the 1st week following hospital discharge [8]. Such changes, as well as complex treat- ment plans, tended to decrease medication adherence and could be a reason for a patient’s non-adherence. Older adults may also have restarted taking medications that were discontin- ued during hospitalisation, failed to start new medications initiated during hospitalisation, or taken incorrect dosages [9, 12]. Moreover, medication changes are poorly communicated to the patient at the time of discharge [13]. Older adults are at a particularly high risk of non-adherence in the 1st days or weeks following hospital discharge [9]. Therefore, it is import- ant for healthcare professionals, especially community health- care nurses, to follow-up with older adults early and frequently to keep them adherent to therapy. Nurses are well placed to provide and coordinate adherence-care because they are pre- sent in the majority of healthcare settings, are in close physical proximity to patients, and act as interfaces between patients and physicians [14].
Previous studies have shown that interventions such as patient education, the use of medication management tools or electronic monitoring reminders, can help to improve medica- tion adherence and continuity of care among older adults [15, 16]. However, few studies have evaluated the effects of inter- ventions to improve medication adherence after hospital dis- charge. Our systematic review focuses on the effectiveness of nurse-led interventions to improve medication adherence in older home-dwelling patients who are discharged from hos- pital; a previous Cochrane review has looked at a broader range of interventions to enhance medication adherence, in a wide range of patient groups [16]. More specifically, there is lit- tle evidence on the impact of nursing interventions—whether alone or in collaboration with other health professionals—on medication adherence among discharged older adults [9].
This systematic review aimed to determine whether nursing interventions alone, or in collaboration with other health professionals, were effective in improving medication adherence among recently discharged, inpatient, home- dwelling older adults aged 65 years old or more, when com- pared with those receiving usual care.
Methods and materials
This systematic review was conducted according to methods in the Cochrane Collaboration Handbook [17] and results were reported according to the PRISMA statement [18].
Data sources and search criteria
In collaboration with a medical librarian (B.K.), a systematic literature search was conducted for any articles published up to 8 November 2016, using predefined search terms in Medline via PubMed (from 1946), EMBASE (from 1947), CINAHL (from 1937), the Cochrane Central Register of Controlled Trials (from 1992), PsycINFO (from 1806), Web of Science (from 1900), JBI database (from 1998), DARE (from 1996), Tripdatabase (from 1997), the French Public Health Database (from 1878), International Pharmaceutical Abstracts (IPA, from 1970) and clinicaltrial. gov (from 2008).
The syntax consisted of four search themes intersected by the Boolean term ‘AND’. MeSH terms included age-related terms (Aged), medication adherence-related terms (Medication Adherence, Patient Medication Knowledge, Prescription Drug Misuse, Polypharmacy, Drug Therapy, Medication Therapy Management, Pharmaceutical Preparations/Administration and Dosage), nurse-related terms (Nursing, Nursing Care, Nurses, Nurse–Patient Relations, Models of Nursing) and hospital-related terms (Patient Discharge, Continuity of Patient Care, Inpatients, Hospitalisation). The search strategy was then adapted for EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, PsycINFO, Web of Science, the JBI database, DARE, Tripdatabase, IPA and clinicaltrial.gov (see Supplementary data 2, available at Age and Ageing online).
In addition to the electronic database searches, a hand search of the bibliographies of all relevant articles was con- ducted, as was a search of unpublished studies using Google Scholar, Proquest, Mednar and Worldcat, without language restrictions. Finally, a forward citation search of the articles selected was also conducted using Google Scholar.
Study selection
Two authors (H.V. and B.K.) independently screened titles, abstracts and full texts from the literature search to deter- mine their eligibility. Full texts were eligible for review if they were written in English, French or German. Studies included: (i) were either randomised clinical trials (RCTs) or controlled clinical trials (CCTs); (ii) had evaluated the effects of nurse interventions or collaborative interventions with other healthcare professionals on medication adherence compared to a usual-care group and (iii) were conducted among recently discharged (<2 weeks after discharge) older adults (aged ≥65 years old), living at home, and taking at least one prescribed medication for any kind of medical condition. Outcomes were changes in medication adherence during follow-up as measured using different methods [1, 14], i.e. electronic monitors, prescription refills, pill counts, medication adherence tools/questionnaires and patient self-reporting. Disagreements between screeners were resolved by consensus.
Nurse interventions were classified as either nurse-led care and nurse-collaborative care, as provided by Registered
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Nurses (RN). Based on the Cochrane Effective Practice and Organisation of Care taxonomy of health systems inter- ventions [19], we considered patient-level interventions con- ducted by nurses (education, counselling and teaching; reminder interventions using telephone contact,…
