Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

Patient Trust in Physicians Matters-Understanding the Role of a Mobile Patient Education System and Patient-Physician Communication in Improving Patient Adherence Behavior: Field Study

BACKGROUND

The ultimate goal of any prescribed medical therapy is to achieve desired outcomes of patient care. However, patient nonadherence has long been a major problem detrimental to patient health and, thus, is a concern for all health care providers. Moreover, nonadherence is extremely costly for global medical systems because of unnecessary complications and expenses. Traditional patient education programs often serve as an intervention tool to increase patients' self-care awareness, disease knowledge, and motivation to change patient behaviors for better adherence. Patient trust in physicians, patient-physician relationships, and quality of communication have also been identified as critical factors influencing patient adherence. However, little is known about how mobile patient education technologies help foster patient adherence.

OBJECTIVE

This study aimed to empirically investigate whether and how a mobile patient education system (MPES) juxtaposed with patient trust can increase patient adherence to prescribed medical therapies.

METHODS

This study was conducted based on a field survey of 125 patients in multiple states in the United States who have used an innovative mobile health care system for their health care education and information seeking. Partial least squares techniques were used to analyze the collected data.

RESULTS

The results revealed that patient-physician communication and the use of an MPES significantly increase patients' trust in their physicians. Furthermore, patient trust has a prominent effect on patient attitude toward treatment adherence, which in turn influences patients' behavioral intention and actual adherence behavior. Based on the theory of planned behavior, the results also indicated that behavioral intention, response efficacy, and self-efficacy positively influenced patients' actual treatment adherence behavior, whereas descriptive norms and subjective norms do not play a role in this process.

CONCLUSIONS

Our study is one of the first that examines the relationship between patients who actively use an MPES and their trust in their physicians. This study contributes to this context by enriching the trust literature, addressing the call to identify key patient-centered technology determinants of trust, advancing the understanding of patient adherence mechanisms, adding a new explanation of the influence of education mechanisms delivered via mobile devices on patient adherence, and confirming that the theory of planned behavior holds in this patient adherence context.

Public target interventions to reduce the inappropriate use of medicines or medical procedures: a systematic review

Background

An epidemic of health disorders can be triggered by a collective manifestation of inappropriate behaviors, usually systematically fueled by non-medical factors at the individual and/or societal levels. This study aimed to (1) landscape and assess the evidence on interventions that reduce inappropriate demand of medical resources (medicines or procedures) by triggering behavioral change among healthcare consumers, (2) map out intervention components that have been tried and tested, and (3) identify the “active ingredients” of behavior change interventions that were proven to be effective in containing epidemics of inappropriate use of medical resources.

Methods

For this systematic review, we searched MEDLINE, EMBASE, the Cochrane Library, and PsychINFO from the databases’ inceptions to May 2019, without language restrictions, for behavioral intervention studies. Interventions had to be empirically evaluated with a control group that demonstrated whether the effects of the campaign extended beyond trends occurring in the absence of the intervention. Outcomes of interest were reductions in inappropriate or non-essential use of medicines and/or medical procedures for clinical conditions that do not require them. Two reviewers independently screened titles, abstracts, and full text for inclusion and extracted data on study characteristics (e.g., study design), intervention development, implementation strategies, and effect size. Data extraction sheets were based on the checklist from the Cochrane Handbook for Systematic Reviews.

Results

Forty-three studies were included. The behavior change technique taxonomy v1 (BCTTv1), which contains 93 behavioral change techniques (BCTs), was used to characterize components of the interventions reported in the included studies. Of the 93 BCTs, 15 (16%) were identified within the descriptions of the selected studies targeting healthcare consumers. Interventions consisting of education messages, recommended behavior alternatives, and a supporting environment that incentivizes or encourages the adoption of a new behavior were more likely to be successful.

Conclusions

There is a continued tendency in research reporting that mainly stresses the effectiveness of interventions rather than the process of identifying and developing key components and the parameters within which they operate. Reporting “negative results” is likely as critical as reporting “active ingredients” and positive findings for implementation science. This review calls for a standardized approach to report intervention studies.

Trial registration

PROSPERO registration number CRD42019139537

Database combinations to retrieve systematic reviews in overviews of reviews: a methodological study

Background

When conducting an Overviews of Reviews on health-related topics, it is unclear which combination of bibliographic databases authors should use for searching for SRs. Our goal was to determine which databases included the most systematic reviews and identify an optimal database combination for searching systematic reviews.

Methods

A set of 86 Overviews of Reviews with 1219 included systematic reviews was extracted from a previous study. Inclusion of the systematic reviews was assessed in MEDLINE, CINAHL, Embase, Epistemonikos, PsycINFO, and TRIP. The mean inclusion rate (% of included systematic reviews) and corresponding 95% confidence interval were calculated for each database individually, as well as for combinations of MEDLINE with each other database and reference checking.

Results

Inclusion of systematic reviews was higher in MEDLINE than in any other single database (mean inclusion rate 89.7%; 95% confidence interval [89.0–90.3%]). Combined with reference checking, this value increased to 93.7% [93.2–94.2%]. The best combination of two databases plus reference checking consisted of MEDLINE and Epistemonikos (99.2% [99.0–99.3%]). Stratification by Health Technology Assessment reports (97.7% [96.5–98.9%]) vs. Cochrane Overviews (100.0%) vs. non-Cochrane Overviews (99.3% [99.1–99.4%]) showed that inclusion was only slightly lower for Health Technology Assessment reports. However, MEDLINE, Epistemonikos, and reference checking remained the best combination. Among the 10/1219 systematic reviews not identified by this combination, five were published as websites rather than journals, two were included in CINAHL and Embase, and one was included in the database ERIC.

Conclusions

MEDLINE and Epistemonikos, complemented by reference checking of included studies, is the best database combination to identify systematic reviews on health-related topics.

Medication management in older people: the MEMORABLE realist synthesis

Background

The number and proportion of older people in the UK are increasing, as are multimorbidity (potentially reducing quality of life) and polypharmacy (increasing the risk of adverse drug events). Together, these complex factors are challenging for older people, informal carers, and health and care practitioners.

Objectives

MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) aimed to understand how medication management works and propose improvements.

Design

A realist approach informed three work packages, combining a realist review of secondary data with a realist evaluation of primary interview data, in a theory-driven, causal analysis.

Setting

The setting was in the community.

Participants

Older people, informal carers, and health and care practitioners.

Interventions

Studies relating to medication management and to reviewing and reconciling medications; and realist-informed interviews.

Main outcome measures

Not applicable.

Data sources

MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and EMBASE were searched (all searched from January 2009 to July 2017; searched on 1 August 2017). Supplementary articles were identified by the Research Team. Data were also obtained through interviews.

Review methods

Searches of electronic databases were supplemented by citation-tracking for explanatory contributions, as well as accessing topic-relevant grey literature. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, articles were screened and iteratively analysed with interview data, to generate theory-informed (normalisation process theory) explanations.

Results

Developing a framework to explain medication management as a complex intervention across five stages: identifying problem (Stage 1), starting, changing or stopping medications (Stage 3) and continuing to take medications (Stage 4), where older people, sometimes with informal carers, make individual decisions and follow routines that fit medication management into their day-to-day lives, engendering a sense of control. In getting diagnosis and/or medications (Stage 2) and reviewing/reconciling medications (Stage 5), older people and practitioners share decision-making in time-limited contacts: involving four steps – sense-making, relationships, action and reflection/monitoring (normalisation process theory); and conceptualising burden – through a detailed analysis of Stage 5, generating a theoretical framework and identifying five burden types amendable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Proposing interventions: risk identification – a simple way of identifying older people and informal carers who are not coping, at risk and who need appropriate help and support; and individualised information – a short, personalised record and reference point, co-produced and shared by older people, informal carers and practitioners that addresses the experience of living with multimorbidities and polypharmacy.

Limitations

Few studies directly address the complexity of medication management as a process and how it works. Limitations included, having identified the overall complexity, the need to focus the analysis on reviewing/reconciling medications (Stage 5), the exclusion of non-English-language literature, the focus on non-institutionalised populations and the broad definition of older people.

Conclusions

MEMORABLE explored the complexity of medication management. It highlighted the way interpersonal stages in the medication management process, notably reviewing/reconciling medications, contribute to the mitigation of burdens that are often hidden.

Future work

Co-produced studies to scope and trial the two proposed interventions; studies to extend the detailed understanding of medication management, linked to burden mitigation; and a study to clarify the medication management outcomes wanted by older people, informal carers and practitioners.

Study registration

This study is registered as PROSPERO CRD42016043506.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 26. See the NIHR Journals Library website for further project information.

Systematic review of the effectiveness of complementary and alternative medicine on nausea and vomiting in children with cancer: a study protocol

INTRODUCTION

Nausea and vomiting are two most common symptoms reported by children with cancer when they undergo active treatment. However, pharmacological treatment is not sufficient to manage these two symptoms, with over 40% of children still experience nausea and vomiting after receiving antiemetics. There has been an exponential growth of studies to demonstrate the effectiveness of different complementary complementary medicine (CAM) to control nausea and vomiting during cancer treatment. Appropriate application of CAM enhances the effectiveness of antiemetics, thus reducing the symptom burden on children as well as improving their general condition and quality of life during cancer treatment. Nevertheless, it remains unclear which CAM is the best approach to help children to prevent or reduce nausea and vomiting during and after cancer treatment. This paper describes a protocol for identifying, analysing and synthesising research evidence on the effectiveness of CAM on nausea and vomiting in children with cancer.

METHODS AND ANALYSIS

A total of 10 databases will be searched to identify appropriate literature: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, CINAHL, PsycINFO, LILACS, OpenSIGLE, the Chinese Biomedical Literature Database, the Chinese Medical Current Contents and the Chinese National Knowledge Infrastructure. All randomised controlled trials which meet the inclusion criteria will be included. The primary outcome is the changes in nausea and vomiting either assessed by self-reported and/or objective measures. Review Manager 5.3 will be used to synthesise the data, calculate the treatment effects, perform any subgroup analysis and assess the risk of bias.

ETHICAL AND DISSEMINATION

The results will be presented at international conferences and published in peer-reviewed journals. As no individual data will be involved in this review, ethical approval is not required.

PROSPERO REGISTRATION NUMBER

CRD42019135404.

A nurse-based intervention for improving medication adherence in cardiovascular patients: an evaluation of a randomized controlled trial

Background: Poor medication adherence is a limitation in the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs. Purpose: To examine the process and effect of a nurse-led, web-based intervention based on behavioral change strategies to improve medication adherence in patients with CVD. Patients and methods: In this single-center, prospective, controlled clinical trial, cardiovascular patients were assigned to usual care, usual care plus a personalized website, or usual care plus a personalized website and personal consultations. Primary outcome was the level of adherence to cardiovascular medication. Data collection occurred between October 2011 and January 2015. Results: In total, 419 patients were randomized. Just 77 patients logged on the website and half of the invited patients attended the group consultation. Due to the limited use of the website, we combined the results of usual care and the usual care plus website group in one group (usual care) and compared these with the results of the group which received the nurse intervention (intervention group). No significant difference in adherence between the usual care group and the intervention group was observed. The adherence level in the usual care group was 93%, compared to 89% in the intervention group (p=0.08). 29% (usual care) and 31% (intervention group) of the patients showed a low adherence according to the Modified Morisky Scale® (p-value=0.94). The mean necessity concern differential was 3.8 with no differences between the two studied groups (mean 3.8 vs mean 3.9, p-value =0.86). Conclusion: Our intervention program did not show an effect. This could indicate that structured usual care provided to all cardiovascular patients already results in high medication adherence or that shortly after a cardiovascular event adherence is high. It could also indicate that the program did not have enough impact because there was not enough compliance with the intervention protocol. Trial registration: ID number NCT01449695, approved May 2011.

The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map

OBJECTIVE

To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI).

METHODS

We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality).

FINDINGS

We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs.

CONCLUSION

A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.

Current perspectives on the role of the pharmacist in heart failure management

Pharmacists play an important role within a multidisciplinary health care team in the care of patients with heart failure (HF). It has been evaluated and documented that pharmacists providing medication reconciliation especially during transition of care, educating patients on their medications, and providing collaborative medication management lead to positive changes in the patient outcomes, including but not limited to decreasing in hospitalizations and read-missions. It is foreseeable that pharmacist roles will continue to expand as new treatment and innovative care are developed for HF patients. I reviewed published role of pharmacists in the care of HF patients. MEDLINE and Current Content database (both from 1966 – December 31, 2017) were utilized to identify peer-reviewed clinical trials, descriptive studies, and review articles published in English using the following search terms: pharmacists, clinical pharmacy, HF, and cardiomyopathy. Citations from available articles were also reviewed for additional references. Preliminary search revealed 31 studies and 55 reviews. They were further reviewed by title and abstract as well as full text to remove irrelevant articles. At the end, 24 of these clinical trials and systematic reviews are described in the following text and Table 1 summarizes 16 pertinent clinical trials. Some roles that are currently being explored include medication management in patients with mechanical circulatory support for end-stage HF, where pharmacokinetics and pharmacodynamics of medications can change, medication management in ambulatory intravenous diuretic clinics, and comprehensive medication management in patients’ home settings. Pharmacists should continue to explore and prospectively evaluate their role in the care of this patient population, including documenting their interventions, and impact to economic and patient outcomes.

Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy

OBJECTIVES

As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence.

METHODS

Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence.

RESULTS

Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%).

CONCLUSION

One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Prevalence and predictors of inadequate patient medication knowledge

OBJECTIVES

To assess medication knowledge in adult patients and to explore its determinants.

METHOD

Cross-sectional study. Medication knowledge was the primary outcome and was assessed using a previously validated questionnaire. A multivariate logistic regression analysis was performed to explore the association between medication knowledge and the factors included in the model.

RESULTS

Seven thousand two hundred seventy-eight patients participated in the study. 71.9% (n = 5234) (95% CI: 70.9%-73.0%) of the surveyed patients had an inadequate knowledge of the medication they were taking. The dimensions obtaining the highest level of knowledge were the 'medication use process' and 'therapeutic objective of medication'. The items 'frequency' (75.4%), 'dosage' (74.5%) and 'indication' (70.5%) had the highest percentage of knowledge. Conversely, 'medication safety' represented the dimension with the lowest scores, ranging from 12.6% in the item "contraindications" to 15.3% in the item 'side effects'. The odds ratio (OR) of having an inadequate medication knowledge increased for unskilled workers (OR: 1.33; 85% CI:1.00-1.78; P = 0.050), caregivers (OR:1.46; 95% CI:1.18-1.81; P < 0.001), patients using more than one medication (OR: 1.14; 95% CI: 1.00-1.31; P = 0.050) and patients who did not know the name of the medication they were taking (OR: 2.14, 95% CI: 1.71-2.68 P < 0.001).

CONCLUSION

Nearly three quarters of the analysed patients had inadequate knowledge regarding the medicines they were taking. Unskilled workers and caregivers were at a higher risk of lacking of medication knowledge. Other factors that correlated with inadequate medication knowledge were the use of more than one drug and not knowing the name of the medication dispensed.

Evaluation of a training program for medicines-oriented policymakers to use a database of systematic reviews

BACKGROUND

Suboptimal prescribing and medications use is a problem for health systems globally. Systematic reviews are a comprehensive resource that can help guide evidence-informed decision-making and implementation of interventions addressing such issues; however, a barrier to the use of systematic reviews is their inaccessibility (due to both dispersion across journals and inaccessibility of content). Publicly available databases, such as Rx for Change, provide quick access to summaries of appraised systematic reviews of professional and consumer-oriented interventions to improve prescribing behaviour and appropriate medication use, and may help maximise the use of evidence to inform decisions. The present study aims to evaluate a training program to improve attitudes towards, confidence in skills, intentions to use, and use of systematic review evidence contained within Rx for Change.

METHODS

Guided by the Knowledge to Action framework, a training program with content customised to local provider and consumer contexts was developed with knowledge user input. The training program consisted of a 6 minute information video, a 1 hour workshop with hands-on, interactive and didactic components, and two post-training reminders. Forty-nine people from five medicines-focused organisations in Canada and Australia attended one of six workshops. Participants were surveyed immediately pre and post and 3 months after training to evaluate their attitudes towards, confidence in skills, intentions to use, and use of Rx for Change, and attitudes towards and confidence in skills for using evidence for decision-making. Analyses for differences for each of the outcomes at three time points (pre, post and 3 months after training) was performed using a random effects model.

RESULTS

Immediately post-training, there were higher respondent attitudes towards Rx for Change (mean increase = 0.54 out of 5, 95% CI, 0.18-0.83, P < 0.005); intention to use Rx for Change (0.53, 95% CI, 0.21-0.86, P < 0.005); confidence in skills for using Rx for Change (2.08, 95% CI, 1.74-2.42, P < 0.005); and confidence in skills for using evidence in policy decision-making (0.50, 95% CI, 0.22-0.77, P < .005) compared to pre-training. Confidence in skills for using both Rx for Change and evidence were maintained 3 months after training (both P < 0.005).

CONCLUSIONS

Participants of this training program reported sustained improvements in their confidence in skills for using evidence in policy decision-making. This may have important implications for uptake of systematic review evidence promoting improved prescribing and medication use.

A Multifaceted Nurse- and Web-Based Intervention for Improving Adherence to Treatment in Patients With Cardiovascular Disease: Rationale and Design of the MIRROR Trial

Background

Poor adherence to medication is one of the limitations in the treatment of cardiovascular diseases, thereby increasing the risk of premature death, hospital admissions, and related costs. There is a need for simple and easy-to-implement interventions that are based on patients’ perspectives, beliefs, and perceptions of their illness and medication.

Objective

The objective is to test the effectivity of this intervention to improve medication adherence in patients with established cardiovascular disease, that is, in secondary prevention.

Methods

In this study the effect of a personalized visualization of cardiovascular risk levels through a website aiming at supporting self management in combination with a group consultation and communication intervention by a nurse on adherence to treatment in 600 patients with manifest cardiovascular diseases will be assessed. The health belief model was chosen as main theoretical model for the intervention.

Results

Primary outcome is adherence to treatment calculated by refill data. Secondary outcomes include the Beliefs about Medication Questionnaire and the Modified Morisky Scale. Patients are followed for one year. Results are expected by 2015.

Conclusions

This study assesses adherence to treatment in a high-risk cardiovascular population by applying an intervention that addresses patients’ capacity and practical barriers as well as patients’ beliefs and perceptions of their illness and medication.

ClinicalTrial

ClinicalTrials.gov NCT01449695; https://clinicaltrials.gov/ct2/show/NCT01449695 (Archived by WebCite at http://www.webcitation.org/6kCzkIKH3)

Development of training for medicines-oriented policymakers to apply evidence

Background

Health systems globally promote appropriate prescribing by healthcare providers and safe and effective medicine use by consumers. Rx for Change, a publicly available database, provides access to systematic reviews regarding best practices for prescribing and using medicines. Despite the value of the database for improving prescribing and medicine use, its use remains suboptimal. This study aimed to develop a training program for five medicine-focused organisations in Canada and Australia to facilitate the use and understanding of the Rx for Change database.

Methods

Four steps were undertaken: 1) key informant interviews were completed across all organisations to understand the knowledge user perspective; 2) a directed content analysis was completed of the interview transcripts and proposed training was developed; 3) a second round of feedback on the proposed training by knowledge users was gathered; and 4) feedback was integrated to develop the final training.

Results

Sixteen key informant interviews with knowledge users were conducted. Themes for training content included the scope of, navigation and strategies for using Rx for Change (generic content) and practical examples on incorporating evidence within their workplace context (tailored content). The final training consisted of an informational video, a 60-minute face-to-face workshop and two post-training reminders.

Conclusions

A method of engaging knowledge users in the development of a training program to improve the use of an on-line database of systematic reviews was established and used to design training. Next steps include the delivery and evaluation of the training.

Are parents of children hospitalized with severe community-acquired pneumonia more satisfied with care when physicians allow them to share decisions on the antibiotic route?

CONTEXT AND OBJECTIVE

Despite convincing evidence that oral and injected amoxicillin have equal efficacy in children with severe community-acquired pneumonia (CAP), hospitalized children often receive injected antibiotics. To investigate whether shared decision-making (choosing the antibiotic route) influences parental satisfaction.

DESIGN, SETTING AND PARTICIPANTS

In a one-year questionnaire-based study, we enrolled consecutive children hospitalized for CAP. At admission, all children's parents received a leaflet on CAP. Parents arriving during the daytime were assigned to a shared group and could choose the antibiotic route, those admitted at other times were assigned to an unshared group for whom physicians chose the antibiotic route. Shared group parents answered anonymous questionnaire investigating why they chose a specific route. Parents in both groups answered another anonymous questionnaire at discharge assessing perceived satisfaction with care.

MAIN OUTCOME MEASURE

Parents' satisfaction with perceived medical information as assessed by data from a questionnaire.

RESULTS

Of the 95 children enrolled, more children's parents were assigned to the unshared than the shared group (77 vs. 18). Of the 18 children's parents in the shared group, 14 chose the oral antibiotic route mainly to avoid painful injections. Doctors explanations were considered better in the shared than in the unshared group (P = 0.02).

DISCUSSION AND CONCLUSIONS

The larger number of children's parents assigned to the unshared group reflects paediatricians' reluctance to offer shared-decision making. Well-informed parents prefer oral antibiotic therapy for children with severe CAP. Allowing parents choose the antibiotic route respects parents' wishes, reduces children's pain and improves satisfaction.

Overview of systematic reviews - a new type of study. Part II

CONTEXT AND OBJECTIVE

Overviews of Systematic Reviews (OoRs) are a new type of study in which multiple evidence from systematic reviews (SRs) is compiled into an accessible and useful document. The aim here was to describe the state of the art and critically assess Cochrane OoRs that have been published.

DESIGN AND SETTING

Descriptive study conducted at a research center.

METHODS

The OoRs identified through the filter developed in Part I of this study were evaluated in five domains: methodological quality; quality of evidence; implications for practice; general profile of OoRs; and length of work.

RESULTS

All 13 OoRs included had high methodological quality. Some OoRs did not present sufficient data to judge the quality of evidence; using sensitivity analysis, the quality of evidence of the OoRs increased. Regarding implications for practice, 64% of the interventions were judged as beneficial or harmful, while 36% of them showed insufficient evidence for judgment. It is expected (with 95% confidence interval) that one OoR will include 9,462 to 64,469 patients, 9 to 29 systematic reviews and 80 to 344 primary studies, and assess 6 to 21 interventions; and that 50 to 92% of OoRs will produce meta-analysis. The OoRs generated 2 to 26 meta-analyses over a period of 18 to 31 months.

CONCLUSION

The OoRs presented high methodological quality; the quality of evidence tended to be moderate/high; most interventions were judged to be beneficial/harmful; the mean length of work was 24 months. The OoR profile adds power to decision-making.

Commentary on Abrahamson and Rubin (2012) “Discourse structure differences in lay and professional health communication”, Journal of Documentation, Vol. 68 No. 6, pp. 826-851

Purpose

– The purpose of this paper is to criticise the paper by Jennie A. Abrahamson and Victoria L. Rubin (2012) “Discourse structure differences in lay and professional health communication”, Journal of Documentation, Vol. 68 No. 6, pp. 826-851.

Design/methodology/approach

– The author reviewed the antecedents of Rhetorical Structure Theory (RST) in discourse analysis, and paid close attention to the differences between the original formulation of RST, later formulations of the RST model and the application of RST in this paper. The author also reviewed the literature on physician-patient communication, and patient-patient support to contextualise the findings of Abrahamson and Rubin.

Findings

– The paper shows evidence of over-simplification of RST since its initial formulation. Next, the Motivation relationship in the original Mann/Thompson formulation of RST appears problematic. This makes the authors’ RST findings that patient-patient (or consumer-consumer) information sharing appear to be more effective than physician-consumer information sharing rather tenuous. An important additional flaw is that there was only one physician participant in this study. A practical limitation to the study is that physicians mostly interact face-to-face with patients and use of consumer advice web sites may not fit well with the current practice of medicine.

Research limitations/implications

– The author had limited examples in the paper to examine how the authors had categorised the binary unit relationships.

Originality/value

– RST is promising for discourse analysis of information advice web sites but simplifications in its application can lead to unwarranted claims.

Implementing strategies in consumer and community engagement in health care: results of a large-scale, scoping meta-review

BACKGROUND

There is growing recognition of the importance of the active involvement of consumers and community members in health care. Despite the long history of consumer and community engagement (CCE) research and practice, there is no consensus on the best strategies for CCE. In this paper, we identify various dimensions of CCE-related strategies and offer a practical model to assist policy-makers, practitioners and researchers.

METHODS

We undertook a large-scale, scoping meta-review and searched six databases using a list of nine medical subject headings (MeSH) and a comprehensive list of 47 phrases. We identified and examined a total of 90 relevant systematic reviews.

RESULTS

Identified reviews show that although there is a significant body of research on CCE, the development of the field is hindered by a lack of evidence relating to specific elements of CCE. They also indicate a diverse and growing enterprise, drawing on a wide range of disciplinary, political and philosophical perspectives and a mix of definitions, targets, approaches, strategies and mechanisms. CCE interventions and strategies aim to involve consumers, community members and the public in general, as well as specific sub-groups, including children and people from culturally and linguistically diverse backgrounds. Strategies for CCE vary in terms of their aim and type of proposed activity, as do the methods and tools which have been developed to support them. Methods and tools include shared decision making, use of decision aids, consumer representation, application of electronic and internet-based facilities, and peer support. The success of CCE is dependent on both the approach taken and contextual factors, including structural facilitators such as governmental support, as well as barriers such as costs, organisational culture and population-specific limitations.

CONCLUSIONS

The diversity of the field indicates the need to measure each component of CCE. This meta-review provides the basis for development of a new eight stage model of consumer and community engagement. This model emphasises the importance of clarity and focus, as well as an extensive evaluation of contextual factors within specific settings, before the implementation of CCE strategies, enabling those involved in CCE to determine potential facilitators and barriers to the process.

Key concepts in consumer and community engagement: a scoping meta-review

BACKGROUND

Although consumer and community engagement (CCE) in health care is receiving increasing attention, research and practice in this area are hampered by the variability of concepts and terminology commonly employed. This scoping meta-review aims to identify key CCE concepts and examine terminology used to describe them.

METHODS

In a scoping meta-review, an extensive list of 47 phrases and 11 Medical Subject Headings (MeSH) was used to undertake a comprehensive and systematic search in PubMed Central, Embase, EBM reviews, CINAHL, APAPsycNET, and Scopus.

RESULTS

59 systematic reviews met the selection criteria and were included in the final analysis. The analysis identified nine different concepts related to CCE: shared decision making, self-management, CCE in health care systems, community-based health promotion, providing access to health care, rehabilitation, participation in research, collaboration in research design and conduct, and peer support. The identified concepts differ from each other in many aspects including the aim of the activity, the role of consumers and the type of professionals' involvement. Each concept was described by a range of terms, with some terms shared by different concepts. In addition, two overlapping concepts of patient-centeredness and patient empowerment were recognised.

CONCLUSIONS

This study describes CCE-related key concepts and provides new insight into their relationship with different CCE-related terms. Identification of key CCE-related concepts and terms will be useful to focus future studies and initiatives and enhance production of CCE-related evidence.

Interventions to improve delivery of isoniazid preventive therapy: an overview of systematic reviews

Background

Uptake of isoniazid preventive therapy (IPT) to prevent tuberculosis has been poor, particularly in the highest risk populations. Interventions to improve IPT delivery could promote implementation. The large number of existing systematic reviews on treatment adherence has made drawing conclusions a challenge. To provide decision makers with the evidence they need, we performed an overview of systematic reviews to compare different organizational interventions to improve IPT delivery as measured by treatment completion among those at highest risk for the development of TB disease, namely child contacts or HIV-infected individuals.

Methods

We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE), and MEDLINE up to August 15, 2012. Two authors used a standardized data extraction form and the AMSTAR instrument to independently assess each review.

Results

Six reviews met inclusion criteria. Interventions included changes in the setting/site of IPT delivery, use of quality monitoring mechanisms (e.g., directly observed therapy), IPT delivery integration into other healthcare services, and use of lay health workers. Most reviews reported a combination of outcomes related to IPT adherence and treatment completion rate but without a baseline or comparison rate. Generally, we found limited evidence to demonstrate that the studied interventions improved treatment completion.

Conclusions

While most of the interventions were not shown to improve IPT completion, integration of tuberculosis and HIV services yielded high treatment completion rates in some settings. The lack of data from high burden TB settings limits applicability. Further research to assess different IPT delivery interventions, including those that address barriers to care in at-risk populations, is urgently needed to identify the most effective practices for IPT delivery and TB control in high TB burden settings.

Lost in Translation (LiT): IUPHAR Review 6

Translational medicine is a roller coaster with occasional brilliant successes and a large majority of failures. Lost in Translation 1 ('LiT1'), beginning in the 1950s, was a golden era built upon earlier advances in experimental physiology, biochemistry and pharmacology, with a dash of serendipity, that led to the discovery of many new drugs for serious illnesses. LiT2 saw the large-scale industrialization of drug discovery using high-throughput screens and assays based on affinity for the target molecule. The links between drug development and university sciences and medicine weakened, but there were still some brilliant successes. In LiT3, the coverage of translational medicine expanded from molecular biology to drug budgets, with much greater emphasis on safety and official regulation. Compared with R&D expenditure, the number of breakthrough discoveries in LiT3 was disappointing, but monoclonal antibodies for immunity and inflammation brought in a new golden era and kinase inhibitors such as imatinib were breakthroughs in cancer. The pharmaceutical industry is trying to revive the LiT1 approach by using phenotypic assays and closer links with academia. LiT4 faces a data explosion generated by the genome project, GWAS, ENCODE and the 'omics' that is in danger of leaving LiT4 in a computerized cloud. Industrial laboratories are filled with masses of automated machinery while the scientists sit in a separate room viewing the results on their computers. Big Data will need Big Thinking in LiT4 but with so many unmet medical needs and so many new opportunities being revealed there are high hopes that the roller coaster will ride high again.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Is adherence a relevant issue in the self-management education of diabetes? A mixed narrative review

While therapeutic patient education is now recognized as essential for optimizing the control of chronic diseases and patient well-being, adherence to treatment and medical recommendations is still a matter of debate. In type 2 diabetes, the nonadherence to therapy, estimated at more than 40%, is perceived as a barrier for improving the prognosis despite recent therapeutic advances. Interventional studies have barely begun to demonstrate the effectiveness of technical and behavioral actions. The aim of this review is to question the concept of adherence in terms of therapeutic education based on quantitative and qualitative data. The research on therapeutic education has shown the effectiveness of structured actions in type 2 diabetes, but adherence is rarely an end point in randomized trials. A positive but inconsistent or moderate effect of education actions on adherence has been shown in heterogeneous studies of varying quality. Program types, outlines, theoretical bases, and curricula to set up for action effectiveness are still being discussed. Qualitative studies, including sociological studies, provide a useful and constructive focus on this perspective. Adherence is a soft and flexible tool available to the patient in his/her singular chronic disease trajectory, and as such, integrates into individual therapeutic strategies, including socio-cultural interactions, beyond the medical explanation of the disease and the patient. Four key elements for the development of structured therapeutic education are discussed: 1) the access to health literacy, 2) the contextualization of education activities, 3) the long-term chronic dimension of self-management, and 4) the organizational aspects of health and care. Rather than focusing the objective on behavioral changes, structured therapeutic education actions should attempt to provide tools and resources aimed at helping individuals to manage their disease in their own context on a long-term basis, by developing health literacy and relational and organizational aspects of the health professionals and system.

Face to face interventions for informing or educating parents about early childhood vaccination

BACKGROUND

Childhood vaccination (also described as immunisation) is an important and effective way to reduce childhood illness and death. However, there are many children who do not receive the recommended vaccines because their parents do not know why vaccination is important, do not understand how, where or when to get their children vaccinated, disagree with vaccination as a public health measure, or have concerns about vaccine safety.Face to face interventions to inform or educate parents about routine childhood vaccination may improve vaccination rates and parental knowledge or understanding of vaccination. Such interventions may describe or explain the practical and logistical factors associated with vaccination, and enable parents to understand the meaning and relevance of vaccination for their family or community.

OBJECTIVES

To assess the effects of face to face interventions for informing or educating parents about early childhood vaccination on immunisation uptake and parental knowledge.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (OvidSP) (1946 to July 2012); EMBASE + Embase Classic (OvidSP) (1947 to July 2012); CINAHL (EbscoHOST) (1981 to July 2012); PsycINFO (OvidSP) (1806 to July 2012); Global Health (CAB) (1910 to July 2012); Global Health Library (WHO) (searched July 2012); Google Scholar (searched September 2012), ISI Web of Science (searched September 2012) and reference lists of relevant articles. We searched for ongoing trials in The International Clinical Trials Registry Platform (ICTRP) (searched August 2012) and for grey literature in The Grey Literature Report and OpenGrey (searched August 2012). We also contacted authors of included studies and experts in the field. There were no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster RCTs evaluating the effects of face to face interventions delivered to individual parents or groups of parents to inform or educate about early childhood vaccination, compared with control or with another face to face intervention. Early childhood vaccines are all recommended routine childhood vaccines outlined by the World Health Organization, with the exception of human papillomavirus vaccine (HPV) which is delivered to adolescents.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed database search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed the risk of bias of included studies. We contacted study authors for additional information.

MAIN RESULTS

We included six RCTs and one cluster RCT involving a total of 2978 participants. Three studies were conducted in low- or middle-income countries and four were conducted in high-income countries. The cluster RCT did not contribute usable data to the review. The interventions comprised a mix of single-session and multi-session strategies. The quality of the evidence for each outcome was low to very low and the studies were at moderate risk of bias overall. All these trials compared face to face interventions directed to individual parents with control.The three studies assessing the effect of a single-session intervention on immunisation status could not be pooled due to high heterogeneity. The overall result is uncertain because the individual study results ranged from no evidence of effect to a significant increase in immunisation.Two studies assessed the effect of a multi-session intervention on immunisation status. These studies were also not pooled due to heterogeneity and the result was very uncertain, ranging from a non-significant decrease in immunisation to no evidence of effect.The two studies assessing the effect of a face to face intervention on knowledge or understanding of vaccination were very uncertain and were not pooled as data from one study were skewed. However, neither study showed evidence of an effect on knowledge scores in the intervention group. Only one study measured the cost of a case management intervention. The estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care.The review also considered the following secondary outcomes: intention to vaccinate child, parent experience of intervention, and adverse effects. No adverse effects related to the intervention were measured by any of the included studies, and there were no data on the other outcomes of interest.

AUTHORS' CONCLUSIONS

The limited evidence available is low quality and suggests that face to face interventions to inform or educate parents about childhood vaccination have little to no impact on immunisation status, or knowledge or understanding of vaccination. There is insufficient evidence to comment on the cost of implementing the intervention, parent intention to vaccinate, parent experience of the intervention, or adverse effects. Given the apparently limited effect of such interventions, it may be feasible and appropriate to incorporate communication about vaccination into a healthcare encounter, rather than conduct it as a separate activity.

An exploratory study of the factors associated with medication nonadherence among youth in adult mental health facilities in Ontario, Canada

Although the issue of medication nonadherence among children and youth appears to be high, there is a paucity of research examining associated factors related to medication nonadherence among youth with mental health difficulties. Using logistic regression, this exploratory study sought to examine specific factors associated with medication nonadherence among youth with mental health needs in Ontario, Canada. Data on 3681 youth between the ages of 12-18 years old were obtained from the Resident Assessment Instrument for Mental Health (RAI-MH). Medication nonadherence was observed among 24.6% of the study population. Multivariate results showed that youth who experienced side effects of psychotropic medication were more than 3 times more likely to have failed to adhere to their medication. Other significant factors contributing to medication nonadherence include age, having multiple psychiatric admissions, limited insight into mental health, and having a disturbed/dysfunctional relationship with immediate family members. Tobacco use, cannabis use, depressive symptoms, and positive symptoms were also associated with medication nonadherence. Our data highlights some of the factors associated with medication nonadherence among youth with mental health needs. Physicians, clinicians and mental health care providers need to consider these factors, particularly when planning for discharge.

Multimedia educational interventions for consumers about prescribed and over-the-counter medications

BACKGROUND

Health consumers increasingly want access to accurate, evidence-based information about their medications. Currently, education about medications (that is, information that is designed to achieve health or illness related learning) is provided predominantly via spoken communication between the health provider and consumer, sometimes supplemented with written materials. There is evidence, however, that current educational methods are not meeting consumer needs. Multimedia educational programs offer many potential advantages over traditional forms of education delivery.

OBJECTIVES

To assess the effects of multimedia patient education interventions about prescribed and over-the-counter medications in people of all ages, including children and carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), PsycINFO (1967 to June 2011), ERIC (1966 to June 2011), ProQuest Dissertation & Theses Database (to June 2011) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of multimedia-based patient education about prescribed or over-the-counter medications in people of all ages, including children and carers, if the intervention had been targeted for their use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Where possible, we contacted study authors to obtain missing information.

MAIN RESULTS

We identified 24 studies that enrolled a total of 8112 participants. However, there was significant heterogeneity in the comparators used and the outcomes measured, which limited the ability to pool data. Many of the studies did not report sufficient information in their methods to allow judgment of their risk of bias. From the information that was reported, three of the studies had a high risk of selection bias and one was at high risk of bias due to lack of blinding of the outcome assessors. None of the included studies reported the minimum clinically important difference for the outcomes that were measured. We have therefore reported results from the studies but have been unable to interpret whether differences were of clinical importance.The main findings of the review are as follows.Knowledge: There is low quality evidence that multimedia education was more effective than usual care (non-standardised education provided as part of usual clinical care) or no education (standardised mean difference (SMD) 1.04, 95% confidence interval (CI) 0.49 to 1.58, six studies with 817 participants). There was considerable statistical heterogeneity (I(2) = 89%), however, all but one of the studies favoured the multimedia group. There is moderate quality evidence that multimedia education was not more effective at improving knowledge than control multimedia interventions (i.e. multimedia programs that do not provide information about the medication) (mean difference (MD) of knowledge scores 2.78%, 95% CI -1.48 to 7.0, two studies with 568 participants). There is moderate quality evidence that multimedia education was more effective when added to a co-intervention (written information or brief standardised instructions provided by a health professional) compared with the co-intervention alone (MD of knowledge scores 24.59%, 95% CI 22.34 to 26.83, two studies with 381 participants).Skill acquisition: There is moderate quality evidence that multimedia education was more effective than usual care or no education (MD of inhaler technique score 18.32%, 95% CI 11.92 to 24.73, two studies with 94 participants) and written education (risk ratio (RR) of improved inhaler technique 2.14, 95% CI 1.33 to 3.44, two studies with 164 participants). There is very low quality evidence that multimedia education was equally effective as education by a health professional (MD of inhaler technique score -1.01%, 95% CI -15.75 to 13.72, three studies with 130 participants).Compliance with medications: There is moderate quality evidence that there was no difference between multimedia education and usual care or no education (RR of complying 1.02, 95% CI 0.96 to 1.08, two studies with 4552 participants).We could not determine the effect of multimedia education on other outcomes, including patient satisfaction, self-efficacy and health outcomes, due to an inadequate number of studies from which to draw conclusions.

AUTHORS' CONCLUSIONS

This review provides evidence that multimedia education about medications is more effective than usual care (non-standardised education provided by health professionals as part of usual clinical care) or no education, in improving both knowledge and skill acquisition. It also suggests that multimedia education is at least equivalent to other forms of education, including written education and education provided by a health professional. However, this finding is based on often low quality evidence from a small number of trials. Multimedia education about medications could therefore be considered as an adjunct to usual care but there is inadequate evidence to recommend it as a replacement for written education or education by a health professional. Multimedia education may be considered as an alternative to education provided by a health professional, particularly in settings where provision of detailed education by a health professional is not feasible. More studies evaluating multimedia educational interventions are required in order to increase confidence in the estimate of effect of the intervention.Conclusions regarding the effect of multimedia education were limited by the lack of information provided by study authors about the educational interventions, and variability in their content and quality. Studies testing educational interventions should provide detailed information about the interventions and comparators. Research is required to establish a framework that is specific for the evaluation of the quality of multimedia educational programs. Conclusions were also limited by the heterogeneity in the outcomes reported and the instruments used to measure them. Research is required to identify a core set of outcomes which should be measured when evaluating patient educational interventions. Future research should use consistent, reliable and validated outcome measures so that comparisons can be made between studies.

The relationship among health literacy, health knowledge, and adherence to treatment in patients with rheumatoid arthritis

BACKGROUND

Patients with poor health literacy often lack the knowledge needed to manage their treatment.

OBJECTIVE

The aim of this cross-sectional study is to determine whether health literacy is a predictor of health knowledge and/or adherence to medication treatment in patients with rheumatoid arthritis.

METHOD

The study was completed in an urban, outpatient rheumatology setting. Health literacy was measured using the Test of Functional Health Literacy in Adults. The Arthritis Knowledge Questionnaire was modified to measure medication specific health knowledge, and the Morisky Medication Adherence scale was used to measure adherence. Researchers used regression analyses to determine if health literacy was a predicator of knowledge and/or adherence.

RESULTS

Participants (N = 125) had high mean health literacy scores. The average medication knowledge score was 0.73. Adherence to medication regimen was 0.84. Controlling for patient covariates, health literacy was positively associated with education, race, and age. In adjusted analyses, health literacy was a significant predictor of health knowledge but not adherence. Race, neighborhood income, and confidence with contacting provider about medications were predictors of adherence.

CONCLUSION

Study findings indicate that health literacy is independently associated with medication knowledge but not medication adherence in patients with rheumatoid arthritis. These results provide useful information for planning initiatives to support individuals with disease self-management.

Predictors of adherence to performance measures in patients with acute myocardial infarction

BACKGROUND

There have been substantial improvements in the use of evidence-based, guideline-recommended therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine those factors associated with lessened adherence to guideline-based care.

METHODS

The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for all measures, in eligible patients.

RESULTS

We identified 10 variables that were associated significantly with either greater adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model. Age, sex, and calendar year were significant in all models.

CONCLUSIONS

Use of evidence-based acute myocardial infarction treatments remains less than ideal for certain high-risk populations. The close correlations among factors associated with underperformance highlights the potential for specifically targeting and tailoring quality improvement interventions.

Intervention to enhance communication about newly prescribed medications

PURPOSE

Physicians prescribing new medications often do not convey important medication-related information. This study tests an intervention to improve physician-patient communication about newly prescribed medications.

METHODS

We conducted a controlled clinical trial of patients in 3 primary care practices, combining data from patient surveys with audio-recorded physician-patient interactions. The intervention consisted of a 1-hour physician-targeted interactive educational session encouraging communication about 5 basic elements regarding a new prescription and a patient information handout listing the 5 basic elements. Main outcome measures were the Medication Communication Index (MCI), a 5-point index assessed by qualitative analysis of audio-recorded interactions (giving points for discussion of medication name, purpose, directions for use, duration of use, and side effects), and patient ratings of physician communication about new prescriptions.

RESULTS

Twenty-seven physicians prescribed 113 new medications to 82 of 256 patients. The mean MCI for medications prescribed by physicians in the intervention group was 3.95 (SD = 1.02), significantly higher than that for medications prescribed by control group physicians (2.86, SD = 1.23, P <.001). This effect held regardless of medication type (chronic vs nonchronic medication). Counseling about 3 of the 5 MCI components was significantly higher for medications prescribed by physicians in the intervention group, as were patients' ratings of new medication information transfer (P = .02). Independent of intervention or control groups, higher MCI scores were associated with better patient ratings about information about new prescriptions (P = .003).

CONCLUSIONS

A physician-targeted educational session improved the content of and enhanced patient ratings of physician communication about new medication prescriptions. Further work is required to assess whether improved communication stimulated by the intervention translates into better clinical outcomes.

Delayed educational reminders for long-term medication adherence in ST-elevation myocardial infarction (DERLA-STEMI): protocol for a pragmatic, cluster-randomized controlled trial

Background

Despite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality.

Methods/design

This is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled.

Discussion

This intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future.

Trial registration

Clinicaltrials.gov NCT01325116

Knowledge translation of research findings

BACKGROUND

One of the most consistent findings from clinical and health services research is the failure to translate research into practice and policy. As a result of these evidence-practice and policy gaps, patients fail to benefit optimally from advances in healthcare and are exposed to unnecessary risks of iatrogenic harms, and healthcare systems are exposed to unnecessary expenditure resulting in significant opportunity costs. Over the last decade, there has been increasing international policy and research attention on how to reduce the evidence-practice and policy gap. In this paper, we summarise the current concepts and evidence to guide knowledge translation activities, defined as T2 research (the translation of new clinical knowledge into improved health). We structure the article around five key questions: what should be transferred; to whom should research knowledge be transferred; by whom should research knowledge be transferred; how should research knowledge be transferred; and, with what effect should research knowledge be transferred?

DISCUSSION

We suggest that the basic unit of knowledge translation should usually be up-to-date systematic reviews or other syntheses of research findings. Knowledge translators need to identify the key messages for different target audiences and to fashion these in language and knowledge translation products that are easily assimilated by different audiences. The relative importance of knowledge translation to different target audiences will vary by the type of research and appropriate endpoints of knowledge translation may vary across different stakeholder groups. There are a large number of planned knowledge translation models, derived from different disciplinary, contextual (i.e., setting), and target audience viewpoints. Most of these suggest that planned knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators. Although our evidence on the likely effectiveness of different strategies to overcome specific barriers remains incomplete, there is a range of informative systematic reviews of interventions aimed at healthcare professionals and consumers (i.e., patients, family members, and informal carers) and of factors important to research use by policy makers.

SUMMARY

There is a substantial (if incomplete) evidence base to guide choice of knowledge translation activities targeting healthcare professionals and consumers. The evidence base on the effects of different knowledge translation approaches targeting healthcare policy makers and senior managers is much weaker but there are a profusion of innovative approaches that warrant further evaluation.

Overview of systematic reviews - a new type of study: part I: why and for whom?

CONTEXT AND OBJECTIVE

Healthcare decision-making is complex and should involve healthcare professionals, patients and the best level of evidence. The speed of information production creates barriers against keeping up to date. In this light, methodologists have proposed a new type of study: overviews of systematic reviews (OoRs). The aim here was to introduce and demonstrate the role of OoRs in information synthesis for healthcare professionals, managers, researchers and patients.

DESIGN AND SETTING

Time-series study conducted at the Brazilian Cochrane Center, jointly with the Postgraduate Program on Internal Medicine and Therapeutics, Discipline of Emergency Medicine and Evidence-Based Medicine, Department of Medicine, Federal University of São Paulo.

METHODS

To show the growth in the numbers of published papers that provide high-level evidence and thus demonstrate the importance of OoRs for synthesis and integration of information, three filters for study designs were applied to two databases. An equation for predicting the expected number of published papers was developed and applied.

RESULTS

Over the present decade, the number of randomized controlled trials in Medline might reach 2,863,203 and the number of systematic reviews might reach 174,262. Nine OoRs and 15 OoRs protocols have been published in the Cochrane Library.

CONCLUSIONS

With the exponential growth of published papers, as shown in this study, a new type of study directed especially towards healthcare decision-makers was proposed, named "overview of systematic reviews". This could reduce the uncertainties in decision-making and generate a new hierarchy in the pyramid of evidence.

Managing side effects of tyrosine kinase inhibitor therapy to optimize adherence in patients with chronic myeloid leukemia: the role of the midlevel practitioner

In the last decade, the development of imatinib, a tyrosine kinase inhibitor, has brought about unprecedented change in the way newly diagnosed, chronic-phase chronic myeloid leukemia patients are treated. Two next-generation tyrosine kinase inhibitors, nilotinib and dasatinib, were initially indicated for imatinib-resistant or imatinib-intolerant chronic myeloid leukemia patients and recently received approval from the Food and Drug Administration for treatment of newly diagnosed, chronic-phase chronic myeloid leukemia patients. In comparison with the previous standards of care, benefits with these three tyrosine kinase inhibitors have included more rapid response rates, increased survival, and fewer side effects. The improved long-term outcomes have altered the approach to management of chronic myeloid leukemia from a progressive fatal disease with a poor prognosis to a chronic condition similar to diabetes or hypertension. Prolonged survival increases the need for patient education, support, monitoring, and assistance with adverse event management. Even low-grade side effects can adversely affect patients' quality of life and, therefore, require prompt attention to prevent long-term complications or suboptimal outcomes. New evidence has indicated that patient adherence to tyrosine kinase inhibitor therapy is essential to successful treatment. Midlevel practitioners can help to optimize outcomes by educating patients regarding the importance of adherence, performing regular monitoring, helping patients to understand their test results, and aggressively managing treatment-related side effects.

Methodology in conducting a systematic review of systematic reviews of healthcare interventions

BACKGROUND

Hundreds of studies of maternity care interventions have been published, too many for most people involved in providing maternity care to identify and consider when making decisions. It became apparent that systematic reviews of individual studies were required to appraise, summarise and bring together existing studies in a single place. However, decision makers are increasingly faced by a plethora of such reviews and these are likely to be of variable quality and scope, with more than one review of important topics. Systematic reviews (or overviews) of reviews are a logical and appropriate next step, allowing the findings of separate reviews to be compared and contrasted, providing clinical decision makers with the evidence they need.

METHODS

The methods used to identify and appraise published and unpublished reviews systematically, drawing on our experiences and good practice in the conduct and reporting of systematic reviews are described. The process of identifying and appraising all published reviews allows researchers to describe the quality of this evidence base, summarise and compare the review's conclusions and discuss the strength of these conclusions.

RESULTS

Methodological challenges and possible solutions are described within the context of (i) sources, (ii) study selection, (iii) quality assessment (i.e. the extent of searching undertaken for the reviews, description of study selection and inclusion criteria, comparability of included studies, assessment of publication bias and assessment of heterogeneity), (iv) presentation of results, and (v) implications for practice and research.

CONCLUSION

Conducting a systematic review of reviews highlights the usefulness of bringing together a summary of reviews in one place, where there is more than one review on an important topic. The methods described here should help clinicians to review and appraise published reviews systematically, and aid evidence-based clinical decision-making.

The Rx for Change database: a first-in-class tool for optimal prescribing and medicines use

BACKGROUND

Globally, suboptimal prescribing practices and medication errors are common. Guidance to health professionals and consumers alone is not sufficient to optimise behaviours, therefore strategies to promote evidence-based decision making and practice, such as decision support tools or reminders, are important. The literature in this area is growing, but is of variable quality and dispersed across sources, which makes it difficult to identify, access, and assess. To overcome these problems, by synthesizing and evaluating the data from systematic reviews, we have developed Rx for Change to provide a comprehensive, online database of the evidence for strategies to improve drug prescribing and use.

METHODS

We use reliable and valid methods to search and screen the literature, and to appraise and analyse the evidence from relevant systematic reviews. We then present the findings in an online format which allows users to easily access pertinent information related to prescribing and medicines use. The database is a result of the collaboration between the Canadian Agency for Drugs and Technologies in Health (CADTH) and two Cochrane review groups.

RESULTS

To capture the body of evidence on interventions to improve prescribing and medicines use, we conduct comprehensive and regular searches in multiple databases, and hand-searches of relevant journals. We screen articles to identify relevant systematic reviews, and include them if they are of moderate or high methodological quality. Two researchers screen, assess quality, and extract data on demographic details, intervention characteristics, and outcome data. We report the results of our analysis of each systematic review using a standardised quantitative and qualitative format. Rx for Change currently contains over 200 summarised reviews, structured in a multi-level format. The reviews included in the database are diverse, covering various settings, conditions, or diseases and targeting a range of professional and consumer behaviors.

CONCLUSIONS

Rx for Change is a novel database that synthesizes current research evidence about the effects of interventions to improve drug prescribing practices and medicines use.

How can we support the use of systematic reviews in policymaking?

John Lavis discusses how health policymakers and their stakeholders need research evidence, and the best ways evidence can be synthesized and packaged to optimize its use.

Building blocks for meta-synthesis: data integration tables for summarising, mapping, and synthesising evidence on interventions for communicating with health consumers

Background

Systematic reviews have developed into a powerful method for summarising and synthesising evidence. The rise in systematic reviews creates a methodological opportunity and associated challenges and this is seen in the development of overviews, or reviews of systematic reviews. One of these challenges is how to summarise evidence from systematic reviews of complex interventions for inclusion in an overview. Interventions for communicating with and involving consumers in their care are frequently complex. In this article we outline a method for preparing data integration tables to enable review-level synthesis of the evidence on interventions for communication and participation in health.

Methods and Results

Systematic reviews published by the Cochrane Consumers and Communication Review Group were utilised as the basis from which to develop linked steps for data extraction, evidence assessment and synthesis. The resulting output is called a data integration table. Four steps were undertaken in designing the data integration tables: first, relevant information for a comprehensive picture of the characteristics of the review was identified from each review, extracted and summarised. Second, results for the outcomes of the review were assessed and translated to standardised evidence statements. Third, outcomes and evidence statements were mapped into an outcome taxonomy that we developed, using language specific to the field of interventions for communication and participation. Fourth, the implications of the review were assessed after the mapping step clarified the level of evidence available for each intervention.

Conclusion

The data integration tables represent building blocks for constructing overviews of review-level evidence and for the conduct of meta-synthesis. Individually, each table aims to improve the consistency of reporting on the features and effects of interventions for communication and participation; provides a broad assessment of the strength of evidence derived from different methods of analysis; indicates a degree of certainty with results; and reports outcomes and gaps in the evidence in a consistent and coherent way. In addition, individual tables can serve as a valuable tool for accurate dissemination of large amounts of complex information on communication and participation to professionals as well as to members of the public.