Browsing by Author "Sun, Kai"
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Item Open Access A qualitative study of facilitators of medication adherence in systemic lupus erythematosus: Perspectives from rheumatology providers/staff and patients.(Lupus, 2024-01) Herndon, Shannon; Corneli, Amy; Dombeck, Carrie; Swezey, Teresa; Clowse, Megan Eb; Rogers, Jennifer L; Criscione-Schreiber, Lisa G; Sadun, Rebecca E; Doss, Jayanth; Eudy, Amanda M; Bosworth, Hayden B; Sun, KaiObjective
Systemic lupus erythematosus (SLE) disproportionately affects patients from racial and ethnic minority groups. Medication adherence is lower among these patient populations, and nonadherence is associated with worse health outcomes. We aimed to identify factors that enable adherence to immunosuppressive medications among patients with SLE from racial and ethnic minority groups.Methods
Using a qualitative descriptive study design, we conducted in-depth interviews with purposefully selected (1) patients with SLE from racial and ethnic minority groups who were taking immunosuppressants and (2) lupus providers and staff. We focused on adherence facilitators, asking patients to describe approaches supporting adherence and for overcoming common adherence challenges and providers and staff to describe actions they can take to foster patient adherence. We used applied thematic analysis and categorized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model.Results
We interviewed 12 patients (4 adherent and 8 nonadherent based on medication possession ratio) and 12 providers and staff. Although each patient described a unique set of facilitators, patients most often described social support, physical well-being, reminders, and ability to acquire medications as facilitators. Providers also commonly mentioned reminders and easy medication access as facilitators as well as patient education/communication and empowerment.Conclusion
Using an established behavioral change model, we categorized a breadth of adherence facilitators within each domain of the COM-B model while highlighting patients' individual approaches. Our findings suggest that an optimal adherence intervention may require a multi-modal and individually tailored approach including components from each behavioral domain-ensuring medication access (Capability) and utilizing reminders and social support (Opportunity), while coupled with internal motivation through improved communication and empowerment (Motivation).Item Open Access Barriers to Taking Medications for Systemic Lupus Erythematosus: A Qualitative Study of Racial Minority Patients, Lupus Providers, and Clinic Staff.(Arthritis care & research, 2022-09) Sun, Kai; Corneli, Amy L; Dombeck, Carrie; Swezey, Teresa; Rogers, Jennifer L; Criscione-Schreiber, Lisa G; Sadun, Rebecca E; Eudy, Amanda M; Doss, Jayanth; Bosworth, Hayden B; Clowse, Megan EBObjective
Underrepresented racial and ethnic minorities are disproportionately affected by systemic lupus erythematosus (SLE). Racial and ethnic minorities also have more severe SLE manifestations that require use of immunosuppressive medications, and often have lower rates of medication adherence. We aimed to explore barriers of adherence to SLE immunosuppressive medications among minority SLE patients.Methods
We conducted a qualitative descriptive study using in-depth interviews with a purposive sample of racial minority SLE patients taking oral immunosuppressants (methotrexate, azathioprine, or mycophenolate), and lupus clinic providers and staff. Interviews were audiorecorded, transcribed, and analyzed using applied thematic analysis. We grouped themes using the Capability, Opportunity, Motivation, Behavior conceptual model.Results
We interviewed 12 SLE patients (4 adherent, 8 nonadherent) and 12 providers and staff. We identified capability barriers to include external factors related to acquiring medications, specifically cost-, pharmacy-, and clinic-related issues; opportunity barriers to include external barriers to taking medications, specifically logistic- and medication-related issues; and motivation factors to include intrinsic barriers, encompassing patients' knowledge, beliefs, attitudes, and physical and mental health. The most frequently described barriers were cost, side effects, busyness/forgetting, and lack of understanding, although barriers differed by patient and adherence level, with logistic and intrinsic barriers described predominantly by nonadherent patients and side effects described predominantly by adherent patients.Conclusion
Our findings suggest that interventions may be most impactful if they are designed to facilitate logistics of taking medications and increase patients' motivation while allowing for personalization to address the individual differences in adherence barriers.Item Open Access Implementation of a Clinician-led Medication Adherence Intervention Among Patients With Systemic Lupus Erythematosus.(The Journal of rheumatology, 2024-06) Sun, Kai; Molokwu, Nneka J; Hanlen-Rosado, Emily; Corneli, Amy L; Pollak, Kathryn I; Rogers, Jennifer L; Sadun, Rebecca E; Criscione-Schreiber, Lisa G; Doss, Jayanth; Bosworth, Hayden B; Clowse, Megan EBObjective
Medication nonadherence in systemic lupus erythematosus (SLE) leads to poor clinical outcomes. We developed a clinician-led adherence intervention that involves reviewing real-time pharmacy refill data and using effective communication to address nonadherence. Prior pilot testing showed promising effects on medication adherence. Here, we describe further evaluation of how clinicians implemented the intervention and identify areas for improvement.Methods
We audio recorded encounters of clinicians with patients who were nonadherent (90-day proportion of days covered [PDC] < 80% for SLE medications). We coded recordings for intervention components performed, communication quality, and time spent discussing adherence. We also conducted semistructured interviews with patients and clinicians on their experiences and suggestions for improving the intervention. We assessed change in 90-day PDC post intervention.Results
We included 25 encounters with patients (median age 39, 100% female, 72% Black) delivered by 6 clinicians. Clinicians performed most intervention components consistently and exhibited excellent communication, as coded by objective coders. Adherence discussions took an average of 3.8 minutes, and 44% of patients had ≥ 20% increase in PDC post intervention. In structured interviews, many patients felt heard and valued and described being more honest about nonadherence and more motivated to take SLE medications. Patients emphasized patient-clinician communication and financial and logistical assistance as areas for improvement. Some clinicians wanted additional resources and training to improve adherence conversations.Conclusion
We provide further evidence to support the feasibility, acceptability, and fidelity of the adherence intervention. Future work will optimize clinician training and evaluate the intervention's effectiveness in a large, randomized trial.Item Open Access Pilot Intervention to Improve Medication Adherence Among Patients With Systemic Lupus Erythematosus Using Pharmacy Refill Data.(Arthritis care & research, 2023-03) Sun, Kai; Eudy, Amanda M; Rogers, Jennifer L; Criscione-Schreiber, Lisa G; Sadun, Rebecca E; Doss, Jayanth; Maheswaranathan, Mithu; Barr, Ann Cameron; Eder, Lena; Corneli, Amy L; Bosworth, Hayden B; Clowse, Megan EBObjective
Despite high rates of medication nonadherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence.Methods
The intervention used pharmacy refill data to monitor nonadherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% 3 months before and after the intervention visit using the McNemar's test.Results
Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial and ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (P = 0.03) after the intervention visit.Conclusion
Our intervention showed feasibility, acceptability, and appropriateness and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings.Item Open Access Racial Differences in Patient-provider Communication, Patient Self-efficacy, and Their Associations With Systemic Lupus Erythematosus-related Damage: A Cross-sectional Survey.(The Journal of rheumatology, 2021-07) Sun, Kai; Eudy, Amanda M; Criscione-Schreiber, Lisa G; Sadun, Rebecca E; Rogers, Jennifer L; Doss, Jayanth; Corneli, Amy L; Bosworth, Hayden B; Clowse, Megan EBObjective
Despite significant racial disparities in systemic lupus erythematosus (SLE) outcomes, few studies have examined how disparities may be perpetuated in clinical encounters. We aimed to explore associations between areas of clinical encounters - patient-provider communication and patient self-efficacy - with SLE-related damage, in order to identify potential areas for intervention to reduce SLE outcome disparities.Methods
We collected cross-sectional data from a tertiary SLE clinic including patient-provider communication, general self-efficacy, self-efficacy for managing medications and treatments, patient-reported health status, and clinical information. We compared racial groups and used logistic regression to assess race-stratified association of patient-provider communication and patient self-efficacy with having SLE-related damage.Results
Among 121 patients (37% White, 63% African American), African Americans were younger, more likely to be on Medicaid, and less likely to be college educated, married, or living with a partner or spouse. African Americans reported less fatigue and better social function, took more complex SLE medication regimens, had lower fibromyalgia (FM) scores, and had higher SLE disease activity and SLE-related damage scores. African Americans reported similar self-efficacy compared to White patients, but they reported more hurried communication with providers, which was reflected in their perception that providers used words that were difficult to understand. Perceiving providers use difficult words and lower general self-efficacy were associated with having SLE-related damage among African American but not White patients.Conclusion
African Americans had more severe SLE and perceived more hurried communication with providers. Both worse communication and lower self-efficacy were associated with having SLE-related damage among African American but not White patients, suggesting that these factors should be investigated as potential interventions to reduce SLE racial disparities.Item Open Access Racial Disparities in Medication Adherence between African American and Caucasian Patients With Systemic Lupus Erythematosus and Their Associated Factors.(ACR open rheumatology, 2020-07) Sun, Kai; Eudy, Amanda M; Criscione-Schreiber, Lisa G; Sadun, Rebecca E; Rogers, Jennifer L; Doss, Jayanth; Corneli, Amy L; Bosworth, Hayden B; Clowse, Megan EBObjective
Medication nonadherence is more common in African Americans compared with Caucasians. We examined the racial adherence gaps among patients with systemic lupus erythematosus (SLE) and explored factors associated with nonadherence.Methods
Cross-sectional data were obtained from consecutive patients prescribed SLE medications seen at an academic lupus clinic between August 2018 and February 2019. Adherence was measured using both self-report and pharmacy refill data. High composite adherence was defined as having both high self-reported adherence and high refill rates. Covariates were patient-provider interaction, patient-reported health status, and clinical factors. We compared adherence rates by race and used race-stratified analyses to identify factors associated with low composite adherence.Results
Among 121 patients (37% Caucasian, 63% African American), the median age was 44 years (range 22-72), 95% were female, 51% had a college education or more, 46% had private insurance, and 38% had high composite adherence. Those with low composite adherence had higher damage scores, patient-reported disease activity scores, and more acute care visits. High composite adherence rate was lower among African Americans compared with Caucasians (30% vs 51%, P = 0.02), and the gap was largest for those taking mycophenolate (26% vs 75%, P = 0.01). Among African Americans, low composite adherence was associated with perceiving fewer "Compassionate respectful" interactions with providers and worse anxiety and negative affect. In contrast, among Caucasians, low composite adherence was only associated with higher SLE medication regimen burden and fibromyalgia pain score.Conclusion
Significant racial disparities exist in SLE medication adherence, which likely contributes to racial disparities in SLE outcomes. Interventions may be more effective if tailored by race, such as improving patient-provider interaction and mental health among African Americans.