Francisca Leiva-Fernández

Background: Medication adherence is particularly challenging in older adults with multimorbidity (MM) and polypharmacy (PP), who face greater therapeutic complexity and an increased risk of adverse health outcomes when treatment is not followed as prescribed. The World Health Organization (WHO) classifies determinants of medication adherence into five dimensions (socio-economic, condition-related, therapy-related, patient-related, and healthcare system-related factors), providing a comprehensive framework to identify modifiable factors. This study aimed to analyze factors associated with medication adherence across the five WHO dimensions in patients aged 65–74 years with MM and PP. Methods: This cross-sectional study used baseline data from the MULTIPAP cohort including 1,057 patients aged 65–74 years with MM (≥3 chronic conditions) and PP (≥5 medications prescribed for at least three months). Medication adherence (dependent variable) was assessed using the 4-item Morisky-Green questionnaire. Independent variables were classified according to the five WHO dimensions of adherence, and included social support, number of chronic conditions and medications, health-related quality of life (EQ-5D-5L), and disability (WHODAS 2.0). Descriptive, bivariate, and mixed-effects logistic regression models were performed. Results: Mean age of patients was 69.79 years (SD 3.47), 57.1% were women, and 727 (68.8%) patients were adherent. Adherent patients had lower urban vulnerability (71% vs 29%), higher social support (mean score 43.71 vs 42.5), fewer prescribed medications (7.8 vs 8.2), better health-related quality of life (mean score 66.66 vs 63.82), and lower disability (mean score 14.35 vs 19.84) compared with non-adherent patients. In the multivariate analysis, higher disability was independently associated with nonadherence (odds ratio 1.02; 95% confidence interval 1.01–1.04). Conclusions: Self-reported medication adherence was relatively high among older adults with MM and PP.Although significant differences between adherents and nonadherents were observed across nearly all dimensions of factors related to adherence, only disability (dimension of patient-related factors) remained independently associated with nonadherence in the multivariate analysis. A patient-centred approach that incorporates a comprehensive assessment of the five dimensions is necessary to improve treatment adherence in this population. Trial registration: ClinicalTrials.gov NCT04147130. Registered on 22 October 2019

Background: Multimorbidity is highly prevalent and poses clinical and organisational challenges, yet the training of doctors and nurses continues to focus mainly on single conditions. In recent years, training interventions for healthcare professionals on multimorbidity have emerged, but evidence of their effectiveness remains limited. Understanding the learning needs of professionals is essential for guiding educational programmes. This study aimed to identify the perceived training needs of primary care physicians and nurses in the management of multimorbidity and to contribute to a proposal of updated curriculum content. Methods: Exploratory cross-sectional study using an online survey of doctors and nurses in primary care and out-of-hospital emergency services in Spain. The questionnaire was developed based on the literature, existing curriculum frameworks and previous findings from the MULTIPAP study, and collected sociodemographic, professional and educational data, as well as perceptions about resources, difficulties and training needs in multimorbidity. Descriptive, bivariate, and multivariable analyses were conducted, and open-ended responses were analysed using thematic content analysis. Results: The main difficulties and training needs concerned medicines management and diagnostic and therapeutic challenges, followed by communication and time management. Participants valued patient–caregiver-centred care, medicines management, and care coordination. An online format with videos was preferred. Differences were observed by profession, gender, field of work, trainee status, and prior participation in the MULTIPAP study. The proposed curriculum comprised eight competency groups, including professionalism and social sciences along with other key issues, especially clinical, communication, and management skills. Conclusion: Professionals share many training needs, obstacles, and resources related to multimorbidity care, with some differences between subgroups. These findings informed a proposal for an updated curriculum content.

Objectives: The objective of this study was to explore the views expressed online by COPD patients regarding adherence to inhaled therapy. Methods: This study applied a qualitative, exploratory-interpretive design and an inductive methodology. Sources analyzed included COPD websites, patient forums, and social networks. Units of analysis were videos, stories, questions and answers, and conversation threads. Saturation criteria were applied. Applying a constant comparative methodology, analyses were conducted at textual (quotes, initial and focused coding, families) and conceptual (categories, networks, meta-network, provisional and final model) levels using ATLAS.ti 7.5. Reports were returned to patients. Results: There were 248 patients (51 men, 148 women, 49 unidentified) corresponding to 29 testimonies (6 narratives, 11 videos, 10 conversation threads, 2 questions collections). Adherence to inhalers is based on their perception of effectiveness to enable a normal life, and benefits should outweigh adverse effects. Adherence facilitators included mutual support between patients encouraging adherence and effective doctor-patient communication. Adherence barriers included (1) side effects; (2) mistaken beliefs about inhalers (habituation, attribution of non-existent side effects, fear of corticosteroids); (3) poor doctor-patient relationship (lack of listening, failure to consider patient’s preferences, communication iatrogenesis); (4) considering natural remedies as substitutes for treatment. Conclusions: Adherence to inhalers as reported in online testimony from COPD patients depends on the balance between efficacy and side effects. Adherence is influenced by peer support and doctor-patient communication. Doubts, erroneous beliefs, and iatrogenic effects of poor communication can hinder adherence.

Objectives: To explore the views expressed online by COPD patients regarding adherence to inhaled therapy. Methods: This study applied a qualitative, exploratory-interpretive design and an inductive methodology. Sources analysed included COPD websites, patient forums, and social networks. Units of analysis were videos, stories, questions and answers, and conversation threads. Saturation criteria were applied. Applying a constant comparative methodology, analyses were conducted at textual (quotes, initial and focused coding, families) and conceptual (categories, networks, meta-network, provisional and final model) levels using ATLAS.ti 7.5. Return report to patients. Results: 248 patients (51 men, 148 women, 49 unidentified) corresponding to 29 testimonies (6 narratives, 11 videos, 10 conversation threads, 2 questions collections). Adherence to inhalers is based on their effectiveness perception to enable a normal life, benefits should outweigh adverse effects. Adherence facilitators included mutual support between patients encouraging adherence and effective doctor-patient communication. Adherence barriers included 1) side effects; 2) mistaken beliefs about inhalers (habituation, attribution of non-existent side effects, fear of corticosteroids); 3) poor doctor-patient relationship (lack of listening, failure to consider patient`s preferences, communication iatrogenesis); 4) consider natural remedies as substitutes for treatment. Conclusions: Adherence to inhalers as reported in online testimony from COPD patients depends on the balance between efficacy and side effects. Adherence is influenced by peer support and doctor-patient communication. Doubts, erroneous beliefs, and iatrogenic effects of poor communication can hinder adherence.

Background: To carry out a validation questionnaire that assesses beliefs about inhaled treatments in patients with chronic obstructive pulmonary disease (COPD), as knowing patients’ beliefs could help to improve medication adherence and health outcomes. Methods: We evaluated data from 260 COPD patients from electronic medical record databases from five primary healthcare centers, in a descriptive, cross-sectional study with a sample size calculated for a 10-item questionnaire, with an estimated Cronbach’s alpha of 0.70 and a 95% confidence level. Study participants were selected via systematic random sampling. Variables: Ten-item Inhaled Therapy Beliefs Questionnaire, CCTI-Questionnaire v.2.0, time for completion, age, sex, educational level, spirometry severity (GOLD criteria), exacerbations (previous year), characteristics of inhaled treatment, and smoking habit. A two-year follow-up in a subsample of 77 patients from one health center was utilized. The Morisky–Green test, pharmacy dispensing data, test–retest (kappa coefficient), and an exploratory analysis of the adherence–belief relationship (ji-squared) were measured. Results: The 10-item questionnaire showed good viability (3 min completion time) when performed face-to-face or telephonically; its psychometric properties were acceptable, with an internal consistency (Cronbach’s alpha) score of 0.613. Three factors explained 47.58% of the total variance (p < 0.0001): use (factor 1), effects (factor 2), and objectives (factor 3) of inhalers. The two-year follow-up ultimately considered 58 out of the 77 patients (10 deceased, 4 unlocated, 2 mistakes, 2 no inhaled treatment, and 1 withdrawal). Non-adherence was 48.3% in terms of the Morisky–Green test; 31% in terms of pharmacy dispensing data; and 40.4% considering both methods. There was low test–retest reliability, indicated by items 4, 8, and 9 of the CCTI-Questionnaire (Kappa = 0.4, 0.26, and 0.34; p-value < 0.0001, 0.008, and 0.001, respectively). There was mild correlation between beliefs and adherence. Conclusions: The ten-item CCTI-Questionnaire v.2.0 demonstrated acceptable psychometric properties regarding feasibility, reliability, and content validity.

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke–UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases.

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Background: Current epidemiological situation has prompted the consideration of multimorbility (MM) as a prevalent condition, influenced by age, educational level and social support, related to unfavorable social and health determinants. Primary Care (PC) has a key role in its approach but further training of professionals in MM is required. The evidence on the effectiveness of training interventions in MM is still limited. Knowing the experiences, opinions and training needs of professionals is essential to enhance training interventions. Objectives: Identify perceived training needs by PC health professionals (doctors and nurses) in MM and polypharmacy. Methods: Design: Cross-sectional study based on an online survey (anonymous-ad hoc questionnaire). Participants and recruitment: 384 doctors and nurses working in healthcare centers and out-of-hospital emergencies of the Spanish National Health System. Non-probabilistic convenience sampling via email addressed to Health Institutions, and social networks. Data: Demographic characteristics and professional profile data (close-ended and multiple-choice questions) will be collected. Open-ended questions will be used to identify training needs, difficulties and resources about MM; required skills to care patients with MM will be assessed using a 4-item ordinal scale. Analysis: Coding of data prior to analysis. Descriptive statistical analysis, participation and completion rates of the questionnaire and estimation of absolute and relative frequencies and 95% confidence intervals in close-ended questions. Content analysis with inductive methodology in open-ended questions. Ethics: Ethical approval, Online informed consent. Conclusions: The identification of training needs of health professionals who care for patients with MM will be necessary data for developing highly effective training activities.

Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria. To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria^® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care. This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model. A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores. The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.