Effects of computer generated reminder charts on patients' compliance with drug regimens.

OBJECTIVE--To investigate whether a reminder chart improved patients'' compliance with their drug regimen after discharge from hospital. DESIGN--Patients were randomly allocated to one of four groups. Two groups received the reminder chart: one also received routine counselling from a nurse and the other received structured counselling from a pharmacist, which included an explanation of the reminder chart. The other two groups received only counseling, either from a nurse or from a pharmacist. Patients were visited about 10 days later: they were questioned about their drug regimen, and their compliance was measured by tablet counting. SETTING--The pharmacy in a district general hospital and patients'' homes. PATIENTS--197 patients being discharged from hospital who were regularly taking two or more drugs. INTERVENTION--An individualised reminder chart, which listed each person''s medicines and when they were to be taken and was automatically generated by a medicine labelling computer. MAIN OUTCOME MEASURES--Patient''s compliance with and knowledge of their drug regimen. MAIN RESULTS--Of the patients who received the reminder chart, 83% (95% confidence interval 74% to 90%) correctly described their dose regimen compared with 47% (37% to 58%) of those without the chart (p < 0.001). The mean compliance score was 86% (81% to 91%) in both groups not given the reminder chart; 91% (87% to 94%) in the group given the chart without an explanation; and 95% (93% to 98%) in the group given the chart and an explanation. A mean compliance score of > 85% was achieved by 63% (53% to 73%) of patients without a reminder chart and by 86% (78% to 93%) of those receiving the chart (p < 0.001). CONCLUSIONS--An automatically generated reminder chart is a practical and cost effective aid to compliance.     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

Evaluating the Effectiveness of Self-Administration of Medication (SAM) Schemes in the Hospital Setting: A Systematic Review of the Literature

Background

Self-administration of medicines is believed to increase patients'' understanding about their medication and to promote their independence and autonomy in the hospital setting. The effect of inpatient self-administration of medication (SAM) schemes on patients, staff and institutions is currently unclear.

Objective

To systematically review the literature relating to the effect of SAM schemes on the following outcomes: patient knowledge, patient compliance/medication errors, success in self-administration, patient satisfaction, staff satisfaction, staff workload, and costs.

Design

Keyword and text word searches of online databases were performed between January and March 2013. Included articles described and evaluated inpatient SAM schemes. Case studies and anecdotal studies were excluded.

Results

43 papers were included for final analysis. Due to the heterogeneity of results and unclear findings it was not possible to perform a quantitative synthesis of results. Participation in SAM schemes often led to increased knowledge about drugs and drug regimens, but not side effects. However, the effect of SAM schemes on patient compliance/medication errors was inconclusive. Patients and staff were highly satisfied with their involvement in SAM schemes.

Conclusions

SAM schemes appear to provide some benefits (e.g. increased patient knowledge), but their effect on other outcomes (e.g. compliance) is unclear. Few studies of high methodological quality using validated outcome measures exist. Inconsistencies in both measuring and reporting outcomes across studies make it challenging to compare results and draw substantive conclusions about the effectiveness of SAM schemes.     

Improving medication compliance: a randomised clinical trial.

A medical monitor which recorded the date and hour each time a medicine bottle was opened was used to evaluate a programme for improving patients'' compliance with their treatment. Eighty-two patients with glaucoma who had been prescribed pilocarpine eye drops three times daily to prevent visual loss were randomised into two groups. Both groups used the medication monitor during two 20-day periods, but before the second period the experimental group were given an education and tailoring programme in an attempt to improve their compliance. Nine patients missed the second treatment period and were excluded from the analysis. The patients in the experimental group showed significantly improved compliance when compared with the control group. The numbers of missed doses were reduced by about half, as was the proportion of time that exceeded the eight-hour dose intervals. Follow-up studies are needed to determine how long the improved compliance persists, but anyone considering setting up an education and tailoring programme should recognise the extent to which therapeutic efforts are wasted because of non-compliance.     

Do-not-resuscitate order. What happens after hospital discharge?

We observed 55 inpatients with "do-not-resuscitate" (DNR) orders to determine what happened to their DNR status after hospital discharge. All were admitted to the medical service of a Department of Veterans Affairs hospital. Of the 55 patients, 16 died in the hospital, 10 were discharged to inpatient hospice units, and 1 was transferred to an acute care hospital. An additional 19 patients were discharged to nursing homes. The other 9 patients (16% of the total) survived their hospital stays; 6 successful contacts were made with patients'' spouses. In 1 case the spouse thought a DNR order was no longer desirable. In the other 5 cases the spouse said the DNR status was "probably" or "definitely" still warranted, but only 1 spouse had a written DNR order at home. We contacted 9 of the 14 house officers who had cared for the patients in hospital. Only 2 had ever written a DNR order after hospital discharge. Two house officers said they routinely discussed with family members a patient''s expected dying process at home. Unwanted resuscitation is as undesirable at home as in the hospital. Physicians should discuss future resuscitation procedures with patients who have DNR orders at the time of hospital discharge. Physicians, paramedic service directors, and policymakers also should develop protocols and standardized home DNR orders so that paramedics can honor the wishes of patients in the prehospital setting.     

Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study

ObjectivesTo prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension.DesignProspective case-control study.SettingOutpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care.Participants110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks.ResultsComplete data were available for 103 patients, of whom 86 took ⩾80% of their prescribed doses (“compliant”) and 17 took <80% (“non-compliant”). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant.ConclusionNon-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.

What is already known on this topic

For many patients with arterial hypertension, blood pressure cannot be adequately controlled despite treatment with antihypertensive drugsPatients'' poor compliance with treatment is often suggested as the reason for lack of response to antihypertensive drugs

What this study adds

When treatment compliance was monitored in hypertensive patients following stable treatment regimens, no difference in compliance was found between those with treatment resistant hypertension and those responsive to treatmentFactors other than patients'' compliance with treatment regimens should be examined to explain lack of response to antihypertensive drugs     

A psychogeriatric survey of old people's homes.

An assessment of mental impairment and behavioral disabilities in 289 residents in six old people''s homes indicated that 50.6% were probably demented and 54% needed considerable help in daily living, 74% were taking prescribed medication, and 11% were taking four or more prescribed drugs. There was a wide variation between homes in those rated as behaviourally disabled, and in the amount of medication prescribed. A follow-up of 60 mentally impaired residents showed few remediable psychiatric disorders or psychotoxic drug effects. A community psychiatric nurse working with the psychogeriatric team would provide a useful support service to old people''s homes, particularly where there is a high proportion of disturbed residents and where the staff lack nursing experience.     

Cost analysis of early discharge after hip fracture.

OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Predicting compliance with a regimen of digoxin therapy in family practice.

The ability of family physicians to predict patients'' compliance with a regimen of digoxin therapy was studied by an analytic survey. Compliance was assessed by a pill count at a home visit and measurement of the serum digoxin level in a blood sample obtained at that visit. Of 74 patients 70% were found to be taking more than 80% of their pills and 86% had a therapeutic serum digoxin level. The 10 physicians were unable to predict compliance better than chance, even for the 58 patients they had known for 5 or more years. Physicians should be cautious in predicting compliance, and when they prescribe oral digoxin therapy they should monitor the patient''s compliance by means of the serum digoxin levels.     

Prevalence and Causes of Prescribing Errors: The PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study

Objectives

Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing.

Method

A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors'' self-efficacy were established.

Results

4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p<0.001), surgical (p = <0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p<0.001), a greater number of prescribed medicines (p<0.001) and the months December and June (p<0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen.

Conclusions

Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.     

Discussing randomised clinical trials of cancer therapy: evaluation of a Cancer Research UK training programme

Objective To evaluate a training intervention aimed at improving healthcare professionals'' communication with cancer patients about randomised clinical trials.Design Before and after evaluation of training programme.Setting Members of the National Cancer Research Network, Scottish Trials Network, and the Welsh Cancer Trials NetworkParticipants 101 healthcare professionals (33 clinicians and 68 research nurses).Intervention Four modules delivered by a trained facilitator using videotapes and interactive exercises to cover general issues about discussing randomised clinical trials with patients, problems specific to adjuvant trials, trials with palliation as the goal, and trials where patients had a strong preference for one treatment arm.Main outcome measures Before and after the intervention, participants were videotaped discussing a trial with an actor portraying a patient. These consultations were assessed for presence of information required by good clinical practice guidelines. The actor patients gave an assessment after each interview. Participants reported their self confidence about key aspects of trial discussion.Results Analysis of the videotaped consultations showed that, after intervention, significantly more participants displayed key communication behaviours such as explaining randomisation (69 v 81, odds ratio 2.33, P = 0.033), checking patients'' understanding (11 v 31, odds ratio 3.22, P = 0.002), and discussing standard treatment (73 v 88, odds ratio 4.75, P = 0.005) and side effects (69 v 85, odds ratio 3.29, P = 0.006). Participants'' self confidence increased significantly (P < 0.001) across all areas. Actor patients'' ratings of participants'' communication showed significant improvements for 12/15 key items.Conclusion This intensive 8 hour intervention significantly improved participants'' confidence and competence when communicating about randomised clinical trials.     

Is an information booklet for patients leaving hospital helpful and useful?

OBJECTIVE--To determine whether a booklet given to patients being discharged from hospital giving details of their admission and treatment increased their knowledge and recall when reviewed in outpatient clinics. DESIGN--Patients alternately allocated to receive a booklet or to serve as controls. Assessment by a questionnaire at first attendance at outpatient clinic after discharge. Data were collected over nine months. SETTING--One general medical and cardiological ward in a large teaching hospital and associated outpatient clinics. PATIENTS--One hundred and thirty one patients discharged taking at least one drug and scheduled to return to clinic within 12 weeks. Patients stratified by age and by the number of weeks between discharge and outpatient appointment. INTERVENTION--A booklet was given to 65 patients at discharge from the ward; 66 patients served as controls. MAIN RESULTS--Of the patients who received the booklet, 56 (86%) knew the names of their drugs, 62 (95%) the frequency of the dose, and 55 (85%) the reasons for taking each drug. The numbers in the control group were 31 (47%), 38 (58%), and 28 (42%) respectively. These differences were highly significant (p less than 0.001). Twenty six (40%) who received the booklet brought all their drugs to clinic compared with 12 (18%) control patients. Appreciably more of the first group of patients than control patients knew the reason they had been in hospital, and more of the first group indicated that they would take the correct action when their prescribed drugs ran out. Most general practitioners thought that the booklet was a good idea, that it was helpful, and that it was better than the existing interim discharge letter. CONCLUSIONS--Giving patients an information booklet at discharge from hospital appreciably increased the accuracy and thoroughness of their recall of important medical details concerning their illness and its treatment. The booklet was shown to be feasible, helpful in the outpatient clinic, and preferred by most general practitioners.     

Parkinson's disease as community health problem: study in Norwegian nursing homes. The Norwegian Study Group of Parkinson's Disease in the Elderly.

OBJECTIVE--To examine the extent of under-diagnosis and overdiagnosis of Parkinson''s disease and to determine quality of treatment in a defined population. DESIGN--Clinical evaluation of an elderly population. SETTING--40 Norwegian nursing homes. SUBJECTS--3322 residents of nursing homes, of whom 500 were selected by nursing staff for evaluation on the basis of a structured information programme on Parkinson''s disease and 269 were examined in detail by neurologists. MAIN OUTCOME MEASURES--Patients'' scores on clinical rating scales, diagnosis of parkinsonism, and effect of changing drug treatment. RESULTS--169 (5.1%) patients were found to have clinical idiopathic Parkinson''s disease, 31 of whom had not had the disease diagnosed previously. In addition, 31 patients without the disease were taking antiparkinsonian drugs unnecessarily. Eighty patients were judged to be receiving "optimal" treatment. In the remaining 58, the treatment was changed, and 36 patients showed a definite functional improvement after a 12 week observation period. CONCLUSIONS--The quality of life of many elderly patients with Parkinson''s disease could be improved by increasing medical and neurological services.     

Comparison of effects of a self management booklet and audiocassette for patients with asthma.

The effects on self management of asthma of a specially prepared book and audiocassette tape with similar contents were observed in a controlled study of 177 patients with asthma in general practice. After a run in period of six months patients were randomly given the book, the tape, both the book and tape, or neither. Patients'' knowledge of the use of drugs, perceptions of their disability, skill in using an inhaler, consumption of drugs, consultations with their general practitioners, morbidity (from patients'' entries on diary cards), and use of the educational material were measured. Knowledge about the use of drugs was significantly increased in the groups who received the material after three months and persisted after 12 months. Patients who had been given the tape or the book and tape increased their scores of knowledge of drugs more than patients given the book alone. Patients in all groups given the material considered that their disability was reduced. There were no other significant changes. Patients given both the book and the tape preferred the book. Patients with asthma can obtain useful information from such material. The paradoxical result whereby patients learnt more from the tape but preferred the book suggests that a distinction can be made between information that patients need, which may be acquired better from an audiocassette, and information that they want, which may be acquired better from a book.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.