Discussion About The Data Analysis Methods Used By The Researchers

Discussion About The Data Analysis Methods Used By The Researchers

Quantitative data was analyzed using descriptive statistics and chi-square analysis with the help of MS Excel software. The qualitative data was analyzed using content analysis. The data from clinical notes was classified into a descriptive level and an interpretive level. The data was then organized into themes and coded to allow the researcher to make inferences and draw conclusions Discussion About The Data Analysis Methods Used By The Researchers.

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Discuss the researcher(s) definition of statistical significance.

According to the researcher, statistical significance is the probability that a difference or relationship between study variables exists due to other underlying factors and not by chance. The researcher did not find any statistical significance in any of the identified variables between adherent and non-adherent groups (Beckner et al., 2021)Discussion About The Data Analysis Methods Used By The Researchers. The study has noted the comparison may be inaccurate due to size differences in groups and a lack of enough clinical notes to prove adherence.

Discuss the results of the research.

The study established that lack of adherence to medication was unintentional and was associated with factors such as communication breakdown, omission by the caregiver, and pill hoarding. The findings indicated that medical nonadherence could be improved through nurses and patients’ education as well as ensuring proper transition of care.

Based on the statistical results, what were the recommendations given by the researcher(s).

The study recommended that medical nonadherence can be improved through effective communication and better coordination and continuation of care (Beckner et al., 2021). The researcher recommended further research to be done on a larger population to improve generalizability. Also, multifactorial intervention studies were recommended to enhance communication in the transition of care.

Discuss any clinical significance found by the researcher(s).

The clinical significance is that medication nonadherence could be improved through high-quality transition of care and proper communication.

How could the results be used to support a change in practice?

The results can be used to support a change to promote medication adherence by implementing the recommendations, which include provision of education on medications, caregiver support, effective communication during care transition, and access to affordable medication.

Reference

Beckner, A., Liberty, K. R., & Cohn, T. (2021). Medication Adherence among Home Health Patients Facing Hospital Readmissions. Medsurg Nursing, 30(6), 396-402. http://americansentinel.idm.oclc.org/login?url=https://www.proquest.com/scholarly-journals/medication-adherence-among-home-health-patients/docview/2616230590/se-2 Discussion About The Data Analysis Methods Used By The Researchers

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For this discussion use the article belowDiscuss the data analysis methods used by the researchers. Discuss the researcher(s) definition of statistical significance. Discuss the results of the research. Based on the statistical results, what were the recommendations given by the researcher(s). Discuss any clinical significance found by the researcher(s). How could the results be used to support a change in practice?

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Use thed following article to answer the above questions

Medication Adherence among Home Health Patients Facing Hospital Readmissions

Beckner, Amy; Liberty, Kimberly R; Cohn, Tanya.

Medsurg Nursing; Pitman Vol. 30, Iss. 6, (Nov/Dec 2021): 396-402.

Abstract

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Home health services (HHS) consist of care provided in the patient’s home by a skilled nurse, physical therapist, speech therapist, or occupational therapist related to a medical condition or change in health status. According to the Centers for Medicare & Medicaid Services (CMS, 2020), unplanned readmission within 30 or fewer days measures the hospital’s performance or quality of care provided in comparison to other hospitals with a similar patient subset that is dually eligible for Medicare and Medicaid services. According to CMS (2020), hospitals can be penalized for any 30-day readmission for index diagnoses, such as heart failure, coronary artery bypass graft surgery, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, and elective total hip or total knee arthroplasty. Higher use of HHS after hospitalization supports the need to understand reasons for readmissions and the relationship with medication adherence. Because medication changes often occur at hospital discharge, skilled nurses at HHAs complete a medication reconciliation to document prescribed versus taken medications on admission to HHS Discussion About The Data Analysis Methods Used By The Researchers.

Full Text

Headnote

Medication nonadherence can contribute to hospital readmissions. Medical-surgical nurses play a crucial role in reducing medication nonadherence by validating patient knowledge of home medications, providing early education on new medications, involving patients and caregivers when providing new education, and delivering effective communication during care transitions to home health services.

Background

Hospitals can be penalized financially for readmission rates above national averages. Medication adherence can be a factor in hospital readmissions; however, there is a gap in research regarding factors contributing to readmission rates among patients receiving home health services.

Aim

Explore the relationship among medication nonadherence, hospital readmission, and factors contributing to medication nonadherence.

Methods

This mixed-methods study analyzed data from 126 adults readmitted to the hospital while receiving home health services from one agency in the southeastern United States. Descriptive statistics, chi-square analysis, and Mann-Whitney U tests were used for quantitative data, and content analysis was used for qualitative data Discussion About The Data Analysis Methods Used By The Researchers.

Results

Average age of participants was 66.0+12.3; 72 (57.1%) were female and 64 (50.8%) were African American. Only 11 (8.7%) were identified quantitatively as nonadherent; however, 46 (37%) were determined to be nonadherent after completing the qualitative data analysis. No significant difference was found in any of the variables between adherent and nonadherent patients. Six main themes emerged from the qualitative data: communication breakdown, pharmacy wrongdoing, caregiver omission, going without, the unknown, and pill hoarding.

Conclusion

Factors related to medication nonadherence appear to be modifiable and improved with patient/caregiver education and higher-quality transitional care. Further research is needed on factors not related to medications that may contribute to nonadherence.

Home health services (HHS) consist of care provided in the patient’s home by a skilled nurse, physical therapist, speech therapist, or occupational therapist related to a medical condition or change in health status. HHS are used increasingly as part of care and recovery as patients are discharged sooner from the hospital. As the number of patients being discharged home with HHS increases, so does the responsibility of home health agencies (HHA) to prevent hospital readmissions.

Medication nonadherence, defined as not taking medications as prescribed (Ellis et al., 2020), can contribute to hospital readmissions (Rosen et al., 2017). According to the Centers for Medicare & Medicaid Services (CMS, 2020)Discussion About The Data Analysis Methods Used By The Researchers, unplanned readmission within 30 or fewer days measures the hospital’s performance or quality of care provided in comparison to other hospitals with a similar patient subset that is dually eligible for Medicare and Medicaid services. Hospitals can receive financial penalties for readmission rates above national averages.

Preventing hospital readmissions is a priority, receiving national policy attention due to its potential impact on healthcare costs and service reimbursement. According to CMS (2020), hospitals can be penalized for any 30-day readmission for index diagnoses, such as heart failure, coronary artery bypass graft surgery, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease, and elective total hip or total knee arthroplasty. Regardless of reason for readmission, these financial penalties occur if the initial hospitalization was due to an index condition. Patients diagnosed with any index condition often are discharged with HHS. Lack of communication and inconsistent nursing reports may lead to poor care transitions and contribute to hospital readmissions (Logan, 2019). No guidelines currently exist for care coordination and transitional care, resulting in gaps and contributing to vulnerability of medication nonadherence as patients transition from hospital to home (Logan, 2019)Discussion About The Data Analysis Methods Used By The Researchers. Staff at HHAs need thorough understanding of reasons for readmissions and ways to improve patient care.

Literature Review

CINAHL and Cochrane Library for Literature Reviews were searched for 2014-2019 using the following terms: home health, readmissions, and hospital readmissions. Only articles written in English were reviewed. Articles of interest focused on readmissions related to medication nonadherence, along with factors that contribute to medication nonadherence and potential interventions. The initial population of interest was adult patients receiving HHS, but this was expanded due to limited identified articles including all patients who experienced hospital readmission. Nine articles met inclusion criteria.

Previous research by Rosen and coauthors (2017) indicated medication nonadherence is common, especially with new medications after hospitalization. Authors asked 385 patients to assess their medication adherence upon hospital admission. Patients with low-to-intermediate medication adherence had readmission rates of 20% compared to patients with high medication adherence (9.2%)Discussion About The Data Analysis Methods Used By The Researchers. Previous research on medication adherence primarily addressed specific index conditions rather than HHS (Ellis et al., 2020; Lay et al., 2019). The lack of published research regarding reasons for hospital readmissions while receiving HHS represents a critical knowledge gap. Higher use of HHS after hospitalization supports the need to understand reasons for readmissions and the relationship with medication adherence.

Because medication changes often occur at hospital discharge, skilled nurses at HHAs complete a medication reconciliation to document prescribed versus taken medications on admission to HHS. Discrepancies in medications usually are found during initial medication reconciliation (Logan, 2019). Medication adherence is a modifiable risk factor for rehospitalization (Rosen et al., 2017). Medication nonadherence tends to be individualized and complex, affected by age, motivation, knowledge, and polypharmacy (Panozzo, 2018). It may predict patients’ functional status and, when improved, may reduce hospital readmissions (Ma et al., 2018)Discussion About The Data Analysis Methods Used By The Researchers.

Ma and coauthors (2018) found hospital readmissions from HHA are prevalent, often with insufficient and inadequate documentation of cause. Although this research has addressed rates, reasons, risks, and prevention strategies concerning hospital readmissions, little has been published about hospital readmission rates and causes for patients discharged with HHS. To the researchers’ knowledge, the present study is the first of its kind to explore the relationship between medication nonadherence and readmission to the hospital and address contributing factors to medication nonadherence among adult patients receiving HHS.

Purpose

The purpose of this study was to explore medication adherence among adults receiving HHS. Quantitative data were collected to examine medication adherence and its relationship to hospital readmissions among adult patients receiving HHS. Through content analysis of qualitative data, authors identified contributing factors to medication nonadherence among adults receiving HHS readmitted to the hospital within 30 days.

Methods

A concurrent mixed methods design was used to facilitate improved understanding of the relationship between hospital readmissions and medication adherence among adult patients receiving HHS.

Setting and Sample

Approval from the site Institutional Review Board (IRB) and university IRB was obtained. Informed consent was waived as this study involved secondary analysis of existing medical documentation and did not include patient contact. Before data review and analysis, any identifiable data were coded to protect patient privacy.

The sample was obtained from one HHA serving only adult patients (average census 100-200 patients). The HHA is affiliated with a local hospital in a moderately sized city in the southeastern United States. All adult patients readmitted to the affiliated hospital within 30 days of original discharge and received HHS from the designated HHA were included. Con- secutive sampling was used by obtaining 30-day reports for August 2017-August 2018 to identify all eligible patients.

Data Collection

Demographic data collected for quantitative analysis are included in Table 1; other descriptive quantitative data points appear in Table 2. Quantitative data were entered into an Excel spreadsheet for analysis. Qualitative data were collected by copying de-identified clinical notes within each patient’s electronic medical chart into a Word document Discussion About The Data Analysis Methods Used By The Researchers.

Data Analysis

prescription labeling, or failure to deliver medication on time. Patient #9 ran out of vancomycin and attempted to refill the prescription; pharmacy was out of the medication and an alternative was not recommended, resulting in patient going without.

Following are two examples of instances when pharmacy did not deliver medications promptly:

Patient #73: “[Patient] noted without Levaquin® in home and per [personal care home] staff, pharmacy never delivered.”

Patient #113: “[Patient] also states that she is out of her milrinone [drip]. [Patient] states she thought they would send it out to her before it ran out.”

Another patient experienced multiple pharmacy errors at different times, affecting safety:

Patient #100: “[Patient] with no Coumadin in the home at this time. [Patient] states he did not receive from pharmacy. Called (retail pharmacy) and staff states that medication was placed on hold [due to] order stating to hold if INR >3.0. Notified staff that this direction is for [patient] and not for pharmacy.”

Patient #100: “Has Coumadin and states did take 1 yesterday but only instruction on bottle is to hold for INR >3.0. Client instructed to not take any more Coumadin until further instructions given at appointment Discussion About The Data Analysis Methods Used By The Researchers.”

With pharmacy mislabeling and unclear instructions for the same medication, it is unknown how long the patient could not take the anticoagulant or took an incorrect dose.

Caregiver Omission. This theme includes several situations involving the caregiver. For example, a medication was not administered because the caregiver had possession of it. The caregiver administered the drug incorrectly, failed to administer medication as a personal responsibility, or did not get the prescription when the patient could not receive it without caregiver assistance. In these instances, medication nonadherence was due to caregiver error rather than patient responsibility. A nurse reported patient #29 was unable to take antibiotics as prescribed because the daughter had them.

Patients may have multiple caregivers, leading to inconsistency with medication administration, confusion, and possible medication nonadherence:

Patient #68: “[Patient’s] family continues to give [patient] her [medications] with some inconsistency] depending on which family member is giving them.”

Lack of education was also a factor leading to caregiver error. One caregiver (patient #69) did not administer the correct doses of multiple medications. Another (patient #70) did not administer an intravenous medication entirely. A third failed to fill prescriptions (patient #77), all due to lack of education.

Other patients required caregiver assistance to fill prescriptions or physically administer them due to physical or mental impairment. One nurse documented a patient had not obtained their prescriptions, solely due to the caregiver’s choice:

Patient #105: “[Patient] has not obtained Lasix or prednisone yet. When asked why they have not picked them up, [patient’s] son stated it’s because ‘of my lazy butt just not getting them yet.'”

Going Without. This theme was defined as the patient not filling a prescription after experiencing a care transition, not filling or refilling a prescription due to cost, lacking transportation, running out of a medication, or running out of prescription refills Discussion About The Data Analysis Methods Used By The Researchers

Patient #27: “MD called in prescription for Celebrex that [patient] is unable to get [due to] cost of $1,800.”

Patient #32: “[Patient] currently does not have his metolazone or Bumex and is unable to afford them at this time [due to] not having Medicare Part D, and they both have significant copays.”

Although patients receiving HHS are required to be homebound, some patients experienced lack of transportation as the key factor to not obtaining prescriptions.

Patient #23: “Pt has [prescriptions] for 4 meds that have not been filled yet. [Patient] states he will get them filled today or tomorrow. [Patient] has not taken [prescriptions] for antibiotics and prednisone in to be filled yet but that he will do so as soon as he can get a ride.”

Patients who had not filled or refilled their prescriptions often had no medication for multiple days and reported physical complaints resulting from medication nonadherence:

Patient #105: “[Patient] still has handwritten [prescription] for prednisone in her home that has not been taken to pharmacy yet to get filled… [Patient] also out of Seroquel, Celexa, stool softener, and only a few left of Daliresp. [Patient] has not received her [prescription] for [potassium] chloride yet and continues to report leg cramps. [Patient] is also out of her Requip and has not called to get [a] refill on that.”

Patient #123: “[Patient] is also out of his Cardizem and states he has been out of it for 2-3 days.”

The Unknown. This theme is defined as the patient not taking medication as prescribed due to lack of education. Some patients were not open to receiving education from the nurse and preferred to wait to meet with their provider. One patient preferred to “Google” information as noted below:

Patient #8: “[Patient] was ordered metoprolol and diltiazem, but he refused to take because he was told his blood pressure was too low and he is scared to take them until he meets with his [provider]… [Patient] stated he did not need education on medications because he could Google them, so [nurse] reviewed verbally with the [patient] and left list with [patient].”

Other patients refused to stop medications despite a provider’s order due to the perception that stopping the drug would do more harm than good: Discussion About The Data Analysis Methods Used By The Researchers

Patient #24: “Wife refused to stop Viibryd as she states, ‘I know better than that,’ and she is unsure why [the] hospitalist would [discontinue] this medication.”

Patient #44: “The doctors wanted to discontinue the diuretic due to kidney function, but [patient] refuses to stop taking the furosemide because she says she knows her body, and she states she will start to swell if she discontinues the medication.”

It was not uncommon for patients to take medications incorrectly, as evidenced by the following example:

Patient #56: “She stated she takes half her medications one day and the other half the next day.”

Patients who were nonadherent with medications sometimes consumed an excessive dose, potentially causing damage to their bodies, ultimately due to a lack of education:

Patient #89: “[Patient] reports significant amount of pain and reports taking 1,300 mg of Tylenol 5 times a day.”

Pill Hoarding. This theme was defined by the patient having possession of a previously prescribed medication, leading to the patient taking a discontinued medication intentionally without a current provider’s order or unintentionally due to confusion. Some patients kept discontinued medications for financial reasons, such as inability to afford changes in prescriptions or frequent changes in prescriptions with the chance they might be represcribed. Most patients who appeared in this theme were nonadherent with their medications due to confusion or were unknowingly nonadherent: Discussion About The Data Analysis Methods Used By The Researchers

Patient #34: “He still had the nifedipine in his [medications], and he had taken it today. He said she [caregiver] didn’t know that he was supposed to stop taking it.”

Patient #106: “Upon assessment of [patient’s] medications, it was noted that [patient] was using the old metoprolol XR twice daily.”

Patient #113: “During [medication reconciliation, nurse] noted that [patient] still has spironolactone and Entresto in her bag of [medications] that she is currently taking, but they are not noted on her hospital list as current or discontinued.”

However, other patients would take a previously prescribed medication intentionally if they believed it would help them:

Patient #44: “[Patient/caregiver] still have several old bottles of [medications] and [caregiver] states he might give them to her if she is feeling bad.”

Discussion

To the researchers’ knowledge, the present study was the first of its kind to explore the relationship between medication nonadherence and hospital readmission, and factors contributing to nonadherence among adult patients receiving HHS. Through qualitative data analysis, many patients were found to be nonadherent with their medication regimens. Medication nonadherence often was not purposeful but rather due to lack of education, cost, and pharmacy-related factors. The findings of unintentional nonadherence are supported by Logan (2019) regarding the role of home health case managers and patient transitions from hospital to home. Patients from this study who were nonadherent with their medications had an average of 2.1 potential medication adherence-related issues per patient, similar to Mahan and coauthors (2017) who found an average of 2.3 potential medication adherence issues.

HHA providers should remember medication adherence is often multifactorial. Reduced copayments and patient/caregiver education on prescribed medications may improve medication adherence (Kini & Ho, 2018). Additionally, the theme involving communication breakdown during care transitions between providers and patients/ caregivers is supported by previous research (Bucknall et al., 2016; Logan, 2019; Mitchell et al., 2018)Discussion About The Data Analysis Methods Used By The Researchers. Transitional care can improve medication adherence when effective communication, coordination, and continuity of care occurs (Logan, 2019). Contrary to previous research suggesting functional deficits contribute to medication nonadherence (Logan, 2019; Smith et al., 2017), this study only found three patients with functional limitations contributing to medication nonadherence.

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Limitations

Analysis of qualitative data was dependent on the content within the clinical notes. One weakness of performing a secondary analysis is charting inconsistency and the researchers’ inability to verify these inconsistencies with authors of the original notes. Careful attention was paid to potential biases and inconsistencies among clinical notes. One source of potential bias was the role of healthcare providers to some persons in the sample held by one of the researchers, which could impact confirmability of the qualitative analysis. However, re- searchers carefully discussed this and compared analysis to maintain objectivity. Diagnoses listed in patients’ medical records were hand-counted and were dependent on the original authors of those records. Finally, no significant difference was found through comparative analysis between adherent (n=80) and nonadherent (n=46) groups. The size difference in groups could have led to an inaccurate comparison study and may under-represent the number of nonadherent patients, because patients did not have enough evidence in the clinical notes to determine adherence. This study analyzed only patients readmitted to one hospital network in the southeastern United States Discussion About The Data Analysis Methods Used By The Researchers.

Recommendations for Future Research

Key findings of the qualitative part of this study indicate medication nonadherence generally is not purposeful and suggests additional avenues for future research. Future quantitative research could assess effects of number and type of medications, and number of medical diagnoses related to medication adherence and hospital readmissions. Future quantitative studies would allow an expansion of subject population and can improve generalizability. In addition, comprehensive multifactorial intervention studies are needed to improve communication during care transitions among the hospital, HHA, and patients and caregivers.

Nursing Implications

Although this study focused on HHA nurses, medical-surgical nurses play a crucial role in reducing medication nonadherence by validating patient knowledge of home medications, providing early education on new medications, involving patients and caregivers when providing new education, and delivering effective communication during care transitions to HHS. Therefore, consistent, evidence-based guidelines on what information is shared and through whom would help decrease gaps in care transition and improve medication adherence after hospital discharge. HHA nurses and medical-surgical nurses are partners in maintaining continuity of care for patients who require HHS Discussion About The Data Analysis Methods Used By The Researchers.

Specifically, medical-surgical nurses can support patients in navigating new medication copays and deductible costs. Effective care coordination between medical-surgical nurses, providers, HHA nurses, pharmacists, and case managers can assist patients in obtaining optimal medication adherence based on individual multifactorial constraints. Medical-surgical nurses should report to HHA nurses regarding discharge needs to help reduce potential pharmacy-related factors that might increase medication nonadherence and contribute to hospital readmission.

Conclusion

Contributing factors to medication nonadherence are mainly modifiable. With appropriate interventions geared toward patient education, proper care transition, access to affordable medications, and caregiver support, medication adherence can be improved. Providers in HHS can focus on these interventions when caring for patients to decrease hospital readmissions.

Sidebar

Home health agency nurses and medical-surgical nurses are partners in maintaining continuity of care for patients who require home health services Discussion About The Data Analysis Methods Used By The Researchers.

References

REFERENCES

Bucknall, T.K., Hutchinson, A.M., Botti, M., McTier, L, Rawson, H., Hewitt, N.A., … Chaboyer, W. (2016). Engaging patients and families in communication across transitions of care: An integrative review protocol. Journal of Advanced Nursing, 72(7), 1689-1700.

Centers for Medicare & Medicaid Sen/ices (CMS). (2020). Hospital readmissions reduction program (HRRP). https://www. cms.gov/Medicare/Medicare-Fee-forService-Payment/AcutelnpatientPPS/ Readmissions-Reduction-Program

Ellis, R.J.B., Hertz, D., Callahan, R, & Ruppar, T.M. (2020). Self-reported nonadherence associated with pharmacy and home medication management inconvenience factors in a US adult population. Patient Preference & Adherence, 14, 529-539. https://doi.org/10.2147/PPA.S223408

Kini, V., & Ho, PM. (2018). Interventions to improve medication adherence: A review. JAMA, 320(23), 2461-2473. https://doi.Org/10.1001 /jama.2018.19271

Lay, S., Moody, N., Johnsen, S., Petersen, D., & Radovich, P. (2019). Home care program increases the engagement in patients with heart failure. Home Health Care Management & Practice, 31(2), 99106. https://doi.Org/10.1177/108482231 8815439

Logan, D.R. (2019). Transition from hospital to home: The role of the nurse case manager in promoting medication adherence in the Medicare population. Creative Nursing, 25(2), 126-131.

Ma, C., Shang, J., Miner, S., Lennox, L, & Squires, A. (2018). The prevalence, reasons, and risk factors for hospital readmissions among home health care patients: A systematic review. Home Health Care Management and Practice, 30(2), 83-92. https://doi.org/10.1177/

Mahan, K.R., Clark, J.A., Anderson, K.D., Koller, N.J., & Gates, B.J. (2017). Development of a tool to identify problems related to medication adherence in home healthcare patients. Home Healthcare Now, 35(5), 277-282. https://doi. org/10.1097/NHH.0000000000000539

Mitchell, S.E., Laurens, V., Weigel, G.M., Hirschman, K.B., Scott, A.M., Nguyen, H.Q., … Li, J. (2018). Care transitions from patient and caregiver perspectives. Annals of Family Medicine, 16(3), 225231. https://doi.Org/10.1370/afrn.2222

Panozzo, G. (2018). An intervention to reduce medication noncompliance and hospitalizations. Home Healthcare Now, 36(1), 34-42. https://doi.Org/10.1097/NHH.0000 000000000628

Rosen, O.Z., Fridman, R., Rosen, B.T., Shane, R., & Pevnick, J.M. (2017). Medication adherence as a predictor of 30-day hospital readmissions. Patient Preference and Adherence, 11, 801-810. https:// doi.org/10.2147/PPA.S125672

Smith, D., Lovell, J., Weller, C., Kennedy, B., Winbolt, M., Young, C., & Ibrahim, J. (2017). A systematic review of medication non-adherence in persons with dementia or cognitive impairment. PLoS ONE, 12(2), 1-19. https://doi.org/10.1371/jour nal.pone.0170651 Discussion About The Data Analysis Methods Used By The Researchers