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

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.

2
Overview

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

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 20033371-4)
• Incidence of adverse drug events in community
  dwelling adults 27.4
• (Gandhi TK et al. NEJM 20033481556-64)
• 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.)

4
Specific AimsTailored 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

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

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 US, community
  research is becoming more complex and
  multi-faceted.

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?
• James P. Spradley (1979). The ethonographic
  interview. New York, NY Holt, Rinehart and
  Winston.

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

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

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

11
Qualitative vs. Quantitative

• Participant observation
• Individual interviews
• Focus groups
• Visual (i.e. video or still image)

• Surveys
• Observational Study Designs
• Experimental Study Designs

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

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

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

15
Our Mixed Methods Approach
DVD/Print Material Development
Feasibility Study
16
Results Focus Groups

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

Morning
MWF
Random
17
Results Patients Survey
18
Results Patients Survey
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 very more up to date with the
  medications
• Besides all the doctors Ive 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
  hes going to go to the doctor with, and he never
  asks any questions
• RG you didnt ask the pharmacist,
• PT no, they know

20
Results Patients Survey
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

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