A Patient-Centered Prescription Drug Label to Promote Appropriate Medication Use and Adherence

Barriers to person-centered service design in pharmacy practice: examples, lessons, and potential solutions

Despite increased attention to, and frameworks conceptualizing person-centered care, systematic, organizational, and provider-level barriers continue to discourage the development and delivery of person-centered care (PCC) in pharmacy practice and beyond. This commentary describes existing pharmacy-specific literature related to PCC, barriers to PCC within the context of pharmacy practice, and potential solutions to increase person-centeredness in pharmacy services. Literature to substantiate and describe barriers and potential solutions was identified from 2008 to 2023, a period where the emphasis on PCC in pharmacy practice dramatically increased. Overall, pharmacy-specific literature was identified describing four key barriers to PCC. Several potential solutions were identified, including: using innovative and theory-informed approaches to collecting individual need and preference information, employing processes and equipping providers to facilitate trust, changing organizational culture, and aligning quality metrics and financial incentives with PCC. Identified solutions may be used to address individual, organizational, and systematic barriers to promote PCC.

Evaluation of marketing authorization and labels of medicines in 2021 WHO Model List of Essential Medicines for Children in China, the Russian Federation and Brazil

OBJECTIVE

This work compares the marketing authorization, labels and dosage forms of medicines in the WHO Model List of Essential Medicines for Children (EMLc) in China, the Russian Federation and Brazil to urge policymakers to pay more attention to paediatric medication.

METHODS

Medicines were selected from the 8th EMLc. By searching relevant databases, which include different types of medical information in China, the Russian Federation and Brazil, the marketing authorization, labels and dosage forms of paediatric medicines in the three countries were evaluated.

RESULTS

A total of 485 drug products containing 312 active pharmaceutical ingredients listed in the WHO EMLc were evaluated. Among them, 344 products were approved for use in China, 286 in the Russian Federation and 264 in Brazil. Out of the 344 approved medicines, 317 (92.15%) were authorized for paediatric use in China, 224 (78.32%) in the Russian Federation and 218 (82.58%) in Brazil. In terms of guidance information labelling on drug labels, 75.08%, 83.04% and 88.07% of paediatric drugs approved in China, the Russian Federation and Brazil, respectively, clearly indicated the usage and dosage for paediatric use. Additionally, injections and tablets were the most prevalent dosage forms in these three countries.

CONCLUSION

There is still scope for enhancing the marketing authorization and development of dosage forms for paediatric medicines in the three countries. Furthermore, additional measures are being implemented to enhance the information provided on drug labels for children, particularly in China.

Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review

INTRODUCTION

Patient misunderstanding of instructions on medication labels is a common cause of medication errors and can result in ineffective treatment. One way to better improve patient comprehension of medication labels is by optimizing the content and display of the information.

OBJECTIVES

To review comparative studies that have evaluated the design of a medication label to improve patient knowledge or safety.

METHODS

Studies were selected from systematic computerized literature searches performed in PubMed, Embase (Elsevier), Cochrane Central (EBSCO), Cumulative Index to Nursing and Allied Health Literature-CINAHL (EBSCO), and Web of Science (Thomson Reuters). Eligible studies included comparative studies that evaluated the design of a medication label to improve patient knowledge or safety.

RESULTS

Of the 246 articles identified in the primary literature search, 14 studies were selected for data abstraction. Thirteen of these studies significantly impacted the patient understanding of medication labels. Three studies included a measure of patient safety in terms of medication adherence and dosing errors. The utilization of patient-centered language, pictograms/graphics, color/white space, or font optimization was seen to have the most impact on patient comprehension.

CONCLUSION

It is essential to present medication information in an optimal manner for patients. This can be done by standardizing the content, display, and format of medication labels to improve understanding and medication usage. Evidence-based design principles can, therefore, be used to facilitate the standardization of the structure of label content for both print and electronic devices. However, more research needs to be done on validating the implications of label content display to measure its impact on patient safety.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42022347510 ( http://www.crd.york.ac.uk/prospero/ ).

Warning Labels as a Public Health Intervention: Effects and Challenges for Tobacco, Cannabis, and Opioid Medications

Warning labels help consumers understand product risks, enabling informed decisions. Since the 1966 introduction of cigarette warning labels in the United States, research has determined the most effective message content (health effects information) and format (brand-free packaging with pictures). However, new challenges have emerged. This article reviews the current state of tobacco warning labels in the United States, where legal battles have stalled pictorial cigarette warnings and new products such as electronic cigarettes and synthetic nicotine products pose unknown health risks. This article describes the emerging research on cannabis warnings; as more places legalize recreational cannabis, they are adopting lessons from tobacco warnings. However, its uncertain legal status and widespread underestimation of harms impede strict warning standards. The article also reviews opioid medication warning labels, suggesting that lessons from tobacco could help in the development of effective and culturally appropriate FDA-compliant opioid warning labels that promote safe medication use and increased co-dispensing of naloxone. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Community pharmacists' perspectives towards automated pharmacy systems and extended community pharmacy services: An online cross-sectional study

Background

Private sector partnerships through community pharmacies are essential for effective healthcare integration to achieve the United Nations 2030 Agenda for Sustainable Development Goals. This partnership can provide significant clinical outcomes and reduce health system expenditures by delivering services focused on patient-centred care, such as public health screening and medication therapy management.

Objectives

To assess the understanding of the proposed strategic and health system reform in Saudi Arabia by exploring community pharmacists' perspectives towards the capacity and readiness of community pharmacies to use automated pharmacy systems, provide extended community pharmacy services, and identify perceived barriers.

Materials and methods

This multicentre, cross-sectional, web-based survey was conducted in Saudi Arabia (October-December 2021). Graphical and numerical statistics were used to describe key dimensions by the background and characteristics of the respondents, and multiple ordinal logistic regression analyses were sought to assess their associations.

Results

Of the 403 consenting and participating community pharmacists, most were male (94%), belonged to chain pharmacies (77%), and worked >48 h per week (72%). Automated pharmacy systems, such as electronic prescriptions, were never utilised (50%), and health screening services, such as blood glucose (76%) and blood pressure measurement (74%), were never provided. Services for medication therapy management were somewhat limited. Age groups ≤40 years, chain pharmacies, >10 years of experience and ≥ 3 pharmacists in place with <100 daily medication prescriptions and Jazan province were significantly more likely to provide all medication therapy management services than others. Operational factors were the barriers most significantly associated with the independent variables.

Conclusion

The results showed that most services and automated pharmacy systems remained limited and well-needed. When attempting to implement these services to drive change, community pharmacies face numerous challenges, and urgent efforts by private and government sectors are essential to improve pharmaceutical care in community pharmacy settings.

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

Comprehensibility of South African pictograms by sub-Saharan African prospective-users

OBJECTIVES

This work aimed to explore the validity of South African pictograms to be comprehended by sub-Saharan migrant populations in Spain.

METHODS

A quantitative cross-sectional study was carried out. A voluntary survey was conducted among a population ≥ 18 years of age in a Temporary Stay Centre for Immigrants located in Spain, in June 2022. The form included a culturally and linguistically validated version of the Health Literacy questionnaire (HLS-EU-Q16), a brief questionnaire of sociodemographic variables and 10 South African pictograms selected to assess the comprehension. According to the International Organization for Standardization, a pictogram must receive 66.70% correct answers to be acceptable. Mann-Whitney U or Kruskal-Wallis tests were used to assess differences between group variables. Statistical significance was set at P < 0.05.

RESULTS

55 sub-Saharan migrants who newly arrived in Europe voluntarily agreed to participate. None of the pictograms evaluated met the validity criterion. For the selected pictograms, the range of correct answers was between 52.50% and 20.00%. Neither sociodemographic variables nor Health Literacy level were significantly associated with pictogram comprehensibility.

CONCLUSION

New culturally sensitive pictograms that are easily comprehended by sub-Saharan African population are needed.

PRACTICE IMPLICATIONS

These results may serve as a starting point for future studies that aim to create and evaluate new pictograms or create new culturally adapted versions of existing pictograms involving the target population.

Comparison of pharmacogenomic information for drug approvals provided by the national regulatory agencies in Korea, Europe, Japan, and the United States

Pharmacogenomics, which is defined as the study of changes in the properties of DNA and RNA associated with drug response, enables the prediction of the efficacy and adverse effects of drugs based on patients' specific genetic mutations. For the safe and effective use of drugs, it is important that pharmacogenomic information is easily accessible to clinical experts and patients. Therefore, we examined the pharmacogenomic information provided on drug labels in Korea, Europe, Japan, and the United States (US). The selection of drugs that include pharmacogenomic information was based on the drug list that includes genetic information from the Korea Ministry of Food and Drug Safety (MFDS) and US Food and Drug Administration (FDA) websites. Drug labels were retrieved from the sites of MFDS, FDA, European Medicines Agency, and Japanese Pharmaceuticals and Medical Devices Agency. Drugs were classified as per the Anatomical Therapeutic Chemical code, and the biomarkers, labeling sections, and necessity of genetic tests were determined. In total, 348 drugs were selected from 380 drugs with available pharmacogenomic information in Korea and the US after applying the inclusion and exclusion criteria. Of these drugs, 137, 324, 169, and 126 were with pharmacogenomics information in Korea, the US, Europe, and Japan, respectively. The most commonly represented drug class was antineoplastic and immunomodulating agents. Regarding the classification as per the mentioned biomarkers, the cytochrome P450 enzyme was the most frequently mentioned information, and the targeted anticancer drugs most commonly required genetic biomarker testing. The reasons for differences in drug labeling information based on country include differences in mutant alleles according to ethnicity, frequencies at which drug lists are updated, and pharmacogenomics-related guidelines. Clinical experts must continuously strive to identify and report mutations that can explain drug efficacy or side effects for safe drug use.

Impact of patient-centered prescription medication labels on adherence in community pharmacy

BACKGROUND

Prescription medication labels are often constructed in a manner which hinders safe and appropriate use of medicines. The United States Pharmacopeia released voluntary standards to revise medication labels in an effort to support patients' understanding and improve medication use.

OBJECTIVE

To examine the impact of label changes on medication adherence before and after pharmacy implementation of the United States Pharmacopeia patient-centered prescription medication label standards.

METHODS

This study used a retrospective pre-post cohort design. Prescription fill claims data were obtained from a community health plan serving Medicaid patients for 1 independent community pharmacy organization across 8 retail pharmacy sites. We calculated medication possession ratios (MPR) and proportion of days covered (PDC) for medications used for contraception, asthma, hypertension, and depression from 15 months before to 13 months after implementation of the label changes.

RESULTS

Findings showed significant increases in mean MPR for asthma controller (increased by 0.111 [t = 0.290, P<0.0001]), antihypertensives (increased by 0.062 [t = 0.146, P < 0.0002]), and contraceptives medications (increased 0.133 [t = 0.209, P < 0.0001]) from preintervention to postintervention periods. Results also revealed increases in mean PDC for asthma controllers (increased by 0.193 [t = 0.267, P < 0.0001]), antihypertensives (increased by 0.067 [t = 0.175, P = 0.049]), and contraceptives (increased by 0.111 [t = 0.208, P < 0.0119]) from preintervention to postintervention periods.

CONCLUSION

We report an association between a change to more patient-centered prescription medication labels and increased medication adherence based on MPR and PDC among Medicaid recipients.

Strategies to optimize comprehension of numerical medication instructions: A systematic review and concept map

OBJECTIVE

To develop evidence-based recommendations for improving comprehension of quantitative medication instructions.

METHODS

This review included a literature search from inception to November 2021. Studies were included for the following: 1) original research; 2) compared multiple formats for presenting quantitative medication information on dose, frequency, and/or time; 3) included patients/lay-people; 4) assessed comprehension-related outcomes quantitatively. To classify the studies, we developed a concept map. We weighed 3 factors (risk of bias in individual studies, consistency of findings among studies, and homogeneity of the interventions tested) to generate 3 levels of recommendations.

RESULTS

Twenty-one studies were included. Level 1 recommendations are: 1) use visualizations of medication doses for liquid medications, and 2) express instructions in time-periods rather than times per day. Level 2 recommendations include: validate icons, use panels or tables with explanatory text, use visualizations for non-English speaking populations and for those with low health literacy and limited English proficiency.

CONCLUSIONS

Visualized liquid medication doses and time period-based administration instructions improve comprehension of numerical medication instructions. Use of visualizations for those with limited health literacy and English proficiency could result in improved outcomes.

PRACTICE IMPLICATIONS

Practitioners should use visualizations for liquid medication instructions and time period-based instructions to improve outcomes.

Health Literacy Level and Comprehension of Prescription and Nonprescription Drug Information

The aim of this study was to investigate the level of misunderstanding of medication information in Korean adults after stratifying by level of health literacy and to identify the factors influencing the misunderstanding of medication information and reading amounts of information on OTC drug labels. A cross-sectional survey was performed with 375 adult participants using the survey instrument. Multiple linear regression analyses were performed to identify factors which influence misunderstanding of medication information. Participants misunderstood 20% of words on OTC drug labels, 9% of prescription drug instructions, and 9% of pictograms. Participants on average read 59% of the overall contents of the OTC drug labels. As prescription drugs’ dosing regimens became more complicated, the level of misunderstanding instructions increased. The level of misunderstanding words on OTC drug labels significantly decreased as participants had adequate health literacy (β = −18.11, p < 0.001) and higher education levels (β = −6.83, p < 0.001), after adjusting for the study variables. The level of misunderstanding instructions for prescription drugs increased as participants became older (β = 8.81, p < 0.001) and had lower education levels (β = −5.05, p < 0.001), after adjusting for the study variables. The level of misunderstanding pictograms was similar to that of misunderstanding instructions for prescription drug labels. The amount of reading information on OTC drug labels significantly increased as respondents had adequate health literacy (β = 9.27, p < 0.001), were older (β = 12.49, p < 0.001), or had chronic diseases (β = 7.49, p = 0.007). Individuals’ health literacy level, reading behaviors, and complexity of medication instructions are associated with misunderstanding of medication information. Appropriate word choices in drug labels and an improved format of medication instructions could increase understanding of medication information and prevent adverse drug reactions.

Evaluating Providers' Prescription Opioid Instructions to Pediatric Patients

Receiving an opioid prescription during childhood increases the risk of hazardous prescription opioid (PO) use during emerging adulthood. Instruction on how to safely use POs plays an essential role in pediatric patients’ capacity to utilize as well as to discontinue POs appropriately. This study aimed to evaluate pediatric PO label instructions provided to a large sample of pediatric outpatients. Data were extracted from the electronic healthcare records system identifying pediatric patients who received a PO between 2016 and 2019 from pediatric outpatient medical clinics were affiliated with a northwestern United States medical center and children’s hospital. Pediatric patients (n = 12,613) between 0−17 years old who received a PO during outpatient care were included. Patients with chronic health conditions (e.g., cancer) or who received their PO from an inpatient medical setting were excluded. Patient demographics, medication instructions, associated diagnoses, and other prescription information (e.g., name of medication, dose, and quantity dispensed) were examined using automated text classification. Many label instructions did not include any indication/reason for use (20.8%). Virtually none of the POs (>99%) included instructions for how to reduce/wean off POs, contact information for questions about the POs, and/or instructions around how to dispose of the POs. Efforts are needed to ensure that pediatric PO instructions contain essential elements to improve comprehension of when and how to use POs for pediatric patients.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

Effect of a Smart Pill Bottle Reminder Intervention on Medication Adherence, Self-efficacy, and Depression in Breast Cancer Survivors

BACKGROUND

Globally, breast cancer has been identified as the most common cancer among women. The clinical efficacy of adjuvant oral antiestrogen therapy-including tamoxifen and aromatase inhibitors-has been proven to be clinically efficacious for breast cancer survivors. However, medication adherence for these therapies remains suboptimal among breast cancer survivors.

OBJECTIVE

The aim of this study was to evaluate the effect of a reminder intervention-a smart pill bottle paired with the Pillsy mobile application-on medication adherence, medication self-efficacy, and depression, among breast cancer survivors who were undergoing oral antiestrogen therapy.

METHODS

This study is a randomized controlled trial. Sixty-one women were allocated to an experimental group (n = 31) and the control group (n = 30). The experimental group received the reminder intervention of a smart pill bottle for 4 weeks. Study outcomes were identified as medication adherence, medication self-efficacy, and depression.

RESULTS

Fifty-seven women completed the follow-up measurement. Significant differences in favor of the experimental group were noted for medication adherence ( P = .004) and medication self-efficacy ( P = .004). There was no statistically significant difference between the 2 groups with regard to depression ( P = .057).

CONCLUSIONS

Reminder intervention using smart pill bottles was effective in improving medication adherence and medication self-efficacy among breast cancer survivors undergoing oral antiestrogen therapy.

IMPLICATIONS FOR PRACTICE

A smart pill bottle method of intervention can be a useful reminder strategy to improve medication adherence among breast cancer survivors.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Investigating the impact of patient-centred labels on comprehension of medication dosing: a randomised controlled trial

OBJECTIVE

This study aims to implement a version of patient-centred labels (PCL) consistent with current labelling practice in Australia; assess the effectiveness of PCL in relation to the proportion of participants that correctly comprehend dosing instructions, and explore the proportion of correct comprehension of PCL in participants with both low and high health literacy.

DESIGN

Randomised controlled trial.

SETTING

A large tertiary care hospital in Brisbane, Queensland, Australia.

PARTICIPANTS

121 participants with a majority born in Australia (65.3%), New Zealand (14.0%), the UK (6.6%) and Ireland (2.5%).

INTERVENTION

Participants were randomly assigned to either a panel of three PCL (n=61) or three standard labels (n=60) and asked to comprehend their assigned panel of labels.

OUTCOME MEASURES

Difference in the proportion of participants that correctly comprehend dosing instructions provided on PCL compared with standard labels. The two-proportion test was used to measure the impact of PCL on the proportion of participants correctly comprehending dosing instructions.

RESULTS

A greater proportion of participants were able to accurately comprehend PCL compared with standard labels. The proportion of participants who were able to correctly comprehend dose instructions provided on all three labels was significantly higher in the group that received PCL; 23.3% standard vs 83.6% PCL, p<0.001. The effect was observed in both low and high health literacy participants. The proportion of participants with accurate label comprehension was higher in participants with low Newest Vital Signs scores (8.3% standard vs 85.7% PCL, p<0.001) and low Rapid Estimate of Adult Literacy in Medicine scores (10.5% standard vs 96.0% PCL, p<0.001) who received PCL.

CONCLUSION

This study supports the use of PCL in Australian pharmacy practice. PCL provide simple, clear and explicit dosing instructions to patients. Implementing PCL may reduce the risk of misinterpreting dosing instructions by patients and improve quality use of medicines.

TRIAL REGISTRATION NUMBER

ACTRN12621000083897; Results.

Literature Review of Type 2 Diabetes Management and Health Literacy

OBJECTIVE

The purpose of this literature review was to identify educational approaches addressing low health literacy for people with type 2 diabetes. Low health literacy can lead to poor management of diabetes, low engagement with health care providers, increased hospitalization rates, and higher health care costs. These challenges can be even more profound among minority populations and non-English speakers in the United States.

METHODS

A literature search and standard data extraction were performed using PubMed, Medline, and EMBASE databases. A total of 1,914 articles were identified, of which 1,858 were excluded based on the inclusion criteria, and 46 were excluded because of a lack of relevance to both diabetes management and health literacy. The remaining 10 articles were reviewed in detail.

RESULTS

Patients, including ethnic minorities and non-English speakers, who are engaged in diabetes education and health literacy improvement initiatives and ongoing follow-up showed significant improvement in A1C, medication adherence, medication knowledge, and treatment satisfaction. Clinicians considering implementing new interventions to address diabetes care for patients with low health literacy can use culturally tailored approaches, consider ways to create materials for different learning styles and in different languages, engage community health workers and pharmacists to help with patient education, use patient-centered medication labels, and engage instructors who share cultural and linguistic similarities with patients to provide educational sessions.

CONCLUSION

This literature review identified a variety of interventions that had a positive impact on provider-patient communication, medication adherence, and glycemic control by promoting diabetes self-management through educational efforts to address low health literacy.

Compliance of Private Primary Health Care Facilities Towards Requirements of Labelling of Dispensed Medicine in Sarawak

BACKGROUND

Compliance towards the requirements of labelling of dispensed medicine (LDM) among private primary health care facilities ensures appropriate use of medicines.

AIM

This study aimed to examine the rate of compliance towards the requirements of LDM among retail pharmacies (RPs) and private medical clinics (PMCs).

METHODS

A cross-sectional study was conducted from April 2019 to January 2020 across all inspected premises in Sarawak. Publics who attended RPs and PMCs and having medicines dispensed, have their medicine labels examined for compliance towards the requirements of LDM upon exiting the premises. Their verbal consents were obtained and the compliance score were recorded into self-developed data collection forms. Compliance rate was the percentage of requirements on the examined medicine labels that fulfil the requirements under Regulation 12 of Poisons Regulations 1952.

RESULTS

A total of 414 LDM were examined, with 135 from RPs and 279 from PMCs. The full compliance towards the requirements of LDM among RPs and PMCs were 23.7% and 41.6%, respectively. The median compliance score of PMCs (0.83) was significantly higher (P<0.001) than RPs (0.67). The requirements of LDM with the lowest compliance was name of medicine (53.1%), followed by name of patient (31.9%) and date of dispensing (25.6%).

CONCLUSION

The full compliance rate on the requirements of LDM among RPs and PMCs were low. More stringent enforcement and public education on their rights for fully compliant medicine labels could improve the compliance.

Health Literate Hawai'i: A Blueprint to Empower Health and Wellbeing

Recent studies have identified high rates of chronic disease in Hawai'i's adults and youth. As the state responds to the COVID-19 pandemic and looks beyond it, the prevention and management of chronic diseases are critical for community health and wellbeing. Low health literacy is more common in rural populations, Filipinos, and Pacific Islanders in Hawai'I, older adults, and many other groups with high rates of chronic disease. Promoting health literacy can reduce chronic disease burdens for individuals, families, and communities. Using the framework of the social-ecological model, which is important for visioning effective chronic disease management and prevention, this article provides a blueprint of layers of influence for building a health literate Hawai'I generally and around chronic disease specifically. The article will close with a call to action informed by the National Action Plan to Improve Health Literacy for stakeholders and providers to address health literacy in the state of Hawai'I in organizations, systems, and policy. These actions should address root causes of disease and help build more equitable health outcomes across the state now and in the future.

Developing and user testing new pharmacy label formats-A study to inform labelling standards

Background

Dispensed prescription medicine labels (prescription labels) are important information sources supporting safe and appropriate medicines use.

Objective

To develop and user test patient‐centred prescription label formats.

Methods

Five stages: developing 12 labels for four fictitious medicines of varying dosage forms; diagnostic user testing of labels (Round 1) with 40 consumers (each testing three labels); iterative label revision, and development of Round 2 labels (n = 7); user testing of labels (Round 2) with 20 consumers (each testing four labels); labelling recommendations. Evaluated labels stated the active ingredient and brand name, using various design features (eg upper case and bold). Dosing was expressed differently across labels: frequency of doses/day, approximate times of day (eg morning), explicit times (eg 7 to 9 AM), and/or explicit dosing interval. Participants’ ability to find and understand medicines information and plan a dosing schedule were assessed.

Results

Participants demonstrated satisfactory ability to find and understand the dosage for all label formats. Excluding active ingredient and dosing schedule, 14/19 labels (8/12 in Round 1; 6/7 in Round 2) met industry standard on performance. Participants’ ability to correctly identify the active ingredient varied, with clear medicine name sign‐posting enabling all participants evaluating these labels to find and understand the active ingredient. When planning a dosing schedule, doses were correctly spaced if the label stated a dosing interval, or frequency of doses/day. Two‐thirds planned appropriate dosing schedules using a dosing table.

Conclusions

Effective prescription label formatting and sign‐posting of active ingredient improved communication of information on labels, potentially supporting safe medicines use.

Patient and Public Involvement

Consumers actively contributed to the development of dispensed prescription medicine labels. Feedback from consumers following the first round was incorporated in revisions of the labels for the next round. Patient and public involvement in this study was critical to the development of readable and understandable dispensed prescription medicine labels.

The impact of textual elements on the comprehensibility of drug label instructions (DLIs): A systematic review

INTRODUCTION

Correct interpretation of drug labels instructions (DLIs) is needed for safe use and better adherence to prescribed drugs. DLIs are often too difficult for patients, especially for those with limited health literacy. What is yet unknown, is how specific textual elements in DLIs (e.g., the presentation of numbers, or use of medical jargon) and patients' health literacy skills are related to the comprehension of DLIs. In order to provide concrete directions for health professionals on how to optimize drug prescriptions, we performed a systematic review to summarize the available research findings on which textual elements facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

METHOD

A systematic search was performed in PubMed, EMBASE, PsychINFO, and Smartcat (until April 2019) to identify studies investigating textual elements that facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

RESULTS

A total of 434 studies were identified of which 28 studies met our inclusion criteria. We found that textual elements contributing to the correct interpretation of DLIs were: using explicit time periods in dosage instructions, using plain language, presenting numbers in a numerical format, and providing DLIs in patients' native language. Multistep instructions per instruction line, using abbreviations and medical jargon seem to hinder the correct interpretation of DLIs. Although health literacy was taken into account in a majority of the studies, none of them assessed the effectiveness of specific textual elements on patients' comprehensibility of DLIs.

CONCLUSION

Based on our findings, we provide an overview of textual elements that contribute to the correct interpretation of DLIs. Optimizing the textual instruction on drug labels may increase the safety and adherence to prescribed drugs, taking into account that a significant proportion of patients has low health literacy.

Ideal instruments used to measure health literacy related to medication use: A systematic review

BACKGROUND

Prior studies showed the association between inadequate health literacy (HL) and poor medication-related skills, while none of the published studies have reviewed and compared the existing instruments used to measure medication-related HL. This systematic review comprehensively summarizes the existing instruments that assess medication-related HL.

OBJECTIVES

To identify appropriate HL instruments related to medication use as screening tools for enhancing patients' ability to use medications correctly.

METHODS

This review retrieved medication-related HL instruments that were published between 2000 and 2019 from three databases (i.e., PubMed, Scopus, EMBASE) and by hand-searching. The PRISMA procedure was followed as well as the SURGE guideline to assess the quality of studies. Psychometric properties, HL dimensions, and types of medication information gleaned from the items in three types of HL instruments (i.e., general, disease-specific, medication-specific) were compared to identify appropriate medication-related HL instruments.

RESULT

Forty-eight instruments were identified from 44 studies, whereas 70.8% instruments were either disease- or medication-specific HL instruments. Most instruments with different sample sizes showed certain an extent of reliability and validity. The distributions of HL dimensions and types of medication information among the relevant items were varied across different types of instruments. The five instruments (named as the 16SQ, AKQ-CQ, DHLKI, AKT, and ChMLM) were identified as the most appropriate instruments for three types of medication-related HL, respectively. These appropriate instruments consistently covered items related to HL dimensions of literacy and comprehension and medication-related information regarding dosing, treatment indication, and side effects/precautions.

CONCLUSION

Of 48 identified instruments mainly derived from disease- or medication-specific studies, the five most appropriate medication-related HL instruments were identified to support clinicians in facilitating patients' correct medication use. Further confirmation to explore the usefulness among these instruments are needed.

Treatment Adherence in Chronic Conditions during Ageing: Uses, Functionalities, and Cultural Adaptation of the Assistant on Care and Health Offline (ACHO) in Rural Areas

The increasingly common scenario of an ageing population is related to a rise in the prevalence of problems associated with chronic conditions and comorbidities. Polypharmacy is frequent among this population, and it is a situation that can create medication management and adherence issues. This article introduces the features and functionalities of a voice assistant (Assistant on Health and Care Offline, ACHO) that aims to facilitate treatment adherence among elderly adults. Specifically adapted for its use in rural contexts, it does not require an Internet connection. Its development consisted of two stages: a first stage of problem diagnosis, in which the classic tools of ethnographic fieldwork were used, and a second stage of design implementing methodologies developed by Ambient Assisted Living (AAL) programmes. The main design characteristic of this new digital care system is that it is adapted to the needs of its end-users. It includes features such as voice customisation and the personal identification of medication, it can be connected to other digital devices, and information is introduced and supervised by healthcare professionals. These custom features introduce a safer medication administration procedure, improve supervision strategies, and increase patients' trust in the prescription process.

Medication management in dialysis: Barriers and strategies

People with end-stage kidney disease (ESKD) who require chronic dialysis are often reliant on complicated medication regimens to manage their health conditions. Due to the complexities of the advanced kidney disease, underlying comorbidities, and special instructions, medication regimens for patients on dialysis put patients at high risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence. This article explores the factors that affect optimal medication use for people on dialysis, including the broader drug use system, and offers recommendations around medication reconciliation, medication review, deprescribing, and considering social determinants of health to improve medication management among patients with ESKD.

Prevalence of Universal Medication Schedule prescribing and links to adherence

PURPOSE

A Universal Medication Schedule (UMS) that uses explicit language to describe when to take medicine has been proposed as a patient-centered prescribing and dispensing standard. Despite widespread support, evidence of its actual use and efficacy is limited. We investigated the prevalence of UMS instructions and whether their use was associated with higher rates of medication adherence.

METHODS

National pharmacy records were analyzed for a cohort of type 2 diabetic adults ≥18 years old (N = 676,739) new to ≥1 oral diabetes medications between January and June 2014. Prescription instructions (N = 796,909) dispensed with medications were classified as UMS or non-UMS. Instructions coded as UMS were further categorized as either providing precise UMS language (tier 1: "take 1 pill at morning, noon, evening, or bedtime") or offering some explicit guidance (tier 2: "take 1 tablet by mouth before breakfast"; tier 3: "take 1 tablet twice daily with a meal"). Adherence over 12 months was measured by proportion of days covered.

RESULTS

One-third of instructions (32.4%, n = 258,508) were classified as UMS (tier 1: 12.6%, n = 100,589; tier 2: 6.0%, n = 47,914; tier 3: 13.8%, n = 110,005). In multivariable analyses, UMS instructions (all tiers) exhibited better adherence compared to non-UMS instructions (relative risk [RR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = 0.01). Patients older than 65 years who were less educated and taking medication more than once daily received greater benefit from tier 1 UMS instructions (RR, 1.14; 95% CI, 1.07-1.21; P < 0.001).

CONCLUSION

While infrequently used, the UMS could help older, less-educated patients adhere to more complex regimens with minimal investment.

Artificial Intelligence-Powered Smartphone App to Facilitate Medication Adherence: Protocol for a Human Factors Design Study

BACKGROUND

Medication Guides consisting of crucial interactions and side effects are extensive and complex. Due to the exhaustive information, patients do not retain the necessary medication information, which can result in hospitalizations and medication nonadherence. A gap exists in understanding patients' cognition of managing complex medication information. However, advancements in technology and artificial intelligence (AI) allow us to understand patient cognitive processes to design an app to better provide important medication information to patients.

OBJECTIVE

Our objective is to improve the design of an innovative AI- and human factor-based interface that supports patients' medication information comprehension that could potentially improve medication adherence.

METHODS

This study has three aims. Aim 1 has three phases: (1) an observational study to understand patient perception of fear and biases regarding medication information, (2) an eye-tracking study to understand the attention locus for medication information, and (3) a psychological refractory period (PRP) paradigm study to understand functionalities. Observational data will be collected, such as audio and video recordings, gaze mapping, and time from PRP. A total of 50 patients, aged 18-65 years, who started at least one new medication, for which we developed visualization information, and who have a cognitive status of 34 during cognitive screening using the TICS-M test and health literacy level will be included in this aim of the study. In Aim 2, we will iteratively design and evaluate an AI-powered medication information visualization interface as a smartphone app with the knowledge gained from each component of Aim 1. The interface will be assessed through two usability surveys. A total of 300 patients, aged 18-65 years, with diabetes, cardiovascular diseases, or mental health disorders, will be recruited for the surveys. Data from the surveys will be analyzed through exploratory factor analysis. In Aim 3, in order to test the prototype, there will be a two-arm study design. This aim will include 900 patients, aged 18-65 years, with internet access, without any cognitive impairment, and with at least two medications. Patients will be sequentially randomized. Three surveys will be used to assess the primary outcome of medication information comprehension and the secondary outcome of medication adherence at 12 weeks.

RESULTS

Preliminary data collection will be conducted in 2021, and results are expected to be published in 2022.

CONCLUSIONS

This study will lead the future of AI-based, innovative, digital interface design and aid in improving medication comprehension, which may improve medication adherence. The results from this study will also open up future research opportunities in understanding how patients manage complex medication information and will inform the format and design for innovative, AI-powered digital interfaces for Medication Guides.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/21659.

How do I keep myself safe? Patient perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis

ABSTRACT

BACKGROUND

Medications are crucial for maintaining patient wellness and improving health in modern medicine, but their use comes with risks. Helping patients to understand why they are taking medications is important for patient-centered care and facilitates patient adherence to prescribed medications. One strategy involves enhancing communication between patients, physicians, and pharmacists through the sharing of reason for use (RFU) information or the indication for medications.

METHODS

Semi-structured interviews were conducted with 20 patients in Ontario, Canada, to gain perspectives on how patients currently store their medication information and benefits and disadvantages of adding RFU to prescriptions and medication labels. An interview guide was used by the two interviewers, and the interviews were recorded, transcribed, and thematically coded.

RESULTS

The analysis yielded three main themes: patient decision making with RFU, RFU in modern, patient-centered care, and logistical aspects of communicating RFU. The patients that were interviewed expressed the value of having RFU when deciding if a medication was effective or to stop taking the medication. Patients felt comfortable with RFU being added to prescriptions and acknowledged the value in adding RFU to medication labels, helping patients and others identify and distinguish medications. Patients generally expressed interest in having RFU written in lay language and identified strengths and weaknesses of having access to RFU via a website or app.

CONCLUSIONS

Patients rated the importance of knowing RFU very highly, identified the value in sharing RFU with pharmacists on prescriptions, and in having RFU on medication labels. These results can be used to inform policy on the addition of RFU on prescriptions and medication labels and support improved communication between patients, pharmacists, and physicians about RFU.

Pharmacists' perspectives on the value of reason for use information

Background

The indication for a particular medication, or its reason for use (RFU), is important information for prescribers, pharmacists and patients but is not often communicated in writing from prescribers to pharmacists. Adding RFU to a prescription and a medication label would ensure that pharmacists are confident that they are providing high-quality, accurate patient care. This study aims to describe the perspectives of pharmacists on how receiving RFU from prescribers would affect their practice and how pharmacists putting this information on prescriptions would affect patients.

Methods

Semi-structured qualitative interviews were conducted with 20 pharmacists in Southwestern Ontario. Thematic analysis was used to analyze the interview transcripts, leading to 4 major themes.

Results

Pharmacists expressed that RFU should be formatted to ensure that it is of clinical utility via the use of written text and noted that either medical or lay (also known as plain) language would be appropriate for use. Pharmacists indicated that patient privacy should be considered when writing RFU on labels and that patient preference with respect to the addition of RFU should dictate its inclusion on a medication label. Pharmacist access to RFU was universally acknowledged to improve patient safety by providing pharmacists with more information to determine whether the given medication was indicated.

Conclusions

This study provides further information about the impact that having access to RFU would have on pharmacy practice and can be used to advocate for the inclusion of RFU information with prescriptions to improve patient outcomes. Can Pharm J (Ott) 2020;153:xx-xx.

Mediators of the association of limited English health literacy with medication non-adherence among Singaporean elderly

Background:

In Singapore, English is predominantly used on prescription medication labels (PMLs). However, many older Singaporeans cannot read English, and among those who read English, their English health literacy (EHL) proficiency varies. It is thus pertinent to examine the link between EHL and medication use outcomes in this population. The present research aims to address this question.

Methods:

Data from a national survey, on 1167 home-dwelling elderly on ⩾1 prescribed medication was analysed. The validated Health Literacy Test for Singapore was used to determine EHL. Medication non-adherence was self-reported. Path analysis examined the association between limited EHL and medication non-adherence and tested possible mediators.

Results:

Limited EHL was associated with medication non-adherence (total effect=0.35; p-value: 0.032), and ‘uncertainty in taking medications correctly due to difficulty in understanding written information on PMLs’ was a significant mediator (indirect effect=0.23, 95% confidence interval (0.12–0.39)).

Conclusions:

Elderly people with limited EHL were significantly more likely than those with adequate EHL to report that they were uncertain about taking medications correctly because they had difficulty understanding the information on PMLs and this misunderstanding contributed to medication non-adherence. Interventions focused on incorporating bilingual text and/or pictograms on PMLs may reduce uncertainty in taking medication correctly and improve medication adherence among the elderly.

A Multifaceted Intervention to Improve Patient Knowledge and Safe Use of Opioids: Results of the ED EMC2 Randomized Controlled Trial

OBJECTIVES

Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC² ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids.

METHODS

This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC² intervention, or 3) EMC²  + short message service (SMS) text messaging. The ED EMC² intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC²  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment.

RESULTS

Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC² group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC²  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC²  + SMS group (β = 0.57, 95% CI = 0.09 to 1.06) than usual care.

CONCLUSIONS

The study found that the EMC² tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.

International Coherence of Pediatric Drug Labeling for Drug Safety: Comparison of Approved Labels in Korea and the United States

The objective of this study was to analyze information on pediatric use in Korean drug product labels and compare it with that in US Food and Drug Administration (FDA) labeling information. Prescription information on pediatric use contained in the commonly used drugs’ product labels approved by Korean government was compared with that approved by the FDA. Among the top 50 commonly prescribed drugs, 20 drugs were deemed to have insufficient prescribing information in Korean drug labels. Pediatric prescribing information regarding indication, approved age, formulations, and safety was insufficient in Korean drug labels compared with those in the FDA. Most important, the adverse events frequently reported in Korean children were not sufficiently presented in drug labels. In conclusion, this study highlights the urgent need for the Korean regulatory agency to encourage and accelerate research and development to increase the extent of pediatric prescribing information to be added to drug labels to promote appropriate drug prescribing for children.

Implementation fidelity of patient-centered prescription label to promote opioid safe use

PURPOSE

Patient-centered labels may improve safe medication use, but implementation challenges limit use. We assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording.

METHODS

As part of a larger investigation, patients received TWS prescriptions (eg, Take: 1 pill if you have pain; Wait: at least 4 h before taking again; Stop: do not take more than 6 pills in 24 h). Prescriptions labels recorded at follow-up were classified into three categories: (1) one-step wording (Take 1 pill every 4 h [without daily limits]), (2) two-step wording (Take 1 pill every 4 h; do not exceed 6 pills/day), and (3) three-step wording. There were three subtypes of three-step wording: (3a) three-step, not TWS (three deconstructed steps, not necessarily TWS wording), (3b) TWS format, employing three steps with leading verbs, but "with additions or replacements" (eg, replaced "do not take" with "do not exceed"), and (3c) verbatim TWS.

RESULTS

Two hundred eleven participants completed follow-up. Mean age was 44.3 years (SD 14.3); 44% were male. One-step bottles represented 12% (n = 25) of the sample, whereas 26% (n = 55) had two-step wording. The majority (44%, n = 93) had three-deconstructed steps, not TWS (3a); 16% (n = 34) retained TWS structure, but not verbatim (3b). Only 2% (n = 4) displayed verbatim TWS wording (3c). All category three labels (utilizing deconstructed instructions) were considered adequate implementation (62%).

CONCLUSIONS

Exact intervention adherence was not achieved in the majority of cases, limiting impact. Nonetheless, community pharmacies were responsive to new instructions, but higher implementation reliability requires additional supports.

Health Literacy: Implications for Child Health

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Nature and frequency of dosing instructions on prescription labels in primary care

PURPOSE

To investigate the nature and frequency of dosing instructions and auxiliary labels on prescription labels in primary care.

METHODS

A retrospective analysis of data on prescription labels of dispensed drugs extracted from the pharmacy information system of community pharmacies in the Netherlands. Dosing instructions were categorized into four types.

RESULTS

Data were extracted from 123 community pharmacies. All drugs dispensed for a random sample of 10% of patients were selected. In the sample of 938 479 prescriptions, 96% had a predefined dosing instruction and 2995 different coded instructions were used. Ninety-five percent of all instructions were covered by 354 coded instructions. Most prescriptions were coded with an instruction indicating once daily use (48.4%) or twice or more times daily use (23.8%) without specification of the time (eg, "1 tablet 1 time a day"). A general instruction ("use as directed") was given for 7.0% of all prescriptions, and for 6.0%, the instruction was to use "as needed." For most prescriptions (80.6%), one or more auxiliary labels were generated with the warning "may cause drowsiness" (17.9%) being the most frequent one.

CONCLUSIONS

A limited set of instructions covered the majority of the prescriptions. About a quarter of the prescription labels contained nonspecific dosing instructions for use multiple times a day, and 13.0% were general or "use as needed" instructions. These instructions can potentially be made more comprehensible by rewording and specification of the time of day.

Consumers' expectations and experiences with chain community pharmacies in Lahore, Pakistan: a qualitative exploratory study

Background The model of community pharmacy practice is changing remarkably not only in the West but also in developing countries, which has led retail pharmacies to transform into chain community pharmacies. However, very little is known about consumers' expectations and experiences with chain community pharmacies in developing countries. Objective This study aims to assess the expectations and experiences of consumers with services provided by chain community pharmacies in Lahore, Pakistan. Setting Four random chain community pharmacies. Methods A qualitative study design was employed and face-to-face, audio-recorded, interviews were conducted with 12 consumers attending 4 randomly selected chain community pharmacies. All interviews were transcribed verbatim and the interview data were analysed thematically using NVivo^® software. Main outcome measure Consumers' expectations and experiences with chain community pharmacies. Results The results contributed to a deeper understanding of the consumers' expectations and experiences with the services provided by chain community pharmacies. Six themes emerged from interview data including; access to pharmacists, quality use of medicines, range of distinct services, staff's behaviour, inventory management, and scope of services. The consumers reported that pharmacists working in chain community pharmacies were building trusting relationships and encouraging them to take an active role in healthcare. Pharmacists working there were providing them medication information and counselling services, which they normally do not expect from traditional pharmacies. Consumers mentioned that they had access to pharmacists and quality services, but the inventory of pharmacies was limited. Conclusions This exploratory study provides preliminary evidence that some of the consumers' expectations and experiences were aligned. However, some deficiencies were highlighted by the consumers that need to be addressed by relevant stakeholders. Further research is needed to assess the expectations and experiences of pharmacists working in the chain community pharmacy sector.

Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give?

This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.

Knowledge mapping of medication literacy study: A visualized analysis using CiteSpace

Objective:

The objective of this study was to analyze knowledge mapping and demonstrate the status quo, intellectual base, and hotspots in the field of medication literacy.

Methods:

Using the data from Web of Science Core database, we constructed a knowledge map to visualize medication literacy using CiteSpace, which revealed the power of the studies, core authors and journals, intellectual base, and hotspots in this field.

Results:

According to an analysis of 2025 literature reports, the stronger studies were mainly conducted at research institutions of higher education in the United States. Core author groups with a higher influence were not identified. The core journals included Patient Educ Couns and Fam Med. The health literacy studies served as the foundation for the medication literacy studies. The keywords formed 13 clusters including 5 major clusters.

Conclusion:

The topics in medication literacy study focused on instruments assessing medication literacy, measurement and assessment of medication literacy, medication literacy for the prevention of chronic disease and medication treatment adherence, medication literacy education, and family practice. This study provides an insight into medication literacy and valuable information for medication literacy researchers to identify new perspectives on potential collaborators and cooperative institutions and hotspots.

Challenges optimizing the after visit summary

BACKGROUND

The after visit summary (AVS) is a paper or electronic document given to patients after a medical appointment, which is intended to summarize patients' health and guide future care, including self-management tasks.

OBJECTIVE

To describe experiences of health systems implementing a redesigned outpatient AVS in commercially available electronic health record (EHR) systems to inform future optimization.

MATERIALS AND METHODS

We conducted semi-structured interviews with information technology and clinical leaders at 12 hospital and community-based healthcare institutions across the continental United States focusing on the process of AVS redesign and implementation. We also report our experience implementing a redesigned AVS in the Epic EHR at the Mount Sinai Hospital in New York City, NY.

RESULTS

Health systems experienced many challenges implementing the redesigned AVS. While many IT leaders noted that the redesigned AVS is easier to understand and the document is better organized, they claim the effort is time-consuming, Epic system upgrades render AVS modifications non-functional, and primary care and specialty practices have different needs in regards to content and formatting. Our team was able to modify the document by changing the order of print groups, modifying the font size, bolding section headers, and inserting page breaks. Similar to other health systems, our team found that it is difficult to achieve some desired features due to limitations in the EHR platform.

CONCLUSION

Health IT leaders view the AVS as a valuable source of information for patients. However, limitations to AVS modifications in EHR systems present challenges to optimizing the tool. EHR vendors should incorporate learning from healthcare systems innovation efforts and consider building more flexibility into their product development.

Implementation of patient-centered prescription labeling in a safety-net ambulatory care network

PURPOSE

An initiative to implement patient-centered medication labeling at 4 pharmacies within a publicly funded safety-net healthcare system is described.

SUMMARY

Medication nonadherence negatively affects patient outcomes and safety. Nonadherence has been attributed to poor understanding of instructions on medication labels. Research has demonstrated that patient-centered labeling (PCL) can improve adherence and produce safer medication-taking practices. As part of a mixed-methods study by a safety-net health system, audits of nearly 9,000 prescription labels generated at 4 pharmacy sites, as well as interviews with 6 stakeholder informants, were conducted to determine PCL adoption rates and factors contributing to success. Descriptive statistics were used to analyze audit data; constructs of the Consolidated Framework for Implementation Research were used to analyze interview data. Among the 4 sites, 3 pharmacies successfully converted more than 85% of audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions and inadequate real-time data on conversion rates. Interviewees perceived that leadership and policy directives promoted PCL conversion efforts. Successful pharmacies used adaptable software, had closer communication networks with prescribers, and/or used automation to facilitate PCL conversion.

CONCLUSION

Three pharmacies successfully converted more than 85% of labels for audited prescriptions to a PCL format; 1 pharmacy converted less than 25% of prescriptions. Barriers to implementation included pharmacists' reluctance to modify prescriber instructions, inadequate real-time data on conversation rates, and lack of customizable software to automate changes.

A narrative review on do's and don'ts in prescription label writing - lessons for pharmacists

Providing medicines information is a key role of a pharmacist. Miscommunication between pharmacist and patient may lead to adverse drug events or therapeutic failure. The aim of the review was to summarize the available research findings on factors that lead to poor communication between pharmacist and patient when providing written medicines information on dispensing and auxiliary labels and identify successful interventional approaches that help to alleviate these concerns. We selected articles available on PubMed, SAGE, and Google Scholar databases that are relevant to our objective. A total of 33 articles that matched the objectives of this review were retrieved and evaluated by all three authors. It was found that patient literacy levels, number of medicines dispensed, format and organization of the label, complexity of dosing instructions, precision of writing dosing instructions and use of icons, graphics and pictograms were aspects that were frequently used, and hence assessed by research groups on medicine label writing. Most studies reported that simple and straight forward instructions written legibly were better comprehended by patients. Based on our findings, we provide here useful tips for pharmacists on writing dosing instructions for patients. Finally, we spotlight crucial research gaps related to communicating written dosing instructions that need to be addressed in the future.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention

PURPOSE OF REVIEW

Given that the primary cause of overdose death in the USA is related to prescribed opioids, one potential strategy to improve awareness and decrease morbidity and/or mortality could include improved labeling. Specific patient populations which significantly struggle with adverse outcomes related to opioid abuse are seen in palliative care, chronic pain, and acute pain treatment settings.

RECENT FINDINGS

An unexplored option for improving the healthcare quality and safety for patients currently prescribed opioids would be to require pharmaceutical companies to provide a morphine milligram equivalent (MME) on opioid packaging. Some limitations to MME conversions include equianalgesic conversions being estimates at best and may not account for variations in genetics and pharmacokinetics. Changing opioid labeling requirements is feasible as it falls under the purview of the US Food and Drug Administration (FDA), which has been mandated to provide mechanisms to reduce or to minimize overdoses related to opioid prescriptions. Labeling opioid packaging with MME per dose will promote clearer communication about opioid strength between patients and physicians. Labeling MME on packaging could help prevent prescriber errors.

Impact of a Universal Medication Schedule on rationalising and understanding of medication; a randomised controlled trial

BACKGROUND

Patients frequently encounter difficulty understanding their prescription drug labels. This problem is more common in patients with limited health literacy (HL). Patients are not always counselled on their medicines by their doctor or pharmacist, therefore this label can be an important source of information.

OBJECTIVE

To assess the impact of a Universal Medication Schedule (UMS) on the knowledge and consolidation of a prescription drug regimen compared to standard pharmacy labelling.

METHODS

Seventy-six in-patients at a specialised rehabilitation hospital in Dublin, Ireland, were randomised into control (usual care) or intervention (UMS) groups. Adult in-patients, receiving oral medicines, who spoke English fluently were included. Patients with dexterity issues documented, or those unable to provide written informed consent were excluded. The Newest Vital Sign (NVS) and validated HL screening questions measured HL. A five medication regimen was presented to each participant, and they were asked questions to assess their understanding of the medication regimen and were asked to dose out the medications into a 24 h dosette box. Data analysis was conducted using SPSS^® (IBM Corp.), V23.

RESULTS

The majority of participants (n = 76) were Irish (89.5%), male (63.2%) and the median age of participants was 49 years. 46% of participants had a third level qualification, however 14.4% of participants had not completed any formal school examinations. Those in the UMS group displayed better understanding of the prescription regimen than those in the usual care group, but this was not statistically significant. (Mean score 9.28 vs 8.81, p = 0.135). Subgroup analysis did not find any additional benefit of UMS in those with limited health literacy (Mean score 8.56 vs 9.06, p = 0.514) but rather in those who said that they found instructions on tablets hard to understand (Mean score 10.00 vs 8.43, p = 0.019).

CONCLUSION

A UMS approach may improve patients understanding and use of their medicines.