A systematic review of older patients' experiences and perceptions of communication about managing medication across transitions of care

Consumer and multidisciplinary clinician experiences after implementation of the Drug Burden Index intervention bundle to facilitate deprescribing in older inpatients: A mixed method study

RATIONALE

The Drug Burden Index (DBI) measures exposure to anticholinergic and sedative drugs, which are associated with harm in older adults. To facilitate deprescribing in older Australian inpatients, we piloted an intervention bundle integrating the DBI in Electronic Medical Records, clinician deprescribing guides, consumer information leaflets and a stewardship pharmacist.

OBJECTIVES

To understand (i) hospital clinician experiences of using the bundle and (ii) consumer (patient and carer) and General Practitioner (GP) experiences of in-hospital deprescribing, following bundle implementation.

METHODS

Hospital clinicians from target services (General and Geriatric Medicine) at an Australian metropolitan tertiary-referral hospital, were invited to complete surveys, including the System Usability Scale (SUS), and interviews. Patients aged ≥75 years with high DBI (DBI ≥1) were admitted to target services, and their carers, received interview invitations. Consenting patients' GPs received surveys. Qualitative data was thematically analysed. Hospital clinician interviews were mapped to the Human Organisation Technology-fit Framework. Patient interviews were mapped to an adaptation of the National Health Service Patient Experience Framework.

RESULTS

Seventeen hospital clinicians (n = 15 medical, n = 2 pharmacists) and four GPs completed surveys. Eight hospital clinicians (n = 7 medical, n = 1 pharmacist), seven patients and two carers completed interviews. Hospital clinicians reported good usability (SUS score 71.5 ± 12.5). Most themes were around system use and user satisfaction. They reported the intervention was useful for medication review, identified challenges from pre-existing heavy workload and suggested further integration into workflows. Patients and carers reported themes around information, communication and education. Patients reported feeling better or no different post-deprescribing. Patients, carers and GPs described poor communication regarding in-hospital medication changes and their rationale.

CONCLUSIONS

The intervention was well accepted by hospital clinicians. The bundle requires further integration into workflows for sustainability and assessment of generalisability in other health services. Given patients, carers and GPs reported poor medication-related communication, future interventions may target this.

Value Propositions for Digital Shared Medication Plans to Boost Patient-Health Care Professional Partnerships: Co-Design Study

BACKGROUND

Health authorities worldwide have invested in digital technologies to establish robust information exchange systems for improving the safety and efficiency of medication management. Nevertheless, inaccurate medication lists and information gaps are common, particularly during care transitions, leading to avoidable harm, inefficiencies, and increased costs. Besides fragmented health care processes, the inconsistent incorporation of patient-driven changes contributes to these problems. Concurrently, patient-empowerment tools, such as mobile apps, are often not integrated into health care professional workflows. Leveraging coproduction by allowing patients to update their digital shared medication plans (SMPs) is a promising but underused and challenging approach.

OBJECTIVE

This study aimed to determine the value propositions of a digital tool enabling patients, family caregivers, and health care professionals to coproduce and co-manage medication plans within Switzerland's national eHealth architecture.

METHODS

We used an experience-based co-design approach in the French-speaking region of Switzerland. The multidisciplinary research team included 5 patients as co-researchers. We recruited polypharmacy patients, family caregivers, and health care professionals with a broad range of experiences, diseases, and ages. The experience-based co-design had 4 phases: capturing, understanding, and improving experiences, followed by preparing recommendations and next steps. A qualitative, participatory methodology was used to iteratively explore collaborative medication management experiences and identify barriers and enabling mechanisms, including technology. We conducted a thematic analysis of participant interviews to develop value propositions for digital SMPs.

RESULTS

In total, 31 persons participated in 9 interviews, 5 focus groups, and 2 co-design workshops. We identified four value propositions for involving patients and family caregivers in digital SMP management: (1) comprehensive, accessible information about patients' current medication plans and histories, enabling streamlined access and reconciliation on a single platform; (2) patient and health care professional empowerment through the explicit co-ownership of SMPs, fostering coresponsibility, accountability, and transparent collaboration; (3) a means of supporting collaborative interprofessional medication management, including tailored access to information and improved communication across stakeholders; and (4) an opportunity to improve the quality of care and catalyze digital health innovations. Participants discussed types of patient involvement in editing shared information and emphasized the importance of tailoring SMPs to individual abilities and preferences to foster health equity. Integrating co-management into the clinical routine and creating supportive conditions were deemed important.

CONCLUSIONS

Coproduced SMPs can improve medication management by fostering trust and collaboration between patients and health care professionals. Successful implementation will require eHealth interoperability frameworks that embrace the complexity of medication management and support diverse use configurations. Our findings underscored the shared responsibility of all stakeholders, including policy makers and technology providers, for the effective and safe use of SMPs. The 4 value propositions offer strategic guidance, while highlighting the need for further research in different health care settings.

Exploring the reasons for self-administration medication errors among illiterate and low-literate community-dwelling older adults with polypharmacy: a qualitative study

BACKGROUND

Polypharmacy and low literacy increase medication self-administration errors (MSEs) among older adults, adversely affecting both patients and healthcare systems through increased costs and reduced treatment efficacy.

OBJECTIVES

This study explored the reasons for MSEs among illiterate and low-literate older adults with polypharmacy from the perspective of older adults, informal family caregivers, physicians, and pharmacists.

METHOD

The qualitative study used a conventional content analysis approach from September 2022 to April 2023. Purposeful sampling was used to recruit participants for interviews.

RESULTS

The study included fifteen older adults, five caregivers, four physicians, and seven pharmacists. Seven main categories were extracted: 1) Age-related physical and cognitive changes, 2) Medication Mismanagement, 3) Inhibitor beliefs of proper medication use, 4) Caregiving challenges, 5) Deficiency in effective communication and education, 6) Health systems inefficiencies, 7) The challenges of producing, dispensing and obtaining medications.

CONCLUSION

The origins of MSEs encompass a broad spectrum of factors, ranging from individual to systemic levels. Successful interventions for reducing errors will be those that take into account all aspects of error occurrence and strive to minimize them through a holistic approach. The findings highlight the importance of improving organizational health literacy strategies for older adults with limited literacy. Tailoring health information to the specific needs of older patients is crucial for addressing MSEs.

Managing medicines-related continuity of care: the views of a range of prescribers in New Zealand general practice

Introduction Continuity of care is considered vital to achieving high-quality health care. Traditionally, general practitioners have played a key role in managing continuity of care and have largely been accountable for prescribing decision-making in primary care. Following prescribing legislation changes, a range of health disciplines make decisions regarding medicines in the general practice setting. To date, few studies have investigated how different prescribing disciplines view the management of medicines-related continuity of care. Understanding the views of these clinicians is important to achieving safe, effective and equitable outcomes from medicines. Aim The purpose of this study was to explore the views of general practitioners, nurse prescribers and pharmacist prescribers about their role in managing medicines-related continuity of care. Methods Qualitative, semi-structured in-depth interviews were undertaken with 16 prescribers based in eight North Island (New Zealand) general practices. Interviews were transcribed verbatim and analysed thematically using an inductive approach. Results Three key themes were identified from data analysis: a patient-focused approach; interdisciplinary teamwork; and optimising the medicine regimen. Discussion Prescribers in this study identify the important connection between continuity of care and achieving good outcomes from medicines. Good patient-prescriber relationships and ongoing interdisciplinary relationships across all health settings are considered essential to medicines-related continuity of care. Prescribers experience challenges associated with increasing multimorbidity, medicines complexities and fragmentation of clinical records.

Co-designing Medication Optimization Patient-Centered Outcomes Research With Older People and Caregivers as Research Partners

Background: Additional evidence is required to address the unintended consequences of medication use in older people and the required caregiver support. To inform priorities for future research efforts, different stakeholder perspectives are needed, including those of older people, caregivers, clinicians, and researchers. Objective: To develop a co-designed medication-related research agenda. Methods: A 12-member Advisory Council, half of which were older people and caregivers, designed the research. An 11-question survey to identify priorities for medication-related patient-centered outcomes research (PCOR) topics was administered to members of the Elder Care Medicine Network (ECMN) (ie, older people, caregivers, clinicians, and researchers). Respondents were categorized into two groups with hierarchical assignment to the clinician/research group over the older adult/caregiver group. Chi-square tests compared priority areas for medication-related PCOR between the two groups. Results: There were 53 responses (48% response rate) from the ECMN, with 39.6% (n = 21) from the clinician/researcher group and 60.4% (n = 32) from the older adult/caregiver group. The priority areas from both groups included safe ways to simplify medicines (62.2%), communicating with pharmacists and prescribers about medications (58.5%), and information about safe supplements with prescription medications (52.8%). Statistically significant differences existed between the two groups in the proportions choosing the priority areas. Conclusion: Co-design of a survey to identify priority areas for PCOR demonstrated successful engagement of older people and caregivers as research partners. While older people and caregivers may have differing perspectives on the importance of specific medication-related PCOR topics, simplifying medication regimen and health care communications were germane to both groups.

Participation in medication safety of older-adult patients with chronic disease during the transition from hospital to home: a descriptive qualitative study

BACKGROUND

Medication safety issues occur frequently among older-adult patients with chronic diseases during the transition from the hospital to their homes. Patient participation in medication safety has been found to be an effective measure for improving patient safety. However, few studies have been conducted on the safety of older-adult patients with chronic disease during the hospital to family transition period. This study aimed to understand the experiences and perceptions of such patients regarding participation in medication safety during the hospital to family transition period and to explore the actual situation and obstacles during this period in the Chinese context.

METHODS

A descriptive, qualitative research approach was adopted using purposive sampling. Eighteen patients with chronic disease (aged 61-84 years) participated, all of whom were in the period of transition from hospital to home. Data were collected through semi-structured face-to-face interviews and analysed using directed qualitative content analysis.

RESULTS

Four themes and 12 sub-themes were identified in this study. The four themes were participation in medication decision-making, participation in medication self-management, participation support, and barriers to patient participation.

CONCLUSIONS

Patient participation is important in ensuring medication safety during the hospital to family transition period. This study highlights that older-adult patients' participation in medication safety includes three aspects: participation in medication decision-making, participation in medication self-management, and participation support. Health literacy, medical communication, and family care support are the key factors affecting patient participation in medication safety. Effective intervention strategies for this patient group during the transition period would target improving patients' cognition, health literacy, doctor-prescription communication, and family care support to encourage patients to be more actively involved in the process of drug treatment.

Experiences and Perceptions of Medication Management Communication During Transitions of Care for Residents in Aged Care Homes and Their Caregivers: A Qualitative Meta-Synthesis

AIM

To explore the experiences and perceptions of communication about managing medication across transitions of care for residents living in aged care homes and their family caregivers.

BACKGROUND

Effective medication communication across transitions of care involves exchanging information, resident, and family caregiver's participation in decision-making, and shared responsibility.

DESIGN

A qualitative meta-synthesis.

METHOD

This review was conducted in accordance with the PRISMA 2020 guidelines and the accompanying 27-item checklist. A systematic search of seven electronic databases (Embase, PsycINFO, Medline Ovid, Scopus, CINAHL, EmCare and Web of Science) was performed from inception to December 2023. Studies eligible for inclusion in this review were required to be published in peer-reviewed English journals and focus on medication communication among healthcare providers, residents and family caregivers during transitions of care for aged care residents. The JBI Critical Appraisal Checklist for Qualitative Research was employed for the critical appraisal of the studies, and the COREQ checklist was used to evaluate their quality.

RESULTS

Of the 2610 studies identified, 12 met the inclusion criteria. No study was excluded based on quality. Two main themes were generated: (1) Medication information exchange involving residents and families, and (2) resident and family factors influencing medication communication engagement. The findings revealed a lack of supportive structure for effective communication and collaboration among residents, family caregivers and healthcare providers during transitions of care, marked by one-way interactions and limited evidence of shared decision-making or family caregiver engagement in medication management communication, despite varying individual needs and preferences.

CONCLUSIONS

Communication about medication management during transitions of care focused on sharing details rather than active engagement. Residents and their family caregivers have individual needs and perspectives regarding communication about medication management, which are not well addressed by healthcare providers during transitions of care. Healthcare providers' communication remains limited, and family caregivers are underutilised.

'You're Just Thinking About Going Home': Exploring Person-Centred Medication Communication With Older Patients at Hospital Discharge

BACKGROUND

The hospital discharge process poses significant safety risks for older patients due to complexities in communication and coordination among stakeholders, leading to potential drug-related problems post-discharge. Adopting a person-centred care (PCC) approach in medication communication by healthcare professionals (HCPs) is crucial to ensure positive health outcomes. This study aimed to explore the practice of PCC in medication communication between older patients and HCPs during the hospital discharge process.

METHODS

We conducted a qualitative study using non-participatory direct observations of patient-HCP consultations during hospital discharge, followed by semi-structured interviews with observed patients and, when applicable, their informal caregivers. Data collection occurred from October 2020 to May 2021 at two Swedish hospitals. We gathered data using an observational form and audio-recorded all consultations and interviews. The data were analysed thematically using the systematic text condensation method.

RESULTS

Twenty patients were included (median age: 81 years [range: 65-94]; 9 female) in observations and 13 of them participated in interviews. Two patients were accompanied by an informal caregiver during the interviews. Three main themes were identified: (1) The impact of traditional authoritarian structures, depicts power dynamics between patients and their HCPs, showing how traditional structures influence the practice of PCC in medication communication during hospital discharge; (2) Consultation timing and mode not on patients' terms, describes suboptimal times and settings for consultations, along with the use of complex language that hinders effective communication; and (3) Discrepancy in expectations of self-care ability, illustrates a mismatch between the self-care guidance provided by HCPs during hospital discharge and the actual needs and preferences of patients and informal caregivers.

CONCLUSION

Medication communication between older patients and HCPs during hospital discharge is frequently inconsistent with the practice of PCC. Not only must HCPs improve their communication strategies, but patients and their informal caregivers should also be better prepared for discharge communication and encouraged to participate in their care. This involvement would give them relevant knowledge and tailor communication to their individual needs, preventing problems in managing their medications after discharge.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group of six patients and/or informal caregiver contributors provided input on the study design, edited the consent forms, and helped develop the interview guide.

Continuity of medication information transfer and continuous medication supply during hospital-to-home transitions - nationwide surveys in hospital and community pharmacies after implementing new legal requirements in Germany

BACKGROUND

While successful information transfer and seamless medication supply are fundamental to medication safety during hospital-to-home transitions, disruptions are frequently reported. In Germany, new legal requirements came into force in 2017, strengthening medication lists and discharge summaries as preferred means of information transfer. In addition to previous regulations - such as dispensing medication at discharge by hospital pharmacies - hospital physicians were now allowed to issue discharge prescriptions to be supplied by community pharmacies. The aim of this survey study was to gain first nationwide insights into how these requirements are implemented and how they impact the continuity of medication information transfer and continuous medication supply.

METHODS

Two nationwide self-administered online surveys of all hospital and community pharmacies across Germany were developed and conducted from April 17th to June 30th, 2023.

RESULTS

Overall, 31.0% (n = 111) of all German hospital pharmacies and 4.5% (n = 811) of all community pharmacies participated. The majority of those hospital pharmacies reported that patients who were discharged were typically provided with discharge summaries (89.2%), medication lists (59.5%) and if needed, discharge prescriptions (67.6%) and/or required medication (67.6%). About every second community pharmacy (49.0%) indicated that up to half of the recently discharged patients who came to their pharmacy typically presented medication lists. 34.0% of the community pharmacies stated that they typically received a discharge summary from recently discharged patients at least once per week. About three in four community pharmacies (73.3%) indicated that most discharge prescriptions were dispensed in time. However, one-third (31.0%) estimated that half and more of the patients experienced gaps in medication supply. Community pharmacies reported challenges with the legal requirements - such as patients´ poor comprehensibility of medication lists, medication discrepancies, unmet formal requirements of discharge prescriptions, and poor accessibility of hospital staff in case of queries. In comparison, hospital pharmacies named technical issues, time/personnel resources, and deficits in patient knowledge of medication as difficulties.

CONCLUSION

According to the pharmacies´ perceptions, it can be assumed that discontinuation in medication information transfer and lack of medication supply still occur today during hospital-to-home transitions, despite the new legal requirements. Further research is necessary to supplement these results by the perspectives of other healthcare professionals and patients in order to identify efficient strategies.

Exploring the Significance of Nurse Introduction for Positive Patient Experience in Saudi Arabia

Empathy plays an important role in nursing so that the patients are provided with quality care and are satisfied with the services provided. Saudi Arabian patient interactions, including initial exploring, tend not to be formulaically initiated as in other countries. In this current study, the researcher aimed to highlight the critical role of nurse introductions in creating a desirable patient experience in the inpatient centers of Ministry Of Health hospitals in Saudi Arabia. This study was a cross-sectional secondary data analysis using the National Health Links/Presses Ganey surveys for every quint between the period 2021 and 2022. The methodology comprised an in-depth analysis of the Patient Experience Management Program (PXMP) survey that was involved as the uniform survey concluded by the Health Links/PressGaney. During the analysis, however, the results were found to have significant differences as 71.3% of the patients had a very good impression of their overall patient experience. This was specifically designed to address specific issues such as personal characteristics. The results of this study contribute to the understanding of what drives the nurses-patient interactions and forge the need for enhancing the way nurses are introduced to their patients to increase the average level of satisfaction of patients in the Ministry Of Health hospitals in Saudi Arabia. This study recommends that Saudi nurses should be trained to establish rapport in their interactions with patients as this promotes patient-centeredness and subsequently patients' experiences and care outcomes.

Enhancing the quality of medicine handover at hospital discharge: a priority setting workshop

BACKGROUND

When a patient is discharged from hospital it is essential that their general practitioner (GPs) and community pharmacist are informed of changes to their medicines. This necessitates effective communication and information-sharing between hospitals and primary care clinicians.

OBJECTIVE

To identify priority medicine handover issues and solutions to inform the co-design and development of a multifaceted intervention.

METHOD

A modified nominal group technique was used to reach consensus on medicine handover priority areas. The first hour of an interactive 2-hr workshop focused on ranking pre-identified issues drawn from literature. In the second hour, participants identified solutions that they then ranked from highest to lowest priority through an online platform. Descriptive statistics were used to analyse workshop data.

RESULTS

In total 32 participants attended the workshop including hospital doctors (n = 8, 25.0%), GPs and hospital pharmacists (n = 6 each, 18.8%), consumers and community pharmacists (n = 4 each, 12.5%), and both hospital and aged care facility nurses (n = 2 each 6.3%). From the list of 23 issues, the highest ranked issue was high workload and time pressures impacting the discharge process (22/32). From the list of 36 solutions, the participants identified two solutions that were equally ranked highest (12/27 each). They were mandating that patients leave hospital with a discharge summary, including medication reconciliation information and, developing an integrated information technology system where medication summary and notes are accessible for primary, secondary and tertiary health provider.

CONCLUSION

The consensus process highlighted challenges in hospital procedures where potential solutions may be implemented through co-design of a multifaceted intervention to improve medicine handover quality.

The influence of written medication reminder on patient experience among older adult patients: a repeat cross-sectional study

BACKGROUND

Older adult patients are particularly vulnerable to medication-related issues during the discharge process. To enhance medication discharge education and patient experience, a written medication reminder, incorporating crucial medication side effects and warning signs, was implemented in medicine wards. This study aimed to examine the influence of this reminder on patient experience and medication-taking behaviors among older adults in public healthcare settings.

METHODS

Two separate rounds of cross-sectional surveys were conducted before and after the program implementation among different discharged patients in each round. The study enrolled older adult patients aged ≥ 65 or their caregivers discharged from the medical wards of four pilot public hospitals in Hong Kong. A structured questionnaire was administered via telephone within 14 days of the patient's discharge. The survey assessed patients' experience with the provided medication information during discharge, including the clarity, adequacy, and usefulness of the information, as well as their overall experience with inpatient services. The self-reported medication-taken behaviors, including adherence and side-effect encounters, were also measured.

RESULTS

A total of 1,265 responses were collected before the implementation of the medication reminder, and 1,426 responses were obtained after the implementation. Pre/post-implementation survey comparison showed significant improvement in patient experience regarding the clarity of the provided medication information (7.93 ± 1.84 vs. 8.18 ± 1.69, P = 0.002), adequacy (7.92 ± 1.93 vs. 8.15 ± 1.76, P = 0.014), and usefulness (8.06 ± 1.80 vs. 8.26 ± 1.70, P = 0.017), significantly positive experience on the overall discharge information (β coefficient, 0.43 [95%CI, 0.30 to 0.56]) and inpatient service (β coefficient, 0.47 [95%CI, 0.32 to 0.61]). In addition, the side effects encounters were significantly lower in the post-implementation survey group (11.6% vs. 9.0%, P = 0.04) and no statistical difference was found in self-reported medication adherence between the two groups.

CONCLUSIONS

The provision of written medication reminders on key medication risks effectively improved older adult patients' experience and reduced side effects without any unintended negative consequences. The findings can serve as a reference for similar settings seeking to enhance post-discharge care among older adult patients. Future studies could investigate the influence in other specialties and age groups and include clinical outcomes to test the program's effectiveness.

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

BACKGROUND

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

METHODS

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

CONCLUSIONS

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

Decision-making about changing medications across transitions of care: Opportunities for enhanced patient and family engagement

BACKGROUND

Older patients often have complex medication regimens, which change as they move across transitions of care. Engagement of older patients and families in making medication decisions across transitions of care is important for safe and high-quality medication management.

AIMS

To explore decision-making between health professionals, older patients and families about medication changes across transitions of care, and to examine how patient and family engagement is enacted in the process of decision-making in relation to these medication changes.

METHODS

A focused ethnographic design was undertaken with semi-structured interviews, observations, and reflective focus groups or interviews. Reflexive thematic analysis was conducted on transcribed data. The study was undertaken at a public teaching acute care hospital and a public teaching community hospital in Australia.

RESULTS

In all, 182 older patients, 44 family members and 94 health professionals participated. Four themes were conceptualised from the data: different customs and routines, medication challenges, health professional interactions, and patient and family involvement. Environments had differences in their customs and routines, which increased the potential for medication delays or the substitution of unintended medications. Medication challenges included health professionals assuming that patients and families did not need information about regularly prescribed medications. Patients and families were informed about new medications after health professionals had already made decisions to prescribe these medications. Health professionals tended to work in disciplinary silos, and they had views about their role in interacting with patients and families. Patients and families were expected to take the initiative to participate in decision-making about medication changes.

CONCLUSIONS

Patient movements across transitions of care can create complex and chaotic medication management situations, which lacks transparency, especially for older patients and their families. A greater focus on pre-emptive and planned discussions about medication changes will contribute to improving patient and family involvement in medication decision-making.

Prevalence of and Risk Factors for Drug-Related Readmissions in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Older adults are at an increased risk of drug-related problems, especially following discharge from hospital. Drug-related readmissions place a large burden on the patient and the healthcare system. However, previous studies report inconsistent results on the prevalence and associated risk factors for drug-related hospital readmissions in older adults.

OBJECTIVES

We aimed to assess the prevalence of drug-related readmissions in older adults aged 65 years and older and investigate the drug classes, preventability and risk factors most associated with these readmissions.

METHODS

A systematic review and meta-analysis were undertaken to answer our objectives. A search of four databases (MEDLINE, Embase, CINAHL and Scopus) was conducted. Three authors independently performed title and abstract screening, full-text screening and data extraction of all included studies. A meta-analysis was conducted to calculate the pooled prevalence of drug-related readmissions across all studies, and a subgroup analysis was performed to explore heterogeneity among studies reporting on adverse drug reaction-related readmissions.

RESULTS

A total of 1978 studies were identified in the initial search, of which four studies were included in the final synthesis. Three studies focused on readmissions due to adverse drug reactions and one study focused on readmissions due to drug-related problems. A pooled prevalence of 9% (95% confidence interval 2-18) was found for drug-related readmissions across all studies, and a pooled prevalence of 6% (95% confidence interval 4-10) was found for adverse drug reaction-related readmissions. Three studies explored the preventability of readmissions and 15.4-22.2% of cases were deemed preventable. The drug classes most associated with adverse drug reaction readmissions included anticoagulants, antibiotics, psychotropics and chemotherapy agents. Polypharmacy (the use of five or more medications) and several comorbidities such as cancer, liver disease, ischaemic heart disease and peptic ulcer disease were identified as risk factors for drug-related readmissions.

CONCLUSIONS

Almost one in ten older adults discharged from hospital experienced a drug-related hospital readmission, with one fifth of these deemed preventable. Several comorbidities and the use of polypharmacy and high-risk drugs were identified as prominent risk factors for readmission. Further research is needed to explore possible causes of drug-related readmissions in older adults for a more guided approach to the development of effective medication management interventions.

The effect of regional transmural agreements on the information transfer of frail older patients

INTRODUCTION

Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital.

METHODS

This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders.

RESULTS

In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91).

DISCUSSION

The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Understanding data collection strategies for the ethical inclusion of older adults with disabilities in transitional care research: A scoping review protocol

INTRODUCTION

A growing body of evidence suggests that older adults are particularly vulnerable to poor care as they transition across care environments. Thus, they require transitional care services as they transition across healthcare settings. To help make intervention research meaningful to the older adults the intervention aims to serve, many researchers aim to study their experiences, by actively involving them in research processes. However, collecting data from older adults with various forms of disability often assumes that the research methods selected are appropriate for them. This scoping review will map the evidence on research methods to collect data from older adults with disabilities within the transitional care literature.

METHODS

The proposed scoping review follows the framework originally described by the Joanna Briggs Institute (JBI) Manual: (1) developing a search strategy, (2) evidence screening and selection, (3) data extraction; and (4) analysis. We will include studies identified through a comprehensive search of peer-reviewed and empirical literature reporting on research methods used to elicit the experiences of older adults with disabilities in transitional care interventions. In addition, we will search the reference lists of included studies. The findings of this review will be narratively synthesized. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews will guide the reporting of the methods and results.

DISCUSSION

The overarching goal of this study is to develop strategies to assist the research community in increasing the inclusion of older adults with disabilities in transitional care research. The findings of this review will highlight recommendations for research to inform data collection within future intervention research for older adults with disabilities. Study findings will be disseminated via a publication and presentations.

Improving Medication Safety in Cancer Services for Ethnic Minority Consumers: Protocol for a Pilot Feasibility and Acceptability Study of a Co-Designed Consumer Engagement Intervention

BACKGROUND

People from ethnic minorities are often exposed to unsafe care contributing to poorer health care outcomes. Medication safety is a high-risk area requiring intervention to improve care outcomes. Using an adapted, experience-based co-design process with cancer service staff and patients from ethnic minorities, a medication communication tool was created: Making it Meaningful (MiM).

OBJECTIVE

We aim to test whether the MiM tool is feasible and acceptable for use with ethnic minority consumers in cancer services in Australia.

METHODS

A single site, controlled before and after this pilot study, will be used. Patients from Mandarin- and Russian-speaking backgrounds are eligible for inclusion. In total, 40 patients from these cultural backgrounds will be recruited and stratified by language to the intervention and control groups, with 20 participants in the intervention and 20 in the control group. Further, 4 health practitioners will be recruited and trained to use the MiM. Clinicians providing care for patients in the intervention will use the MiM during their usual appointment while providing medication communication using standard care processes for the control group. Telephone surveys will be conducted with participants at 3 time points, T1 before the intervention, T2 1 week post intervention, and T3 1 month post intervention, to assess knowledge and self-efficacy in medication management, perceived usability, and acceptability of the MiM. Qualitative interviews with clinicians who have used the MiM will be conducted 1 month postintervention to explore their perceptions of MiM feasibility and acceptability.

RESULTS

Ethical approval for this research has been provided by the South Eastern Sydney Area Health Human Research Ethics Committee (HRECXXX). Bilingual field-workers, 1 Mandarin-speaking and 1 Russian-speaking, are contacting eligible patients to enroll. It is anticipated that recruitment will be completed by October 2023, with data collection completed by December 2023.

CONCLUSIONS

Using experience-based co-design, we identified communication about medication, particularly between appointments, as a key issue impacting the safety of care for patients from ethnic minorities accessing cancer services. Increasing consumer engagement in medication management was identified as a strategy to reduce medication safety problems in cancer care; the MiM strategy was developed to address this issue. It is anticipated that by using the MiM, patient knowledge about prescribed medications and confidence in medication management will increase. Evidence from the pilot study will be used to inform a full-scale trial of the MiM tool with a range of ethnic minority communities accessing cancer services. A full-scale trial will seek to determine whether the MiM intervention is effective in knowledge and confidence about medication management, but also whether this improves patient outcomes in cancer care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials ACTRN12622001260718p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384658&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49902.

Exploring the attitudes of general medical students toward older adult's care in a lower middle-income country: implications for medical education

OBJECTIVE

The motivation for this study stemmed from the growing population of older adults and the increasing demand for healthcare professionals who possess the necessary skills and knowledge to provide quality care to this demographic. By exploring the attitudes, perceptions, and beliefs of medical students towards older adult care, the study aimed to identify gaps in their training and areas where improvements can be made to better equip them for this critical aspect of healthcare.

METHOD

This study was a qualitative thematic analysis. The participants of this research were selected from among the general medicine internship students of Iran University of Medical Sciences by purposive sampling method. In-depth individual semi-structured interviews were used to collect data. Sampling continued until data saturation. The interviews were recorded, transcribed, and analyzed using a hybrid approach of inductive and deductive thematic analysis. Using this approach, the analysis of the data became more adaptable and open-ended, free from the restrictions of pre-existing theoretical frameworks. MAXQDA 22 was used to analyze qualitative data.

RESULTS

A total of 27 medical students were interviewed semi-structured, and audio files were transcribed immediately after the interview. In the process of reading the interviews carefully and separating the conceptual units into codes, 167 primary codes were obtained, and these codes were divided into five main categories under the title of root factors after constant comparison analysis. Five main themes are including discrimination in service delivery, a lack of inter-professional training, interpersonal communication skills, inadequate infrastructure and human resources, and enhancing attitudes towards older person care through experiential learning.

CONCLUSION

This study sheds light on the attitudes and perceptions of medical students toward older adult care in a lower-middle-income country. The findings reveal that there are significant gaps in their training and preparation for providing quality care to this demographic profile. The four main categories identified as root factors highlight key areas where improvements can be made in medical education. It is recommended that medical schools in low and middle-income countries consider incorporating these themes into their curricula to better equip future healthcare professionals with the necessary skills and knowledge to provide quality care to older adults.

Examining transitions of care among nursing home residents with and without antipsychotic medication use

OBJECTIVES

This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population.

METHODS

This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated.

RESULTS

Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use.

CONCLUSIONS

Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Integrating shared decision-making, expressing preferences and active participation of older adults in primary care nursing: a systematic review of qualitative studies and qualitative meta-synthesis

OBJECTIVES

To systematically synthesise the results of primary qualitative studies on how community-dwelling older adults experience shared decision-making processes, express preferences and actively participate in care.

DESIGN

Systematic review of qualitative studies and qualitative meta-synthesis.

METHODS

We focused on studies about community-dwelling participants aged ≥65 undergoing a health-disease process circumscribed to a primary healthcare setting, and the central theme should focus on either shared decision-making, expressing preferences or patient participation. We searched the following databases: MEDLINE, CINAHL, Web of Science, Scopus and PsycINFO (time publication frame 2012-2022). We excluded studies in those cases where the qualitative results were not analysed or unrelated to the phenomenon addressed, phenomena were not clear enough to be included or the setting did not occur in the community.

RESULTS

A total of 12 studies were included in this meta-synthesis. We appraised the quality of the selected studies through Critical Appraisal Skills Programme (CASP) Checklist. The metasummary comprised the frequency and intensity of qualitative patterns across the included studies. The meta-synthesis revealed four influential elements in their interaction: recognising personal qualities, facing professional characteristics, experiences of discrimination and a double-edged context.

CONCLUSIONS

The phenomena studied were influenced by how older people approached their role in their binomial relationship with healthcare professionals. Those with a reinforced self-concept were better aware of health-disease-related situations regarding shared decision-making and the importance of being communicatively assertive. Professional characteristics were also crucial in how older people modulated their acting ability through their personality, communication skills and the approach healthcare professionals used towards older adults. Situations of discrimination generated through an imbalance of power inhibited the expression of preferences and hindered the active participation of older people. The context surrounding the participants influenced all these situations, key in tipping the balance between a therapeutic and a harmful side.

PROSPERO REGISTRATION NUMBER

CRD42022363515.

Barriers and Facilitators of Communication in the Medication Reconciliation Process during Hospital Discharge: Primary Healthcare Professionals' Perspectives

The WHO established that medication errors are the most common and preventable errors and represent an expenditure of 42 billion U.S. dollars annually. The risk of medication errors increases in transitions between levels of care, mainly from hospital care to primary healthcare after hospital discharge. In this context, communication is a key element in the safety of the medication reconciliation process. The aim of this paper was to describe the barriers to, and facilitators of, effective communication during the medication reconciliation process at hospital discharge in people over 65 years of age, from the perspective of primary healthcare professionals. A qualitative descriptive study was designed, and in-depth interviews were conducted with 21 individuals, of whom 13 were nurses and 8 were physicians. This study was carried out with healthcare professionals belonging to primary healthcare centres in Huelva (Spain). Following content analysis of the discourses we identified 19 categories, grouped into three areas: interlevel communication, communication between primary healthcare professionals, and communication between healthcare professionals and patients/caregivers. The barriers found mainly relate to the adequacy and use of technological tools, time available, workload and the level of collaboration of patients/caregivers. Facilitating elements for communication in medication reconciliation included technologies, such as computerized medical history, protocolization of clinical sessions, the presence of case management nurse and interdisciplinary teamwork.

Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service

BACKGROUND

Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process.

OBJECTIVES

To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers.

METHOD

An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge.

RESULTS

Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed.

CONCLUSION

Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12^th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .

Medication safety education in nursing research: Text network analysis and topic modeling

OBJECTIVES

This study aimed to identify the knowledge structure of medication safety nursing education literature by developing schematic diagrams of the relationship between keywords from a macro perspective. This study also identifies the research topics and trends over time.

DESIGN

This quantitative content study used text network analysis to explore keywords and research topics using topic modeling within the medication safety nursing education literature.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were used to search for the medication safety nursing education literature published until December 2021.

METHODS

Keywords from 2085 articles were examined using text network analysis and topic modeling with NetMiner 4.4.3.

RESULTS

The keywords with the most frequency and the highest networking degree in centrality were "patient," "medication," "program," "nurse," and "care." The emerging keywords assessed by time periods were identified; the first phase ("heart failure," "insulin," "chemotherapy," and "infusion"), the second phase ("medication errors," "staff," and "information"), the third phase ("program," "management," and "data"). The results of topic modeling were as follows: safe medication administration, safe medication reconciliation process, medication education for patients, medication errors in nursing practice, and multidisciplinary teamwork for medication safety.

CONCLUSION

These findings will help nursing researchers and educators to understand the trends and insights for medication safety education and educate future nurses to provide safer nursing care.

Older Individuals' Experiences of Medication Management and Care After Discharge from Hospital: An Interview Study

PURPOSE

To develop an in-depth understanding of older individuals' attitudes and perceptions of medication management and care after discharge from hospital-to-home.

PATIENTS AND METHODS

A qualitative study using semi-structured interviews with selected individuals 75 years and older, discharged from hospital within the last 6-12 months, living at home, and managing their own medications. Face-to-face interviews were audio-recorded, transcribed and analyzed with thematic analysis.

RESULTS

Among the 15 respondents, mean age was 83.5 years (range 75-95 years), 67% were women, and 60% lived alone. The majority (80%) managed their medications with a pill organizer or directly from the pill boxes, while 20% used dose dispensed medications. The analysis of the data led to six themes: Medication adherence, Personal responsibility, Transitions of care, Beliefs about medications, Participation (experience of participation, willingness to participate) and Accessibility (easier to reach hospital than primary care, navigating in the care system, continuity, personal chemistry).

CONCLUSION

The included respondents who were older individuals, living at home and managing their own medications, expressed that they were medical adherent and self-managing. Two important aspects which were seen were difficulties to reach primary care on their own initiative and the lack of continuity with the same physician over a longer period of time.

Pharmacist-Involved Antiretroviral Stewardship Programs in People Living with HIV/AIDS: A Systematic Review

People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; PLWHA) frequently encounter antiretroviral (ARV) therapy-related problems. Clinical pharmacists with specialized training in ARV stewardship play an important role in managing these problems. However, there is a paucity of evidence to clarify the impact of clinical pharmacists' interventions on managing ARV therapy-related problems in PLWHA. Therefore, we aim to systematically review the literature to determine the nature and impact of pharmacists' interventions on managing medication-related problems in PLWHA. The review protocol was registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42020173078). Relevant records were identified from six electronic bibliographic databases (PubMed, Embase, EBSCOhost, ProQuest, Scopus, and the Cochrane Central Register) from their inception until September 2022. We included all randomized and nonrandomized interventional studies that were published in English. After the abstract and full-text screening, data were extracted from the selected studies, and the quality of the studies was assessed. The electronic database search and citation tracking identified two thousand and three citations. The review included 21 of these studies, involving 2998 PLWHA, published between 2014 and 2022. Pharmacists' interventions, working alone or in a multi-disciplinary team, comprised ARV medication review, management of adverse drug reactions (ADRs), therapeutic drug monitoring, prevention of drug interactions, and provision of drug information to PLWHA or the health care team. The pharmacist-involved interventions significantly reduced incorrect/incomplete ARV regimens, drug interactions, incorrect dosages, duplicate therapy, polypharmacy, administration errors, missing medication, wrong formulation, ADRs, and prescribing errors. Most studies reported that physicians usually accept more than 90% of the pharmacists' recommendations. ARV medication-related problems remain highly prevalent in PLWHA. Pharmacist-led interventions and stewardship significantly reduce ARV therapy-related problems in PLWHA and are widely accepted by physicians. Dedicated pharmacists with specialized training and credentialing in infectious diseases or HIV/AIDS have a great potential to improve health outcomes in PLWHA.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

Background

Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.

Aim

To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.

Design

Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.

Data sources

Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.

Results

Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.

Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.

Conclusion

A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.

Trial registration

PROSPERO Protocol CRD42021214137.

Towards patient-centred communication in the management of older patients' medications across transitions of care: A focused ethnographic study

BACKGROUND

Communication about managing medications during transitions of care can be a challenging process for older patients since they often have complex medication regimens. Previous studies highlighted that links between communication breakdowns and medication incidents in older patients occur mainly at discharge or in the post-discharge period. Little attention has been paid to exploring communication strategies facilitating patient-centred medication communication at transitions of care from a discourse-analytic perspective.

OBJECTIVES

To explore, through a discursive lens, strategies that enable patient-centred medication communication at transitions of care.

DESIGN

A focused ethnographic study was employed for this study. The study was reported according to the COREQ checklist.

METHODS

Interviews, observations and focus groups were analysed utilising Critical Discourse Analysis and the Medication Communication Model following thematic analysis. Data collection was undertaken in eight wards across two metropolitan hospitals in Australia.

RESULTS

Patient preferences and beliefs about medications were identified as important characteristics of patient-centred communication. Strategies included empathetic talk prioritising patients' medication needs and preferences for medications; informative talk clarifying patients' concerns; and encouraging talk for enhancing shared decision-making with older patients. Challenges relating to the use of these strategies included patients' hearing, speech or cognitive impairments, language barriers and absence of interpreters or family members during care transitions.

RELEVANCE TO CLINICAL PRACTICE

To enhance medication communication, nurses, doctors and pharmacists should incorporate older patients' preferences, previous experiences and beliefs, and consider the challenges faced by patients across transitions. Strategies encouraging patients' contribution to decision-making processes are crucial to patient-centeredness in medication communication. Nurses need to engage in informative talk more frequently when administering the medications to ensure older patients' understanding of medications prescribed or altered in hospital settings.

Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the 'Your Care Needs You' intervention versus usual care

BACKGROUND

The 'Your Care Needs You' (YCNY) intervention aims to increase the safety and experience of transitions for older people through greater patient involvement during the hospital stay.

METHODS

A cluster randomised controlled feasibility trial was conducted on NHS inpatient wards (clusters) where ≥ 40% of patients were routinely ≥ 75 years. Wards were randomised to YCNY or usual care using an unequal allocation ratio (3:2). We aimed to recruit up to 20 patients per ward. Follow-up included routine data collection and questionnaires at 5-, 30-, and 90-days post-discharge. Eligible patients were ≥ 75 years, discharged home, stayed overnight on participating wards, and could read and understand English. The trial assessed the feasibility of delivering YCNY and the trial methodology through recruitment rates, outcome completion rates, and a qualitative evaluation. The accuracy of using routinely coded data for the primary outcome in the definitive trial was assessed by extracting discharge information for up to ten nonindividual consenting patients per ward.

RESULTS

Ten wards were randomised (6 intervention, 4 control). One ward withdrew, and two wards were unable to deliver the intervention. Seven-hundred twenty-one patients were successfully screened, and 161 were recruited (95 intervention, 66 control). The patient post-discharge attrition rate was 17.4% (n = 28). Primary outcome data were gathered for 91.9% of participants with 75.2% and 59.0% providing secondary outcome data at 5 and 30 days post-discharge respectively. Item completion within questionnaires was generally high. Post-discharge follow-up was terminated early due to the COVID-19 pandemic affecting 90-day response rates (16.8%). Data from 88 nonindividual consenting patients identified an error rate of 15% when using routinely coded data for the primary outcome. No unexpected serious adverse events were identified. Most patients viewed YCNY favourably. Staff agreed with it in principle, but ward pressures and organisational contexts hampered implementation. There was a need to sustain engagement, provide clarity on roles and responsibilities, and account for fluctuations in patients' health, capacity, and preferences.

CONCLUSIONS

If implementation challenges can be overcome, YCNY represents a step towards involving older people as partners in their care to improve the safety and experience of their transitions from hospital to home.

TRIAL REGISTRATION

ISRCTN: 51154948.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool's effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

‘Everyone should know what they’re on’: a qualitative study of attitudes towards and use of patient held lists of medicines among patients, carers and healthcare professionals in primary and secondary care settings in Ireland

Objectives

Managing multiple medicines can be challenging for patients with multimorbidity, who are at high risk of adverse outcomes, for example, hospitalisation. Patient-held medication lists (PHMLs) can contribute to patient safety and potentially reduce medication errors. The aims of this study are to investigate attitudes towards and use of PHMLs among healthcare professionals (HCPs), patients and carers.

Design

Qualitative study based on 39 semistructured telephone interviews.

Setting

Primary and secondary care settings in Ireland.

Participants

Twenty-one HCPs and 18 people taking medicines and caregivers.

Methods

Telephone interviews were conducted with HCPs, people taking multiple medicines (5+ medicines) and carers of people taking medicines who were purposively sampled via social media, patient groups and research collaborators. Interviews were transcribed and thematically analysed based on the Framework approach, with the Consolidated Framework for Implementation Research and Theoretical Domains Framework.

Results

Three core themes emerged: (1) attitudes to PHML, (2) function and preferred features of PHML and (3) barriers and facilitators to future use of PHML. All participating (patients/carers and HCP) groups considered PHML beneficial for patients and HCPs (eg, empowering for patients and improved adherence). While PHML were used in a variety of situations such as emergencies, concerns about their accuracy were shared across all groups. HCPs and patients differed on the level of detail that should be included in PHML. HCPs’ time constraints, patients’ multiple medicines and cognitive impairments were reported barriers. Key facilitators included access to digital/compact lists and promotion of lists by appropriate HCPs.

Conclusions

Our findings provide insight into the factors that influence use of PHML. Lists were used in a variety of settings, but there were concerns about their accuracy. A range of list formats and encouragement from key HCPs could increase the use of PHML.

Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication

BACKGROUND

Communicating about medications across transitions of care is important in older patients who frequently move between health care settings. While there is increasing interest in understanding patient communication across transitions of care, little is known about older patients' involvement in formal and informal modes of communication regarding managing medications.

OBJECTIVE

The aim of this paper was to explore how older patients participated in managing their medications across transitions of care through formal and informal modes of communication.

METHODS

The study was conducted across two metropolitan hospitals: an acute hospital and a geriatric rehabilitation hospital in metropolitan Melbourne, Australia. A focused ethnographic design was used involving semi-structured interviews (n = 50), observations (203 h) and individual interviews or focus groups (n = 25). Following thematic analysis, data were analysed using Fairclough's Critical Discourse Analysis.

RESULTS

Data analysis revealed two major discursive practices, which comprised of an interplay between formal and informal communication and environmental influences on formal and informal communication. Self-created patient notes were used by older patients to initiate informal discussion with health professionals about medication decisions, which challenged traditional unequal power relations between health professionals and patients. Formal prompts on electronic medication administration records facilitated the continuous information discourse about patients' medications across transitions of care and encouraged health professionals to seek out older patients' preferences through informal bedside interactions. Environmental influences on communication comprised health professionals' physical movements across private and public spaces in the ward, their distance from older patients at the bedside and utilization of the computer systems during patient encounters.

CONCLUSION

Older patients' self-created medication notes enabled them to take on a more active role in formal and informal medication communication across transitions of care. Older patients and family members did not have continuous access to information about medication changes during their hospital stay and systems often failed to address older patients' key concerns about their medications, which hindered their active involvement in formal and informal communication.

PATIENT OR PUBLIC CONTRIBUTION

Older adults, family members and health professionals volunteered to be interviewed and observed.

Associations between hyper-polypharmacy and potentially inappropriate prescribing with clinical and functional outcomes in older adults

BACKGROUND

: Hyper-polypharmacy and potentially inappropriate prescribing (PIP) are common among older inpatients. This study investigated associations between hyper-polypharmacy and PIP with clinical and functional outcomes in older adults at 3-months after hospital discharge.

RESEARCH DESIGN AND METHOD

: At discharge, prescribed medications were collected and PIPs, comprising potentially inappropriate medications (PIM) and potential prescribing omissions (PPO), were retrospectively identified using STOPP/START version 2. Clinical and functional outcomes were collected prospectively via telephone follow-up and audit.

RESULTS

: Data for 232 patients (mean age 80 years, 51.7 % female) were analysed. PIP prevalence at discharge was 73.7% (PIMs 62.5%, PPOs 36.6%). Exposure to at least 1 PIM was associated with an increased occurrence of unplanned hospital readmission (adjusted odds ratio (AOR) 5.09; 95% CI 2.38─10.85), emergency department presentation (AOR 4.69; 95% CI 1.55─14.21) and the composite outcome (AOR 6.83; 95% CI 3.20─14.57). The number rather than presence of PIMs was significantly associated with increased dependency in at least 1 activity of daily living (ADL) (AOR 2.31; 95% CI 1.08─4.20). Increased PIP use was associated with mortality (AOR 1.45; 95% CI 1.05─1.99).

CONCLUSION

: PIPs overall, and PIMs specifically, were frequent in older adults at hospital discharge, and were associated with increased re-hospitalizations and dependence in ADLs at 3-months post-discharge.

A systematic review of de-escalation strategies for redeployed staff and repurposed facilities in COVID-19 intensive care units (ICUs) during the pandemic

BACKGROUND

Intensive care units (ICUs) experienced a surge in patient cases during the COVID-19 pandemic. Demand was managed by redeploying healthcare workers (HCWs) and restructuring facilities. The rate of ICU admissions has subsided in many regions, with the redeployed workforce and facilities returning to usual functions. Previous literature has focused on the escalation of ICUs, limited research exists on de-escalation. This study aimed to identify the supportive and operational strategies used for the flexible de-escalation of ICUs in the context of COVID-19.

METHODS

The systematic review was developed by searching eight databases in April and November 2021. Papers discussing the return of redeployed staff and facilities and the training, wellbeing, and operational strategies were included. Excluded papers were non-English and unrelated to ICU de-escalation. Quality was assessed using the mixed methods appraisal tool (MMAT) and authority, accuracy, coverage, objectivity, date, and significance (AACODS) checklist, findings were developed using narrative synthesis and thematic analysis.

FINDINGS

Fifteen papers were included from six countries covering wellbeing and training themes encompassing; time off, psychological follow-up, gratitude, identification of training needs, missed training catch-up, and continuation of ICU and disaster management training. Operational themes included management of rotas, retainment of staff, division of ICU facilities, leadership changes, traffic light systems, and preparation for re-expansion.

INTERPRETATION

The review provided an overview of the landscape of de-escalation strategies that have taken place in six countries. Limited empirical evidence was available that evaluated the effectiveness of such strategies. Empirical and evaluative research from a larger array of countries is needed to be able to make global recommendations on ICU de-escalation practices.

Predictors of Polypharmacy Among Elderly Patients in China: The Role of Decision Involvement, Depression, and Taking Chinese Medicine Behavior

Introduction: The prevalence of polypharmacy is gradually increasing in geriatrics, which may contribute to adverse effects, such as potential drug-drug and drug-disease interactions. These side effects remain an important challenge in patient safety, which has a significant impact on mortality and incidence rate. Aims: Therefore, this study aims to understand the epidemiology of polypharmacy and identify factors that have an impact on the management of potentially inappropriate prescribing. Methods: This study is a cross-sectional study, analyzing the prescription data from 720 hospitalized patients aged 50+ with a random cluster sampling method. We used inverse probability treatment weighting (IPTW) method to group and match polypharmacy and non-polypharmacy patients, and logistic regression was conducted to explore the factors associated with polypharmacy. Results: The prevalence of polypharmacy accounted for 50.14% among the old patients in this study. Female patients (67.34%) have more polypharmacy than male patients, and key predictors associated with polypharmacy in the logistic regression model included the following: domicile (AOR = 0.63, 95% CI 0.42-0.95), annual income (AOR = 0.38, 95% CI 0.20-0.70), the number of chronic diseases (AOR = 3.68, 95% CI 2.69-5.06), taking Chinese medicine (AOR = 1.70, 95% CI 1.22-2.36), decision involvement (AOR = 1.49 95% CI 1.10-2.03), and depression (AOR = 1.42, 95% CI 1.03-1.96). Conclusion: Polypharmacy is common among the participants with chronic diseases in Hubei province, China. The study emphasizes that gerontology practitioners should be prudent in applying clinical guidelines to provide personalized, comprehensive assessment of decision making of prescriptions, especially in socioeconomically deprived areas.

Older patients' engagement in hospital medication safety behaviours

BACKGROUND

Increasing age is associated with more medication errors in hospitalised patients. Patient engagement is a strategy to reduce medication harm.

AIMS

To measure older patients' preferences for and reported medication safety behaviours, identify the relationship between preferred and reported medication safety behaviours and identify whether perceptions of medication safety behaviours differ between groups of young-old, middle-old and old-old patients (65-74 years, 75-84 years, and ≥ 85 years).

METHODS

A survey, which included the Inpatient Medication Safety Involvement Scale (IMSIS) was administered to 200 older patients from medical settings, at one hospital. Data were analysed using descriptive statistics, Spearman's rho and the Kruskal-Wallis test.

RESULTS

Patients reported a desire to ask questions (59.5% n = 119) and check with healthcare professionals if they perceived that a medication was wrong (86.5% n = 173) or forgotten (87.0% n = 174). Patients did not have particular preferences, which differed from their experiences in terms of viewing the medication administration chart and self-administering medications. Preferred and reported behaviours correlated positively (r = 0.46-0.58, n = 200, p ≤ 0.001). Young-old patients preferred notifying healthcare professionals of perceived medication errors more than middle-old and old-old patients (p ≤ 0.05).

CONCLUSIONS

Older patients may prefer verbal medication safety behaviours like asking questions and notifying healthcare professionals of medication errors, over viewing medication charts and self-administering medications. The young-old group wanted to identify perceived medication errors more than other age groups. Older patients are willing to engage in medication safety behaviours, and healthcare professionals and organisations need to embrace this engagement in an effort to reduce medication harm.

Knowledge and Power Relations in Older Patients' Communication About Medications Across Transitions of Care

Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients' experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough's Critical Discourse Analysis and Medication Communication Model. Older patients' medication knowledge and family members' advocacy challenged unequal power relations between clinicians and patients and families. Doctors' use of authoritative discourse impeded older patients' participation in the medication communication. Older patients perceived that nurses' involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.

Communication related to medication incidents-A concept analysis and literature review

AIMS

(1) To identify and analyse the conceptual framework and operationalise the concept of communication issues related to medication incidents in hospital to facilitate the development of a future tool for measuring frequencies of the communication issues. (2) To determine how the concept is distinct from related concepts.

DESIGN

Concept analysis.

DATA SOURCES

Twenty-three articles from seven scientific databases covering the years 2010-2020 and two official documents.

METHODS

Walker and Avant's concept analysis method was used. That was started by a systematised literature review on 2 November 2020 using specified criteria. Two authors evaluated articles' quality by Joanna Brigg's Institute's criteria. Literature review results were analysed deductive-inductively; conceptual framework was developed and concept defined presenting case scenarios. EQUATOR's standards were used in study reporting.

RESULTS

A conceptual framework and the concept of 'communication related to medication incidents in hospitals' were defined, comprising six main attribute categories: (1) communication dyads involved in communication, (2) patients' or professionals' individual issues, (3) institutional, (4) contextual and process issues, (5) communication concerning medication prescriptions and (6) qualitative characteristics of communication. The categories consisted of 128 quantitatively measurable and 10 qualitative attributes describing communication issues. The concept is distinct from related concepts by collating fragmented communication issues into the same concept.

CONCLUSION

The 128-item conceptual framework and the concept of communication related to medication incidents in hospitals were defined, as there was not one. The concept assembled parts of previous theories and fragmented information to one entity. The concept needs further condensing and validation to develop a tool for measuring communication issues.

IMPACT ON MEDICATION SAFETY

The conceptual framework can be used in practice and education as indicative rationale for reflection of current communication issues. The concept contributes to research by providing necessary grounding for tool development for measuring communication factors relating medication incidents.

Healthcare professionals' perceptions on medication communication challenges and solutions - text mining and manual content analysis - cross-sectional study

BACKGROUND

Communication challenges contribute to medication incidents in hospitals, but it is unclear how communication can be improved. The aims of this study were threefold: firstly, to describe the most common communication challenges related to medication incidents as perceived by healthcare professionals across specialized hospitals for adult patients; secondly, to consider suggestions from healthcare professionals with regard to improving medication communication; and thirdly, to explore how text mining compares to manual analysis when analyzing the free-text content of survey data.

METHODS

This was a cross-sectional, descriptive study. A digital survey was sent to professionals in two university hospital districts in Finland from November 1, 2019, to January 31, 2020. In total, 223 professionals answered the open-ended questions; respondents were primarily registered nurses (77.7 %), physicians (8.6 %), and pharmacists (7.3 %). Text mining and manual inductive content analysis were employed for qualitative data analysis.

RESULTS

The communication challenges were: (1) inconsistent documentation of prescribed and administered medication; (2) failure to document orally given prescriptions; (3) nurses' unawareness of prescriptions (given outside of ward rounds) due to a lack of oral communication from the prescribers; (4) breaks in communication during care transitions to non-communicable software; (5) incomplete home medication reconciliation at admission and discharge; (6) medication lists not being updated during the inpatient period due to a lack of clarity regarding the responsible professional; and (7) work/environmental factors during medication dispensation and the receipt of verbal prescriptions. Suggestions for communication enhancements included: (1) structured digital prescriptions; (2) guidelines and training on how to use documentation systems; (3) timely documentation of verbal prescriptions and digital documentation of administered medication; (4) communicable software within and between organizations; (5) standardized responsibilities for updating inpatients' medication lists; (6) nomination of a responsible person for home medication reconciliation at admission and discharge; and (7) distraction-free work environment for medication communication. Text mining and manual analysis extracted similar primary results.

CONCLUSIONS

Non-communicable software, non-standardized medication communication processes, lack of training on standardized documentation, and unclear responsibilities compromise medication safety in hospitals. Clarification is needed regarding interdisciplinary medication communication processes, techniques, and responsibilities. Text mining shows promise for free-text analysis.

Evaluation of financial outcomes under a value-based payment program for community pharmacies

BACKGROUND: Value-based payment models have been shown to limit health care spending and waste while improving quality of care. Evidence from value-based pharmacy programs (VBPPs) is needed to guide the use of these mechanisms in health care. OBJECTIVE: To evaluate financial outcomes of a VBPP implemented in 73 community pharmacies for about 40,000 commercial beneficiaries of Wellmark, Inc. METHODS: Beneficiaries were attributed to pharmacies based on the number of prescriptions dispensed. The VBPP paid community pharmacies a per capita payment based on their performance on a set of metrics to deliver care the pharmacists believed was necessary to optimize the beneficiaries' medication therapy and associated outcomes. Financial outcome variables were analyzed for the calendar year of 2018, including total cost of care, hospital admissions, and emergency department (ED) visits. Hospital admissions and ED visits were identified through claims data. Generalized linear models were used to test the effect of the VBPP on each of the outcome variables by comparing outcomes for beneficiaries attributed to the pharmacies participating in the VBPP (73 pharmacies) to Wellmark's beneficiaries attributed to nonparticipating pharmacies (847 pharmacies). Independent variables used in the models to control for possible confounding included beneficiary demographics and complexity scores, region code, accountable care organization (ACO) attribution, beneficiary product type (health maintenance organization (HMO), preferred provider organization (PPO), and several disease indicator variables. RESULTS: Analyses showed in 2018 that the per beneficiary per month total costs of care for the beneficiaries going to the VBPP pharmacies (N = 15,463) was $30.48 (4.5%; 95% CI = -6.2% to -2.7%) lower than that of the non-VBPP group (N = 140,717). The hospital admission rate for the VBPP group was 5.1% lower but was not statistically significant (95% CI = -12.9% to 3.3%). Similarly, the ED visit rate for the VBPP group was 2.1% lower than the non-VBPP group but did not reach statistical significance (95% CI = -8.6% to 3.3%). CONCLUSIONS: With the growing need for solutions to improve quality of care while reducing health care costs and waste, a value-based payment program using performance-determined capitated payments to community pharmacies offering enhanced clinical services significantly reduced total costs of care in a commercial population with one or more chronic conditions. Future work with this promising model is encouraged. DISCLOSURES: No external funding was obtained to support this study. Devolder and Heggen are employed by Wellmark, Inc. Doucette is supported by the Deborah K. Veale Professorship in Healthcare Policy at the University of Iowa. The authors have no other potential conflicts of interest to disclose.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

Resident and family engagement in medication management in aged care facilities: a systematic review

Introduction: Medication-related harms may occur if residents and families are not involved when important medication decisions are made. We examined how residents and families engage in the management of residents' medications in aged care facilities.Areas covered: A systematic review was undertaken, which was registered with PROSPERO (CRD42020152700). Electronic databases were searched from inception until 27 August 2020 using MEDLINE/PubMed, CINAHL, PsycINFO and EMBASE. Data synthesis was undertaken using thematic analysis.Expert opinion: Forty studies were included. Communication tended to be unidirectional comprising consultations where residents and families provided medication information to health care providers or where health care providers provided medication information to residents and families. Many challenges prevailed that prevented effective engagement, including families' hesitation about making decisions, and the lack of adequately-trained health care providers. Testing of interventions often did not include residents or families in developing these interventions or in examining how they participated in medication decisions following implementation of interventions. Areas for improvement comprise actively involving residents and families in planning interventions for resident-centered care. Health care providers need to have greater appreciation of families' ability to detect dynamic changes in residents' behavior, which can be used to enable optimal alterations in medication therapy.

Interprofessional and Intraprofessional Communication about Older People's Medications across Transitions of Care

Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients' medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and 'real-time' (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications.

The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review

PURPOSE

To synthesise knowledge and to explore the role of the nurse in medicines management during transitional care.

METHODS

An integrative systematic review was conducted. Electronic databases such as PubMed [including Medline], Web of Knowledge, Scopus, and Cinahl from January 2010 to April 2020 were searched. Original qualitative and quantitative studies written in English that focused on the role of the nurse in medicines management during transitional care, which included movement between short-term, long-term, and community healthcare settings were included.

RESULTS

The search process led to the retrieval of 10 studies, which were published in English from 2014 to 2020. They focused on the role of the nurse in patients' medicines management during transitional care in various healthcare settings. Given variations in the aims and methods of selected studies, the review findings were presented narratively utilizing three categories developed by the authors. In the first category as 'medication reconciliation process' the nurse participated in obtaining medication history, performing medication review, identifying medication discrepancies, joint medication reconciliation and adjustment. The second category as 'collaboration with other healthcare providers' highlighted the nurses' role in clarifying medicines' concerns, interdisciplinary communication and consultation, discharge planning and monitoring. In the third category as 'provision of support to healthcare recipients', the nurse was responsible for interpersonal communication with patients, education about medicines, and simplification of medication regimens, and symptoms management during transitional care.

CONCLUSION

Nurses play a crucial role in the safety of medicines management during transitional care. Therefore, they should be empowered and more involved in medicines management initiatives in the healthcare system. Patient safety and avoidance of medication errors during transitional care require that medicines management becomes a multidisciplinary collaboration with effective communication between healthcare providers.