Costs and Cost-Effectiveness of User-Testing of Health Professionals' Guidelines to Reduce the Frequency of Intravenous Medicines Administration Errors by Nurses in the United Kingdom: A Probabilistic Model Based on Voriconazole Administration

AIM

In the UK, injectable medicines are often prepared and administered by nurses following the Injectable Medicines Guide (IMG). Our earlier study confirmed a higher frequency of correct administration with user-tested versus standard IMG guidelines. This current study aimed to model the cost-effectiveness of user-testing.

METHODS

The costs and cost-effectiveness of user-testing were explored by modifying an existing probabilistic decision-analytic model. The adapted model considered administration of intravenous voriconazole to hospital inpatients by nurses. It included 11 error types, their probability of detection and level of harm. Model inputs (including costs) were derived from our previous study and other published data. Monte Carlo simulation using 20,000 samples (sufficient for convergence) was performed with a 5-year time horizon from the perspective of the 121 NHS trusts and health boards that use the IMG. Sensitivity analyses were undertaken for the risk of a medication error and other sources of uncertainty.

RESULTS

The net monetary benefit at £20,000/quality-adjusted life year was £3,190,064 (95% credible interval (CrI): -346,709 to 8,480,665), favouring user-testing with a 96% chance of cost-effectiveness. Incremental cost-savings were £240,943 (95% CrI 43,527-491,576), also favouring user-tested guidelines with a 99% chance of cost-saving. The total user testing cost was £6317 (95% CrI 6012-6627). These findings were robust to assumptions about a range of input parameters, but greater uncertainty was seen with a lower medication error risk.

CONCLUSIONS

User-testing of injectable medicines guidelines is a low-cost intervention that is highly likely to be cost-effective, especially for high-risk medicines.

User Testing to Improve Retrieval and Comprehension of Information in Guidelines to Improve Medicines Safety

OBJECTIVE

The aim of the study was to investigate the effectiveness of user testing for improving healthcare professionals' retrieval and comprehension of information in medicines guidelines.

METHODS

The United Kingdom's Injectable Medicines Guide was selected as a case study. This gives guidance to nurses on preparing and administering intravenous medicines on hospital wards, in line with standard UK practice. Three rounds of user testing were completed with 10 hospital nurses per round, using the Injectable Medicines Guide for voriconazole and aminophylline. Participants used the guidelines to answer 17 questions related to the administration of these medicines. Answers were scored for "finding" and "understanding" the required information. Semistructured interviews explored participants' opinions of guideline content, design, and wording, with responses analyzed thematically. The guidelines were revised between rounds.

RESULTS

In round 1, 8 of 17 questions were answered correctly by all participants. Participants had difficulty with dose, dilution, administration rate, and adverse effects questions. Revisions included new subsections and increased calculation support. In round 2, 14 of 17 questions were answered correctly by all participants. Difficulty persisted with dose and administration rate questions and further revisions made. In round 3, 15 of 17 questions were answered correctly by all participants. Across all rounds, participants considered appropriate subheadings and information order as important for fast location of information. Specific, detailed, and practical instructions were perceived as important to improve understandability and usefulness.

CONCLUSIONS

Key information in medicines guidelines may not be found and/or understood by healthcare professionals. User testing increased information retrieval and comprehension and could have an important role in improving the safety of medicines use.

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study

BACKGROUND

User-testing and subsequent modification of clinical guidelines increases health professionals' information retrieval and comprehension. No study has investigated whether this results in safer care.

OBJECTIVE

To compare the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing.

METHOD

Single-blind, randomised parallel group in situ simulation. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing. Direct observation was used to time the simulation and identify errors. Participant confidence was measured using a validated instrument. The primary outcome was the percentage of simulations with at least one moderate-severe IMG-related error, with error severity classified by an expert panel.

RESULTS

In total, 133 participants were randomised to current guidelines and 140 to user-tested guidelines. Fewer moderate-severe IMG-related errors occurred with the user-tested guidelines (n=68, 49%) compared with current guidelines (n=79, 59%), but this difference was not statistically significant (risk ratio: 0.82; 95% CI 0.66 to 1.02). Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines (n=67, 48%) compared with current guidelines (n=26, 20%) (risk ratio: 2.46; 95% CI 1.68 to 3.60). Median simulation completion time was 1.6 min (95% CI 0.2 to 3.0) less with the user-tested guidelines. Participants who used user-tested guidelines reported greater confidence.

CONCLUSION

User-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.

TRIAL REGISTRATION NUMBER

researchregistry5275.

What has been the impact of the Traditional Herbal Registration (THR) scheme in the UK on information provided with herbal products bought over the counter?

BACKGROUND

In 2011 there was a strengthening of European Union (EU) legislation on the licencing of herbal products which, in the UK, resulted in the introduction of the Traditional Herbal Registration (THR) scheme. This scheme sets out standards for the safety and quality of herbal medicines and includes the provision of information to the customer on the safe use of the product. The aim of this study is to replicate a survey undertaken in 2011, prior to the implementation of the THR scheme, and evaluate the impact of this scheme on the information provided with herbal products bought over-the-counter.

METHODS

We undertook a survey on 5 herbal products commonly available over-the-counter (St John's wort, echinacea, Ginkgo biloba, Asian ginseng, garlic). The information was searched for key safety messages identified by the National Center for Complementary and Integrative Health (NCCIH). We also explored the presence of risk of harm information.

RESULTS

We recorded a rise in the number of products registered with the THR scheme (37% in 2016 compared to 7% in 2011). We also identified a reduction in the number of products that did not contain key safety information (75% in 2011 compared to 20% of products obtained in 2016). Risk of harm information was only communicated in products containing a PIL. We identified more products containing frequency of risk of harm information but this was not statistically significant.

CONCLUSION

The introduction of the THR scheme appears to be associated with an increase in the provision of information about key safety messages on the safe use of herbal products. However, it is important to note that at least half of the products on the market that are not included in the THR scheme do not contain any information about their safe use; this includes information about precautions, interactions and side effects. The use of NCCIH herbal monographs replicated the methods used in the previous study; we recognise that the use of a different resource might effect the appraisal of the information provided. We also acknowledge that surveying presence of information does not assure that the latter is effectively communicated to patients, for which a close textual analysis would be required. While it is promising that more information is available after the introduction of the THR scheme, the public needs to be informed about ways to optimise safe use of all herbal products.

Community IntraVenous Antibiotic Study (CIVAS): protocol for an evaluation of patient preferences for and cost-effectiveness of community intravenous antibiotic services

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) is used to treat a wide range of infections, and is common practice in countries such as the USA and Australia. In the UK, national guidelines (standards of care) for OPAT services have been developed to act as a benchmark for clinical monitoring and quality. However, the availability of OPAT services in the UK is still patchy and until quite recently was available only in specialist centres. Over time, National Health Service (NHS) Trusts have developed OPAT services in response to local needs, which has resulted in different service configurations and models of care. However, there has been no robust examination comparing the cost-effectiveness of each service type, or any systematic examination of patient preferences for services on which to base any business case decision.

METHODS AND ANALYSIS

The study will use a mixed methods approach, to evaluate patient preferences for and the cost-effectiveness of OPAT service models. The study includes seven NHS Trusts located in four counties. There are five inter-related work packages: a systematic review of the published research on the safety, efficacy and cost-effectiveness of intravenous antibiotic delivery services; a qualitative study to explore existing OPAT services and perceived barriers to future development; an economic model to estimate the comparative value of four different community intravenous antibiotic services; a discrete choice experiment to assess patient preferences for services, and an expert panel to agree which service models may constitute the optimal service model(s) of community intravenous antibiotics delivery.

ETHICS AND DISSEMINATION

The study has been approved by the NRES Committee, South West-Frenchay using the Proportionate Review Service (ref 13/SW/0060). The results of the study will be disseminated at national and international conferences, and in international journals.

The recording of drug sensitivities for older people living in care homes

AIMS

The aims of this study were to determine the recording of drug sensitivities of elderly care home residents, to describe the nature of sensitivities and to identify and describe discrepancies in the documentation of drug sensitivity status in general practices, pharmacies and care homes.

METHODS

A random sample of residents within a purposive sample of care homes (nursing and residential) was selected. A clinical pharmacist inspected the GP medical record, the medicines administration record, and the care home record for each resident to identify drug sensitivities and discrepancies between records and to describe the nature of the recorded sensitivities.

RESULTS

The records of 121 residents in 31 care homes were studied. Thirty-one (26%) residents had at least one documented drug sensitivity in one of the sources inspected, with 48 sensitivities in total recorded. There was no description of the nature of the sensitivities recorded in 39/48 (81%) cases. The number of sensitivities recorded on the medicines administration record, care home record and the GP record were 3 (6%), 29 (60%) and 35 (73%), respectively. Only two sensitivities were simultaneously recorded on all three records.

CONCLUSIONS

It was of concern that over 90% of drug sensitivities were not recorded on the medicines administration record which is the final checking document when administering medication. The reason for this was that the dispensing pharmacy was responsible for generating the medicines administration record; however, drug sensitivity status is seldom shared between the GP and the dispensing pharmacy. Printing sensitivities on prescriptions would help to resolve this.

Are health professionals ready for the new philosophy of concordance in medicine taking?

Objectives

To develop and administer a practical, valid and reliable tool to measure attitudes to concordance in medicine taking, a new concept where decisions depend on an equal partnership between patient and prescriber.

Method

A postal questionnaire was devised comprising statements from the original concordance document, along with statements reflecting the orthodox model of medicine taking. There was a total of 22 statements. Respondents rated each statement on a four-point Likert agreement scale. The questionnaire also included three scenarios of consultations involving medicine prescribing and taking, with associated statements for rating as true or false.

Setting

A random sample of 207 medical, nursing and pharmacy graduates in the North of England at the time of qualification. We received 81 completed questionnaires (39 per cent)

Key findings

Item analysis reduced the 22-item scale to a 12-item scale with good reliability (Cronbach's alpha = 0.79) and construct validity was demonstrated through correlation with responses to the scenarios. Although the typical respondent had a positive attitude towards concordance (mean = 2.3), 25 per cent of respondents had negative attitudes. Pharmacists showed the least favourable attitudes (P<0.05)

Conclusions

The 12-item Leeds Attitude Towards Concordance (LATCon) scale is a reliable and valid tool for assessing health care providers' attitudes to the new concept of concordance in medicine taking. Newly qualified doctors, nurses and pharmacists tended to hold favourable attitudes, although a significant minority — especially pharmacists — hold negative attitudes. These results have implications for undergraduate education and continuing professional education.

Pain relief in the elderly: are we doing enough?

Focal points

Clinical medication review in general practice: what is the benefit of a second review?

Focal points

Mind the gap: how compliance aids increase the distance between patients and their medicines

Focal points

How much do recent users know about emergency hormonal contraception?

Focal points

Preliminary investigation of patient information leaflets as package inserts

In the United Kingdom, patient information leaflets (PILs) are now supplied with all medicines licensed or re-licensed since January, 1994. This means that, by 1998, all medicines will come with one of these detailed leaflets inside the pack. In a preliminary investigation of the impact of these leaflets, 117 elderly inpatients were questioned on their experience of PILs prior to admission. Ninety-one (78 per cent) said they had received a PIL and 57 (49 per cent) had read one. The main reasons for not reading a leaflet were the perceived difficulty in understanding and being put off by excessive information. Of the patients who had read a leaflet, 23 (40 per cent) reported difficulty in reading the small print and 26 (46 per cent) said they had difficulty understanding the content. Thirteen patients (23 per cent) reported having to seek help with reading a leaflet. Forty-two of those who had read a leaflet rated it as helpful. Eleven patients said they had asked for advice from their doctor or pharmacist as a result of reading a leaflet. Nine patients said the leaflet had caused some anxiety, with two stopping their medicine as a result. The move to universal PILs in patient packs is a major development in the provision of information to patients about medicines. This study suggests that elderly patients have problems relating to understanding the content of PILs and reading the size of print used in these leaflets.

Clare wants the morning-after pill: what do practitioners think?

Focal points

Testing two methods of presenting side effect risk information about common medicines

Focal points

How professionals define medicines management: a preliminary qualitative investigation

Focal points

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective

To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non-adherence.

Method

Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence-related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self-reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress.

Setting

Six community pharmacies in the city of Leeds, UK, and patients' homes.

Key findings

A total of 143 patients were recruited and 441 medicine-related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non-adherence fell from 38 per cent to 14 per cent (P<0.001).

Conclusion

This study shows that community pharmacists can target patients at risk of medication non-adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non-adherence and should be closely linked with the rest of the primary health care team.

Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice

Focal points

Patient compliance: the pharmacist's role

Pharmacists can influence patients' compliance with prescribed medicines not only by educating and informing patients but also by helping to simplify their medication regimens. This article discusses the measurement of compliance and looks at ways of improving it.

Developing and testing a patient information booklet for thrombolysis used in acute stroke

Objective  Thrombolysis decreases the chance of post-stroke dependence, although its use carries significant risk, notably of intra-cerebral haemorrhage. Patients (and families) face an important risk/benefit decision before consenting. We drafted a patient information booklet for this purpose, and applied performance-based readability testing with the aim that the most important information in the booklet could be found and understood. Methods  The booklet was developed with reference to best practice in information writing and design. We User-Tested its performance on 56 people without prior experience of stroke. After reading the booklet they were asked to find and explain 15 pieces of information. The booklet was revised according to its performance and re-tested, until each item was found and understood by at least 80% of participants. Key findings  The four-page information booklet contained approximately 900 words, organised into six sections. A risk-palette graphic showed the chance of positive and negative outcomes. The booklet was tested on four participant cohorts and revised, including more bold text, re-wording, changing the title and changing the graphic to a coloured bar chart. Testing the final version on the fourth cohort of 20 people showed that each of the 15 tested items of information met the target of at least 80% participants being able to find and understand it. Conclusions  The use of information design and User Testing produced a booklet that is understandable by people with no prior experience of stroke. User Testing is an inexpensive and quick method to ensure that information intended for patients is usable.

Evaluation of website medicines information content, in comparison with official patient information

Objective

To evaluate the content and presentation of websites accessed by the public for information about two non-steroidal anti-inflammatory drugs, ibuprofen and naproxen. To assess the accuracy and completeness of website content compared with official patient leaflets, and assess the quality of presentation of each site.

Setting

Medicines are the most frequent intervention in healthcare, and people need appropriate information to use them safely and effectively. There is evidence that the leaflets supplied with medicines do not meet peoples' needs. There are many websites containing medicines information, but it is not known how the content compares with the official information.

Method

The search words ‘Brufen’ and then ‘Naprosyn’ were used in the Google search engine. We identified the first 10 sites containing information comparable to that in conventional medicines leaflets (more than 100 words and at least three of five categories of information). Each site was scored for presence and accuracy of each point of information included in official leaflets. Each site was also scored for quality of presentation, assessing 10 attributes (scored 1–3).

Key findings

We found 7 Brufen and 10 Naprosyn sites meeting the inclusion criteria and the mean score for completeness of information was 50% (range 23–79%). Eight inaccuracies were found in 7 out of the 17 sites. Four had significant potential clinical impact (all relating to dose) and four were minor in significance. The overall mean score for website presentation was 77%.

Conclusion

Compared to official leaflets, information found on websites generally contained about half the total amount of pieces of information. There were a small number of inaccuracies related to dose, which are potentially dangerous. The websites scored well overall for quality of presentation. The two overall highest-scoring websites were a manufacturer's site and one aimed at health professionals.

How do patients use medicine information leaflets in the UK?

Objective

To determine how patients use patient information leaflets (PILs) for prescription medicines. Setting Community pharmacies and patients' homes in the North of England.

Method

Patients were recruited as they collected their prescriptions, and telephoned about 7 days later. A structured telephone interview was administered with questions about how the PIL had been used (either this time or from previous prescriptions).

Key findings

Structured telephone interviews were completed for 456 patients (81% of those who consented), with a mean age of 54 years. Almost all patients (97%) were aware of the leaflet, a significant improvement on previous studies. Thirty-five per cent said they had read at least some of the leaflet with this supply. However, this figure was 71% for first-time users, and 87% of repeat users said they had read the leaflet at some time in the past. Of repeat users, nearly 60% said they had never or rarely looked at the leaflet after the first time. The side-effects section was most commonly read, and the information in this section was the most common specific reason given for reading the PIL. Eleven per cent of first-time users and 15% of repeat users said they had at some time taken action as a result of reading the PIL.

Conclusions

Almost all patients surveyed were aware of the PIL, showing that 8 years after becoming mandatory, the presence of the leaflets is now being felt. It is encouraging that most read the leaflet with the first supply, although the same cannot be assumed for very old individuals, who were under-represented. The fact that a majority taking a medicine long term did not read the leaflet again, after the first time, is a concern. Much will have been forgotten and some information may have changed. Pharmacists continue to have a role in encouraging the use of PILs.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

INTRODUCTION

Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

METHODS

A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

RESULTS

The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

CONCLUSIONS

That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Performance-based readability testing of participant materials for a phase I trial: TGN1412

BACKGROUND

Concern has been expressed about the process of consent to clinical trials, particularly in phase I "first-in-man" trials. Trial participant information sheets are often lengthy and technical. Content-based readability testing of sheets, which is often required to obtain research ethics approval for trials in the USA, is limited and cannot indicate how information will perform.

METHODS

An independent-groups design was used to study the user-testing performance of the participant information sheet from the phase I TGN1412 trial. Members of the public were asked to read it, then find and demonstrate understanding of 21 key aspects of the trial. The participant information sheet was then rewritten, redesigned and tested on 20 members of the public, using the same 21-item questionnaire.

RESULTS

On the original TGN1412 participant information sheet, participants could not find answers and some of the found information was not understood. Six of 21 questions, including those relating to placebo, follow-up visits and the emergency phone number, were found by eight or fewer of 10 participants. The revised information sheet performed better, with the answers to 17 of 21 questions found and understood by all 20 participants.

CONCLUSIONS

Tests showed that the TGN1412 participant information sheet may not inform participants adequately for consent. Revising its content and design led to significant improvements. Writers of materials for trial participants should take account of good practice in information design. Performance-based user testing may be a useful method to indicate strengths and weaknesses in trial materials.

Performance-based readability testing of participant information for a Phase 3 IVF trial

BACKGROUND

Studies suggest that the process of patient consent to clinical trials is sub-optimal. Participant information sheets are important but can be technical and lengthy documents. Performance-based readability testing is an established means of assessing patient information, and this study aimed to test its application to participant information for a Phase 3 trial.

METHODS

An independent groups design was used to study the User Testing performance of the participant information sheet from the Phase 3 'Poor Responders' trial of In Vitro Fertilisation (IVF). 20 members of the public were asked to read it, then find and demonstrate understanding of 21 key aspects of the trial. The participant information sheet was then re-written and re-designed, and tested on 20 members of the public, using the same 21 item questionnaire.

RESULTS

The original participant information sheet performed well in some places. Participants could not find some answers and some of the found information was not understood. In total there were 30 instances of information being not found or not understood. Answers to three questions were found but not understood by many of the participants, these related to aspects of the drug timing, Follicle Stimulating Hormone and compensation. Only two of the 20 participants could find and show understanding of all question items when using the original sheet. The revised sheet performed generally better, with 17 instances of information being not found or not understood, although the number of 'not found' items increased. Half of the 20 participants could find and show understanding of all question items when using the revised sheet. When asked to compare the versions of the sheet, almost all participants preferred the revised version.

CONCLUSION

The original participant information sheet may not have enabled patients fully to give valid consent. Participants seeing the revised sheet were better able to understand the trial. Those who write information for trial participants should take account of good practice in information design. Performance-based User Testing may be a useful method to indicate strengths and weaknesses in trial information.

Perceived risk of medicine side effects in users of a patient information website: a study of the use of verbal descriptors, percentages and natural frequencies

OBJECTIVES

Research into the provision of patient information has demonstrated that, under certain conditions, patients overestimate the risks of medicine side effects. Gigerenzer and Edwards (2004) argue that 'natural frequencies' are a less confusing way of expressing risk information. Two experiments with users of an existing high profile patient information website, investigate the effectiveness of presenting medicine side-effect risk information in different forms.

DESIGN

In both experiments participants were randomly allocated to one of the three conditions for representing risk information (a form of 'natural frequency', percentages and verbal descriptors).

METHOD

Participants were recruited from users of the Cancer Research UK patient information website (Cancer Help UK). In Experiment 1, participants (N=148) were asked to imagine that they had to take a chemotherapy drug (Taxol) and were asked to estimate the risks of two side-effects occurring. In Experiment 2 participants (N=137) estimated the risk for three different side-effects occurring with the painkiller ibuprofen.

RESULTS

In both experiments, verbal descriptions led to significantly higher estimations of risk compared to the other two formats. There was some evidence that people given information as frequencies were more accurate in their estimates than those given percentage information.

CONCLUSIONS

These findings provide partial support for the advantages of a form of 'natural frequencies' when presenting side-effects to patients. They also add weight to the growing body of research highlighting the deficiencies in using verbal descriptions of side-effect risk alone.

Adequacy of patient information on adverse effects: an assessment of patient information leaflets in the UK

BACKGROUND

One of the most important categories of information that patients want to know about the drug they are taking is the likelihood or probability of adverse effects. All patients should receive such information in the patient information leaflet that is supplied with all drugs. Anecdotal evidence suggests that most leaflets give little indication of the likelihood of adverse effects. The UK Medicines and Healthcare products Regulatory Agency (MHRA) suggests using a combination of words and numbers to convey this information. However, an EU guideline suggests using five verbal descriptors on a scale from common to rare, the use of which has been shown to lead to gross overestimation of the risk of adverse effects.

METHODS

We assessed the leaflets supplied with the 50 most frequently prescribed drugs in England, to determine the extent to which the likelihood of adverse effects was described, and whether it met the requirements of the EU guidance and/or best practice. We examined both the method used to describe the likelihood of adverse effects, and the format of this information in the leaflet.

RESULTS

Twenty of the 50 leaflets (40%) gave no indication of the likelihood of adverse effects occurring. Six (12%) used the recommended EU terms and a further 20 (40%) used a wide range of other verbal descriptors. Only four leaflets (8%) provided any form of numerical indication of risk. Over half (52%) presented long lists of adverse effects in paragraphs of continuous text.

CONCLUSIONS

Patient need is not being met in terms of the provision of usable information about the likelihood of adverse effects. Most patients receive no information, whereas some are given verbal descriptors, both of which lead to overestimation of the risk. Very few of the patient information leaflets assessed used currently described best practice, i.e. to present verbal descriptions alongside numerical information in the form of natural frequencies, e.g. 'rare (affects less than 1 in 1000 people)'.

A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines

OBJECTIVES

To establish the role and value of written information available to patients about individual medicines from the perspective of patients, carers and professionals. To determine how effective this information is in improving patients' knowledge and understanding of treatment and health outcomes.

DATA SOURCES

Electronic databases searched to late 2004, experts in information design, and stakeholder workshops (including patients and patient organisations).

REVIEW METHODS

Data from selected studies were tabulated and the results were qualitatively synthesised along with findings from the information design and stakeholder workshop strands.

RESULTS

Most people do not value the written information they receive. They had concerns about the use of complex language and poor visual presentation and in most cases the research showed that the information did not increase knowledge. The research showed that patients valued written information that was tailored to their individual circumstances and illness, and that contained a balance of harm and benefit information. Most patients wanted to know about any adverse effects that could arise. Patients require information to help decision-making about whether to take a medicine or not and (once taking a medicine) with ongoing decisions about the management of the medicine and interpreting symptoms. Patients did not want written information to be a substitute for spoken information from their prescriber. While not everyone wanted written information, those who did wanted sufficient detail to meet their need. Some health professionals thought that written information for patients should be brief and simple, with concerns about providing side-effect information. They saw increasing compliance as a prime function, in contrast to patients who saw an informed decision not to take a medicine as an acceptable outcome.

CONCLUSIONS

The combination of a quantitative and qualitative review, an exploration of best practice in information design, plus the input of patients at stakeholder workshops, allowed this review to look at all perspectives. There is a gap between currently provided leaflets and information which patients would value and find more useful. The challenge is to develop methods of provision flexible enough to allow uptake of varying amounts and types of information, depending on needs at different times in an illness. This review has identified a number of areas where future research could be improved in terms of the robustness of its design and conduct, and the use of patient-focused outcomes. The scope for this research includes determining the content, delivery and layout of statutory leaflets that best meet patients' needs, and providing individualised information, which includes both benefit and harm information. In particular, studies of the effectiveness and role and value of Internet-based medicines information are needed.

Do themes in consumer medicines information literature reviews reflect those important to stakeholders?

OBJECTIVE

To compare the themes emerging from a stakeholder workshop on consumers' medicines information with themes in relevant published reviews.

METHODS

A stakeholder workshop was held to permit consumer orientation of a systematic review of consumer medicines information. Analysis of the workshop outputs was compared to a content analysis of the identified published reviews.

RESULTS

The workshop generated a range of responses inductively grouped into 12 over-arching themes. No reviews tackled all of these themes, nor addressed 'informed choice and autonomy'. More recent reviews reflected more workshop themes than older ones, suggesting a temporal trend towards a greater sensitivity to consumer issues. The most common workshop themes were covered by all reviews. Six themes in the reviews were related to traditional professional concerns including compliance, which did not arise in the workshop.

CONCLUSION

The results highlight a mismatch between the themes in previous published reviews and the themes emerging from the workshop. The most commonly reflected themes in reviews conform to the 'patient education' model of discourse, while workshop themes less often echoed in reviews reflect the discourse of 'patient empowerment'.

PRACTICE IMPLICATIONS

The findings suggest the importance of involving patients in the development of patient literature from the outset.

Comparison of two methods of presenting risk information to patients about the side effects of medicines

OBJECTIVE

To determine whether the use of verbal descriptors suggested by the European Union (EU) such as "common" (1-10% frequency) and "rare" (0.01-0.1%) effectively conveys the level of risk of side effects to people taking a medicine.

DESIGN

Randomised controlled study with unconcealed allocation.

PARTICIPANTS

120 adults taking simvastatin or atorvastatin after cardiac surgery or myocardial infarction.

SETTING

Cardiac rehabilitation clinics at two hospitals in Leeds, UK.

INTERVENTION

A written statement about one of the side effects of the medicine (either constipation or pancreatitis). Within each side effect condition half the patients were given the information in verbal form and half in numerical form (for constipation, "common" or 2.5%; for pancreatitis, "rare" or 0.04%).

MAIN OUTCOME MEASURE

The estimated likelihood of the side effect occurring. Other outcome measures related to the perceived severity of the side effect, its risk to health, and its effect on decisions about whether to take the medicine.

RESULTS

The mean likelihood estimate given for the constipation side effect was 34.2% in the verbal group and 8.1% in the numerical group; for pancreatitis it was 18% in the verbal group and 2.1% in the numerical group. The verbal descriptors were associated with more negative perceptions of the medicine than their equivalent numerical descriptors.

CONCLUSIONS

Patients want and need understandable information about medicines and their risks and benefits. This is essential if they are to become partners in medicine taking. The use of verbal descriptors to improve the level of information about side effect risk leads to overestimation of the level of harm and may lead patients to make inappropriate decisions about whether or not they take the medicine.

Comparison of two methods of presenting risk information to patients about the side effects of medicines

OBJECTIVE

To determine whether the use of verbal descriptors suggested by the European Union (EU) such as "common" (1-10% frequency) and "rare" (0.01-0.1%) effectively conveys the level of risk of side effects to people taking a medicine.

DESIGN

Randomised controlled study with unconcealed allocation.

PARTICIPANTS

120 adults taking simvastatin or atorvastatin after cardiac surgery or myocardial infarction.

SETTING

Cardiac rehabilitation clinics at two hospitals in Leeds, UK.

INTERVENTION

A written statement about one of the side effects of the medicine (either constipation or pancreatitis). Within each side effect condition half the patients were given the information in verbal form and half in numerical form (for constipation, "common" or 2.5%; for pancreatitis, "rare" or 0.04%).

MAIN OUTCOME MEASURE

The estimated likelihood of the side effect occurring. Other outcome measures related to the perceived severity of the side effect, its risk to health, and its effect on decisions about whether to take the medicine.

RESULTS

The mean likelihood estimate given for the constipation side effect was 34.2% in the verbal group and 8.1% in the numerical group; for pancreatitis it was 18% in the verbal group and 2.1% in the numerical group. The verbal descriptors were associated with more negative perceptions of the medicine than their equivalent numerical descriptors.

CONCLUSIONS

Patients want and need understandable information about medicines and their risks and benefits. This is essential if they are to become partners in medicine taking. The use of verbal descriptors to improve the level of information about side effect risk leads to overestimation of the level of harm and may lead patients to make inappropriate decisions about whether or not they take the medicine.

Medical students' attitudes towards concordance in medicine taking: exploring the impact of an educational intervention

BACKGROUND AND OBJECTIVES

Concordance has been suggested as a new way of describing the agreement about medicine taking during the consultation process. The aim is a decision on management agreed on by both doctor and patient. As such it has strong links with shared decision-making and patient partnership. In order to encourage doctors to adopt a concordant model, we need to foster a positive attitude towards the concept. We decided to investigate the attitudes of first and second year medical students towards concordance as a base for further educational interventions.

SETTING

The School of Medicine, Leeds University.

METHODS

We administered the Leeds Attitude toward Concordance scale (LATCon) to first and second year medical students at the beginning of the academic year, and to the same second year students after they had completed a written exercise relating to concordance.

RESULTS

The response rate was over 80% for each group. There was no difference in the attitudes towards concordance of the first years and the second years prior to the intervention. After they had completed the exercise, the second years' attitudes towards concordance improved by a small but significant amount.

CONCLUSIONS

A paper-based exercise with questions focusing on concordance and based around cases appears to improve medical students' attitudes towards the concept. This exercise needs to be followed up with skills training and observation of role models in order that the attitudes of the students translate into practice once they are qualified.

Patients' views of a pharmacist-run medication review clinic in general practice

BACKGROUND

Reviewing elderly patients' medication is a requirement of the National Service Framework for Older People. Many general practitioners have insufficient time to review patients' medications in a consultation. Pharmacist review has been offered as an alternative and this will be a new experience for many patients.

AIM

To ascertain patients' views of a pharmacist-conducted medication review clinic, run in their general practice surgery.

DESIGN OF STUDY

Qualitative study using focus group interviews.

SETTING

General practices in Leeds Health Authority area.

METHOD

Patients aged 65 years and over, who had attended a medicine review clinic, took part in focus groups that were recorded and transcribed. Units of information representing an idea were identified and similar ideas were grouped together as themes.

RESULTS

Patients had a number of prior beliefs about the clinic. Most patients knew that the clinic's purpose was to review repeat medication, to find out more about their medicines, and to ask questions about efficacy and side effects. Some patients were suspicious about the purpose of the clinic but others welcomed the opportunity to have an in-depth review and an explanation of their condition and its treatment; some patients did not accept advice or were disappointed that their expectations were not fulfilled. Most patients were happy to attend a yearly review but some expressed guilt about attending the surgery too frequently.

CONCLUSION

Patients who attended the medication review clinics expressed a range of views about the service. Further research into patients' and carers' opinions about medicine review is needed to inform the development of these services.

Patients' understanding of risk associated with medication use: impact of European Commission guidelines and other risk scales

Patients want and need comprehensive and accurate information about their medicines so that they can participate in decisions about their healthcare. In particular, they require information about the likely risks and benefits that are associated with the different treatment options. However, to provide this information in a form that people can readily understand and use is a considerable challenge to healthcare professionals. One recent attempt to standardise the language of risk has been to produce sets of verbal descriptors that correspond to specific probability ranges, such as those outlined in the European Commission (EC) Pharmaceutical Committee guidelines in 1998 for describing the incidence of adverse effects. This paper provides an overview of a number of studies involving members of the general public, patients, and hospital doctors, that evaluated the utility of the EC guideline descriptors (very common, common, uncommon, rare, very rare). In all studies it was found that people significantly over-estimated the likelihood of adverse effects occurring, given specific verbal descriptors. This in turn resulted in significantly higher ratings of their perceived risks to health and significantly lower ratings of their likelihood of taking the medicine. Such problems of interpretation are not restricted to the EC guideline descriptors. Similar levels of misinterpretation have also been demonstrated with two other recently advocated risk scales (Calman's verbal descriptor scale and Barclay, Costigan and Davies' lottery scale). In conclusion, the challenge for risk communicators and for future research will be to produce a language of risk that is sufficiently flexible to take into account different perspectives, as well as changing circumstances and contexts of illness and its treatments. In the meantime, we urge the EC and other legislative bodies to stop recommending the use of specific verbal labels or phrases until there is a stronger evidence base to support their use.

Official warnings on thromboembolism risk with oral contraceptives fail to inform users adequately

Following the 1995 "pill scare" relating to the risk of venous thrombosis from taking second- or third-generation oral contraceptives, the Committee on Safety of Medicines (CSM) withdrew their earlier recommended restrictions on the use of third-generation pills and published recommended wording to be used in patient information leaflets. However, the effectiveness of this wording has not been tested. An empirical study (with 186 pill users, past users, and non-users) was conducted to assess understanding, based on this wording, of the absolute and relative risk of thrombosis in pill users and in pregnancy. The results showed that less than 12% of women in the (higher education) group fully understood the absolute levels of risk from taking the pill and from being pregnant. Relative risk was also poorly understood, with less than 40% of participants showing full understanding, and 20% showing no understanding. We recommend that the CSM revisit the wording currently provided to millions of women in the UK.

Provision of information about drug side-effects to patients

To make informed decisions about taking medicinal drugs, people need accurate information about side-effects. A European Union guideline now recommends use of qualitative descriptions for five bands of risk, ranging from very rare (affecting <0.01% of the population), to very common (>10%). We did four studies of more than 750 people, whom we asked to estimate the probability of having a side-effect on the basis of qualitative and quantitative descriptions. Our results showed that qualitative descriptions led to gross overestimation of risk. Until further work is done on how patients taking the drugs interpret these terms, the terms should not be used in drug information leaflets.

Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice

OBJECTIVE

To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.

DESIGN

Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.

SETTING

Four general practices.

PARTICIPANTS

1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.

INTERVENTION

Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.

MAIN OUTCOME MEASURES

Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.

RESULTS

590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference 4.72 pound sterling per 28 days, - 7.04 pound sterling to - 2.41 pound sterling); equivalent to 61 pound sterling per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference -0.2, -0.4 to -0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.

CONCLUSIONS

A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.

Patient information leaflets for medicines: using consumer testing to determine the most effective design

Comprehensive medicine information leaflets for patients are now mandatory across the European Union. In 1997, the European Commission (EC) proposed a prescriptive 'model' for the leaflets and a method for consumer testing. This exploratory study compared consumers' ability to use a leaflet based on the EC model leaflet and an alternative leaflet based on best practice in information design (Mark II). The leaflets were tested in two matched groups of 20 consumers, who were required to find, and understand, 15 pieces of information in the leaflets. The target that each question should be answered correctly by 16 out of 20 consumers, was achieved for three of the 15 points in the EC leaflet, compared with eight in the Mark II leaflet. Open questioning confirmed the problems with the EC leaflet, including a failure to understand key concepts about medicine interactions and contraindications. This research demonstrates the benefits of consumer testing, ensuring that leaflets are patient-orientated. A rigid model leaflet would prevent these benefits from being utilised.

"No thank you": why elderly patients declined to participate in a research study

OBJECTIVES

To compare the population consenting for a study of the effectiveness of a pharmacist-run medication review clinic with the population not consenting for patients aged over 65 years old with respect to age, sex and number of repeat medicines. To explore the reasons why some patients declined to consent to the study.

METHODS

Letters were sent to 2,403 patients aged 65 and over and taking at least one repeat medicine from 4 general practices. If no reply was received to a second letter they were followed up by telephone. If they declined to consent they were asked for their reasons. Data for consenting and non-consenting patients was collected on the stratification factors: age, sex and number of repeat medicines. Multiple logistic regression was used to assess the association of each factor with consent rates.

RESULTS

Consenting patients were dissimilar to non-consenting patients. Patients were less likely to consent if they were older, OR (95% CI) = 0.54 (0.46, 0.64), or female, OR (95% CI) = 0.74 (0.63, 0.88). Patients were more likely to consent if on 5 or more repeat medicines: OR (95% CI) = 1.3 (1.1, 1.5). Ten broad categories of reasons why patients did not wish to participate were identified from the patient interviews.

CONCLUSIONS

Patients were less likely to give their consent if they were elderly, female and on fewer repeat medicines. A number of administrative and behavioural factors were identified which reduced the chances of informed consent being given. These factors need to be addressed to maximise numbers of consenting patients in medication review studies.

Effects of a medicine review and education programme for older people in general practice

AIMS

To determine whether a medicine review and education programme influences the compliance and knowledge of older people in general practice.

METHODS

Older people taking at least three medicines were randomly allocated to a control or intervention group. Both groups received three visits from a clinical pharmacist: Visit 1: Assessment and patients' medicines rationalized in intervention group. Visit 2: Intervention group given medicines education. Visit 3: Knowledge and compliance in both groups assessed by structured questionnaire

RESULTS

Compliance in the intervention group was 91.3%, compared with 79.5% in the control group (P < 0.0001). The number of intervention group patients correctly understanding the purpose of their medicines increased from 58% to 88% on the second visit, compared with 67% to 70% in the control group (P < 0.0005).

CONCLUSIONS

A general practice based medication review and education programme improved medicine compliance and knowledge of older people in the short term.