• Site Eval 2 Article: bmjopen-2020-044987.pdf

• Article Summary:

This meta-analysis found that nearly 43% of patients with 2 or more chronic conditions (aka multi-morbidity) are non-adherent to their medication regimen. Interestingly, the study suggests that the strongest predictor for this barrier to care is a patient’s beliefs about their medications. Beliefs encompassing medication administration/co-administration, side effects, contraindications, provider mistrust and doubts surrounding efficacy/necessity are huge contenders.

Furthermore, these predictors are stronger than pill-burden. There is also the concept of selective adherence, which suggests that patients mentally stratify the severity of their conditions and take medications as such. For example, they may diligently apply their eczema creams but skip out on cholesterol medications. For clinicians, the takeaway is to focus less on the “pill count” but more so on patient education, listening to specific concerns and correcting perceived barriers to treatment.

• Presentation Summary:

For my presentation, I connected the findings of the article to a patient I interviewed who was awaiting hospital admission in the emergency department. The most significant failure in her care was not her eventual admission to the hospital, but rather the inability to address the barriers that led her there in the first place. I elaborated on the unintentional obstacles she faced, including mild post-prandial epigastric pain, a lack of appetite, and immobility due to lower extremity edema and pain. Furthermore, I addressed the belief-system barriers, such as her misconception regarding medication and food co-administration, which prevented her from taking them.

While counseling the patient about the necessity of taking her medications, it was even more crucial to understand the reasons behind her lack of appetite. Therefore, I also spoke on simple patient education regarding easy and palatable meal options like crackers. Furthermore, involving interdisciplinary care was important for the case. Involving professionals like a dietitian for meal planning, or PT to assess and encourage activity, could also stimulate her gastrointestinal tract and increase her appetite. Even more importantly, I discussed how my patient complained of abdominal pain as another driving factor for lack of eating. In situations like this, it is vital it  to find the root cause, whether pathological or simply a sign of hunger, to improve her care.

Feedback from my preceptor emphasized the need to continue exploring the experiences of elderly patients or those with comorbidities. Multi-morbidity is a grueling affliction, and patients deserve care and attention to their treatment adherence in hopes of healing. We discussed the socio-economic barriers to care, such as insurance issues, lack of housing, poor hygiene, insufficient support systems at home, lack of transportation, and financial constraints. It is crucial for clinicians to consider these factors. Additionally, we talked about setting small, manageable nutrition goals for patients with a poor appetite, such as incorporating crackers or fruit, which can help ease discomfort with oral swallowing. Ultimately, gaining a holistic understanding of patients can help prevent events such as illness progression, exacerbations, and hospitalization.