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What Is a Medication-Related Problem? A Qualitative Study of Older Adults and Primary Care Clinicians

  • Francesca M. NicosiaEmail author
  • Malena J. Spar
  • Marilyn Stebbins
  • Rebecca L. Sudore
  • Christine S. Ritchie
  • Kirby P. Lee
  • Kevin Rodondi
  • Michael A. Steinman
Original Research

Abstract

Background

Older adults often take multiple medications, leading to a myriad of medication-related problems. Addressing these problems requires thoughtful approaches that align with patients’ perspectives and experiences.

Objective

To (1) identify and categorize medication-related problems from the patient perspective and (2) understand patient and clinician attitudes toward these problems and experiences with addressing these problems.

Design

Qualitative, semi-structured interviews with patients and focus groups with physicians and pharmacists.

Participants

Twenty older adults recruited from an academic medical center and from a community senior center; 14 primary care physicians and 6 pharmacists affiliated with an academic medical center.

Approach

Hybrid deductive-inductive thematic analysis.

Key Results

Older adults identified a variety of medication-related problems that could be classified into four broad categories: (1) obtaining medications (e.g., problems with cost and insurance coverage); (2) taking medications (e.g., organization and remembering to take pills); (3) medication effects, including side effects and concerns over lack of effectiveness; and (4) communication and care coordination, including information related to medications. Many of the problems described by older adults were framed within the person’s socioemotional context, including the impact of medications on interpersonal relationships, emotional wellbeing, and activities that add meaning and quality to life. In contrast, clinicians almost exclusively focused on discrete medication issues without reference to this larger context and expressed relatively little interest in learning more about their patients’ perspectives.

Conclusions

Older adults experience medication-related problems as inseparable from their broader life context. Incorporating the social and emotional context of medications and related communication into a problem-focused framework can guide clinicians in specific actions and interventions to address medication-related problems from the patient perspective.

KEY WORDS

geriatrics primary care qualitative research medication medication-related problems 

Notes

Funding

Drs. Steinman and Ritchie: Tideswell at UCSF. Dr. Steinman: National Institute on Aging, National Institutes of Health (P30 AG044281, K24AG049057, and R24AG064025). Dr. Sudore is funded in part by the National Institute on Aging, National Institutes of Health (K24AG054415).

Compliance with Ethical Standards

The study was approved by the institutional review boards (IRBs) of the University of California, San Francisco and the San Francisco VA Medical Center.

Conflict of Interest

Dr. Steinman served as a consultant for iodine.com, an internet startup company focused on collecting and sharing patient-reported information on medication effectiveness and harms. Dr. Rodondi is an advisor to Arine.io, a medication therapy management company. All remaining authors declare that they do not have a conflict of interest

Supplementary material

11606_2019_5463_MOESM1_ESM.docx (18 kb)
ESM 1 (DOCX 18 kb)

References

  1. 1.
    Tran VT, Montori VM, Eton DT, Baruch D, Falissard B, Ravaud P. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med. 2012 Jul 4;10:68.CrossRefGoogle Scholar
  2. 2.
    Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014 Oct 7:CD008165.Google Scholar
  3. 3.
    Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging. 2003;20:817-32.CrossRefGoogle Scholar
  4. 4.
    Viswanathan M, Kahwati LC, Golin CE, Blalock SJ, Coker-Schwimmer E, Posey R, Lohr KN. Medication therapy management interventions in outpatient settings: a systematic review and meta-analysis. JAMA Intern Med. 2015 Jan;175:76-87.CrossRefGoogle Scholar
  5. 5.
    Marcum ZA, Gellad WF. Medication adherence to multidrug regimens. Clin Geriatr Med. 2012;28:287-300.CrossRefGoogle Scholar
  6. 6.
    Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-16.CrossRefGoogle Scholar
  7. 7.
    Opondo D, Eslami S, Visscher S, de Rooij, Verheij R, Korevaar JC, Abu-Hanna A. Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. PLoS One 2012;7:e43617.CrossRefGoogle Scholar
  8. 8.
    Fried TR, McGraw S, Agostini JV, Tinetti ME. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc. 2008 Oct;56:1839-44.CrossRefGoogle Scholar
  9. 9.
    Fried TR, Tinetti ME, Iannone L. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011 Jan 10;171:75-80.PubMedGoogle Scholar
  10. 10.
    Willeboordse F, Hugtenburg JG, Schellevis FG, Elders PJ. Patient participation in medication reviews is desirable but not evidence-based: a systematic literature review. Br J Clin Pharmacol. 2014 Dec;78:1201-16.CrossRefGoogle Scholar
  11. 11.
    Tinetti ME, McAvay GJ, Fried TR, Allore HG, Salmon JC, Foody JM, Bianco L, Ginter S, Fraenkel L. Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. J Am Geriatr Soc. 2008 Aug;56:1409-16.CrossRefGoogle Scholar
  12. 12.
    Patton DE, Cadogan CA, Ryan C, Francis, JJ, Gormley GJ, Passmore P, Kerse N, Hughes CM. Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators. Health Expect. 2018 Feb;21:138-48.CrossRefGoogle Scholar
  13. 13.
    Garavalia L, Garavalia B, Spertus JA, Decker C. Medication Discussion Questions (MedDQ): developing a guide to facilitate patient-clinician communication about heart medications. J Cardiovasc Nurs. 2011;26:E12-9.CrossRefGoogle Scholar
  14. 14.
    Weingart SN, Gandhi TK, Seger AC, Seger DL, Borus J, Burdick E, Leape LL, Bates DW. Patient-reported medication symptoms in primary care. Arch Intern Med. 2005;165:234-40.CrossRefGoogle Scholar
  15. 15.
    Brown M, Frost R, Ko Y, Woosley R. Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research. Patient Educ Couns. 2006;62:302-15.CrossRefGoogle Scholar
  16. 16.
    Basger BJ, Moles RJ, Chen TF. Development of an aggregated system for classifying causes of drug-related problems. Ann Pharmacother. 2015;49:405-18.CrossRefGoogle Scholar
  17. 17.
    Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. Misunderstandings in prescribing decisions in general practice: qualitative study. BMJ. 2000 Feb 19;320:484-8.CrossRefGoogle Scholar
  18. 18.
    Joensson ABR, Guassora AD, Freil M, Reventlow S. What the doctor doesn't know: Discarded patient knowledge of older adults with multimorbidity. Chronic Illn. 2018 Sep 13:1-14.Google Scholar
  19. 19.
    Tarn DM, Mattimore TJ, Bell DS, Kravitz RL, Wenger NS. Provider views about responsibility for medication adherence and content of physician-older patient discussions. J Am Geriatr Soc. 2012;60:1019-26.CrossRefGoogle Scholar
  20. 20.
    Richard C, Lussier MT. Measuring patient and physician participation in exchanges on medications: Dialogue Ratio, Preponderance of Initiative, and Dialogical Roles. Patient Educ Couns. 2007;65:329-41.CrossRefGoogle Scholar
  21. 21.
    Mohammed MA, Moles RJ, Chen TF. Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies. BMJ Open. 2016 Feb 2;6:e010035.CrossRefGoogle Scholar
  22. 22.
    Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira MM, Persell, SD, Jacobs E, Abrams RI. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153:69-75.CrossRefGoogle Scholar
  23. 23.
    Shoemaker SJ, Ramalho de Oliveira D. Understanding the meaning of medications for patients: the medication experience. Pharm World Sci. 2008 Jan;30:86-91.CrossRefGoogle Scholar
  24. 24.
    Pound P, Britten N, Morgan M, Yardley L, Pope C, Daker-White G, Campbell R. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med. 2005 Jul;61:133-55.CrossRefGoogle Scholar
  25. 25.
    Krska J, Morecroft CW, Poole H, Rowe PH. Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study. Int J Clin Pharm. 2013;35:1161-9.CrossRefGoogle Scholar
  26. 26.
    Patton MQ. Qualitative research and evaluation methods. Thousand Oaks, CA: SAGE; 2002.Google Scholar
  27. 27.
    Morgan DL. Focus groups as qualitative research. 2nd ed. Thousand Oaks, CA. SAGE; 1997.CrossRefGoogle Scholar
  28. 28.
    Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433-41.CrossRefGoogle Scholar
  29. 29.
    Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42:533-44.CrossRefGoogle Scholar
  30. 30.
    Bajcar J. Task analysis of patients' medication-taking practice and the role of making sense: a grounded theory study. Res Social Adm Pharm. 2006 Mar;2:59-82.CrossRefGoogle Scholar
  31. 31.
    Shoemaker SJ, Ramalho de Oliveira D, Alves M, Ekstrand M. The medication experience: preliminary evidence of its value for patient education and counseling on chronic medications. Patient Educ Couns. 2011 Jun;83:443-50.CrossRefGoogle Scholar
  32. 32.
    Mohammed MA, Moles RJ, Hilmer SN, Kouladjian O'Donnel L, Chen TF. Development and validation of an instrument for measuring the burden of medicine on functioning and well-being: the Medication-Related Burden Quality of Life (MRB-QoL) tool. BMJ Open. 2018 Jan 11;8:e018880.CrossRefGoogle Scholar
  33. 33.
    Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5:80-92.CrossRefGoogle Scholar
  34. 34.
    Foley G, Timonen V. Using grounded theory method to capture and analyze health care experiences. Health Serv Res. 2015;50:1195-210.CrossRefGoogle Scholar
  35. 35.
    Modig S, Kristensson J, Troein M, Brorsson A, Midlov P. Frail elderly patients' experiences of information on medication: a qualitative study. BMC Geriatr. 2012;12:46.CrossRefGoogle Scholar
  36. 36.
    Henriques MA, Costa MA, Cabrita J. Adherence and medication management by the elderly. J Clin Nurs. 2012;21:3096-105.CrossRefGoogle Scholar
  37. 37.
    Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014 Feb;103:126-33.CrossRefGoogle Scholar
  38. 38.
    Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012 Jun 1;29:495-510.CrossRefGoogle Scholar
  39. 39.
    Verloo H, Chiolero A, Kiszio B, Kampel T, Santschi V. Nurse interventions to improve medication adherence among discharged older adults: a systematic review. Age Ageing 2017;46:747-54.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Francesca M. Nicosia
    • 1
    • 2
    • 3
    Email author
  • Malena J. Spar
    • 1
    • 2
  • Marilyn Stebbins
    • 4
  • Rebecca L. Sudore
    • 1
    • 2
  • Christine S. Ritchie
    • 1
    • 5
  • Kirby P. Lee
    • 4
  • Kevin Rodondi
    • 4
  • Michael A. Steinman
    • 1
    • 2
    • 5
  1. 1.Division of GeriatricsUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.San Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  3. 3.Institute for Health & AgingUniversity of California, San FranciscoSan FranciscoUSA
  4. 4.Department of Clinical Pharmacy, School of PharmacyUniversity of California, San FranciscoSan FranciscoUSA
  5. 5.San Francisco Campus for Jewish Living Center for Research in AgingSan FranciscoUSA

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