Use of Mixed-Method Designs To Inform Patient-Centered Tools To Improve Medication Management

Slide Presentation from the AHRQ 2008 Annual Conference

By Brian J. Quilliam, Roberta E. Goldman, Anne L. Hume, Charles Eaton, and Kate L. Lapane

On September 9, 2008, Brian J. Quilliam, Roberta E. Goldman, Anne L. Hume, Charles Eaton, and Kate L. Lapane made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.4 MB).

Slide 1

Use of Mixed-Method Designs To Inform Patient-Centered Tools To Improve Medication Management

Brian J. Quilliam, Roberta E. Goldman, Anne L. Hume, Charles Eaton, and Kate L. Lapane

Slide 2

Overview

• Background.
• Introduction to Tailored DVD Project.
• Highlight the Mixed Methods Approach.
• Our Application of Mixed Methods Approach.
• Preliminary Results.
• Next Steps.

Slide 3

Importance of Improving Medication Management in Ambulatory Settings

• ~62% of all outpatient office visits result in prescribing of at least one medication (Cherry, et al. Adv Data 2003;337:1-4$).
• Incidence of adverse drug events in community dwelling adults 27.4% (Gandhi TK, et al. NEJM 2003;348:1556-64).
• At least $887 million spent on preventable adverse drug events among Medicare beneficiaries in outpatient settings (Field TS, et al. Medical Care 2005;43(12):1171-76).

Slide 4

Specific Aims: Tailored DVDs for Patients

• Identify medical management issues for minority and low-income geriatric patients.
• Develop personalized materials in English and Spanish to improve adherence.
• To pre-test these materials by conducting a feasibility study in 4 clinics and 100 patients.

Slide 5

The Mixed Methods Approach

• Quantitative data can reveal generalizable information for a large group of people.
  • These data often fail to provide specific answers, reasons, explanations or examples.
• Qualitative research provides data about meaning and context regarding the people and environments of study.
  • Findings are often not generalizable because of the small numbers & narrow range of participants.
• Both methods have strengths and weaknesses.
  • When used together, these methods can be complimentary.

Slide 6

Why the Mixed Methods Approach?

• Study populations are increasingly alert to how they are being approached by interventionists, and how they are represented in research.
• With increasing diversity in the U.S., community research is becoming more complex and multi-faceted.

Slide 7

The Qualitative Perspective

• "I want to understand the world from your point of view. I want to know what you know in the way you know it. I want to understand the meaning of your experience, to walk in your shoes, to feel things as you feel them, to explain things as you explain them. Will you become my teacher and help me understand?" (Spradley, JP. The Ethonographic Interview. New York, NY: Holt, Rinehart and Winston; 1979).

Slide 8

Nature of Qualitative Research

• Attempts to "make sense of" the social world in terms of the meanings people bring to it.
• To uncover ideas, insights, or ways of thinking of and explaining phenomena about which little is known.
• To gain novel and fresh perspectives on things about which quite a bit is already known.

Slide 9

Perspectives

• "We are all natives—insiders to some groups and outsiders to others—even as we aspire also to be scientists and transcend the tribal."  --Howard Stein, 1992

Slide 10

Qualitative vs. Quantitative

• Qualitative:
  • Looking for a range of phenomena.
  • Rarely use statistical analyses.
  • Not representative of the population.
• Quantitative:
  • Focused search, limited factors.
  • Formal statistical analyses are common.
  • Sampling may be done to maximize generalizability.

Slide 11

Qualitative vs. Quantitative

• Participant observation.
• Individual interviews.
• Focus groups.
• Visual (i.e., video or still image).
• Surveys.
• Observational Study Designs.
• Experimental Study Designs.

Slide 12

Focus Groups

• Ideal number participants = 8.
• Select participants carefully.
• Ensure there is no status conflict among the participants.
• Private space for discussion.
• Audio record or video record (use 2 audio recorders; consider going digital and upgrading your mic!).
• Refreshments.
• Develop discussion guide and use it loosely.

Slide 13

Uses for Qualitative Research in Developing Patient Centered Materials

Obtain data that are useful on their own:

• Detailed, contextually-based data on subtle meanings associated with attitudes, beliefs, and behaviors.
• What, how, and why people conceptualize issues differently in different contextual circumstances.
• Generate "indigenous" terms and categories.
• Generate new avenues for study.

Slide 14

Uses for Qualitative Research in Developing Patient Centered Materials

Obtain data that serve as building blocks or can be triangulated with other data:

• Information that enhances intervention design.
• Information that informs survey design and implementation.
  • Understand the range of relevant survey questions and responses.
• Test surveys and intervention elements.
• Information that complements and/or explains other results.

Slide 15

Our Mixed Methods Approach

The diagram shows a "pathway of circles":

• Evaluation of Electronic Medication History Data plus Systematic Literature Review.
• Exploratory Focus Groups.
• Patient Survey.
• DVD/Print Material Development.
• Confirmatory Focus Groups.
• Feasibility Study.

Slide 16

Results: Focus Groups

The slide shows three "Media" icons representing, "Morning," "MWF," and "Random."

• From Exploratory Focus Group:
  • "How do you decide whether you want to take this medicine?"

Slide 17

Results: Patients Survey

The slide presents two separate bar graphs:

• "In the past month, how often did you accidentally miss doses of medicines/took less than what your doctor told you to take?"
  • Often:  2.
  • Sometimes:  15.
  • Rarely:  29.
  • Never:  55.
• "In the past month, how often did you find that you remembered to take your medicine, but decided to skip doses or take less than what your doctor told you to take?"
  • Often:  1.
  • Sometimes:  10.
  • Rarely:  17.
  • Never:  78.

Slide 18

Results: Patients Survey

The bar graph answers the question, "When you took less medication, did you do it because of:"

• Cost:  13.
• Side Effects:  31.
• Avoid a Side Effect:  34.
• Inconvenient:  33.
• Needed a Break:  27.
• Not Helping:  7.

Slide 19

Results: Focus Groups

From Exploratory Focus Group: "When you have questions about your medications, who do you ask? Why?"

• "I really trust the pharmacist."
• "Pharmacists are more up to date with the medications."
• "Besides all the doctors I've talked about, I run it by (the pharmacist)."
• ".he has a very poor habit of going to the doctors, whether they are specialists or whatever he's going to go to the doctor with, and he never asks any questions."
• RG "you didn't ask the pharmacist,"
  • PT "no, they know."

Slide 20

Results: Patients Survey

The slide presents both a bar graph and a pie chart.

• Bar Graph: "When you have a question regarding your medicines, who do you normally ask?"
  • Doctor:  75.
  • Nurse:  17.
  • Pharmacist:  30.
  • Friend/Relation:  5.
• Pie Chart: "When you need information regarding medicines, who do you think gives you the best and most accurate information?"
  • Doctor:  71%.
  • Nurse:  4%.
  • Pharmacist:  24%.
  • Friend/Relation:  1%.

Slide 21

What We Learned Utilizing the Mixed Methods Approach

• Patients sometimes take their medications at random or rationalize their medication taking behavior.
  • Point of intervention.
• Patients utilize both physicians and pharmacists for medication information.
  • Incorporated into design of video.
• Terminology is important.
  • "Medicine" verses "Medication."

Slide 22

Next Steps

• Continue Analysis of Focus Group and Patient Survey Results.
  • Triangulation of data.
• Stratification of patient survey results.
• Development of video segments.
  • General tips segment in progress.
• Conduct Confirmatory Focus Groups.
• Pre-test developed materials.