To err is human: patient misinterpretations of prescription drug label instructions

Interventions to promote health literacy among working-age populations experiencing socioeconomic disadvantage: systematic review

Background

Experiencing financial insecurity and being underserved is often associated with low health literacy, i.e., the ability to identify, obtain, interpret and act upon health information, which may result in poor health outcomes. Little is known about effective interventions for promoting health literacy among underserved populations. The objective of this systematic review is to summarize the literature on such interventions and identify characteristics that differentiate more effective interventions.

Methods

Following PRISMA guidelines we searched the databases SCOPUS, Pubmed, Web of Science core collection and CINAHL. We included primary studies with a quantitative study design and control groups testing interventions to increase health literacy or health knowledge in underserved populations between 18 and 65 years. Where possible, we converted effect sizes into Cohen's d and compared mean differences of intervention and control groups. Albatross plots were created to summarize the results according to different health literacy and health knowledge outcomes.

Results

We screened 3,696 titles and abstracts and 206 full texts. In total, 86 articles were analyzed, of which 55 were summarized in seven albatross plots. The majority of the studies (n = 55) were conducted in the United States and had a randomized controlled study design (n = 44). More effective intervention approaches assessed needs of participants through focus group discussions prior to conducting the intervention, used bilingual educational materials, and included professionals fluent in the first languages of the study population as intervention deliverers. Additionally, the use of educational materials in video and text form, fotonovelas and interactive group education sessions with role playing exercises were observed to be effective.

Discussion

Although the outcomes addressed in the included studies were heterogeneous, effective intervention approaches were often culturally sensitive and developed tailored educational materials. Interventions aiming to promote health literacy in underserved populations should hence consider applying similar approaches.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323801, PROSPERO registration ID: CRD42022323801.

Pharmaceutical pictograms to improve textual comprehension: A systematic review

INTRODUCTION

Written instructive information for the patient is key in pharmaceutical care. However, the preexisting literature agrees on the discordance between the readability of written medication messages intended for patients. The aim of our work was to systematically review the available evidence on the effect of pharmaceutical pictograms as elements that facilitate understanding of the text in primary or secondary medication packaging.

METHODS

A parallel systematic search was conducted of the literature covering evidence of the effect of including pictograms in primary or secondary packaging on comprehension by potential users or caregivers up to April 9, 2023. The databases consulted were Scopus, MEDLINE and Web of Science. Only randomized controlled studies, whose main outcome measure was comprehension, were included.

RESULTS

Only 8 papers met our search criteria. In most of the included studies, the intervention of including pictograms improved participants' performance in comprehending instructions. A debatable methodological quality, and differences in the target population, textual complexity of the materials or the cultural affinity of the pictograms with the target population in each study, could have had a decisive influence on the results.

CONCLUSION

The heterogeneity in the design of each study poses a significant barrier to establishing commonalities and generalizing the results. This heterogeneity also prevented us from conclusively confirming the usefulness of pictograms complementary to instructional text in improving the comprehension of instructions for the rational use of medicines.

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/ ).

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.

Development of oral oncolytic nonadherence estimator (ORACLE): A pretreatment nonadherence risk assessment for oral oncolytics

INTRODUCTION

To date, there is no adherence estimator to identify risk of nonadherence prior to initiating oral oncolytics.

METHODS

A workgroup was assembled through the National Community Oncology Dispensing Association and tasked with creating a tool to meet this need. Tool constructs were defined after a review of the literature identifying top barriers to adherence. A second literature search was conducted to identify questions targeting specific barriers from validated adherence questionnaires. Once a finalized draft was complete, the risk assessment tool was built into an electronic survey where a risk category can be automatically calculated for the patient.

RESULTS

The six most impactful factors affecting compliance to oral oncolytics were identified as patient's confidence, health literacy, perception of treatment, quality of life, social support, and complexity of chemotherapy regimen. A six-item questionnaire was created with five patient-directed questions and one clinician-directed question. Examples and descriptions were provided for clinicians to consider when categorizing complexity of a regimen. The tool was designed for responses to each question to be indexed into categories through a 10-point system. Results will be stratified into low, moderate, or high risk for nonadherence.

CONCLUSION

The creation of a tool to predict nonadherence prior to starting therapy is an unmet need for patients initiating oral oncolytics. The aim of this tool is to meet those needs and better guide clinicians to provide patients with strategies to better manage nonadherence. Next steps include tool validation and piloting in clinical practice.

Does health literacy affect older people's avoidance of medical care? The sense of medical care policy alienation and perceptions of control

We aimed to clarify whether health literacy (HL)  impacts medical care avoidance through an underexplored mediator: a sense of policy alienation towards medical care policy for residents (SPA-M). A moderated mediation model with control perception as a moderator was used to analyze the inner relationship between HL and SPA-M. A cross-sectional survey of 470 people ≥ 60 years old, revealed a significant negative association between HL and medical care avoidance intention, which bootstrapped moderated mediation analysis confirmed is partially mediated by SPA-M. When older people's control perception was high, HL had a significant negative impact on medical care avoidance intention through SPA-M; for low control perception, the effect was insignificant. This study elucidates HL's impact of HL on medical care avoidance, highlighting control perception's relevance to medical care policymaking for older people.

Utility of patient information leaflet and perceived impact of its use on medication adherence

BACKGROUND

Although patients frequently use patient information leaflets (PILs) to obtain information about medicine, their confidence in using it may be diminished after reading it. This study aimed to assess the public perception of PIL's quality and the perceived impact of its use on medication adherence.

METHODS

A community-based cross-sectional study of 1,138 adult individuals in Saudi Arabia, April-May 2020, was conducted via Survey Monkey using an anonymous validated e-questionnaire. Data were collected on personal characteristics, PIL readership and preferences, perception towards PIL quality and impact of its use on taking medication, and reasons for not reading PIL. In addition, logistic regression analysis was performed to identify the significant predictors of reading PIL. Significance was considered at p < 0.05.

RESULTS

Nearly all participants (91.1%) reported reading PIL. The more read PIL's sections were directions of use (52.7%) and side effects (30.3%). Female gender (OR = 5.64, 95%CI: 3.53,9.02), age over 40 years (OR = 2.80, 95%CI: 1.69,4.64), and secondary education or more (OR = 1.74, 95%CI: 1.06,2.85) were the significant predictors of reading PIL. The majority of PIL readers reported their preference for verbal information (65.8%), hard copy presentation (77%), adding graphics (71.1%), and concise content of PIL (68.8%). In addition, most participants reported PIL always/usually adds to their knowledge of medicines (70.6%) and said that PIL reading positively impacted their medication adherence (64.9%). For only 8.8%, PIL reading negatively impacted their adherence, primarily because of reading information on medicine's side effects and complications (74.4%). More than one-half of participants perceived the PIL quality as good/excellent in terms of; font size (51.3%), language comprehensiveness (64.9%), paper quality (68.0%), and general appearance (64.9%). Getting sufficient information from doctors and pharmacists was the main reason for not reading the PIL (59.2%). Most participants (92.5%) agreed on standardizing how information is displayed in the PIL among all PILs of all companies.

CONCLUSION

PIL is read by nearly all the study sample, especially females, older, and educated subjects. It was perceived as beneficial in upgrading medication adherence. Effective designing of PILs should focus on patients' literacy level and age. Standardization of the PIL structure in all pharmaceutical companies is recommended.

Challenges encountered by pharmacy staff in using prescription medication labels during medication counselling with older adults and solutions employed: A mixed-methods study

Background

Prescription medication labels (PMLs) predominantly dispensed in English, are an important adjunct to medication counselling. PMLs are routinely used by pharmacy staff to counsel older adults about their medications. This study sought to identify challenges that pharmacy staff observe older adults face in using their PMLs, and to identify and quantify solutions employed by pharmacy staff during medication counselling to address such challenges.

Methods

Ten in-depth interviews were done with primary care pharmacy staff to gather the range of challenges and solutions. Subsequently, a quantitative survey, informed by the qualitative findings, was administered to 121 pharmacy staff to assess if the reported solutions were commonly used.

Results

The two main challenges were incongruity between PML language (English) and older adults' language proficiency, and poor PML legibility. The solutions, classified under three themes, were simplifying medication information on PMLs, supplementing PMLs with additional medication information and mitigating poor readability.

Conclusions

Pharmacy staff observed challenges faced by older adults in using PMLs during medication counselling. Ad-hoc improvisations by pharmacy staff to PMLs were pervasive. System-level PML improvements, such as provision of legible bilingual medication instructions, pharmaceutical pictograms and additional medication information, through patient information leaflets or using quick response (QR) codes on PMLs, should be considered. This will facilitate patient-provider communication, especially in settings with language dissonance between PMLs and patients.

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.

"Quality, Readability, and Understandability of Online Posterior Glottic Stenosis Information"

OBJECTIVES

To assess the quality, readability, and understandability of posterior glottic stenosis (PGS) information available to patients online.

METHODS

The top 50 Google search results for "posterior glottic stenosis" were categorized based on website affiliation and target audience (patient or provider). Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) scores. The DISCERN tool was used to assess quality and the Patient Education Assessment Tool for Printed Materials (PEMAT-P) was used to assess understandability and actionability. Simple descriptive statistics were used to analyze the data.

RESULTS

36 of the top 50 results were eligible for scoring. 17% (6 of 36) were classified as patient-focused while 83% (30 of 36) were provider-focused. Patient-focused materials had a higher mean FRE score (36.9) than provider-focused materials (15.5) (P < 0.001). Patient-focused materials had an average reading level of 12.5 compared to 15.8 for provider-focused materials (P < 0.001). There was a significant correlation between overall PEMAT-P and DISCERN (r = 0.63, P < 0.001), PEMAT-P understandability and DISCERN (r = 0.63, P < 0.001) and FRES and FKGL (r = -0.67, P < 0.001). From this, we can infer that higher quality sites are easier to understand but not necessarily tailored to a certain reading level.

CONCLUSIONS

Shared decision making in PGS management is crucial as patients must be aware of how treatment modalities affect airway, voice, and swallowing. However, this study shows that patient targeted PGS information is limited, and the readability, quality, and understandability is generally low. We suggest the development of web pages with PGS information tailored for patient education and search optimization to make this information appear earlier in Google search results. Furthermore, future studies should seek to characterize the link between online health information and socioeconomic-based health disparities.

Racial disparities in minimally invasive esophagectomy and gastrectomy for upper GI malignancies

BACKGROUND

Esophageal cancer and gastric cancer are two important causes of upper GI malignancies. Literature has shown that minimally invasive esophagectomies (MIE) and gastrectomies (MIG), have shorter length of stay and fewer complications. However, limited literature exists about the association between race and access to MIE and MIG. This study aims to identify the racial disparities in the different approaches to esophagectomy and gastrectomy. We further evaluate the relationship between the race and postoperative complications.

METHODS

This IRB-approved retrospective study utilized data from the American College of Surgeons National Quality Improvement Program. All recorded cases of MIE, MIG, open gastrectomy, and esophagectomy between 2012 and 2019 were isolated. Propensity score matching and univariate analysis was performed to assess the independent effect of black self-identified race on access and outcomes. p < 0.05 was required to achieve statistical significance.

RESULTS

7891 cases of esophagectomy and 5,132 cases of gastrectomy cases were identified. Using Propensity and logistic regression, we identified that black self-reported race is an independent predictor of open approach to gastrectomy (OR 1.6871943, 95% CI 1.431464-1.989829, p < 0.001). Black self-reported race was not predictive of operative approach among esophagectomy patients (OR 0.7942576, 95% CI 0.5698645-1.124228, p = 0.183). In contrast, black self-reported is an independent predictor of postoperative complications among esophagectomy patients only. Esophagectomy patients of black self-reported race were more likely to experience any complication (OR 1.4373437, 95% CI 1.1129239-1.8557096, p = 0.00537), severe complications (OR 1.3818966, 95% CI 1.0653087-1.7888454, p = 0.0144), and death (OR 2.00779762, 95% CI 1.08034921-3.56117535, p = 0.0211) within 30 days of their surgeries.

CONCLUSION

Our analysis revealed a significant racial disparity in access to MIG and a higher incidence of post-operative complications amongst esophagectomy patients. Minimally invasive techniques are underutilized in racial minorities. The findings herein warrant further investigation to eliminate barriers and disparities.

Comprehensibility of a personalized medication overview compared to usual-care prescription drug labels

Poor understanding of prescription drug label (PDL) instructions can lead to medication errors, suboptimal treatment (side) effects, and non-adherence. A personalized medication hard-copy overview listing PDL instructions and visual information may support patients in their medication use. This study aimed to investigate the comprehensibility of PDL instructions on a personalized medication overview compared to usual-care PDL instructions presented on a medication box. A hypothetical-online-experiment was set up, comparing groups of respondents exposed vs not exposed to the medication overview and who received PDL instructions for three, five, or eight medications. Participants were divided randomly in six groups. Online questionnaires were sent to a stratified sample of 900 members from the Nivel Dutch Healthcare Consumer Panel. Outcome measures included comprehension of instructions for medication use, e.g. how often, dose timing, usage advice and warnings for a medication with simple use instructions (omeprazol) and more complex use instructions (levodopa/carbidopa (L/C)). To analyze differences between experimental conditions ANOVA testing was used. 604 respondents (net response 67%) completed the questionnaires. Respondents exposed (E) to the overview gave a higher proportion of correct answers compared to non-exposed (NE) respondents for usage advice (L/C: mean 0.83, SD 0.4 E; 0.03, SD 0.2 NE, p &lt; 0.001; omeprazol: mean 0.85, SD 0.4 E; 0.10, SD 0.3 NE, p &lt; 0.001). Both groups gave the same proportion of correct answers (mean 0.80, SD 0.4, p = 1.0) for dose timing of omeprazol. More NE respondents gave correct answers for how often (mean 0.85, SD 0.4 NE; mean 0.76, SD 0.4 E, p = 0.02) and dose timing (mean 0.92, SD 0.3 NE; mean 0.86, SD 0.4 E, p = 0.04) of L/C. No differences were found regarding number of medications nor were interaction effects found between the number of medications and information type. As a medication overview contains additional information, it can be a good addition in supporting patients in their medication use compared to usual-care PDLs. Future research should focus on identifying patient groups who might benefit more from a medication overview, by testing the effect of such overview on this group.

Evidence for the reliability and validity of a Spanish translation of the Medication Management Ability Assessment administered via tele-assessment

We translated the Medication Management Ability Assessment (MMAA) from English to Spanish for use via tele-assessment and examined its reliability and validity. Following International Test Commission Guidelines for Translating and Adapting Tests, we used translation/back-translation and a small focus group (n = 6) to adapt a Spanish version of the MMAA. Eighty-six Spanish-speaking adults completed the adapted MMAA via tele-assessment at baseline and at a two-week follow-up visit. Participants also completed several self-report and performance-based cognitive and functional measures. The internal consistency of the MMAA was excellent (standardized Cronbach's α = 0.90). Performance-based functional assessments (PBFAs) and objective cognition were positively associated with the MMAA at small to medium effect sizes. Self-report measures of daily function and cognition, measures of health literacy, and estimates of premorbid intellectual functioning were not significantly associated with MMAA performance. The test-retest reliability of the MMAA was good (CCC = 0.73, 95% CI [0.62, 0.81]; rs = 0.37, p < 0.001) and demonstrated a small practice effect (Cohen's d = 0.36, p = 0.001). Preliminary evidence for the construct validity of a Spanish-language MMAA administered via tele-assessment further expands the potential clinical utility of PBFAs in culturally diverse, Spanish-speaking populations.

Medication Adherence among Patients with Chronic Diseases in Saudi Arabia

Introduction: The management of chronic illnesses commonly includes a long-term pharmacological approach. Although these medications effectively control disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Medication adherence has become a big concern to clinicians and healthcare systems in Saudi Arabia and worldwide because of growing evidence associating nonadherence with adverse outcomes and higher costs of care. Despite it being a well-recognized problem, few studies have investigated medication adherence in Saudi Arabia. Therefore, this study aims to gain a better perspective on medication adherence among patients with chronic diseases in Saudi Arabia. Method: A questionnaire-based cross-sectional study was conducted among patients with chronic diseases in the Makkah region, Saudi Arabia, from 1 May to 31 July 2021. Patients aged 18 years and above who were taking prescribed or over-the-counter medications were included. Descriptive statistics were used to describe the participants’ characteristics, and categorical variables were reported as frequencies and percentages. A Chi-square test was used to test the relations between variables. Results: In total, 239 participants were included in the study. Females represented 62% of the participants. In terms of the history of chronic diseases, 44% had hypertension, 40% had diabetes mellitus, 21% had heart diseases and 9% had asthma. Nearly half (49%) of participants did not follow up regularly with a primary healthcare center and 42% said that they had forgotten to take their medications in the past. However, most of the participants (78%) stated that they took their medicine as instructed by their doctor or pharmacist, and 61% took their medications on time. The majority of participants (85%) said that the pharmacist explained the method of using the medications and the instructions for use, while 30% thought that the medications they took were too much. In regard to the reasons for medication nonadherence, having no specific reasons for medication nonadherence was the most common cause for nonadherence in our study. The relationship between patients taking medications as instructed by a healthcare provider (the doctor or pharmacist) and the healthcare provider giving clear instructions to patients about medication use was significant (p < 0.001). Conclusions: Failure to adhere is a significant problem that not only affects the patient but also the healthcare system. Additional research is needed to monitor medication adherence and identify factors contributing to this problem to provide successful strategies to improve medication adherence in Saudi Arabia.

Implementation outcomes of the Structured and Codified SIG format in electronic prescription directions

OBJECTIVE

To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions).

MATERIALS AND METHODS

A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component.

RESULTS

Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases.

DISCUSSION

Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented.

CONCLUSION

Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary.

Medication adherence and persistence among patients with non-small cell lung cancer receiving tyrosine kinase inhibitors and estimation of the economic burden associated with the unused medicines

BACKGROUND

Non-small cell lung cancer (NSCLC) is a leading cause of cancer deaths. Its treatment includes specific oral tyrosine kinases inhibitors (TKIs).

OBJECTIVES

To estimate adherence and persistence among patients receiving TKIs and to assess the economic burden of the unused medicines in Alsace (France).

METHOD

This retrospective study was carried out using the Insurance Healthcare database.

MAIN OUTCOME MEASURES

Adherence was calculated using medication possession ratio (MPR), persistence using estimated level of persistence with therapy (ELPT) and economic impact using prescription refill data.

RESULTS

242 patients were receiving TKIs. The most common TKIs prescribed were erlotinib (75.6%, n = 183) and crizotinib (12.8%, n = 31). Total of 149 patients were included in the adherence analysis. Overall MPR was 0.98. 180 patients were included in the persistence analysis. Almost half of patients had stopped treatment at 60 days and only 38.3% (n = 69) were still persistent with the therapy at 120 days. The expenses related to unused TKIs amounted to €356,392 and were related majorly to treatment discontinuation followed by overlapping refills, patient deaths and dose- or drug-switching, respectively.

CONCLUSIONS

Our data indicated overall adherence medicines above the acceptable limit of 0.80 but also pointed out a significant decline in persistence over time. The resulting economic losses justify the need for physicians and pharmacists to closely monitor their patients to ensure continuity of treatment. To limit the cost associated with unused medicines, interventions such as app-based monitoring, dispensing TKIs per unit over shorter periods and not only on monthly intervals could be implemented.

Associations between health literacy, cognitive function and general literacy in people with schizophrenia attending community mental health clinics in Australia

BACKGROUND

Health literacy (HL) has been defined as the ability of individuals to access, understand, and utilise basic health information. HL is crucial to patient engagement in treatment through supporting patient autonomy, informed consent and collaborative care. In people with physical disorders, poor HL is associated with poor health outcomes, but less is known about HL in people with severe mental illness. This study aimed to assess HL and investigate the associations between education, cognitive function, general literacy, and HL in participants with schizophrenia attending community mental health clinics.

METHOD

Fifty-two outpatients with schizophrenia attending a public community mental health clinic in Adelaide, Australia completed the Test of Functional Health Literacy in Adults-Short Form (S-TOFHLA) along with tests of cognition, aural and reading literacy and numeracy including Digit Symbol Coding (DSC), verbal fluency, the Wechsler Adult Intelligence Scale (WAIS-IV), Woodcock-Johnson III (Part 4 and 9) and the Lipkus numeracy scale. Sixty-one percent of participants were male. Participants had a mean age of 41.2 (SD 9.9) years and a mean of 11.02 (SD 1.5) years of education.

RESULTS

The majority of participants had very poor aural and verbal literacy and poorer literacy correlated with fewer years of education. On the S-TOFHLA, 81% of participants had adequate HL; 6% were marginal and 13% were inadequate. There was a positive correlation between education and HL, with those with more years of education scoring higher for HL. There was also a significant association between better HL and better working memory and attention.

CONCLUSIONS

Consistent with previous research in schizophrenia, our participants had reduced educational attainment, aural and reading literacy and cognitive function compared to population norms. However, HL was better than expected given that previous research has found that people with psychiatric disorders tend to have lower HL, compared to the general population. This may reflect effective case management of our participants whilst attending the community clinics and supports ongoing research and intervention regarding HL in people living with mental illness.

Evaluation of use, comprehensibility and clarity of over-the-counter medicine labels: Consumers' perspectives and needs in Taiwan

An estimate of one third of preventable medication errors occurred annually due to patients' misunderstanding of use instructions. To safeguard consumers' over-the-counter (OTC) medicine use and to develop future initiatives, this study evaluated the use, comprehensibility and clarity of the information labels on OTC packages from consumers' perspectives in Taiwan. This cross-sectional study was conducted at 29 community pharmacies; 50 pharmacy clerkship students helped participant enrolment from June to September 2017. Participants (n = 470) were 20 years old or above, Mandarin speaking, and with specific OTC purchases. A face-to-face survey was administered to investigate the degree to which participants read the package labels and their comprehension of correct medicine use. An 11-item survey was used to measure participants' specific OTC purchases (3 items), the use (2 items), comprehensibility (1 item) and clarity (2 items) of OTC package labels, in addition to the sociodemographic information (3 items). Participants were also solicited to provide opinions regarding package label redesign. Descriptive statistics and logistic regressions were applied for analyses. Findings show that most (84.0%) participants read instruction labels before use, with indications (79.4%), drug names (64.5%) and dosage and administration (59.8%) being the top reads. Only 30.0% of the participants fully understood how to take the medicines correctly. Younger (OR = 1.033, p < .001) and female participants (OR = 1.965, p = .014) with a higher level of education (OR = 1.940, p = .034) tended to read package label information prior to purchase or use. Younger participants (OR = 1.030, p < .001) and those who read OTC medicine labels before use (OR = 2.317, p = .004) were more likely to correctly understand medicine use. The findings indicate that older, male adults with a lower level of education should be targeted to ensure their correct understanding of OTC labels. Pharmacists should recite pertinent label information and, concomitantly, ensure consumers' understanding when providing medicine counselling.

Older adult and family caregiver experiences with prescription medication labels and their suggestions for label improvement

Background

Prescription medication labels (PMLs) are an important source of written medication information for patients. However, real-world PMLs do not entirely conform with available labelling best practices and guidelines. Given this disconnect, older adults remain particularly at risk of misinterpreting their PMLs. Past studies have commonly assessed hypothetical PMLs, warranting studies that explore the lived experiences of older adults with real-world PMLs. Furthermore, the perspective of family caregivers of older adults is yet to be studied.

Objective(s)

This qualitative study documented the challenges faced by older adults and their family caregivers in using real-world PMLs, their strategies to cope with these challenges, and their suggestions to improve existing PMLs.

Methods

We conducted two focus group discussions (n = 17) and 30 in-depth interviews with older adults (n = 20; including those who can read in English and those with limited English proficiency) and caregivers (n = 10) in Singapore. The data were systematically assigned to codes that were continuously refined to accommodate emergent themes.

Results

Challenges, coping strategies and suggested improvements were related to the comprehensibility, availability, readability and consistency of medication information on PMLs.

Conclusions

Real-world PMLs continue to pose challenges for older adults and their caregivers, necessitating them to seek unique and personal coping strategies. The identified PML improvements, desired by older adults and their caregivers, urge healthcare systems to implement improved PMLs. Future research should explore system-level logistical, financial, and administrative barriers (or opportunities) that hinder (or facilitate) this implementation.

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Older adults and caregivers still face challenges with English medicine labels.

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Small font and lack of desired information were also enduring challenges.

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Inconsistency in label format and content confused older adults and caregivers.

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Caregivers and pharmacy staff adopted unique strategies to help older adults.

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Challenges and ad-hoc strategies necessitate real-world, systemic change to labels.

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.

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.

Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients

BACKGROUND

Using an on-site pharmacy or medication to bedside (MTB) program allows patients to obtain prescriptions and education before discharge, potentially improving adherence and preventing harm. The aim of this project was to improve discharge processes for pediatric acute care patients by increasing the proportion of oral antibiotics (1) prescribed to the on-site pharmacy from 15% to 70% and (2) delivered to bedside from 0% to 50%.

METHODS

The Model for Improvement was used to iteratively implement interventions: increased on-site pharmacy capabilities, MTB program creation and streamlined enrollment, and secure electronic health record (EHR) messaging between clinicians and pharmacy staff regarding prescriptions. Process measures were proportion of antibiotics prescribed to the on-site pharmacy and delivered to bedside. Outcomes included surveys of family satisfaction with discharge medication education and discharge medication-related safety reports. Discharge before noon (DBN) was the balancing measure. Aims were analyzed using statistical process control charts and chi-square tests.

RESULTS

A total of 1,908 antibiotics were prescribed over 28-months. On-site pharmacy prescriptions increased from 15% to 46% after pharmacy capabilities increased, then to 86% after MTB program launch, optimized workflow, and initiation of EHR messaging. Bedside medication delivery increased from 0% to 58% with these interventions. Family satisfaction with discharge medication education and frequency of discharge medication-related safety reports was not significantly different pre- and postintervention. DBN varied throughout the study.

CONCLUSION

Through clinician and pharmacy staff partnership, this initiative increased on-site pharmacy use and discharge antibiotics delivered to bedside. Key interventions included increased pharmacy capabilities, MTB program with streamlined workflow, and EHR-based communication.

Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis

IMPORTANCE

Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes.

DATA SOURCES

PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021.

STUDY SELECTION

Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge.

RESULTS

We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66).

CONCLUSIONS AND RELEVANCE

These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.

Universal access to essential health information: accelerating progress towards universal health coverage and other SDG health targets

The information that people need to protect and manage their own health and the health of those for whom they are responsible is a fundamental element of an effective people-centred healthcare system. Achieving universal health coverage (UHC) requires universal access to essential health information. While it was recently recognised by the World Medical Association, universal access to essential health information is not yet reflected in official monitoring of progress on UHC for the sustainable development goals (SDGs). In this paper, we outline key features that characterise universal access to essential health information and indicate how it is increasingly achievable. We highlight the growing evidence of the impact of wider access to practical and actionable information on health for the public, carers and frontline health workers and provide illustrative, evidence-based, examples of how increasing access to essential health information can accelerate the achievement of UHC and other health targets of the SDGs. The paper ends with an assessment of reasons why universal access to essential health information has not yet been achieved, and an associated call to action to key stakeholders—such as governments, multilaterals, funding bodies, policy-makers, health professionals and knowledge intermediaries—to explicitly recognise the foundational role of universal access to essential health information for achieving UHC and the rest of the health SDGs, to include it in the relevant SDG target and associated monitoring indicators, and to incorporate actions in their own policies and programmes to promote and enable this access.

KeMRE: Knowledge-enhanced medical relation extraction for Chinese medicine instructions

Medicine instructions usually contain rich medical relations, and extracting them is very helpful for many downstream tasks such as medicine knowledge graph construction and medicine side-effect prediction. Existing relation extraction (RE) methods usually predict relations between entities from their contexts and do not consider medical knowledge. However, understanding a part of medical relations may need some expert knowledge in the medical field, making it challenging for existing methods to achieve satisfying performances of medical RE. In this paper, we propose a knowledge-enhanced framework for medical RE, which can exploit medical knowledge of medicines to better conduct medical RE on Chinese medicine instructions. We first propose a BERT-CNN-LSTM based framework for text modeling and learn representations of characters from their contexts. Then we learn representations of each entity by aggregating representations of their characters. Besides, we propose a CNN-LSTM based framework for entity modeling and learn entity representations from their relatedness. In addition, there are usually many different instructions for the same medicine, which usually share general knowledge on this medicine. Thus, to obtain medical knowledge of medicines, we annotate relations on a randomly-sampled instruction of each medicine. Then we build knowledge embeddings to represent potential relations between entities from knowledge of medicines. Finally, we use an MLP network to predict relations between entities from their representations and knowledge embeddings. Extensive experiments on a real-world dataset show that our method can significantly outperform existing methods.

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.

The effectiveness of using text and pictograms on oral rehydration, dry-mixture sachet labels

Background

Medication labels are often the only information available to patients after obtaining medication from a healthcare practitioner. Pictograms are graphic symbols that have shown to increase understanding of medicine use instructions.

Aim

To compare the accuracy of the interpretation of medicine use instructions from two different oral rehydration (OR) dry-mixture sachet labels – the control ‘routine textonly’ label and an experimental label with ‘text-and-pictograms’.

Setting

Participants were recruited from waiting rooms in public primary health care (PHC) facilities in Cape Town.

Method

Each participant was required to answer six questions about OR preparation. Response accuracy was determined by comparing the participant’s answer to the actual information written on the relevant label. Afterwards, participants could offer their opinion about the label and ways to improve their understanding.

Results

Of the 132 participants who were recruited, 67 were allocated to the experimental group and 65 to the control group. Only the significant difference between the experimental and control groups for the six questions regarding the label, was recorded for the answer that could be read from a single pictogram (p = 0.00) on the experimental group’s label. When asked about this question, more control participants (15/65) found the dosing instruction difficult to understand when compared to the experimental group (1/67). A third of the control participants (22/65) indicated that they could not see or locate instructions on the label.

Conclusion

Text and pictograms on written medicine labels may be an effective tool to aid understanding of medicine use instructions amongst patients attending PHC facilities.

Prescription understanding among out-patients in government and private hospitals: A cross-sectional study in Lahore, Pakistan

INTRODUCTION

Like many other countries, Pakistan's healthcare system is divided into the public and the private sector. According to some studies and the mindset of many Pakistani people, private hospitals provide better services than government hospitals.

PURPOSE

The paucity of research studies compelled us to compare the understanding of prescription among outpatients of the government and private hospitals since the understanding of prescription by the patient is an important patient care indicator according to WHO.

METHOD

A cross sectional study was conducted by virtue of convenience sampling. The study included 365 patients; 182 from the government sector and 183 from the private sector. The study was conducted over a period of 3 months. A structured questionnaire was prepared to gather data that was analyzed using SPSS Version 22.0.

RESULTS

Patients from both government and private hospitals got no counseling while only 45.9% of the government hospital patients and 65.9% of private hospital patients were satisfied with the counseling they received. Our study concluded that the role of a pharmacist must be extended besides dispensing only, in counseling and educating patients to reduce the burden on the physicians and hospitals as well.

CONCLUSION

It was concluded that although the patients of private hospitals scored somewhat better at answering the questions than the government hospital patients but they failed to hit the benchmark. Their slightly better results were attributed to higher education levels and better socioeconomic status rather than better services of the hospital.

Communicative and Discursive Perspectives on the Medication Experience

Taking the ‘medication experience’ in the broad sense of what individuals hear and say about their medication, as well as how they experience it, this paper explores diverse research on medication information available to patients and their modes and capacities for interaction, including personal circles, doctors and pharmacists, labeling and promotion, websites, and the patient’s own inner conversations and self-expression. The goal is to illustrate, for nonspecialists in communication, how the actors, messages, mediums, genres, and contextual factors within a standard ethnographic and social semiotic model of discourse and communication are operating, not always effectively or beneficially, to mediate or construct a patient’s medication experience. We also suggest how disparate insights can be integrated through such a model and might generate new research questions.

Information on antibiotics in an Indonesian hospital outpatient setting: What is provided by pharmacy staff and recalled by patients?

Background:

The provision of information by pharmacy staff is a key factor to ensure patients’ understanding and quality use of medications, including antibiotics. However, little is known regarding the transmission of information between pharmacy staff and patients in Indonesia.

Objective:

This study aimed to identify information on antibiotics provided by pharmacy staff and recalled by patients in an Indonesian outpatient setting.

Methods:

The study was conducted in a hospital outpatient clinic in Malang, Indonesia, in 2019. A checklist was used to obtain the data on information provided by pharmacy staff, while interviews were conducted to determine information recalled by patients (only presenting patients were included); a total of 15 information items – i.e. 14 essential and one secondary – were observed. Descriptive analysis was used to summarise data on the checklists (‘given’ versus ‘not given’) as well as responses from the interviews (‘recalled’ versus ‘missed’).

Results:

Eleven pharmacy staff (two pharmacists and nine pharmacy technicians) were involved in providing information for patients obtaining oral antibiotics during the study period. Of 14 essential information items, only about half was given by pharmacy staff, with pharmacists significantly providing on average more information items than pharmacy technicians (7.96 versus 7.67 respectively; p<0.001). The most frequently information items provided (>90%) included “antibiotic identification”, “indication”, administration directions (i.e. “dosage”, “frequency”, “hour of administration”, “administration before/after meal”, “route of administration”), and “duration of use”. A total of 230 patients consented to the study, giving 79.9% response rate. The average number of information items recalled by patients was 7.09 (SD 1.45). Almost all patients could recall information on administration directions [i.e. “route of administration” (97.0%), “frequency” (95.2%), “dosage” (92.6%), “hour of administration” (85.7%), “administration before/after meal” (89.1%)] and “duration of use” (90.9%). Fewer patients were able to recall “antibiotic identification” (76.5%) and “indication” (77.0%).

Conclusions:

Pharmacy staff provided antibiotic information in a limited fashion, while patients showed adequate ability to recall the information given to them. Further study is needed to better understand the effective process of information transmission between pharmacy staff and patients, especially if more information was provided, to better optimise the use of antibiotics in outpatient settings in Indonesia.

Speech Technology for Healthcare: Opportunities, Challenges, and State of the Art

Speech technology is not appropriately explored even though modern advances in speech technology-especially those driven by deep learning (DL) technology-offer unprecedented opportunities for transforming the healthcare industry. In this paper, we have focused on the enormous potential of speech technology for revolutionising the healthcare domain. More specifically, we review the state-of-the-art approaches in automatic speech recognition (ASR), speech synthesis or text to speech (TTS), and health detection and monitoring using speech signals. We also present a comprehensive overview of various challenges hindering the growth of speech-based services in healthcare. To make speech-based healthcare solutions more prevalent, we discuss open issues and suggest some possible research directions aimed at fully leveraging the advantages of other technologies for making speech-based healthcare solutions more effective.

Assessment of Patients Misunderstanding of Dosing Instructions Among Outpatients in Dessie Referral Hospital, Northeast Ethiopia

Background

Lack of clear and precise oral and written information from both the doctors and/or pharmacists on the management of prescribed medication has led to therapeutic failure, as a result of patients not comprehending instructions. Incorrect interpretation of labels can lead to incorrect usage of medication therefore the occurrence of medication error and/or adverse event. The concern of this study was to assess misunderstanding of dosing instructions among outpatients in Dessie Referral Hospital (DRH).

Methods

An institution-based cross-sectional study was conducted on 384 outpatients at DRH from February 10 to March 15, 2019. Study subjects were selected by using a systematic random sampling technique and data was collected by using questionnaires and observation. The data was coded individually and entered in a computer using Epi Info™ version 3.5.1 and then exported to SPSS version 23.0 for analysis. Univariate analyses were used to describe the categorical variables. Chi-square test was used to assess association of variables with primary outcome. P-value <0.05 was considered as statistical significance.

Results

This study showed that most of the respondents n=298 (77.6%) misunderstood more than one dosage instruction, 8.75% misunderstood the dose, 51.3% misunderstood the frequency while 58.59% misunderstood the duration of treatment. The misunderstanding was higher for labeled medications (11.4%) than unlabelled (7.7%).

Conclusion

The prevalence of misunderstanding of dosing instruction was high in outpatients of DRH. Hence standard procedures must be developed to provide easy and clear dosing instructions to patients, and continuous training must be provided for pharmacists on proper communication of dosing instructions to patients.

Age and education as factors associated with medication literacy: a community pharmacy perspective

BACKGROUND

Aging implies a higher prevalence of chronic pathologies and a corresponding increase in medication. The correct adherence and use of the medication are prerequisites for reducing risks of disease progression, comorbidity, and mortality. Medication literacy (ML) is the specific ability to safely access and understand the information available concerning medication, and to act accordingly. Currently, there are few specific instruments that ascertain the extent of ML in the general population. The aim of this work was to analyse ML in a large cohort of pharmacy customers.

METHODS

A total of 400 community pharmacy clients were analyzed to assess the level of ML (documental and numeracy) through the validated MedLitRxSE tool.

RESULTS

The results showed that out of a total of 400 community pharmacy clients only 136 (34%) had an adequate degree of ML, while the rest of the clients (n = 264; 66%) were adjudged not to have this ability. Statistically significant differences were found between the different age groups in terms of ML (P < 0.001; OR = 0.312; 95% CI: 0.195-0.499), the 51-65 and >65-year age groups having a lower frequency of adequate ML (23.5 and 7.1%, respectively) than the rest of the age groups. A statistically significant increase in adequate ML was observed as the academic level of the clients increased (P < 0.001; OR = 15.403; 95% CI: 8.109-29.257). Multivariate logistic regression confirmed the influence of both variables on ML.

CONCLUSIONS

An inadequate ML level was found in community pharmacy clients over the age of 51, and also in those with primary or non-formal studies. Our data add to our knowledge about ML, and should pharmacists and other health professionals to adopt new strategies to prevent, or at least reduce, errors in taking medicines, thus avoiding the undesirable effects of any misuse.

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.

User testing to examine patient understanding of pharmacy generated medication labels

OBJECTIVE

To examine patients' and carers' understanding of pharmacy generated medication labels.

METHODS

A user testing questionnaire was conducted individually for 80 participants at 2 hospitals through a face-to face semi-structured interview. Pharmacy generated medication labels from different locations were grouped based on components into 4 different variations. Participants were asked to read and demonstrate understanding of the dose and frequency from 1 of the 4 variations for 4 prescription medications. Twenty participants for each variation were recruited so that demographic characteristics matched between variations.

RESULTS

Overall, only 45% of participants were able to correctly understand the dose and frequency presented on all the pharmacy labels presented on medications. Medication labels with standardised timing performed better than other variations with 91% of participants able to determine the correct frequency. The use of numeric figures was understood by 80-90% of participants compared to the use of capitalised text (65-70%). Pharmacy generated medication labels that proposed one step were better understood than instructions that incorporated several steps.

CONCLUSION/PRACTICE IMPLICATIONS

The study supports the use of simple, clear and explicit written instructions along with the use of numeric figures in pharmacy generated medication labels to achieve higher understandability in patients.

Instruments assessing medication literacy in adult recipients of care: A systematic review of measurement properties

OBJECTIVES

The assessment of medication literacy in patients is an important step in assisting clinicians to plan for education, prescription simplification, assistance and/or medication aids. There have been several attempts to develop a standardised, objective measure of medication literacy. The objectives of this systematic review were to critically appraise, compare and summarise the measurement properties of existing instruments that assess medication literacy in adult recipients of care.

DESIGN

A systematic review was performed.

SEARCH METHODS

Structured searches were conducted in Embase, MEDLINE PubMed, CINAHL, APA PsycINFO and Web of Science Core Collection in March 2020. Additional searches were performed in ProQuest Dissertations and Theses, DART Europe, and Google Scholar, followed by citation tracking of included studies.

REVIEW METHODS

Two researchers independently identified eligible studies. Two researchers then assessed the methodological quality of the studies and quality of measurement properties, using the Consensus-based Standards for selection of health Measurement Instruments (COSMIN) guidelines. A best-evidence synthesis for each instrument was performed.

RESULTS

From the 5035 citations, 17 studies were included that concerned 13 instruments using different administration methods (i.e., performancebased or self-report), medication type (i.e., prescribed or nonprescribed) and context of use (i.e., clinical or community settings). Very low- to moderate-quality evidence supported satisfactory content validity regarding relevance and comprehensibility, while comprehensiveness remained inconsistent. Other measurement properties were less frequently examined and were supported by moderate-quality evidence (i.e., structural validity) to low- or very low-quality evidence (i.e., internal consistency, reliability, construct validity). The bestvalidated instrument is the unidimensional 14-item Medication Literacy in Spanish and English assessment tool (MedLitRxSE), based on direct testing of participant performance regarding four hypothetical scenarios on medication use. Nine instruments have the potential to be recommended but require additional research, while for others, their psychometric soundness is too limited and they require content revisions.

CONCLUSION

This is the first systematic review to identify instruments for medication literacy. None of the identified instruments had all measurement properties properly assessed and none reported measurement invariance, measurement error and responsiveness of the instrument. Further research is necessary for a better theoretical understanding of medication literacy in order to assist health professionals in identifying patient needs for education, regimen simplification, assistance and/or medication aids. Such research will help conceptualise new instruments that not only cover relevant domains dedicated to specific populations (e.g., polymorbid and/or older individuals), but also exhibit satisfactory measurement properties.

Document-Engineering Methodology in Health Care: An Innovative Behavioral Science–Based Approach to Improve Patient Empowerment

Engaging patients in their treatment and making them experts of their condition has been identified as a high priority across many medical disciplines. Patient empowerment claims to improve compliance, patient safety, and disease outcome. Patient empowerment may help the patient in shared decision making and in becoming an informed partner of the health care professional. We consider patient empowerment to be in jeopardy if written medical information for patients is too complex and confusing. We introduce document-engineering methodology (DEM) as a new tool for the health care industry. DEM tries to implement principles of cognitive science and neuroscience-based concepts of reading and comprehension. It follows the most recent document design techniques. DEM has been used in the aviation, mining, and oil industries. In these very industries, DEM was integrated to improve user performance, prevent harm, and increase safety. We postulate that DEM, applied to written documents in health care, will help patients to quickly navigate through complex written information and thereby enable them to better comprehend the essence of the medical information. DEM aims to empower the patient and help start an informed conversation with their health care professional. The ultimate goals of DEM are to increase adherence and compliance, leading to improved outcomes. Our approach is innovative, as we apply our learning from other industries to health care; we call this cross-industry innovation. In this manuscript, we provide illustrative examples of DEM in three frequent clinical scenarios: (1) explaining a complex diagnosis for the first time, (2) understanding medical leaflet information, and (3) exploring cannabis-based medicine. There is an urgent need to test DEM in larger clinical cohorts and for careful proof-of-concept studies, regarding patient and stakeholder engagement, to be conducted.

Understanding shared decision-making experience among vulnerable population: Focus group with food bank clients

Introduction

Shared decision-making (SDM) is a critical component of delivering patient-centered care. Members of vulnerable populations may play a passive role in clinical decision-making; therefore, understanding their prior decision-making experiences is a key step to engaging them in SDM.

Objective

To understand the previous healthcare experiences and current expectations of vulnerable populations on clinical decision-making regarding therapeutic options.

Methods

Clients of a local food bank were recruited to participate in focus groups. Participants were asked to share prior health decision experiences, explain difficulties they faced when making a therapeutic decision, describe features of previous satisfactory decision-making processes, share factors under consideration when choosing between treatment options, and suggest tools that would help them to communicate with healthcare providers. We used the inductive content analysis to interpret data gathered from the focus groups.

Results

Twenty-six food bank clients participated in four focus groups. All participants lived in areas of socioeconomic disadvantage. Four themes emerged: prior negative clinical decision-making experience with providers, patients preparing to engage in SDM, challenges encountered during the decision-making process, and patients' expectations of decision aids. Participants also reported they were unable to discuss therapeutic options at the time of decision-making. They also expressed financial concerns and the need for sufficiently detailed information to evaluate risks.

Conclusion

Our findings suggest the necessity of developing decision aids that would improve the engagement of vulnerable populations in the SDM process, including consideration of affordability, use of patient-friendly language, and incorporation of drug-drug and drug-food interactions information.

Racial Disparities in Outcomes After Common Abdominal Surgical Procedures-The Impact of Access to a Minimally Invasive Approach

BACKGROUND

It is presently considered the standard of care to perform many routine intra-abdominal operations using a minimally invasive approach. The authors recently identified a racial disparity in access to a laparoscopic approach to inguinal hernia repair, cholecystectomy, appendectomy, and colectomy. The present study further evaluates this patient cohort to assess the relationship between the race and postoperative complications and test the mediating effect of the selected surgical approach.

METHODS

After institutional review board approval, patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent inguinal hernia repair, cholecystectomy, appendectomy, or colectomy in 2016 were identified. Patient demographics, including the self-reported race and ethnicity, as well as clinical, operative, and postoperative variables were recorded. After the exclusion of cases associated with diagnoses of cancer, a 4:1 propensity score matching algorithm generated a clinically balanced cohort of patients of white and black self-reported race. The mediating effect of an open approach to surgery on the relationship between black self-reported race and postoperative complications was evaluated via a series of regressions.

RESULTS

There were 41,340 unilateral inguinal hernia repairs, 3182 bilateral inguinal hernia repairs, 60,444 cholecystectomies, 50,523 appendectomies, and 58,012 colectomies included in the database in 2017. Exclusion of cases associated with cancer and subsequent propensity score matching returned 17,540 unilateral hernia repairs, 890 bilateral hernia repairs, 23,865 cholecystectomies, 11,660 appendectomies, and 12,320 colectomies. On mediation analysis, any complication, severe complication, and death were significant when regressed on black self-reported race (any: odds ratio [OR] = 1.210, 95% confidence interval [CI] = 1.132-1.291, P < 0.001; severe: OR = 1.352, 95% CI = 1.245-1.466, P < 0.001; death: OR = 1.358, 95% CI = 1.000-1.818, P = 0.044), and open surgery was a significant mediator in the incidence of any complication and severe complication (any: OR = 1.180, 95% CI = 1.105-1.260, P < 0.001 and severe: OR = 1.307, 95% CI = 1.203-1.418, P < 0.001).

CONCLUSIONS

These findings underscore the importance of access to a minimally invasive approach to surgery. However, other factors may contribute to racial disparities in postoperative complications after common abdominal operations.

Development of Comprehensible Prescription Label Instructions: A Study Protocol for a Mixed-Methods Approach

Introduction

Patients receive information about their medication from different sources, including prescription labels. These labels are physically attached to each package dispensed to patients and contain the most important instructions on how to use the medication correctly. However, many patients experience difficulties in understanding and applying the instructions on these labels correctly, especially patients with limited health literacy. The aim of this study is to investigate the comprehensibility of prescription label instructions among patients with adequate and limited health literacy skills, and to implement improvements in primary health care.

Methods

We used a mixed-methods approach, which consisted of four phases. Phase 1 (desk research) was divided into a systematic literature review on the comprehensibility of prescription label instructions (1a) and a content analysis of the textual elements in Dutch prescription label instructions (1b). In phase 2 (patient studies), semi-structured interviews were conducted to investigate the comprehensibility of seven prescription labels among patients with different health literacy skills (2a), and a quantitative study in which the comprehensibility of six optimized prescription labels was compared among patients with different health literacy skills (2b). Patient studies were conducted in eight Dutch pharmacies. In phase 3 optimized prescription label instructions were implemented in national medication databases which has been supported by a guideline (3a), and education of pharmacy workers (3b). Phase 4 consists of evaluating the optimized prescription label instructions by experiences from patients and pharmacists.

Anticipated Results

This mixed-methods approach will result in scientific publications of the individual studies, and a guideline on how to compose comprehensible prescription label instructions to be put on medication packages. Optimized prescription label instructions will be implemented in national medication databases.

Discussion

This protocol describes a mixed-method research to compose and implement comprehensible prescription label instructions and will lead to knowledge about the comprehensibility of textual elements in these labels, with specific attention for patients with limited health literacy. Implementation of optimized prescription label instructions will lead to a better understanding of them, which may contribute to improved medication adherence. A limitation is that non-textual aspects of prescription labels are not investigated.

Student Pharmacists' Ability to Organize Complex Medication Regimens According to the Universal Medication Schedule

Objective. To assess student pharmacists' ability to impact the administration of complex prescription regimens using the universal medication schedule in a standardized laboratory exercise. Methods. First and third professional year (P1 and P3) student pharmacists at three colleges of pharmacy completed a required activity to simplify and organize a complex medication regimen. Using a medication box, students planned how and when they would advise a patient to take seven fictitious medications over a 24-hour period. Picture documentation of each students' activity was used for data analysis. Descriptive statistics were used to compare P1 and P3 students' performance, and an independent t test was used to assess the frequency of daily dosing. A chi-square analysis was used to compare differences between P1 and P3 students, and analysis of variance was used to compare differences among individual institutions. Results. Of 842 students invited, 459 P1 and 372 P3 students (98.7%) consented to participate. Student pharmacists recommended 5.1 (SD=1.0; Range=3-11) dosing intervals per 24 hours, with 27% of students successfully reducing the regimen to four total intervals. The P3 students were more effective than the P1 students in planning the number of dosing intervals (4.9 vs 5.4 per 24 hours). Conclusion. Student pharmacists may become more effective at organizing complex medication regimens as they proceed through the pharmacy curriculum and gain experience. Student pharmacists can translate what they learned from this exercise to potentially improve patients' self-organized medication regimens.

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis

Background

Free-text directions generated by prescribers in electronic prescriptions can be difficult for patients to understand due to their variability, complexity and ambiguity. Pharmacy staff are responsible for transcribing these directions so that patients can take their medication as prescribed. However, little is known about the quality of these transcribed directions received by patients.

Methods

A retrospective observational analysis of 529 990 e-prescription directions processed at a mail-order pharmacy in the USA. We measured pharmacy staff editing of directions using string edit distance and execution time using the Keystroke-Level Model. Using the New Dale-Chall (NDC) readability formula, we calculated NDC cloze scores of the patient directions before and after transcription. We also evaluated the quality of directions (eg, included a dose, dose unit, frequency of administration) before and after transcription with a random sample of 966 patient directions.

Results

Pharmacy staff edited 83.8% of all e-prescription directions received with a median edit distance of 18 per e-prescription. We estimated a median of 6.64 s of transcribing each e-prescription. The median NDC score increased by 68.6% after transcription (26.12 vs 44.03, p<0.001), which indicated a significant readability improvement. In our sample, 51.4% of patient directions on e-prescriptions contained at least one pre-defined direction quality issue. Pharmacy staff corrected 79.5% of the quality issues.

Conclusion

Pharmacy staff put significant effort into transcribing e-prescription directions. Manual transcription removed the majority of quality issues; however, pharmacy staff still miss or introduce following their manual transcription processes. The development of tools and techniques such as a comprehensive set of structured direction components or machine learning–based natural language processing techniques may help produce clear directions.

Patient education interventions for prescription opioids: A systematic review

OBJECTIVE

The objective of this systematic review is to evaluate the impact of prescription opioid-related education provided to a patient by a health care provider on patient outcomes.

DATA SOURCES

The databases searched were PubMed, Cumulative Index of Nursing and Allied Health Literature (EBSCO), Academic Search Premier (EBSCO), Health Source: Nursing/Academic Edition (EBSCO), and International Pharmaceutical Abstracts (OVID).

STUDY SELECTION

Studies were included if they were in English, peer-reviewed, and published between 1996 and October 22, 2018. Patient educational approaches initiated by health care providers for opioid medications in adults older than 18 years of age were evaluated. Studies were excluded if the full articles were unavailable or duplicates, or if they involved studies that did not explore provider-initiated patient educational interventions targeting opioid medications. Studies taking place outside the United States were excluded, as well.

DATA EXTRACTION

Titles and abstracts of 4863 manuscripts were screened for inclusion in this review. Of these, 4794 were removed because they did not meet the inclusion criteria. The full texts of the remaining 69 documents were evaluated for inclusion.

RESULTS

Ten articles were identified for inclusion in this review. Studies explored the impact of prescription opioid-related education on mortality, adherence, self-efficacy, self-care, quality of life, or knowledge. A variety of educational methods were used, including face-to-face follow-up, multimedia tools, predischarge counseling, and written information complementing verbal information. The interventions yielded inconsistent results, with improvements in patient outcomes seen in some studies, but not all.

CONCLUSION

There are several well-documented interventions identifying methods to manage opioid-use disorder, but less about providing education to patients before they receive opioid prescriptions. Future research should explore the type of education and information being shared with patients, as this could inform pharmacists on how they should educate their patients.

Patient safety in primary and outpatient health care

Primary care services provide an entry point into the health system which directly impact's people well-being and their use of other health care resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organization (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, majority of the work has been focussed on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. The present paper focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.

Recall of Pharmaceutical Pictograms by Older Adults

BACKGROUND

Low health literacy and high medication burden in the older adult population are contributing factors to the misunderstanding of medication instructions, leading to an increased risk of poor adherence and adverse events in this group of patients.

OBJECTIVE

To evaluate the ability of older adults to recall the meaning of 13 pharmaceutical pictograms 4 weeks after receipt of feedback on pictogram meaning.

METHODS

Older adults (aged 65 or older) were recruited from one community pharmacy in Canada. One-on-one structured interviews were conducted to assess the comprehensibility of 13 pharmaceutical pictograms from the International Pharmaceutical Federation's database of pictograms. Each participant was then told the meaning of each pictogram. Recall was assessed 4 weeks later.

RESULTS

A total of 58 participants met the inclusion criteria and agreed to participate. The number of pictograms meeting the ISO threshold for comprehensibility of symbols increased from 10 at the initial comprehensibility assessment to 13 at the recall assessment. Analysis of demographic data showed no associations between initial comprehensibility of the pictograms and age, sex, education level, or number of medications taken.

CONCLUSIONS

The results of this study indicate that after being informed of the meaning of pharmaceutical pictograms, older adults were able to recall the pictogram meanings for at least 4 weeks.

What do adult outpatients included in clinical trials know about the investigational drugs being assessed: A cross-sectional study in France

This study aimed to assess patient investigational medication knowledge and to identify factors associated with medication understanding by adult outpatients included in clinical trials. A cross-sectional prospectively designed survey was conducted on consecutive volunteers at 21 university teaching hospitals (in France) from February to December 2014. Investigational medication understanding was assessed at the time of the first dispensing using a structured interviewer-administered questionnaire based on information obtained from the literature that provided an 8-point score. Demographic and other baseline data were collected using structured interviews. Of the 236 participants, 139 (58.9%) of the respondents were male, and the median age was 54.9 years (range: 18–83 years). The mean understanding score was 6.24 and 72.5% of the patients had a score of 6 or higher. In univariate analysis, the medication understanding score was negatively correlated with age (r = -0.15, p = 0.0247) and positively correlated with the level of education (r = 0.25, p = 0.0002). In multivariate analysis, prognostic factors of a higher medication understanding score were: graduation from high school or a higher level of education; HIV infection; phase II/III/IV studies; mention of the drug on the prescription form, and the dispensing of a single investigational medication. Only a quarter of the adult outpatients included in clinical trials had a maximum possible investigational medication understanding score. Being old and having a low level of education were found to be important risk factors for inadequate medication understanding. This and other data suggest that sponsors should encourage initiatives aimed at improving investigational medication understanding in adults enrolled in clinical trials.