Utilizing a cognitive engineering approach to conduct a hierarchical task analysis to understand complex older adult decision-making during over-the-counter medication selection

Evaluating the sustained effectiveness of a novel pharmacy-based intervention to reduce older adult misuse of over-the-counter medications: A case for non-significance

INTRODUCTION

Misuse of over-the-counter (OTC) medications by older adults (age 65+) can comprise Drug-Age, Drug-Drug, Drug-Disease, and Drug-Label types. Pharmacies in the United States are prevalent sources of OTCs and are an apt setting to address OTC misuse. Senior Safe™ is a pharmacy-system redesign for preventing older adult OTC misuse. The redesign uses signage to designate high-risk OTCs and safer products for older adult use, as well as prompting older adults to engage with pharmacy staff around medication safety issue.

OBJECTIVES

This study compared misuse in pharmacies with initial Senior Safe implementation (Immediate Effects group) to pharmacies with Senior Safe after 3 months (Sustained Effects group).

METHODS

A non-equivalent group design, involving older adults recruited from matched and randomly-allocated pharmacy sites within a health system, compared the Immediate Effects (n = 83) and Sustained Effects (n = 65) groups. All participants were recruited outside the pharmacy and were given hypothetical symptom scenarios from which to choose (i.e., cough/cold/allergy, pain, or sleep). Participants were then asked to select an OTC to treat that symptom, and explain their OTC use at symptom onset and if symptoms persisted/worsened. Participants' reported OTC use was evaluated for each misuse type. Multivariate modeling estimated differences in misuse between the Immediate and Sustained Effects groups.

RESULTS

No significant differences emerged between Immediate and Sustained Effect groups for any misuse type for which statistical modeling was conducted. Drug-Age misuse was statistically less likely for sleep products (OR = 0.170, p = .005) and for adults aged 85+ when compared to the 65-74 and 75-84 age categories (OR = 3.979, p = .053; OR = 6.900, p = .031, respectively).

CONCLUSIONS

These non-significant results suggest that the intervention effect was maintained at three months. Overall, then, misuse reductions occurring immediately after intervention implementation did not significantly increase after three months. System buy-in, including assessing costs to implement and maintain Senior Safe, is critical to promote broader adoption.

Older Adult Misuse of Over-the-Counter Medications: Effectiveness of a Novel Pharmacy-Based Intervention to Improve Patient Safety

OBJECTIVES

Older adults' (ages ≥65) inappropriate over-the-counter medications (OTC) use is prevalent, comprising Drug-Age, Drug-Drug, Drug-Disease, and Drug-Label types. Given that pharmacies sell many OTCs, structurally redesigning pharmacy aisles for improving patient safety (Senior Safe) was conceived to mitigate older adult OTC misuse, using Stop Signs and Behind-the-Counter Signs for high-risk OTCs. This study determined whether Senior Safe reduced high-risk OTCs misuse, while secondarily evaluating misuse changes for all OTCs.

METHODS

A randomized controlled trial design matched and randomly allocated 20 health system community pharmacies to control or intervention groups. All 288 study participants completed an OTC choice task in which they chose a hypothetical symptom scenario (pain, sleep, cough/cold/allergy), selected an OTC, and described how they would use it at symptom onset and if symptoms persisted or worsened. Reported OTC use was evaluated for each misuse type. Intervention and control sites were compared for each misuse type using multivariate modeling.

RESULTS

For high-risk OTCs, Drug-Age and Drug-Drug misuse were more likely in control sites (OR = 2.752, P = 0.004; OR = 6.199, P = 0.003, respectively), whereas Drug-Disease and Drug-Label misuse had too few occurrences in intervention sites for statistical comparisons. For all OTCs, only Drug-Age misuse was more likely for control sites (OR = 5.120, P = 0.001). Adults aged 85+ years had the greatest likelihood of all misuse types.

CONCLUSIONS

Results demonstrated that older adults frequently reported multiple misuse types, highlighting safety concerns. Senior Safe reduced high-risk OTC misuse, especially for older adults younger than 85 years. Cumulatively, these findings provide insights into practice recommendations supported through regulatory guidance.

Elevating Safe Use of Over-The-Counter Medications in Older Adults: A Narrative Review of Pharmacy Involved Interventions and Recommendations for Improvement

Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor's visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.

"What brought you in today?": Modeling patient-provider clinic visits to characterize rural providers' antibiotic treatment decisions

BACKGROUND

Designing clinical decision support (CDS) tools is challenging because clinical decision-making must account for an invisible task load: incorporating non-linear objective and subjective factors to make an assessment and treatment plan. This calls for a cognitive task analysis approach.

OBJECTIVES

The objectives of this study were to 1.) understand healthcare providers' decision making during a typical clinic visit, and 2.) explore how antibiotic treatment decisions are made when they arise.

METHODS

Two cognitive task analysis methods were applied - Hierarchical Task Analysis (HTA) and Operations Sequence Diagramming (OSD) - to 39 h of observational data collected at family medicine, urgent care, and emergency medicine clinical sites.

RESULTS

The resulting HTA models included a coding taxonomy detailing ten cognitive goals and associated sub-goals and demonstrated how the goals occur as interactions between the provider and electronic health record, the patient, and the physical clinic environment. Although the HTA detailed resources for antibiotic treatment decisions, antibiotics were a minority of drug classes ordered. The OSD shows the sequence of events and when decisions are made solely at the provider level and when shared decision making occurs with the patient. Qualitative data from the observations informed a constructed vignette case example portraying select tasks from the HTA.

CONCLUSIONS

These findings emphasize that the scope of disease states presenting to a generalist clinical setting is broad and could include acute exacerbations of rare diseases within a time-pressured environment. CDS must be accessible, time efficient, and fit within the resource gathering task before treatment decisions are made.

Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: A randomized controlled trial

INTRODUCTION

The Senior Section is a continuation of a previous intervention that aims to address a gap in medication safety, specifically related to older adult selection and use of over-the-counter medications. The purpose of this paper is to describe the protocol of this study.

METHODS

This study will occur in three phases: an adaptation phase, an effectiveness phase using a randomized controlled trial, and a sustainment phase. This study will take place in conjunction with administrative leadership and pharmacy sites of a regional Midwest integrated health system. Eye tracking technology will inform the adaptation of the intervention and demonstrate effectiveness in the randomized controlled trial. Following the randomized controlled trial, the health system will implement the intervention without research team support. Fidelity and long-term effectiveness outcomes will be collected to demonstrate sustainment.

DISCUSSION

The potential implications of this study are a complete and sustained redesign of the pharmacy setting to include educational and directional materials on medication safety, leading to a decrease in over-the-counter medication misuse in older adults. This project could provide a road map for pharmacy organizations to tailor and adopt the Senior Section, to ultimately reduce inappropriate over-the-counter medication use in older adults.