Adherence and medication instructions. Review and recommendations

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

A randomized controlled trial to assess the influence of a picture-based antiemetic medication calendar on medication-taking behavior in adults receiving chemotherapy

OBJECTIVE

A prospective open-label randomized controlled trial to assess the role of a picture-based medication calendar on adherence to antiemetic regimens for adult patients receiving chemotherapy and assess the effect on other medication taking behaviors as well as patient satisfaction with the tool.

METHODS

Participants were randomly assigned 1:1 to routine care with or without calendar.

RESULTS

Adherence, stratified by education (university or postgraduate, p = 0.09; grade school, high school or college p = 0.32), was non-significantly different between study arms. At least 70% of intervention arm participants moderately or completely agreed that the calendar helped with medication taking behaviors. There was no statistical difference between study arms for perceived regimen complexity (p = 0.16). Medication Use and Self Efficacy score (adjusted for age) used to assess perceived self-efficacy with medication taking behaviors were not statistically significant between study arms (p = 0.09).

CONCLUSION

The picture-based medication calendar did not statistically affect adherence to scheduled antiemetics among outpatients receiving chemotherapy for solid organ tumor origins. However, participants indicated that the calendar was effective for keeping track of medications, had an easy-to-understand layout, and provided help around when and how to take medications related to the oncology regimen.

Sex differences in the adherence of antihypertensive drugs: a systematic review with meta-analyses

OBJECTIVES

Poor worldwide rate of blood pressure control is largely due to poor adherence to antihypertensive (AHT) drug treatment. The question of whether sex affects adherence has long been debated but conflicting findings have been reported on this issue. Our objective was to evaluate sex differences in the adherence to AHT therapy.

RESEARCH DESIGN AND METHODS

Studies were identified through a systematic search of PubMed, CINAHL, PsycINFO, Web of Science and Google Scholar (through January 2020) and manual handsearching of relevant articles. Observational studies reporting adherence to AHT drugs measured by self-report or pharmacy refill prescription-based methods among men and women were included. Summarised estimates of OR_s with 95% CIs were calculated using random-effects model and meta-regression models.

RESULTS

From 12 849 potentially relevant publications, 82 studies (15 517 457 men and 18 537 599 women) were included. No significant between-sex differences in adherence to AHT were observed, whether all study-specific estimates were summarised (OR_s 1.04, 95% CI 1.00 to 1.09, p=0.07), nor estimates were pooled according to the method for measuring adherence. Among patients aged 65 years or older, lower self-reported adherence was observed in women (OR_s 0.84, 95% CI 0.72 to 0.97, p=0.02), while the main result remained unchanged according to other subgroup analyses.

CONCLUSIONS

Definitive evidence of sex differences in adherence to AHT therapy cannot be drawn. Our little knowledge about factors affecting adherence, in particular of sex effect among elderly, urgently requires high-quality studies investigating these issues.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

The Effects of an Educational Intervention on Preventing Cervical Cancer Among Vietnamese Women in Southern Taiwan

This paper aims to conduct and evaluate an educational intervention on preventing cervical cancer among married immigrant women of Vietnamese origin. The study design was a quasi-experimental method with two groups. In total, 260 married immigrant women of Vietnamese origin with national health insurance at least 30 years of age were recruited from November 2013 to January 2015 in southern Taiwan. The effects of the educational intervention, including cervical cancer and Papanicolaou test knowledge, attitudes towards cervical cancer, fatalism, barriers to receiving Papanicolaou tests, intention for receiving Papanicolaou tests within the next year, and intention for receiving Papanicolaou tests within the next 3 years, were evaluated. Repeated measures analyses of variance showed significant interactions between the intervention group and time for cervical cancer knowledge, knowledge of Papanicolaou test, attitudes towards cervical cancer, and intention for receiving a Papanicolaou test within the next 3 years; in addition, 71.4 % reported being satisfied or very satisfied with the intervention. The results of this study can provide information for governments to make appropriate health policies for screening behavior of cervical cancer, increase healthcare professionals' competencies towards Vietnamese women, and increase Papanicolaou test screening rates to decrease cervical cancer mortality. Effective interventions may require particular consideration of married immigrant women.

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs.

Older adults' memory for medical information, effect of number and mode of presentation: An experimental study

OBJECTIVE

To analyze different ways of presenting medical information to older adults, tailoring the information and its presentation to the characteristics of memory function in old age.

METHODS

Experimental study. We took into account the following variables: amount of information, type of information and mode of presentation, and time delay.

RESULTS

The greater the number of recommendations, the lower the recall; visual presentation does not enhance verbal presentation; lifestyle information is recalled better than medication information; after ten minutes the percentage of memory decreases significantly; the first and last recommendations are better remembered.

CONCLUSION

As a whole, these findings show that older adults remember more medical information when very few recommendations are provided in each session.

PRACTICE IMPLICATIONS

It is inadvisable to overload older adults with a large amount of information: It is better to program more consultations and provide less information.

Medication Safety: Effect of Content and Format of Prescription Drug Labels on Readability, Understanding, and Medication Use: A Systematic Review

Objective:

To evaluate the evidence regarding the optimal content and format of prescription labels that might improve readability, understanding, and medication use.

Data Sources:

We performed a systematic review of randomized controlled trials, observational studies, and systematic reviews from MEDLINE and the Cochrane Database (1990–June 2005), supplemented by reference mining and reference lists from a technical expert panel.

Study Selection:

We selected studies that focused on the content of physician–patient communication about medications and the content and format of prescription drug iabels.

Data Extraction:

Two reviewers extracted and synthesized information about study design, populations, and outcomes,

Data Synthesis:

Of 2009 articles screened, 36 that addressed the content of physician–patient communication about medications and 69 that were related to the content or format of medication labels met review criteria. Findings showed that patients request information about a drug's indication, expected benefits, duration of therapy, and a thorough list of potential adverse effects. The evidence about label format supports the use of larger fonts, lists, headers, and white space, using simple language and logical organization to improve readability and comprehension. Evidence was not sufficient to support the use of pictographic icons. Little evidence linked label design or content to measurable health outcomes, adherence, or safety.

Conclusions:

Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.

Designing Medication Instructions for Older Adults

We examined if medication instructions were better remembered when organized in terms of older adults' pre-existing schemes for taking medication. A preliminary study suggested that older adults share a general scheme with medication information grouped into 3 categories: (a) General Information (e.g., medication purpose), (b) How to take (dose), and (c) Possible Outcomes (side-effects). In the present study, we investigated age differences in this scheme and in instruction recall. We also examined if individual differences in organization related to cognitive abilities, health care beliefs, and medication taking experience. For the most part, the results provided further evidence that older adults share a scheme for taking medication and revealed few age differences in this organization. Verbal ability was more important than health attitudes for predicting individual differences in instruction organization. Most important, older and younger subjects preferred and better remembered instructions that were organized in terms of their medication taking scheme.

Age Differences in Search Time for Two Over-Thecounter (OTC) Drug Label Formats

This study compared older and younger adults' knowledge acquisition and search times for information on older and newer over-the-counter (OTC) drug label formats. The results showed that younger adults were faster than older adults. The younger group performed significantly faster with the newer formatted labels than the older formatted labels, whereas the older adults yielded no difference between the two formats. Potential directions for future research are discussed.

Over-The-Counter (OTC) Drug Labeling: Format Preferences

The present research examines two different consumer groups' perceptions of the readability of OTC medication labels. Twelve labels depicting an OTC medication with a fictitious name were constructed and attached to bottles. The labels varied in (a) print size (4 point, 7 point, 10 point), (b) amount of white space between lines or sections of text (no spacing; label section spacing; and line spacing), and (c) label design (standard vs. extended/pull-out). Ninety-nine older adults and 102 undergraduates rank-ordered the labels according to overall ease of reading. In general, participants preferred the labels printed with larger type and line spacing. White space appeared to have less influence over the rankings than print size for older adults. However, the use of both a larger print size and increased white spacing appeared to influence the undergraduates' ratings. Also, there was no clear preference between the extended and standard label designs but their evaluation was only conducted with for the small print conditions. The implications of these results for the design of OTC medication labels and other consumer products are discussed.

A Comparison of Older vs. Newer Over-the-Counter (OTC) Nonprescription Drug Labels on Search Time Accuracy

The present study evaluated response time and accuracy to answer a series of questions of information in 16 (8 older and 8 newer ‘Drug Facts’) over-the-counter (OTC) drug labels. The newer labels include aspects, based on previous research, which should benefit performance. The results indicated that participant's response times were significantly faster with the newer labels compared to the older ones. However, this was not true of all OTC product samples. Accuracy was high (error rate low) for both label formats. Response times for females were significantly faster than males for both label types. The benefits of formatting text for facilitating information acquisition from drug labels and other kinds of printed information are discussed.

Reducing and Mitigating Human Error in Medicine

Although precise definitions and models of human error in medicine remain elusive, there is little doubt that adverse events, sometimes involving human error, threaten patient safety and can be addressed by human factors approaches to error. In this chapter, we combine an information-processing framework that identifies perceptual, cognitive, and behavioral requirements of operators involved in health care activities with a system-based perspective that helps define when these needs are met by the health care context. We focus on errors and adverse events related to four broad areas of medical activities: medical device use, medication use, team collaboration, and diagnostic/decision support. For each area, we review evidence for specific error types, operator and system factors that contribute to these errors, and possible mitigating strategies related to design and training interventions that enable health care systems to better meet operators' perceptual, cognitive, and behavioral needs. This review reveals progress in identifying sources of human error and developing mitigating strategies in the areas of medical device and medication use, in part because of tools from human factors engineering that identify user needs and how to design environments to support them. Much less is known about how error emerges from work practices in complex settings, such as collaboration among team members. There is a need for theoretical frameworks to analyze error in the context of routine work practices. Such frameworks will bridge cognitive analyses of individual operators and tasks and more comprehensive theories of organizations, to guide interventions that target medical error at multiple levels.

Hypertensive Elders' Perceptions and Management of Their Disease: Health Beliefs or Health Decisions?

This study attempted to validate the Health Belief Model (HBM) as a model for explaining health behavior among elderly people diagnosed with hypertension. Using the construct validation perspective within psychometric theory, factor analysis with principal axis factoring and orthogonal varimax rotation was performed on data obtained from 275 elderly patients seen for hypertension in outpatient clinics. The structure of the HBM as originally proposed by Rosenstock (1966) was not confirmed. Instead, a six-factor structure reflecting a decision-making perspec tive as opposed to a belief perspective was obtained This factor structure accounted for 100% of the variance and was established on the basis of eigenvalues meeting more than one criterion for factor retention. The six factors are (a) inference of susceptibility, (b) understanding of hypertension, (c) use of health services, (d) inference of illness, (e) likelihood of disease-related complications, and (f) health locus of control. This study reveals patients' need to process information about their illness and health, to apply their cognitive-inferential skills to analyze and draw conclusions from this information, and to use these inferences to chart their course of behavioral response to their illness and its management.

Cognitive Function and Medication Usage in Older Adults

Research is presented from three different cognitive aging laboratories that examines the relationship between cognitive function, age, and the ability to adhere to medication regimens. The first section focuses on the effectiveness of complete, explicit instructions that emphasize the importance of organization of medication information on adherence behaviors for both younger and older adults. The second section examines the role of literal versus inferential medication information in normal elderly and in Alzheimer's patients. This research demonstrates that traditional measures of cognitive functioning are correlated with the comprehension of medication information and medication adherence. Finally, the third section presents an overview of research issues m adherence, including the relative effectiveness of two adherence measurement techniques, as well as a discussion of the effects of illness beliefs on adherence and evidence that adherence is not a global behavior but may vary within the individual as a function of certain medications. Directions for future research are suggested.

Promoting colorectal cancer screening in public health outreach campaigns

OBJECTIVE

Research on public outreach campaigns is presented.

BACKGROUND

One study examines the effects of instruction design on adherence to cancer self-screening instructions. A second study examines the effect of persuasive announcements on increasing screening campaign participation.

METHOD

The first study examined adherence to screening (operationalized as returning results for evaluation) given standard instructions, or one of three other versions: persuasive, human factored, or a combination of the two.The second study investigated combining persuasion with a campaign announcement to increase participation (operationalized as picking up a test kit).

RESULTS

The first study found that among first-time participants, the persuasive and human-factored instructions evoked higher result return rates than did the standard. The second study found that participation was significantly increased by adding persuasion to the campaign announcement.

CONCLUSION

Enhancing motivation and reducing cognitive barriers increase adherence to test instructions and increase participation.

APPLICATION

These are simple, cost-effective strategies that increase adherence to cancer screening in public outreach campaigns,which may reduce cancer-specific mortality.

Improving pregnancy drug warnings to promote patient comprehension

OBJECTIVE

We sought to evaluate the effectiveness of a pharmaceutical labeling strategy intended to improve comprehension of a teratogen warning.

STUDY DESIGN

This is a secondary analysis that evaluated women of childbearing age who were assigned prescription containers with the current teratogen warning, a label with simplified text, or a label with simplified text and icons. The association between label type and understanding of label instructions was assessed.

RESULTS

A total of 132 women were interviewed. Comprehension of the icon label (94%) was higher than for the standard and enhanced text-only labels (76% and 79%), respectively (P < .05). Adjustment for age, race/ethnicity, education, literacy, and number of current medications revealed that the label with the enhanced text and icon yielded superior comprehension (risk ratio vs standard, 1.26; 95% confidence interval, 1.04-1.53; risk ratio vs enhanced, 1.22; 95% confidence interval, 1.02-1.46).

CONCLUSION

In our study, a teratogen warning label that had easy-to-read messages with icons significantly improved comprehension.

Effect of standardized, patient-centered label instructions to improve comprehension of prescription drug use

OBJECTIVE

To evaluate the effectiveness of standardized, patient-centered label (PCL) instructions to improve comprehension of prescription drug use compared with typical instructions.

METHODS

A total of 500 adult patients recruited from 2 academic and 2 community primary care clinics in Chicago, IL and Shreveport, LA were assigned to receive as follows: (1) standard prescription instructions written as times per day (once, twice 3 times per day) (usual care), (2) PCL instructions that specify explicit timing with standard intervals (morning, noon, evening, bedtime) (PCL), or (3) PCL instructions with a graphic aid to visually depict dose and timing of the medication (PCL + Graphic). The outcome was correct interpretation of label instructions.

RESULTS

Instructions with the PCL format were more likely to be correctly interpreted compared with standard instructions (adjusted relative risk [RR]: 1.33, 95% confidence interval [CI]: 1.25-1.41). Inclusion of the graphic aid (PCL + Graphic) decreased rates of correct interpretation compared with PCL instructions alone (RR: 0.93; 95% CI: 0.89-0.97). Patients with low literacy were better able to interpret PCL instructions (low literacy: RR: 1.39; 95% CI: 1.14-1.68; P = 0.001).

CONCLUSION

The PCL approach could improve patients' understanding and use of their medication regimen.

Prescription Drug Use and Seniors

L'augmentation des dépenses de médicaments a placé les aîné(e)s sous les feux de la réforme de santé puisqu'ils en sont les plus grands consommateurs. On pourrait apporter des modifications substantielles à la consommation de médicaments presents, ce qui rehausserait les bienfaits des traitements et en minimiserait les effets négatifs, surtout chez les aîné(e)s. On documente ici un bon nombre de problèmes, notamment la surconsommation et la sous-consommation des médicaments, les erreurs d'ordonnances, la conformité au traitement et les médicaments inutilement coûteux. On a démontré l'efficacité de certaines éléments à l'égard de certains aspects du problème; qu'on cite simplement les politiques reliées au système de soins de santé, les interventions de certains médecins et de pharmaciens d'hôpitaux, les aides à la prise de dècisions et à la conformité aux traitements. Il faut mettre en place l'intégration des principales politiques et des interventions en une solution globale visant une meilleure utilisation des médicaments. Elle pourrait se composer des éléments suivants: (1) la révision des politiques de relations entre l'industrie pharmacologique et le secteur de la santé; (2) l'établissement de règlements d'expérimentation des médicaments chez les aînés avant leur approbation; (3) un institut du consommateur servant de ressource centrale objective aux demandes de renseignements des patients et de système d'appui aux décisions; (4) des systèmes intégrés d'information clinique à l'appui des systèmes de gestion des ordonnances et de la fourniture des médicaments et de la gestion des médicaments et des maladies à l'intention des pharmaciens et des médecins de premier recours; (5) une réforme de la formation médicale et de l'octroi des permis.

Providing health information to older adults

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.

A field test of the effects of instruction design on colorectal cancer self-screening accuracy

A field experiment tested whether instruction design improves accurate adherence to instructions for medical do-it-yourself tests like the Fecal Occult Blood Test (FOBT). As part of an outreach campaign, 16,073 participants received FOBTs with instructions that were (i) human factored, (ii) motivational, (iii) human factored/motivational combined, or (iv) the standard used in the past. Among all test results returned (N = 2483), only the human factors instructions reduced errors in filling out result cards. However, after post-validating result cards that had errors, the human-factored, motivational and merged instructions reduced errors. The present findings show that medical instructions designed with human factors and persuasion principles increase accurate adherence. These design principles provide simple and cost-effective ways to increase test taking accuracy and FOBT effectiveness. Better screening instructions can improve the chances of detecting colorectal cancer early, which may help to decrease cancer mortality.

Younger-Old and Older-Old Adults' Recall of Medication Instructions

The present study was conducted to expand research showing that older adults' expectations that they will recall particular medication instructions do not coincide with their actual ability to do so. Seventy-one younger-old adults (M = 68.10 years, range = 57–74) and 62 older-old adults (M = 80.31 years, range = 75–89) made judgements about the likelihood of their recalling medication instructions and about their confidence in their recall. The results indicate that older-old adults recall fewer instructions than do younger-old adults and that both groups overestimate their ability to recall the instructions. This research suggests that problems remembering to take medication may be due, in part, to older adults' overestimating the ease with which they will remember medication instructions.

Improving prescription drug warnings to promote patient comprehension

BACKGROUND

Prior studies have documented a high prevalence of patients who misunderstand prescription drug warning labels, placing them at risk for medication error. We evaluated whether the use of "enhanced print" drug warnings could improve patient comprehension beyond a current standard.

METHODS

An evaluation of enhanced print warning labels was conducted at 2 academic and 2 community health primary care clinics in Chicago, Illinois, and Shreveport, Louisiana. In total, 500 adult patients were consecutively recruited and assigned to receive (1) current standard drug warning labels on prescription containers (standard), (2) drug warnings with text rewritten in plain language (simplified text), or (3) plain language and icons developed with patient feedback (simplified text + icon). The primary outcome was correct interpretation of 9 drug warning labels as determined by a blinded panel review of patients' verbatim responses.

RESULTS

Overall rates of correct interpretation of drug warnings varied among standard, simplified text, and simplified text + icon labels (80.3%, 90.6%, and 92.1%, respectively; P < .001). Warnings with simplified text and simplified text + icons were more likely to be correctly interpreted compared with standard labels (simplified text - adjusted odds ratio [AOR] = 2.64; 95% confidence interval [CI], 2.00-3.49; simplified text + icons - AOR = 3.26; 95% CI, 2.46-4.32). Patients' ability to correctly interpret labels was not significantly different with the inclusion of icons (simplified text + icons - AOR = 1.23; 95% CI, 0.90-1.67; P = .20). Low literacy was also an independent predictor of misinterpretation (AOR, 0.65; 95% CI, 0.44-0.94). Patients with marginal and low literacy were better able to correctly interpret warning labels with simplified text + icons compared with labels with simplified text only (marginal literacy - AOR = 2.59; 95% CI, 1.24-5.44; P = .01; low literacy - AOR = 3.22; 95% CI, 1.39-7.50; P = .006).

CONCLUSIONS

Simple, explicit language on warning labels can increase patient understanding; the addition of appropriate icons is particularly useful for adults with lower literacy skills. Evidence-based standards are needed to promote patient-centered prescription labeling practices.

Management of medication noncompliance in solid-organ transplant recipients

Solid-organ transplantation has emerged as one of the most significant medical advances in the management of end-stage organ disease to date. However, a long term successful outcome after transplantation relies heavily upon the extended, if not lifelong, intake of immunosuppressive medication. Noncompliance with the medication regimen may have devastating effects on the graft and the patient. Furthermore, the effects of noncompliance place an additional burden on the medical resources available and the already scarce organ supply. The magnitude of post-transplant noncompliance and factors associated with noncompliance with various immunosuppressant drugs are reviewed. Patient, physician, social and family relationships interact in a complex manner in the post-transplant scenario and problems here could underlie noncompliance. The paper also includes a review of the methods of evaluating and monitoring noncompliance. Preventive and remedial measures that may help the transplant team to effectively manage this problem are suggested. The multidisciplinary nature of post-transplant patient management and the need for a cohesive approach toward the patient is emphasised. With the identification of patients at higher risk for noncompliance, close monitoring and early intervention, it may be possible to effectively control the effects of noncompliance until newer strategies are developed which permit immunosuppression-free transplantation.

Use of a discharge facilitator improves recall of emergency department discharge instructions for acute gastroenteritis

OBJECTIVE

To determine whether the use of a bilingual discharge facilitator (DF) improves parental recall of discharge instructions in acute gastroenteritis in a pediatric emergency department (ED).

METHODS

A nonrandomized educational intervention study with a historical control was conducted in a tertiary children's hospital between January 2004 and November 2004. English- or Spanish-speaking parents of patients aged 3 months to 18 years with conditions diagnosed as acute gastroenteritis were eligible. The standard discharge group received written discharge instructions and standard ED discharge protocols. The intervention group received the written discharge instructions reinforced verbally by the DF in the parent's language of choice. Recall of 7 warning signs and symptoms was assessed 24 to 48 hours after the ED visit for both groups.

RESULTS

For the English-speaking subgroup, a mean of 3.5 (95% confidence interval [CI], 3.26-3.78) signs or symptoms was identified correctly by 71 subjects in the standard discharge group, and a mean of 4.1 (95% CI, 3.83-4.43) signs or symptoms was identified correctly by 94 subjects in the DF group. For the Spanish-speaking subgroup, a mean of 3.0 (95% CI, 2.67-3.36) signs or symptoms was identified correctly by 62 subjects in the standard discharge group, and a mean of 4.5 (95% CI 4.18-4.88) signs or symptoms was identified correctly by 64 subjects in the DF group. The differences remained significant after adjusting for patient age and the highest level of education attained by the parent.

CONCLUSIONS

Verbal reinforcement of written discharge instructions by a bilingual DF improves parental recall of discharge instructions for gastroenteritis.

Estudo de base populacional da subutilização de medicamentos por motivos financeiros entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil

O objetivo deste trabalho foi estimar a prevalência e avaliar os fatores associados à subutilização de medicamentos por motivos financeiros em amostra representativa de 1.134 idosos, residentes na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. A prevalência da subutilização foi de 12,9%, estando independentemente associada à renda pessoal mensal inferior a dois salários mínimos (RP = 0,57; IC95%: 0,34-0,97), à filiação a plano privado de saúde (RP = 0,68; IC95%: 0,46-0,99), à freqüência com que o profissional de saúde esclareceu sobre a saúde/tratamento (raramente/nunca, RP = 1,79; IC95%: 1,10-2,90), à auto-avaliação de saúde (razoável, RP = 1,66; IC95%: 0,95-2,90 e ruim/muito ruim, RP = 2,49; IC95%: 1,38-4,48) e ao número de condições crônicas (uma, RP = 2,51; IC95%: 0,99-6,35; duas, RP = 3,51; IC95%: 1,40-8,72 e três ou mais, RP = 4,52; IC95%: 1,79-11,41). Os resultados confirmam a importância dos aspectos sócio-econômicos para a subutilização, mas indicam que sua determinação também está ligada à qualidade da comunicação médico-paciente. Evidencia-se ainda uma situação de risco para idosos em piores condições de saúde.

Assessment of older adults' knowledge of and preferences for medication management tools and support systems

BACKGROUND

A variety of strategies are available to assist older adults who have difficulties managing medications. Little is known about older adults' knowledge of or willingness to use these strategies.

OBJECTIVE

To assess older adults' current use of, knowledge of, and preferences for medication management tools and supports.

METHODS

A cross-sectional study was conducted at a continuing care retirement community. All 152 independent-living residents were approached for participation. We developed a 6-page survey to gather information about knowledge of and preferences for medication management tools (eg, medi-sets, bubblepacks) and supports (eg, family, caregivers, regimen simplification). Information on demographic variables, medication management capacity, cognition, self-reported difficulty taking medications, and medication use were collected along with survey answers during an in-home interview. chi(2) and t-tests were used to compare knowledge and preferences by complexity and organizer use.

RESULTS

Our sample consisted of 109 participants ranging in age from 73 to 98 years (average 85.9). Most of the subjects were well educated (average 15.5 y of education), 98% were white, and 80% were female. The majority (82%) were using a medication tool, mainly simple, self-filled medi-sets (62%) and easy-open vials (55%). Knowledge about, use of, and preferences for other devices, including pharmacist-filled tools and programmable devices, were low. Participants who used medication organizers rated self-filled medi-sets higher than did non-users (4.7 vs 1.6; p < 0.01). Only 18% of participants had asked a provider to simplify their medications, while 40% did not realize that they could do so. Of those who did ask a provider, 80% asked a physician.

CONCLUSIONS

Educational strategies are needed to increase awareness of the pharmacist's role in facilitating medication management and the option of simplifying complex regimens. It is within the scope of pharmacy to provide this type of medication education.

Improving patient understanding of prescription drug label instructions

BACKGROUND

Patient misunderstanding of instructions on prescription drug labels is common and a likely cause of medication error and less effective treatment.

OBJECTIVE

To test whether the use of more explicit language to describe dose and frequency of use for prescribed drugs could improve comprehension, especially among patients with limited literacy.

DESIGN

Cross-sectional study using in-person, structured interviews.

PATIENTS

Three hundred and fifty-nine adults waiting for an appointment in two hospital-based primary care clinics and one federally qualified health center in Shreveport, Louisiana; Chicago, Illinois; and New York, New York, respectively.

MEASUREMENT

Correct understanding of each of ten label instructions as determined by a blinded panel review of patients' verbatim responses.

RESULTS

Patient understanding of prescription label instructions ranged from 53% for the least understood to 89% for the most commonly understood label. Patients were significantly more likely to understand instructions with explicit times periods (i.e., morning) or precise times of day compared to instructions stating times per day (i.e., twice) or hourly intervals (89%, 77%, 61%, and 53%, respectively, p < 0.001). In multivariate analyses, dosage instructions with specific times or time periods were significantly more likely to be understood compared to instructions stating times per day (time periods--adjusted relative risk ratio (ARR) 0.42, 95% Confidence Interval (CI) 0.34-0.52; specific times--ARR 0.60, 95% CI 0.49-0.74). Low and marginal literacy remained statistically significant independent predictors of misinterpreting instructions (low--ARR 2.70, 95% CI 1.81-4.03; marginal--ARR 1.66, 95% CI 1.18-2.32).

CONCLUSIONS

Use of precise wording on prescription drug label instructions can improve patient comprehension. However, patients with limited literacy were more likely to misinterpret instructions despite use of more explicit language.

Assessment and management of pain in older adults with dementia: a review of current practice and future directions

PURPOSE OF REVIEW

The purpose of this paper is to consolidate the literature around pain assessment and management in older adults with dementia and to make recommendations for future research and practice developments. This review is provided following the introduction of guidelines for the assessment of pain that were published last year.

RECENT FINDINGS

The key issues that have been identified from the literature and will be discussed in this paper are assessment, pharmacotherapy, complementary therapies, education and guidelines.

SUMMARY

Pain in older adults has received increasing attention within the literature during the last decade, and in the past 12 months, there have been a number of papers published that highlight several key issues in the area. In terms of pharmacology and complementary therapies, there is still a need to evaluate their use in older adults in general. We have seen guidelines introduced and we need to consider how well these are being implemented. However, most importantly, we are now seeing increasing evidence supporting the use of three behavioural pain assessment scales, which look promising for the future.

[Adherence to neurologic treatment. Lessons from multiple sclerosis]

In light of increasing prevalence rates of chronic conditions and a growing elderly population, patients' nonadherence to medical regimes reflects a significant problem in modern health care. In the past, patients were primarily held responsible for problematic adherence. Over the past decades this attitude has changed dramatically, and it is now acknowledged that lack of adherence reflects a problem requiring different approaches and interventions on many different levels. Here we highlight central aspects and consequences of adherence problems in long-term therapy. Factors affecting treatment motivation in multiple sclerosis patients are summarized focusing on neurologic treatment issues, and specific intervention strategies for patients, doctors, and nurses are discussed.

Designing a Resource Guide to help promote health in caregiving

Aim.  To describe development of a Resource Guide, one component of a theory-based intervention. The Guide contains information and ideas to illuminate caregivers' self-care knowledge as a basis for organizing and reinforcing self-care activities. Background.  Inherent in the complexity of caregiving roles is the emergence of caregiving as a responsibility, often overshadowing caregiver's personal care needs. Health care professionals can partner with caregivers to promote caregiver health. Self-Care TALK is a multimodal intervention to support this partnership. Methods.  Two theoretical perspectives guided Resource Guide content; adult learning theory and the schema model of cognitive behavioural theory. Materials to stimulate conversations about caregivers' personal concerns about self-care were adapted from extant literature. Sources of information were chosen based on caregivers' learning needs and images of health. Areas of development focused on content, reading level/readability, graphic design, and self-evaluation. Results.  The Resource Guide standardizes Self-Care TALK protocol while personalizing caregivers' self-care. The Resource Guide provides structure for conversations about what self-care is and ways to promote health. Conclusion.  The Resource Guide promotes a learning environment that complements interests and experiences of older caregivers. Use of the Guide supports and extends caregivers' self-care vocabularies, and helps clarify self-care schemas and health promotion.

Use of pictorial aids in medication instructions: a review of the literature

PURPOSE

The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.

SUMMARY

Many patients depend on medication labels and patient information leaflets for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients' satisfaction with medication instructions.

CONCLUSION

The use of pictorial aids enhances patients' understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

BACKGROUND

The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.

OBJECTIVES

To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).

MEASURES

Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%.

RESULTS

Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).

CONCLUSIONS

The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

Can elderly people take their medicine?

This study used performance tests to assess the cognitive, visual and physical abilities related to taking medicines in the elderly population. The study population consisted of the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD II), a nationally representative interview survey. SWEOLD II is a random sample of all community-based and institutionalized persons aged 77+ in Sweden. Five tests related to medication management were administered in the direct interviews (n=492): hand function (opening bottle), vision (reading label), and medication competence (comprehension and calculation). Results showed that 9.4% could not read instructions on a medicine container and 14.6% had difficulty opening a plastic flip-top medicine bottle. The three cognitive tests related to taking medicine resulted in 30.7, 47.4 and 20.1% errors. Combining all the tests revealed that 66.3% of the sample had at least one limitation of capacity related to taking medicine. There were no significant gender differences. Among those people who did not pass all the tests, 31.8% lived alone with no home-help. Taking medicines is a complex task and a large proportion of the Swedish elderly population has cognitive, visual or physical limitations that may hinder their ability to take medicines accurately. Awareness of these limitations is essential to concordance.

Individualizing memory strategies to improve medication adherence

Changes in cognitive processes are well documented among even essentially healthy community-dwelling older adults. Although these changes do not produce the level of cognitive impairment associated with dementia, they do have the capacity to influence the degree to which elderly individuals self-manage chronic conditions. This pilot investigation tested the effect of an intervention to improve remembering to take medications and tracking if medications were taken as intended. Twenty-seven older adults (age range = 67-89 years, M = 78 years) all self-managing prescribed medications had one medication electronically monitored for 8 weeks preintervention and then 8 weeks postintervention. The percentage of days the correct number of doses was taken increased from a mean of 64.5% to that of 78%. With the use of Wilcoxon's signed ranks test, this improvement in adherence is significant. When participants with dementia or mild cognitive impairment were eliminated from the analysis (n = 6), the intervention continued to improve adherence (70.6% to 86%), suggesting that many older adults have the potential to improve adherence through individualized implementation of memory strategies.

Assessing medication adherence in the elderly: which tools to use in clinical practice?

Adherence to prescribed medication regimens is difficult for all patients and particularly challenging for the elderly. Medication adherence demands a working relationship between a patient or caregiver and prescriber that values open, honest discussion about medications, i.e. the administration schedule, intended benefits, adverse effects and costs. Although nonadherence to medications may be common among the elderly, fundamental reasons leading to nonadherence vary among patients. Demographic characteristics may help to identify elderly patients who are at risk for nonadherence. Inadequate or marginal health literacy among the elderly is common and warrants assessment. The number of co-morbid conditions and presence of cognitive, vision and/or hearing impairment may predispose the elderly to nonadherence. Similarly, medications themselves may contribute to nonadherence secondary to adverse effects or costs. Especially worrisome is nonadherence to 'less forgiving' drugs that, when missed, may lead to an adverse event (e.g. withdrawal symptoms) or disease exacerbation. Traditional methods for assessing medication adherence are unreliable. Direct questioning at the patient interview may not provide accurate assessments, especially if closed-ended, judgmental questions are posed. Prescription refill records and pill counts often overestimate true adherence rates. However, if elders are asked to describe how they take their medicines (using the Drug Regimen Unassisted Grading Scale or MedTake test tools), adherence problems can be identified in a non-threatening manner. Medication nonadherence should be suspected in elders who experience a decline in functional abilities. Predictors of medication nonadherence include specific disease states, such as cardiovascular diseases and depression. Technological aids to assessing medication adherence are available, but their utility is, thus far, primarily limited to a few research studies. These computerised devices, which assess adherence to oral and inhaled medications, may offer insight into difficult medication management problems. The most practical method of medication adherence assessment for most elderly patients may be through patient or caregiver interview using open-ended, non-threatening and non-judgmental questions.

Underrecognition of cognitive impairment in assisted living facilities

OBJECTIVES

To determine the prevalence of cognitive impairment (CI), dementia diagnosis and treatment, assistance with medications, and surrogate decision-makers for residents of assisted living facilities (ALFs).

DESIGN

Cross-sectional study.

SETTING

Seven ALFs in Omaha, Nebraska, and the surrounding area. None of the ALFs in this study were designated "Alzheimer's" or "dementia" facilities.

PARTICIPANTS

Four hundred seven of 455 ALF residents were solicited, and 230 consented. The average age +/- standard deviation of participants was 83.3+/-8.3.

MEASUREMENTS

ALF residents were examined using the Mini-Mental State Examination (MMSE), and their medical charts were reviewed.

RESULTS

Fifty-eight percent of ALF residents had CI according to the MMSE. Of those with CI, 63% had no diagnosis of dementia, 75% were not treated for dementia, 41% with a documented diagnosis of dementia were not treated for dementia, 22% self-administered an average of 5.4+/-3.4 medications daily, and 11% had surrogate decision makers.

CONCLUSION

More than half of ALF residents in this study had CI and a significant percentage was undiagnosed. Even when diagnosed as dementia, CI is significantly undertreated in this setting. These deficits must be addressed to promote quality of care and the need for specialized attention.

Methodology of an ongoing, randomized, controlled trial to improve drug use for elderly patients with chronic heart failure

BACKGROUND

Medications can improve the functioning and health-related quality of life of patients with chronic heart failure (CHF) and reduce morbidity, mortality, and costs of treatment. However, patients may not adhere to therapy. Patients with complex medication regimens and low health literacy are at risk for nonadherence.

OBJECTIVE

The primary goal of this project is to develop and assess a multilevel pharmacy-based program to improve patient medication adherence and health outcomes for elderly CHF patients with low health literacy.

METHODS

In this 4-year, controlled trial, patients aged 50 years with a diagnosis of CHF who are being treated at Wishard Health Services (Indianapolis, Indiana) are randomly assigned to pharmacist intervention or usual care. Intervention patients receive 9 months of pharmacist support and 3 months of postintervention follow-up. The intervention involves a pharmacist providing verbal and written education, icon-based labeling of medication containers, and therapeutic monitoring. The pharmacist identifies patients' barriers to appropriate drug use, coaches them on overcoming these barriers, and coordinates medication use issues with their primary care providers. Daily updates of relevant monitoring data are delivered via an electronic medical record system and stored in a personal computer system designed to support pharmacist monitoring and facilitate documentation of interventions. To measure medication adherence objectively, electronic monitoring lids are used on all CHF medications for patients in both study groups. Other assessments include self-reported medication adherence, results of echocardiography (eg, ejection fraction), brain natriuretic peptide concentrations, and health-related quality of life. Health services utilization, refill adherence, and cost data derive from electronic medical records. After completion of this study, the data can be used to assess the effectiveness and cost-effectiveness of our intervention.

RESULTS

One hundred twenty-two patients have been assigned to receive the intervention and 192 to receive usual care.

CONCLUSIONS

Our study aims to improve patients' knowledge and self-management of their medication and to improve medication monitoring in a multilevel pharmacy-based intervention. By doing so, we intend that the intervention will improve the health outcomes of elderly patients with CHF.