Managing ‘sick days’ in patients with chronic conditions: An exploration of patient and healthcare provider experiences

Abstract Introduction People with chronic medical conditions often take medications that improve long‐term outcomes but which can be harmful during acute illness. Guidelines recommend that healthcare providers offer instructions to temporarily stop these medications when patients are sick (i.e., sick days). We describe the experiences of patients managing sick days and of healthcare providers providing sick day guidance to their patients. Methods We undertook a qualitative descriptive study. We purposively sampled patients and healthcare providers from across Canada. Adult patients were eligible if they took at least two medications for diabetes, heart disease, high blood pressure and/or kidney disease. Healthcare providers were eligible if they were practising in a community setting with at least 1 year of experience. Data were collected using virtual focus groups and individual phone interviews conducted in English. Team members analyzed transcripts using conventional content analysis. Results We interviewed 48 participants (20 patients and 28 healthcare providers). Most patients were between 50 and 64 years of age and identified their health status as ‘good’. Most healthcare providers were between 45 and 54 years of age and the majority practised as pharmacists in urban areas. We identified three overarching themes that summarize the experiences of patients and healthcare providers, largely suggesting a broad spectrum in approaches to managing sick days: Individualized Communication, Tailored Sick Day Practices, and Variation in Knowledge of Sick Day Practices and Relevant Resources. Conclusion It is important to understand the perspectives of both patients and healthcare providers with respect to the management of sick days. This understanding can be used to improve care and outcomes for people living with chronic conditions during sick days. Patient or Public Contribution Two patient partners were involved from proposal development to the dissemination of our findings, including manuscript development. Both patient partners took part in team meetings and contributed to team decision‐making. Patient partners also participated in data analysis by reviewing codes and theme development. Furthermore, patients living with various chronic conditions and healthcare providers participated in focus groups and individual interviews.

status as 'good'. Most healthcare providers were between 45 and 54 years of age and the majority practised as pharmacists in urban areas. We identified three overarching themes that summarize the experiences of patients and healthcare providers, largely suggesting a broad spectrum in approaches to managing sick days: Chronic complications and progression of these conditions can be avoided by taking appropriate medications. Those living with these conditions are also susceptible to common acute illnesses like seasonal influenza, 3 4 and other gastrointestinal 5 and pulmonary infections. 6 Such illnesses can lead to volume depletion through fever, anorexia or fluid loss. When this occurs, some preventive medications can cause severe complications, such as acute kidney injury 7 or hypoglycemia. 8 These complications often require acute medical care, 7,9 and can be fatal. 8,10,11 To prevent such complications, patients should temporarily adjust their medication routines during periods of acute illness, including temporarily withholding a number of medications, a strategy commonly referred to as 'sick day management'. Several major international organizations (i.e., Diabetes Canada, 12 the Canadian Cardiovascular Society, 13 and the UK's National Health Service 14 ) recommend that healthcare providers (HCPs) deliver this guidance to their patients.
We conducted a systematic scoping review on this topic and found minimal empiric evidence about the effectiveness of current approaches for the delivery of sick day guidance (SDG). 15 Furthermore, only a few qualitative studies have reported on patients' and HCPs' experiences with interventions for delivering SDG like a 'medicine sick day guidance' card, 16 and sick day rule plan. 17 Two other studies have focused solely on patient experiences about selfcare with heart failure during sick days, 18 and a telephone support intervention during sick days 19 Qualitative studies are crucial to effectively capture behaviours, beliefs and experiences 20particularly to better understand a complex situation like navigating sick days and managing medications during periods of acute illness.
While a few interventional studies have been conducted in this area, a major gap remains in the literature as we still do not have a comprehensive understanding of the experiences of patients and HCPs with respect to SDG. We sought to comprehensively describe the experiences of patients managing sick days and of HCPs giving SDG to their patients.

| Design and framework
Qualitative description is a methodology that is well suited to provide a comprehensive summary of events and experiences. 21 Researchers using this approach stay close to the data as compared to more interpretive qualitative methodologies. 21 We undertook a qualitative descriptive study 21,22 to accomplish our study objective.
The theoretical domains framework (TDF) provided the conceptual underpinning to conceptualize the potential influences on the behaviours of interest in this study 23 (i.e., patients managing sick days and HCPs providing SDG). We used the TDF to inform data collection DHALIWAL ET AL. | 1747 and analysis, such as shaping our focus group, and interview guide questions, and codebook. Our study received ethical and operational approvals from research ethics boards at the University of Calgary (REB20-1989) and the University of Alberta (Pro00103809).

| Participants, sampling and recruitment
All study participants were required to be at least 18 years of age and be able to provide informed consent in English. The inclusion criteria for patient participants included: 1. taking two medications from the following classes: Renin-angiotensin-aldosterone system-antagonists, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), sodium-glucose transport protein 2 (SGLT2) inhibitors, insulin, sulfonylureas, meglitinides; 2. have access to an internet connection (i.e., able to attend online focus groups and complete electronic surveys) and/or a dataenabled mobile device; and 3. able to read, write and speak English.
Patients were excluded if they had kidney failure which required chronic dialysis, were pregnant or they did not manage their own medications (i.e., this was done by a nurse or other professional).
The inclusion criteria for HCPs included: 1. practicing as a nurse practitioner (NP), pharmacist or primary care physician (PCP, i.e., family physician) in a community setting; and 2. possessed at least 1 year of experience working in this type of setting.
We undertook purposive sampling, 21 aiming for maximum variation across domains such as age, sex and race (White and non-White) for all participants, and type of chronic condition(s) for patients, and profession, practice area (rural vs. urban), and years of practice for HCPs.
Recruitment sources for patients included websites, university networks, specialist and PCP practice settings, community pharmacies, and other local, provincial and national organizations. PCPs and NPs were recruited through our contacts and other key stakeholders in the following clinical domains: nursing, primary care, endocrinology, nephrology and cardiology. Pharmacists were recruited through provincial organizations and personal connections.

| Data collection
Data were collected using virtual focus groups (patients and pharmacists) and individual interviews (patients, NPs and PCPs) via Zoom™ teleconference software from January 2021 to April 2022.
Focus groups were preferred, where possible, to enable participants to respond to each others' experiences, however, interviews were offered to those who were more comfortable with this format. K. M. D. developed the semi-structured focus group and interview guides for patients and HCPs (Supporting Information: Table S1) 25 We then reviewed our findings for relevance to the TDF, which illuminated the potential influences on patient management of sick days and HCP delivery of SDG ( Figure 1). 23 The team members regularly liaised with each other to discuss their work in progress and presented their emerging findings to the larger team and the senior investigator (D. J. T. C.), who provided guidance in the analytic processes.

| Rigour
We used various strategies to enhance the trustworthiness of our findings such as triangulation, member checking, peer examination and maintaining an audit trail. 26 Method triangulation was achieved by using both focus groups and individual interviews. Data F I G U R E 1 Findings relevant to theoretical domains framework (TDF). 23  Our team is comprised of patients, HCPs, and research personnel who each contributed their personal expertize to the study. These varied perspectives were useful for conducting our study and bringing rich and nuanced interpretations to the data. One of the reasons we used such a large team was to ensure that no one individuals' experiences dominated the analysis and that the perspectives of patients and HCPs were both adequately represented while interpreting the data. We regularly engaged in reflexivity exercises where we reported on why we felt certain data had specific interpretations. We recorded these discussions and our reflections in a project diary, to maintain an audit trail. These practices (i.e., project diary, ongoing team meetings) were important to help team members understand how their beliefs, values and professional experiences impacted the work being conducted. 27

| RESULTS
Forty-eight participants took part in this study (Tables 1 and 2).
Patients participated in focus groups (n = 9) and individual interviews (n = 11). There was an even spread across the different patient age ranges. Pharmacists (n = 13) only participated in focus groups. PCPs  (Table 3). We have also shown the potential affective, cognitive and environmental influences on patient management of sick days and HCPs delivery of SDG ( Figure 1). 23

| Individualized communication
The theme of 'individualized communication' conveys that both patients and HCPs described how their individual circumstances determined the need and modality for communication about sick days (Table 3).
Many patients described assessing the severity of their acute illness to determine if and when to initiate communication with HCPs. Overall, many patients voiced intent to communicate with HCPs due to the fear of potential consequences (e.g., adverse medical complications) that might arise from not seeking professional assistance. Most patients attempted to self-manage their sick days until they felt that it was not possible to continue on their own. Patients reported that they found it acceptable to receive virtual or telehealth advice for sick day self-care but, when serious concerns arose, they preferred face-to-face T A B L E 1 Self-reported patient demographics.

Demographics
Total number of patients in study (n = 20)

| Tailored sick day practices
The theme of 'tailored sick day practices' conveys that patients and HCPs tailor sick day practices depending upon their specific context (Table 3).
Patients often reported having the knowledge to self-identify sick days based on their acute illness context such as, the signs and symptoms they were experiencing, and they subsequently took actions in response to these symptoms. The specific actions taken included tracking and monitoring health status and adjusting

| Variation in knowledge of sick day practices and relevant resources
The theme of 'variation in knowledge of sick day practices and relevant resources' conveys that there is a spectrum of knowledge and resource use about sick day practices among both patients and HCPs (Table 3).
Many patients were knowledgeable about why they were