Assessment of anti-infective medication adherence in pediatric outpatients

Efficacy of an mHealth App to Support Patients' Self-Management of Hypertension: Randomized Controlled Trial

BACKGROUND

Hypertension is a significant global disease burden. Mobile health (mHealth) offers a promising means to provide patients with hypertension with easy access to health care services. Yet, its efficacy needs to be validated, especially in lower-income areas with a high-salt diet.

OBJECTIVE

This study aims to assess the efficacy of an mHealth app-based intervention in supporting patients' self-management of hypertension.

METHODS

A 2-arm randomized controlled trial was conducted among 297 patients with hypertension at the General Hospital of Ningxia Medical University, Ningxia Hui Autonomous Region, China. Participants selected via convenience sampling were randomly allocated into intervention and control groups. Intervention group participants were trained and asked to use an mHealth app named Blood Pressure Assistant for 6 months. They could use the app to record and upload vital signs, access educational materials, and receive self-management reminders and feedback from health care providers based on the analysis of the uploaded data. Control group participants received usual care. Blood pressure (BP) and 2 questionnaire surveys about hypertension knowledge and lifestyle behavior were used to assess all participants at baseline and 6 months. Data analysis was performed with SPSS software using 2-tailed t tests and a chi-square test.

RESULTS

There were no significant differences in baseline characteristics and medication use between the 2 groups (all P>.05). After 6 months, although both groups show a significant pre-post improvement (P<.001 each), the BP control rate (ie, the proportion of patients with a systolic BP of <140 mm Hg and diastolic BP of <90 mm Hg) in the intervention group was better than that in the control group (100/111, 90.1% vs 75/115, 65.2%; P<.001). The mean systolic and diastolic BP were significantly reduced by 25.83 (SD 8.99) and 14.28 (SD 3.74) mm Hg in the intervention group (P<.001) and by 21.83 (SD 6.86) and 8.87 (SD 4.22) mm Hg in the control group (P<.001), respectively. The differences in systolic and diastolic BP between the 2 groups were significant (P<.001 and P=.01, respectively). Hypertension knowledge significantly improved only in the intervention group in both pre-post and intergroup comparisons (both P<.001). However, only intragroup improvement was observed for lifestyle behaviors in the intervention group (P<.001), including medication adherence (P<.001), healthy diet (P=.02), low salt intake (P<.001), and physical exercises (P=.02), and no significant difference was observed in the control group or on intergroup comparisons.

CONCLUSIONS

This research shows that the mHealth app-based intervention has the potential to improve patient health knowledge and support self-management among them toward a healthier lifestyle, including medication adherence, low-salt diets, and physical exercises, thereby achieving optimal BP control. Further research is still needed to verify the specific effects of these interventions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900026437; https://www.chictr.org.cn/showproj.html?proj=38801.

Examining factors that influence medication adherence with children seen at outpatient department in Western China: a cross-sectional survey

We aimed to evaluate the prevalence of medication adherence, assess the association between guardians' mental health and medication adherence for children seen at outpatient department from western China, and identify characteristics associated with nonadherence. We conducted a cross-sectional survey. Participants were recruited by consecutive sampling from the outpatient of the West China Second Hospital from October 2021 to April 2022. The Morisky Medication Adherence Scale (MMAS-8) was used to evaluate patients' medication adherence. A multivariate linear regression model was used to analyze influencing factors. 1206 children with a mean age of 6.02 ± 3.86 years were included. Seventeen percent (208/1206) of patients showed good adherence, 24.7% (298/1206) showed moderate adherence, and 58% (700/1206) showed poor adherence. Thirty-five percent (428/1206) of guardians had anxiety. Factors that influenced medication adherence included anxiety score of guardian (P = 0.030), education level of guardian (P = 0.003), annual household income (P = 0.001), and days the patient is on the medication (P = 0.023). A majority of children seen at outpatient department from West China had low medication adherence, and depression and anxiety among guardians were common. Implementing health education measures will be important for improving medication adherence in future.

Adherence and utilization of short-term antibiotics: Randomized controlled study

Enhancing adherence to medication has the potential to improve clinical outcomes and decrease healthcare cost. The role of clinical pharmacist-led education on adherence to short-term antibiotic has never been investigated in Jordan. This study aimed to evaluate the impact of an educational intervention on antibiotic short-term adherence and to assess the antibiotic utilization pattern. A prospective, single blinded, randomized controlled study was conducted in a tertiary referral hospital in Jordan. Adult patients diagnosed with acute infection and prescribed a short-term antibiotic course (< 30 day) were included in the study. Recruited patients were randomly allocated into control and intervention groups. Pharmaceutical education about the correct use of antibiotic/s was provided to the intervention group. The results showed that penicillins were the most prescribed antibiotics (38.7%) followed by fluoroquinolones (23.9%) and cephalosporines (20.9%). Patients in the intervention group were more likely to be adherent to the prescribed antibiotics compared to control group (OR = 1.445, 95CI% = 1.029-2.030, p = 0.033). Employed patients, less frequent administration of antibiotic, and searching information related to the prescribed antibiotics were factors associated with better adherence to short-term antibiotic (p<0.05). The most common reasons for non-adherence were feeling better and forgetfulness to take medication. These findings highlighted that pharmacist-led educational intervention significantly enhance adherence to prescribed short-term antibiotics which is a major drive to control antibiotic resistance. Initiatives should be adopted to include patient education as a regular element in the medication dispensing process. Clinical trial registration: The trial is registered at ClinicalTrials.gov (identifier: NCT05293977).

Assessment of adherence to at-home oral anti-infective therapy among paediatric patients discharged from a Quebec hospital

OBJECTIVES

Non-adherence to anti-infective therapy contributes to treatment failure and the emergence of bacterial resistance. This study aimed to assess at-home adherence, by paediatric patients, to oral anti-infective (OAI) therapy prescribed for treatment of acute infections and to explore the factors contributing to non-adherence.

METHODS

This prospective descriptive study involved French-speaking patients under 16 years of age who were discharged with one or more OAIs prescribed for home administration for a maximum of 30 days. Telephone surveys were used to assess overall adherence, which consisted of primary adherence (patient's ability to procure the medication) and secondary adherence (patient's ability to take the treatment as prescribed).

RESULTS

Overall, 51.7% (30/58) of patients were adherent to OAI therapy, with 100% primary adherence (n=69/69) and 51.7% secondary adherence (n=30/58). On average, patients took 98% of the total number of doses prescribed, and non-adherence was related mostly to not following medication administration schedules (63.3% of patients followed the exact schedule). Indeed, the adherence rate for patients taking one or two doses per day was twice the rate for patients taking more than two doses per day (81.8% vs 44.7%, p=0.043).

CONCLUSIONS

Half of the paediatric patients treated for acute infections were non-adherent to OAI therapy at home. Interventions are needed to improve this situation.

KidzMed e-learning to upskill student pharmacists to teach pill swallowing to children

BACKGROUND

Appropriate medication use is essential in ensuring optimal pharmacotherapeutic outcomes. It is mistakenly assumed that adults can swallow solid oral dosage forms (SODFs, e.g. tablets/capsules colloquially referred to as 'pills'), without difficulty and that children cannot. KidzMed is a 'pill swallowing' training programme designed to teach effective SODF use in patients of all ages. It may be utilised by healthcare professionals to assist patients taking SODFs. E-learning was essential for training during COVID pandemic to reduce viral transmission. The aim of this study was to explore UK student pharmacists views of e-learning to support swallowing solid oral dosage forms.

METHODS

This study used pre- and post-intervention online surveys on Microsoft Forms to evaluate self-directed eLearning about pill swallowing on MPharm programmes at three UK Universities using a 13-item survey. A combination of five-point Likert Scales and free-text items were used. The eLearning was available via the virtual learning environment at the University and embedded within existing curriculum. Descriptive statistical analysis was used to explore responses.

RESULTS

In total, 113 of 340 (33%) students completed the survey. Seventy-eight percent (n = 65) reported the eLearning would enable them to teach adults and children to swallow SODFs successfully. Learners either agreed or strongly agreed that they felt comfortable to teach patients (95%, n = 62/113) and parents or carers (94%, n = 60) to swallow medications having completed the e-learning. Student pharmacists generally found eLearning as an acceptable way to reflect on their own experiences of 'pill' swallowing and how to support patients to swallow SODFs.

CONCLUSION

The KidzMed eLearning was well received by student pharmacists. Further work is needed to explore whether skills translates into real life application in the clinical settings.

Electronically Monitored Adherence to Short-Term Antibiotic Therapy in Children

BACKGROUND

Nonadherence to short-term antibiotic treatment in children can lead to treatment failure and the development of drug-resistant microorganisms. We aimed to provide reliable adherence estimates in this population.

METHODS

A prospective, blinded, electronically monitored, observational study between January 2018 and October 2021. Patients aged 2 months to 5 years diagnosed with an acute bacterial infection requiring short-term (5-10 days) oral antibiotic monotherapy, were provided with an electronically monitored medication bottle, recording every manipulation of the cap. Primary outcomes were overall adherence, predefined as administration of >75% of doses relative to the number of doses prescribed, and timing adherence, defined as the administration of >75% of prescribed doses taken within ±20% of the prescribed interval.

RESULTS

One hundred infants (49 boys, mean [range] age 1.87 years [0.2-5.1]) were included in the final analysis. Only 11 participants received all the recommended doses. Overall adherence was 62%, whereas timing adherence was 21%. After applying a logistic regression model, the only factor significantly associated with nonadherence was being a single parent (odds ratio = 5.7; 95% confidence interval [1.07-30.3]). Prescribers overestimated adherence, defining 49 of 62 (77.7%) participants as likely adherent. Patients predicted to be adherent were not more likely to be adherent than those predicted to be nonadherent (31/47 actual adherence among those predicted to be adherent vs 6/16, P = .77).

CONCLUSIONS

Adherence of children to the short-term antimicrobial treatment of an acute infection is suboptimal. Providers were unable to predict the adherence of their patients. These data are important when considering recommended treatment durations and developing interventional programs to increase adherence.

Pediatric Medication Noninitiation in Spain

OBJECTIVES

To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior.

METHODS

Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported.

RESULTS

Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician).

CONCLUSIONS

The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

OUP accepted manuscript

Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of the humanistic care teaching model on nurse patient conflict and nurse turnover intention in a pediatric outpatient department: results of a randomized trial

BACKGROUND

This study was carried out based on the background that sharp nurse-patient conflicts in the pediatric outpatient department lead to a high turnover rate of nurses.

METHODS

A total of 68 nurses working in the pediatric outpatient department of Xiangyang No. 1 People's Hospital were selected as the study subjects, and randomly divided into an experimental group (n=34) and a control group (n=34). Nurses in the control group received a traditional pediatric nursing teaching model, while those in the experimental group received a traditional pediatric nursing teaching model combined with the humanistic care teaching model. The effect of these two nursing teaching models on nurse-patient conflicts in the pediatric outpatient department and the turnover intention of nurses was then compared and analyzed.

RESULTS

There were no significant differences in personal information between the two groups (P>0.05). The strain capacity, operational capacity, nurse-patient communication skills, autonomous learning ability, and teamwork ability of the nurses in the experimental group after training were significantly higher than those in the control group (P<0.05). Both groups after training had significantly higher scores on a professional identity scale than before training, and nurses in the experimental group had significantly higher scores of professional identity than those in the control group (P<0.001). The turnover intention of the nurses in the experimental group were significantly lower than those in the control group (P<0.001). The problem solving ability of nurses in the experimental group was significantly better than that in the control group (P<0.001). Scores in the domains of waiting to see the doctor, the health knowledge education, the ward environment, and nursing quality of nurses in `the experimental group were significantly higher than those in the control group (P<0.001).

CONCLUSIONS

The humanistic care teaching model can significantly improve the professional identity and problem solving ability of nurses in facing different nurse-patient conflicts with significant effect and is worthy of application and popularization in clinical nursing teaching.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100048751.

Paediatric nurses', children's and parents' adherence to infection prevention and control and knowledge of antimicrobial stewardship: A systematic review

INTRODUCTION

Infection prevention and control precautions help to decrease microbial transmission, and through the appropriate use of antibiotics, Antimicrobial Stewardship programs aim to decrease the prevalence and emergence of Antimicrobial Resistance.

METHODS

A systematic review was undertaken to critically appraise and synthesise evidence for nurses', children's and parents' knowledge and understanding of antimicrobial stewardship, and of infection prevention and control in acute paediatric care settings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guided the review. Studies were included if they examined the factors that contributed to nurses' adherence to, or consumers' practice in relation to, antimicrobial stewardship and infection prevention and control.

RESULTS

Of the 16,957 papers identified, 50 studies conducted in acute paediatric settings met the eligibility criteria, and were included. Most studies were of low methodological quality. Fourteen studies evaluated nurses' knowledge and self-reported adherence to Infection Prevention and Control principles and identified consistent practice gaps by nurses. Six studies evaluating the effectiveness of education programs reported modest improvements in nurses' knowledge and adherence to infection prevention and control. There were 15 studies, that investigated consumers' involvement in infection prevention and control that identified the following themes: Consumer knowledge and attitudes to infection prevention and control and transmission-based precautions, and parents' willingness to take an active role in infection prevention. Six studies focused on paediatric nurses' role in antimicrobial stewardship, exploring the following themes: (1) nurses' understanding and beliefs of antimicrobial stewardship roles, and (2) barriers to nurses taking a greater role in antimicrobial stewardship. Nine studies explored the role of consumers in antimicrobial stewardship and identified consumers' misconceptions about the benefits and downplayed concerns regarding antibiotic use.

DISCUSSION

Although consumers articulated a willingness to be actively involved in infection prevention, observed practice remained lower than that required to consistently prevent infection transmission.

CONCLUSION

These findings highlight a critically important gap in current practice. In relation to optimal use of antimicrobials, although paediatric nurses were involved in supporting antimicrobial stewardship processes and educating consumers, they identified limited antimicrobial stewardship knowledge. Consumers appeared to lack understanding about the benefits of antibiotics and negated concerns regarding antibiotic use.