Patient reporting of potential adverse drug reactions: a methodological study

The real-world effectiveness and safety of perampanel in Europe: A scoping review

In order to characterize the real-world effectiveness and safety of perampanel during clinical use in Europe, we conducted a structured literature search and scoping review of real-world studies conducted in Europe in adolescents (aged ≥ 12 years) or adults who were prescribed perampanel for focal epilepsy or primary generalized tonic-clonic seizures in the context of idiopathic generalized epilepsy, published between January 2016 and July 2021. We identified 29 relevant studies (20 retrospective and 9 prospective) in 3608 patients; median study duration was 12 months. Most patients (76.1%) were receiving two or more antiseizure drugs (ASDs) when perampanel was initiated. The maintenance perampanel dose ranged from 2 to 16 mg/day (most commonly 6 mg/day). Retention rate at 12 months ranged from 46% to 90.5% (median 71.1%). The proportion of patients who were free of seizures during perampanel ranged from 1.8% to 84.6%, but were consistently below 20% in studies where patients had received an average of ≥5 prior ASDs and above 20% where patients had received an average of <5 prior ASDs. The proportion of patients who achieved ≥50% reduction in seizures during perampanel ranged from 20.0% to 85.7%. Across all studies, the incidence of adverse events (AEs) ranged from 18.2% to 67.4% (median 37.1%) and discontinuation due to AEs from 6.2% to 56% (median 12.5%). Discontinuation rates tended to be higher in UK studies than in studies from Italy or Spain. The most commonly reported individual AEs were dizziness/vertigo (median incidence 13.7%), somnolence (median 11.9%), aggression (median 9.8%), irritability (median 9.1%), and cognitive deficits (median 7.0%). There was no relationship between the overall rate of AEs and perampanel dose, perampanel plasma levels, or number of concomitant medications. Our global overview of European observational studies with perampanel provides evidence that this agent is effective and safe in clinical practice in a range of countries, patients, and settings.

Development of a web-based system to report medication-related adverse effects: a design and usability study (Preprint)

Background

Medicine use is the most common intervention in health care. The frequency with which medicines are used means medication-related problems are very common. One common type of medication-related problems is adverse drug events, which are unintended and harmful effects associated with use of medicines. Reporting of adverse drug events to regulatory authorities is important for evaluation of safety of medicines; however, these adverse effects are frequently unreported due to various factors, including lack of consumer-friendly reporting tools.

Objective

The aim of this study was to develop a user-friendly digital tool for consumers to report medication-related adverse effects.

Methods

The project consisted of 3 parts: (1) content development, including a systematic literature search; (2) iterative system development; and (3) usability testing. The project was guided by participatory design principles, which suggest involving key stakeholders throughout the design process. The first 2 versions were developed as a mobile app and were tested with end users in 2 workshops. The third version was developed as a web application and was tested with consumers who were taking regular medicines. Consumers were asked to complete a modified version of the mHealth app usability questionnaire (MAUQ), an 18-item questionnaire with each item scored using a 7-point Likert scale ranging from 0 (strongly disagree) to 7 (strongly agree). The MAUQ assessed 3 subscales including ease of use (5 items), interface and satisfaction (7 items), and usefulness (6 items). Continuous variables were reported as mean (SD) values, whereas categorical variables were presented as frequencies (percentages). Data analysis was conducted in Microsoft Excel.

Results

The content for the system was based on a systematic literature search and short-listing of questions, followed by feedback from project team members and consumers. Feedback from consumers in the 2 workshops were incorporated to improve the functionality, visual design, and stability of the third (current) version. The third version of the system was tested with 26 consumers. A total of 79% (N=307/390) of all responses on the MAUQ were scored 6 or 7, indicating that users generally strongly agree with the usability of the system. When looking at the individual domains, the system had an average score of 6.3 (SD 0.9) for “ease of use,” 6.3 (SD 0.8) for “interface and satisfaction,” and 5.2 (SD 1.4) for “usefulness.”

Conclusions

The web-based system for medicine adverse effects reporting is a user-friendly tool developed using an iterative participatory design approach. Future research includes further improving the system, particularly the usefulness of the system, as well as testing the scalability and performance of the system in practice.

Patient-Reported Questionnaires to Identify Adverse Drug Reactions: A Systematic Review

Background: This systematic review aims to summarise available patient-reported questionnaires to detect adverse drug reactions (ADRs) that can be utilised by healthcare professionals in clinical practice and to summarise the psychometric properties (validity, reliability, and responsiveness) of the questionnaires. Methods: A systematic literature search was conducted using Medline, Pubmed, Embase, and Emcare databases to screen for articles published between January 2000 and July 2020. Data items regarding validity, reliability, and responsiveness were extracted independently by two authors. The methodological quality was assessed using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Results: A total of 1563 unique article titles were identified after removing duplicates. Following shortlisting of relevant articles, 19 patient-reported ADR questionnaires were identified. Questionnaires most commonly focused on mental health medications (42.1%, n = 8), followed by general questionnaires applicable to any medication (21.1%, n = 4). Many questionnaires did not report assessing the validity and reliability of the measurement tool. For example, only 11 questionnaires (58%) mentioned assessing content validity, in addition to criterion or construct testing. Conclusion: This systematic review summarised the available patient-reported questionnaires that can be used in research and clinical practice to identify ADRs. Results of this systematic review highlight the need for more robust validity and reliability testing when developing patient-reported ADR questionnaires.

Community Pharmacists' Views and Experiences with ADR Reporting for Complementary Medicines: A Qualitative Study in New Zealand

INTRODUCTION

Detecting signals of safety concerns associated with complementary medicines (CMs) relies on spontaneous reports submitted by health professionals and patients/consumers. Community pharmacists are well placed to identify and report suspected adverse drug reactions (ADRs) associated with CMs, but pharmacists submit few CMs ADR reports.

OBJECTIVES

The aim of this study was to explore New Zealand community pharmacists' views and experiences with ADR reporting for CMs.

METHODS

Qualitative, in-depth, semi-structured interviews were undertaken with 27 practising community pharmacists identified through purposive and convenience sampling. Data were analysed using a general inductive approach.

RESULTS

Participants were familiar with systems for reporting ADRs, believed ADR reporting for CMs important, and that pharmacists should contribute. However, few submitted reports of CMs ADRs and none encouraged patients/consumers to do so. Participants explained this was because they had never been informed by patients about ADRs associated with CMs. Participants said they would report serious ADRs; time pressures, lack of certainty around causality, lack of awareness of mechanisms for reporting CMs ADRs, and lack of remuneration were deterrents to reporting. Participants were aware of intensive-monitoring studies for prescription medicines, understood the rationale for considering this approach for CMs and recognised there would be potential practical difficulties.

CONCLUSIONS

Participants used their knowledge of CMs safety concerns to minimise risk of harms to consumers from CMs use, but most had a passive approach to identifying and reporting ADRs for CMs. There is substantial potential for pharmacists to adopt proactive strategies in pharmacovigilance for CMs, particularly in recognising and reporting ADRs, and empowering CMs users to do the same.

Safety and efficacy of ripasudil in Japanese patients with glaucoma or ocular hypertension: 12-month interim analysis of ROCK-J, a post-marketing surveillance study

Background

Ripasudil is approved in Japan for glaucoma or ocular hypertension (OH) when other treatments are ineffective or cannot be administered. Its long-term safety and efficacy are being examined in a post-marketing surveillance study; 12-month data are described here.

Methods

This prospective, open-label, observational study enrolled patients with glaucoma or OH who started ripasudil during routine care. The key safety outcome was the incidence of adverse drug reactions (ADRs), focusing on allergy and/or inflammation-related ADRs such as blepharitis (including allergic) or conjunctivitis (including allergic). The primary efficacy endpoint was least squares mean (LSM) ± standard error (SE) change in intraocular pressure (IOP) from baseline to 12 months in all patients and in diagnostic groups. Secondary endpoints were change in IOP in groups stratified by treatment initiation pattern, number of concomitant drugs, and baseline IOP.

Results

Overall, 3359 patients (48% male, mean age ± standard deviation [SD] 69.1 ± 12.7 years) were evaluated for safety and 3323 for efficacy. Diagnoses were primary open-angle glaucoma (43.9%), normal-tension glaucoma (36.6%), secondary glaucoma (8.7%), OH (4.2%), and primary closed-angle glaucoma (2.4%). Mean ± SD observation period was 300.1 ± 122.4 days; 1010 patients (30.1%) discontinued ripasudil by 12 months. ADRs occurred in 626 patients (18.6%); the most common were conjunctival hyperemia and blepharitis. Allergy and/or inflammation-related ADRs occurred in 388 patients (11.6%), most commonly blepharitis (5.6%) and conjunctivitis (4.2%). IOP decreased significantly from a mean ± SD 18.1 ± 6.1 mmHg at baseline; the LSM ± SE IOP change throughout 12 months of ripasudil treatment was − 2.6 ± 0.1 mmHg (− 14.0 ± 0.4%; p < 0.001). A significant decrease in IOP at 12 months was seen in all categories of baseline IOP (p < 0.001), and all types of glaucoma (p < 0.001), except neovascular glaucoma. Ripasudil was associated with a significant reduction in IOP at 12 months whether initiated as monotherapy or in combination with ≤4 concomitant glaucoma therapies (p < 0.001).

Conclusions

Ripasudil was safe and effective in patients with glaucoma or OH during routine care. No new safety signals were identified, and significant reductions in IOP were maintained over 12 months.

Development of the Ketamine Side Effect Tool (KSET)

BACKGROUND

Currently, no specific, systematic assessment tool for the monitoring and reporting of ketamine-related side effects exists. Our aim was to develop a comprehensive Ketamine Side Effect Tool (KSET) to capture acute and longer-term side effects associated with repeated ketamine treatments.

METHODS

Informed by systematic review data and clinical research, we drafted a list of the most commonly reported side effects. Face and content validation were obtained via feedback from collaborators with expertise in psychiatry and anaesthetics, clinical trial piloting and a modified Delphi Technique involving ten international experts.

RESULTS

The final version consisted of four forms that collect information at time points: screening, baseline, immediately after a single treatment, and longer-term follow-up. Instructions were developed to guide users and promote consistent utilisation.

LIMITATIONS

Further evaluation of feasibility, construct validity and reliability is required, and is planned across multiple international sites.

CONCLUSIONS

The structured Ketamine Side Effect Tool (KSET) was developed, with confirmation of content and face validity via a Delphi consensus process. This tool is timely, given the paucity of data regarding ketamine's safety, tolerability and abuse potential over the longer term, and its recent adoption internationally as a clinical treatment for depression. Although based on data from depression studies, the KSET has potential applicability for ketamine (or derivatives) used in other medical disorders, including chronic pain. We recommend its utilisation for both research and clinical scenarios, including data registries.

Development of the Adverse Analgesic Drug Event Measure

BACKGROUND

Little is known about how people respond to an analgesic adverse drug event despite the significant incidence of deaths and hospitalizations associated with analgesic adverse drug events.

OBJECTIVE

The purpose of this two-phase instrument development study was to test the validity and reliability of the Analgesic Adverse Drug Event Measure (AADEM).

METHODS

Content validity was established during Phase I. Six experts rated the 58-item measure developed from a pilot survey of adults who had experienced an analgesic adverse drug event. Experts' ratings supported a 17-item AADEM with a scale content validity index of .86. Phase II consisted of online administration of the AADEM to a national Qualtrics panel who reported an adverse drug event from a self-administered analgesic. Exploratory factor analysis was conducted using principal axis factoring and oblique rotation including Direct Oblimin and Promax rotations with Kaiser normalization.

RESULTS

Four factors emerged from the analysis: sought care, consulted provider, discontinued or continued analgesic, and attributed adverse drug event with a total explained variance of 55.4%. Scale content validity index for the 13-item AADEM was .88. Internal consistency for the four subscales was acceptable, but low for the full 13-item AADEM.

DISCUSSION

Results establish preliminary evidence for the validity and reliability of the 13-item AADEM to measure response to an analgesic adverse drug event. Next steps involve confirmatory factor analysis in a different sample to examine the underlying construct of the AADEM. The AADEM might help identify people at risk for serious analgesic adverse drug events.

Utility of an adverse drug event database based on the narrative accounts of patients with breast cancer

Patient narratives of adverse drug events (ADEs) often differ from the symptoms listed on the package inserts of pharmaceutical products using common ADE terminology and could be a source of great comfort to patients with the same disease. To explore this idea, we analyzed written narratives obtained from 48 patients with breast cancer using the NPO Corporation Database of Individual Patients' Experiences, Japan (DIPEx-Japan). Our analysis aimed to determine the utility of an "Adverse Drug Event Database" for use in clinical settings as a novel source of disease information in patients' own words. An analysis of transcripts from 29 patients, in which they recounted their treatment drugs and the time of onset and duration of ADEs in great detail, revealed several discrepancies between the language they used to describe various side effects and the standard ADE terminology on package inserts. We conclude that the language used to describe ADEs on package inserts is insufficient for helping patients as they struggle to recognize, internalize, and overcome ADEs, and argue the need for available, detailed information in the words of real patients about the nature of the ADEs predicted, as well as their clinical course and duration. Such information would be invaluable in supplementing the standardized language used on package inserts. Databases of patients' narrative accounts of ADEs are needed as information sources that can be reliably disseminated among patients.

Development and preliminary validation of an instrument to enable laypersons to assess suspected side effects from medicines

PURPOSE

Research into causality assessment tools enabling patients to assess suspected adverse drug reactions (ADRs) is limited. Supporting patients with tools could improve their confidence in discussions with health professionals and encourage reporting of suspected ADRs to regulators. This study describes development and preliminary validation of an instrument: Side Effect Patient ASsessment Tool (SE-PAST).

METHODS

SE-PAST was developed from survey and interview data involving patients experiencing suspected ADRs. It included 10 statements enabling causality assessment, covering timing, additional information sources, and experiences, with four options: yes/no/don't know/not applicable. Scoring and weighting resulted in four categories of causal association: highly probable, probable, possible, unlikely. Validation involved obtaining feedback from 31 individuals experiencing an ADR. Further validation involved online distribution through patient support groups and comparison of reported symptoms to known ADRs.

RESULTS

Validators found SE-PAST easy to read (31), to understand (27), and to complete (29). A total of 294 respondents completed SE-PAST online, with 98% completing eight or more causality assessment statements. Symptoms were categorised as highly probable (46; 16%), probable (80; 62%), possible (44; 15%), and unlikely (21; 7%). A total of 221 respondents identified one suspected medicine, with 95% of these reporting at least one symptom known to be an ADR. Of 227 providing feedback, 139 (61%) found SE-PAST useful, 160 (71%) felt motivated to discuss their experience with a health professional, and 136 (60%) were encouraged to report to the regulator.

CONCLUSION

SE-PAST was easily completed and understood by people experiencing suspected ADRs and could be useful in encouraging patient reporting to health professionals and agencies.

Knowledge, awareness, perception and reporting of experienced adverse drug reactions among outpatients in Nigeria

Background Higher incidence of adverse drug reactions (ADRs) remain a major cause of morbidity and mortality. Most targeted ADR reporting activities are mainly professional-centered with less attention to patients' knowledge, perception and selfreporting of experienced ADRs. Objectives To comprehensively evaluate patients' knowledge, awareness, perception and reporting of experienced ADRs. Setting Three public healthcare facilities in Ibadan, southwestern Nigeria. Method A questionnaire-guided cross-sectional interview of 1190 consented ambulatory adult patients consecutively recruited from various clinics of the selected hospitals between February and June 2018. The 32-item pretested questionnaire comprised open- and closed-ended questions, as well as open-ended questions with relevant prompts. Data were summarised using descriptive statistics, while Chi square was used to investigate association between relevant categorical variables at p < 0.05. Main outcome measure Knowledge, awareness, perception and reporting of experienced ADRs among patients. Results Response rate was 99.1%. Mean age was 40.6 ± 14.9 years. Forty-nine (4.1%) patients were aware of pharmacovigilance. A total of 964 (81.0%) correctly understood what can be regarded as serious adverse drug reactions (ADRs), 444 (37.3%) had previously experienced ADRs, while 77 (6.5%) experienced reactions with current medication(s). Of this, 64 (83.1%) made a report largely to physician (52; 81.3%). Summarily, reported reactions were more with antimalarials (214; 49.1%), with itching (168; 78.5%) constituting the most frequently occurring reaction. Use of text message (276; 27.2%) and filling of ADR report form (248; 24.4%) were topmost on the list of suggested methods for ADR reporting. There was a significant association between patient's age and awareness of pharmacovigilance (p = 0.015), while educational qualification (p = 0.001) significantly influenced tendency to make a report of experienced ADRs. Conclusion Approximately four percent of patients were aware of pharmacovigilance, while more than three-quarters correctly understood the concept of serious adverse drug reactions. A little above one-quarter had previously experienced one form of reaction or the other, with majority reporting such reactions to physician. Continuous education of stakeholders in pharmacovigilance activities is advocated, while patient's active involvement in spontaneous reporting of ADRs should be carefully considered.

Medication-Taking Behaviors and Perceptions Among Adults With Heart Failure (from the REasons for Geographic And Racial Differences in Stroke Study)

Medication regimens in adults with heart failure (HF) are complex which can complicate patient adherence. Individuals with HF frequently use beta blockers (BBs) for multiple indications, including hypertension and HF, but BBs can have significant side effects that may affect their use. We examined medication-taking behaviors and perceptions in individuals with HF with a particular focus on BBs. A mailed survey on medication use was administered to US adults with HF enrolled in the REasons for Geographic And Racial Differences in Stroke study. Among 518 respondents, 357 (69%) reported taking a BB. Nearly half (42%) reported taking ≥10 medications per day. However, 45% indicated that they did not miss any days taking medications, and over 85% reported willingness to take additional medications to prevent further healthcare encounters. Participants' perceptions of BB symptoms varied, but 56% of those who reported experiencing symptoms did not discuss this with their healthcare providers. Adults who experienced HF hospitalization had higher odds of reporting taking BBs to treat HF (odds ratio 1.51, 95% confidence interval 1.19, 1.91). Adults with hypertension were also likely to report taking BBs to treat high blood pressure (odds ratio 2.42, 95% confidence interval 1.79, 3.26). In conclusion, despite extensive medication regimens, individuals with HF were willing to take additional medications for their disease. Participant recognition of BB use for treating HF and co-morbidities was high, yet many do not report side effects to healthcare providers. In conclusion, better understanding of patients' medication-taking behaviors and perceptions may facilitate optimization of HF treatments.

Post-radical prostatectomy urinary incontinence: is there any discrepancy between medical reports and patients' perceptions?

Background

Post-radical prostatectomy urinary incontinence (PPI) negatively affects the quality of life of patients. Accurate identification of the problem by physicians is essential for adequate postoperative management. In this study we sought to access whether there is, for urinary incontinence, any discrepancy between medical reports and the perception of patients.

Methods

We performed a retrospective analysis of medical records of 337 patients subjected to radical retropubic prostatectomy (RRP) between 2005 and 2010. Sociodemographic variables were collected, as well as continence status over the course of treatment. Next, we contacted patients by phone to determine continence status at present and at time of their last appointment, as well as to apply ICIQ – SF questionnaire. Poisson regression model with robust variance was used to estimate the factors associated with discrepancy, using the stepwise backward strategy. Software used was Stata® (StataCorp, LC) version 11.0.

Results

There is discrepancy between medical reports and patients’ perceptions in 42.2% of cases. This discrepancy was found in 56% of elderly patients and 52% of men with low schooling, with statistical significance in these groups (p = 0.069 and 0.0001, respectively), whereas in multivariate regression analysis the discrepancy rate was significantly higher in black men (discrepancy rate of 52.6%) with low schooling (p = 0.004 and 0.043, respectively).

Conclusion

There is discrepancy between medical reports and the perception of black men with low schooling in respect to post-radical prostatectomy urinary incontinence and a need for more thorough investigation of this condition in patients that fit this risk profile.

Identifying Adverse Drug Events in Older Community-Dwelling Patients

PURPOSE

To evaluate a patient-report instrument for identifying adverse drug events (ADEs) in older populations with multimorbidity in the community setting.

METHODS

This was a retrospective cohort study of 859 community-dwelling patients aged ≥70 years treated at 15 primary care practices. Patients were asked if they had experienced any of a list of 74 symptoms classified by physiologic system in the previous 6 months and if (1) they believed the symptom to be related to their medication, (2) the symptom had bothered them, (3) they had discussed it with their family physician, and (4) they required hospital care due to the symptom. Self-reported symptoms were independently reviewed by 2 clinicians who determined the likelihood that the symptom was an ADE. Family physician medical records were also reviewed for any report of an ADE.

RESULTS

The ADE instrument had an accuracy of 75% (95% CI, 77%-79%), a sensitivity of 29% (95% CI, 27%-31%), and a specificity of 93% (95% CI, 92%-94%). Older people who reported a symptom had an increased likelihood of an ADE (positive likelihood ratio [LR+]: 4.22; 95% CI, 3.78-4.72). Antithrombotic agents were the drugs most commonly associated with ADEs. Patients were most bothered by muscle pain or weakness (75%), dizziness or lightheadedness (61%), cough (53%), and unsteadiness while standing (52%). On average, patients reported 39% of ADEs to their physician. Twenty-six (3%) patients attended a hospital outpatient clinic, and 32 (4%) attended an emergency department due to ADEs.

CONCLUSION

Older community-dwelling patients were often not correct in recognizing ADEs. The ADE instrument demonstrated good predictive value and could be used to differentiate between symptoms of ADEs and chronic disease in the community setting.

Confidence and accuracy in identification of adverse drug reactions reported by outpatients

Background Patient reporting of adverse drug reactions (ADRs) could supplement the existing reporting system and contribute to early detection of ADRs. The confidence in ADR identification and their attribution of ADRs were limited to outpatients. Objective To determine the type and frequency of ADRs reported by outpatients, to evaluate confidence and accuracy in ADR identification as well as contributing factors. Setting University hospital in northeastern Thailand Method Cross-sectional study using questionnaires distributed to 500 outpatients who claimed to have experienced an ADR. Confidence in identifying ADRs was measured by visual analogue score (VAS), while accuracy of reported ADRs was determined using Naranjo algorithm and WHO criteria. Main outcome measure Number and type of ADRs, confidence rating and accuracy category. Results In total, 390 outpatients completed the questionnaire (response rate = 78.0%). Rash (19.0%), nausea/vomiting (7.4%), and dizziness (5.8%) were the top three reported ADRs. Sixty-one percent of respondents rated their level of confidence in identifying ADRs as high (VAS 9.2 ± 0.95), which was associated with having underlying diseases (OR 1.93), low number of reported symptoms (OR 0.38) and severe ADRs (OR 1.33). Causality assessment was classified as true ADRs in 90.0% and 88.9% of cases, using Naranjo algorithm and WHO criteria, respectively. Respondents with low number of reported symptoms (OR 0.27) and high level of confidence had greater accuracy in ADR identification (OR 1.11). Conclusion The outpatients reported a high proportion of potential ADRs with high confidence and accuracy. Patient reporting of ADRs has potential to support the pharmacovigilance system.

Patient safety issues and concerns in Bhutan's healthcare system: a qualitative exploratory descriptive study

OBJECTIVES

To investigate what healthcare professionals perceived and experienced as key patient safety concerns in Bhutan's healthcare system.

DESIGN

Qualitative exploratory descriptive inquiry.

SETTINGS

Three different levels of hospitals, a training institute and the Ministry of Health, Bhutan.

PARTICIPANTS

In total, 140 healthcare professionals and managers.

METHODS

Narrative data were collected via conversational in-depth interviews and Nominal Group Meetings. All data were subsequently analysed using thematic analysis strategies.

RESULTS

The data revealed that medication errors, healthcare-associated infections, diagnostic errors, surgical errors and postoperative complications, laboratory/blood testing errors, falls, patient identification and communication errors were perceived as common patient safety concerns. Human and system factors were identified as contributing to these concerns. Instituting clinical governance, developing and improving the physical infrastructure of hospitals, providing necessary human resources, ensuring staff receive patient safety education and promoting 'good' communication and information systems were, in turn, all identified as processes and strategies critical to improving patient safety in the Bhutanese healthcare system.

CONCLUSION

Patient safety concerns described by participants in this study were commensurate with those identified in other low and middle-income countries. In order to redress these concerns, the findings of this study suggest that in the Bhutanese context patient safety needs to be conceptualised and prioritised.

Evaluation of Potentially Drug-Related Patient-Reported Common Symptoms Assessed During Clinical Medication Reviews: A Cross-Sectional Observational Study

Introduction

Healthcare professionals tend to consider common non-alarming drug-related symptoms to be of little clinical relevance. However, such symptoms can have a substantial impact on the individual patient. Insight into patient-reported symptoms could aid pharmacists to identify improvements in medication treatment, for instance in the patient interview at the start of a clinical medication review (CMR).

Objective

The objectives of this study were to describe the numbers and types of patient-reported symptoms assessed during a CMR and to elucidate their potential association with the drugs in use.

Methods

This observational study was performed using data from a clinical trial on patient-reported outcomes of CMRs. Patients taking at least five drugs and who were eligible for a CMR were selected by 15 community pharmacies. Patients were asked to fill in a structured instrument, the Patient Reported Outcome Measure, Inquiry into Side Effects (PROMISE). Among other domains, this instrument offers a list of 22 symptom categories to report symptoms and their relationship with the drugs in use. The results of the PROMISE instrument together with information on patients’ actual drug use were available for analysis. Besides descriptive analysis, associations with side effects as listed in the summary of product characteristics (SPC) of the drugs in use were assessed with logistic regression analysis.

Results

Of the 180 patients included, 168 patients (93.3%) reported at least one symptom via the PROMISE instrument, which could be discussed with the pharmacist during the patient interview. In total, the patients reported 1102 symptoms in 22 symptom categories. Of these patients, 101 (56.1%) assumed that at one or more of the symptoms experienced were related to the drugs in use and 107 (59.4%) reported at least one symptom that corresponded to a ‘very common’ side effect listed in the SPC of a drug in use. Each additional drug in use with a specific symptom listed as a ‘very common’ side effect in its SPC statistically significantly increased the probability of a patient reporting the symptoms of ‘dry mouth/thirst, mouth complaints’, ‘constipation’, ‘diarrhoea’ and ‘sweating’.

Conclusion

Many patient-reported symptoms and symptoms potentially related to drugs in use were identified by administering the PROMISE instrument to users of at least five drugs being taking long-term. This information can be used in CMRs to improve patients’ drug therapy.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0504-7) contains supplementary material, which is available to authorized users.

Adverse drug reactions reported to the drug and poison information center of Tehran, Iran

BACKGROUND

Burden of adverse drug reactions (ADRs), in home-environment and domestic settings, is unknown.

OBJECTIVE

To discuss the epidemiology of reported ADRs to 13-Aban drug and poison information center (DPIC) and to discuss the burden of hospitalization caused by these ADRs from commonly implicated therapeutic groups.

METHODS

A retrospective analysis of the yellow card schemes of suspected ADRs reported to the 13-Aban DPIC was conducted from 21 March 2013 to 21 November 2016 inclusive.

MAIN OUTCOME MEASURES

Characteristics of the ADRs, such as the sex and age of the patient, the therapeutic group involved, and the medical outcome of the exposure, were examined. ADR Hospitalization (ADRH) index was calculated for each drug group by dividing the number of ADR-related hospitalizations with total number of reported ADR cases (n = 748), and then multiplying by 100.

RESULTS

ADRs were reported for 748 patients representing 5 cases per 1000 enquiries to the 13-Aban DPIC over almost 4-years of the study period. Public were responsible for reporting every 4 out of 5 ADR cases (n = 651, 87%) and the remaining 1 out of 5 ADR cases was reported by the health care professionals (n = 97, 13%). Most of the ADRs had a medical outcome documented as having a minor effect or were minimally bothersome to the patients (n = 509, 68%), and less than 4.9% (n = 37) were documented as having a major effect or were life-threatening. Overall, 7.4% (n = 55) of ADRs were resulted in hospitalization. Antibacterials for systemic use represented the therapeutic group with the highest hospitalization index (1.7%).

CONCLUSIONS

The study concluded that ADRs to antibiotics are common and some of them resulted in hospitalization.

Development and Initial Validation of a Patient-Reported Adverse Drug Event Questionnaire

BACKGROUND

Direct patient reporting of adverse drug events (ADEs) is relevant for the evaluation of drug safety. To collect such data in clinical trials and postmarketing studies, a valid questionnaire is needed that can measure all possible ADEs experienced by patients.

OBJECTIVE

Our aim was to develop and test a generic questionnaire to identify ADEs and quantify their nature and causality as reported by patients.

METHODS

We created a draft list of common ADEs in lay-terms, which were classified in body categories and mapped to the Medical Dictionary for Regulatory Activities (MedDRA(®)) terminology. Questions about the nature and causality were derived from existing questionnaires and causality scales. Content validity was tested through cognitive debriefing, revising the questionnaire in an iterative process. Feasibility and reliability were assessed using a Web-based version of the questionnaire. Patients received the questionnaire twice. Feasibility was assessed by the reported time needed for completion and ease of use. Reliability was calculated using Cohen's kappa and proportion of positive agreement (PPA) on: (1) any ADE at patient level; (2) similar ADEs at MedDRA(®) System Organ Class level; and (3) the same ADE at ADE-specific level.

RESULTS

In the development phase, 28 patients with type 2 diabetes or asthma/chronic obstructive pulmonary disease (COPD) participated. Questions and answer options were rephrased, layout was improved, and changes were made in the classification of ADEs. The final questionnaire consisted of 252 ADEs organized in 16 body categories, and included 14 questions per reported ADE. A total of 135 patients using a median of five different drugs completed the Web-based questionnaire twice. The median completion time was 15 min for patients not reporting any ADE, and 30 min for patients reporting at least one ADE. Three quarters of the patients found the questionnaire easy to use. Test-retest reliability was acceptable at patient level (κ = 0.50, PPA 0.64) and at MedDRA(®) System Organ Class level (κ = 0.52, PPA 0.54), but was low at ADE-specific level (κ = 0.38, PPA 0.38).

CONCLUSION

We developed a generic patient-reported ADE questionnaire and confirmed its content validity. The questionnaire was feasible and reliable for reporting any ADE and similar ADEs at MedDRA(®) System Organ Class level. Additional work is, however, needed to reliably quantify specific ADEs reported by patients.

Measuring medicine-related experiences from the patient perspective: a systematic review

BACKGROUND

There is an increasing drive to measure and so improve patients' experiences and outcomes of health care. This also applies to medicines, given their ubiquity as health care interventions. Patients' experiences of using medicines vary, and instruments which measure these are seen as an essential component to improve care. We aimed to identify generic measures of patients' experiences of using prescription medicines and to examine their properties and suitability for use in research or practice.

METHODS

Multiple electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycARTICLES, CINHAL Plus, PROQOLID®, and Google Scholar. We identified, critically appraised, and summarized generic questionnaires assessing one or more aspects of the medicine use experience among adult patients using prescription medicines for chronic conditions, and the process of questionnaire development, degree of patient involvement, and/or validation processes.

RESULTS

Fifteen questionnaires were included. Of these, nine measures were multidimensional, covering various aspects of medicine use. Six instruments covered only a single domain, assessing a specific facet of using medicines. Domains covered were the following: effectiveness; convenience, practicalities, and/or managing medicines; information, knowledge, and/or understanding; side effects; relationships and/or communication with health professionals; impact on daily living and/or social life; general satisfaction; attitudes; beliefs, concerns, and/or perceptions; medical follow-up and/or adherence-related issues; treatment- and/or medicine-related burden, perceived control, or autonomy; self-confidence about medicine use; availability and accessibility; and medicine-related quality of life. None of the identified questionnaires covered all domains. Instruments varied in the extent of patient involvement in both their development and validation.

CONCLUSION

There is a scarcity of psychometrically sound, comprehensive, and generic measures of experiences of using prescription medicines among adult patients living with chronic illnesses. There is a need for further development and/or validation of existing instruments suitable for use in this population.

Initial development and testing of an instrument for patient self-assessment of adverse drug reactions

PURPOSE

To develop and conduct preliminary testing of a causality assessment tool for patients, for potential use in encouraging both discussions with clinicians about suspected adverse drug reactions (ADRs) and reporting to authorities.

METHODS

Ten causality statements, developed from qualitative studies involving patients, with a scoring system allowing categorization, were embedded in a questionnaire which also included a symptom checklist and additional details about one suspected ADR and medicine, selected for causality assessment. Patients with experiences of suspected ADRs were involved in cognitive interviews (15), piloting (20) and psychometric testing (120). Test-retest reliability, construct validity and criterion-related validity were evaluated, through repeated causality assessment, comparison with a visual analogue scale assessing certainty of causality and comparison with causality assessment using World Health Organization-Uppsala Monitoring Centre (WHO-UMC) criteria, respectively. The study involved outpatients at a university hospital in northeast Thailand.

RESULTS

Ninety-eight patients completed causality assessment twice: both causality scores (Spearman rs  = 0.715; p < 0.001) and causality classification [percentage of positive agreement (PPA) = 68.4; κ = 0.419; p < 0.001] showed satisfactory reliability. Causality scores were positively correlated with certainty of causality (Spearman rs  = 0.556; p < 0.01). There was moderate agreement against WHO-UMC criteria [PPA = 70.4; κ = 0.440; p < 0.001]. Of the 91 completing an evaluation, 88% agreed that the tool should be used routinely, 78% agreed that it gave them useful results and 80% agreed that it was easy to use.

CONCLUSIONS

This novel instrument has satisfactory psychometric properties and was acceptable to Thai patients, but it requires further testing. It has potential for use in supporting patients with suspected ADRs to discuss these with health professionals, and perhaps to report directly.

Undesirable effects related to oral antineoplastic drugs: comparison between patients' internet narratives and a national pharmacovigilance database

BACKGROUND

The Internet is changing the way people learn about health and illness. Over the previous decade, the oral antineoplastic (OAN) agents have changed patient management allowing more ambulatory care. In this regard, websites could be an interesting source of data about OAN-induced adverse events (AEs).

OBJECTIVE

The aim of the study was to describe the characteristics of AEs, as reported on websites by patients exposed to OAN agents, and to compare these to those recorded in the French pharmacovigilance database (FPVD).

METHODS

We performed a retrospective study to collect AEs reported by patients in five of the best-known website forums in France over 1 year (2011). For each report, we recorded demographic data, cancer type, drug involved and AEs. The same analysis was done in the FPVD for OAN-induced adverse drug reactions (ADRs).

RESULTS

A total of 202 AEs were identified in website posts and 1,448 ADRs were found in the FPVD. The most cited drugs in websites were protein kinase inhibitors (n = 88, 43.5%) and hormone antagonists (n = 61, 30.2%). More musculoskeletal disorder reports were found in the patient websites compared with the FPVD (16.34 vs. 4.70%, p < 0.001). As for skin disorders, we collected fewer reports in the patient website forums than in the FPVD (13.37 vs. 22.17%, p = 0.004). AEs reported in the patient websites were less serious (n = 10, 4.95%) than ADRs recorded in the FPVD (n = 999, 68.99%) (p < 0.001).

CONCLUSIONS

AEs reported in the website forums are considered by patients to be relevant enough to be shared. Data from patient websites could be used as a source of data to detect AEs alongside conventional pharmacovigilance.

Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients

AIMS

This study aimed to determine the association between potentially inappropriate prescribing (PIP) and health related outcomes [adverse drug events (ADEs), health related quality of life (HRQOL) and hospital accident and emergency (A&E) visits] in older community dwelling patients.

METHODS

A retrospective cohort study of 931 community dwelling patients aged ≥70 years in 15 general practices in Ireland in 2010. PIP was defined by the Screening Tool of Older Person's Prescriptions (STOPP). ADEs were measured by patient self-report and medical record for the previous 6 months and reviewed by two independent clinicians. HRQOL was measured by the EQ-5D. A&E visits were measured by patients' medical records and self-report. Multilevel logistic, linear and Poisson regression examined how ADEs, HRQOL and A&E visits varied by PIP after adjusting for patient and practice level covariates: socioeconomic status, co-morbidity, number of drug classes and adherence.

RESULTS

The overall prevalence of PIP was 42% (n = 377). Patients with ≥2 PIP indicators were twice as likely to have an ADE (adjusted OR 2.21; 95% CI 1.02, 4.83, P < 0.05), have a significantly lower mean HRQOL utility (adjusted coefficient -0.09, SE 0.02, P < 0.001) and nearly a two-fold increased risk in the expected rate of A&E visits (adjusted IRR 1.85; 95% CI 1.32, 2.58, P < 0.001). The number of drug classes and adherence were also significantly associated with these same adverse health outcomes.

CONCLUSIONS

Reducing PIP in primary care may help lower the burden of ADEs, its associated health care use and costs and enhance quality of life in older patients.

Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments

BACKGROUND

Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field.

OBJECTIVE

To identify and characterize available patient reported instruments to measure patient safety in primary care.

METHODS

We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers.

RESULTS

We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of adverse drug reactions. Face validity was assessed for 10 instruments (43%), three reported construct validity (13%) and three described reliability (13%). Responsiveness was not ascertained.

CONCLUSIONS

Although there is evidence of good psychometric properties for a reduced number of patient reported instruments, currently available instruments do not offer a comprehensive set of resources to measure the effects of interventions to improve patient safety in primary care from a patient perspective. Future research in the field should prioritize (i) the evaluation of the performance of already available instruments and (ii) the development of new instruments that enable an comprehensive assessment of patient safety at general practices.

Statin adverse effects: patients' experiences and laboratory monitoring of muscle and liver injuries

BACKGROUND

Although statins have great benefit on the prevention of cardiovascular diseases with limited adverse effects (AEs), little is known about patients' contribution of AE reports in clinical practice.

OBJECTIVES

To explore patients' experiences of statin AEs and related laboratory monitoring in clinical practice.

SETTING

Outpatient clinics of two University hospitals in northeast Thailand.

METHODS

Generic symptom checklist questionnaires for self-reporting AEs were distributed to patients prescribed simvastatin, atorvastatin, or rosuvastatin at outpatient clinics. Clinical information was obtained from medical records. Reported symptoms were assessed for causality considering previously known statin AEs, concomitant diseases and drugs.

MAIN OUTCOME MEASURE

Potential statin AEs reported by patients and monitoring of laboratory parameters related to musculoskeletal and liver disorders.

RESULTS

Of the total 718 valid responses, 76.0 % of patients reported at least one symptom, most of which (69.0 %) were probable/possible statin AEs. Musculoskeletal and liver-related symptoms were reported by 283 (39.4 %) and 134 patients (18.7 %), respectively. Probable/possible AEs were categorized in 56.7 % of their musculoskeletal and gastrointestinal symptoms. Majority of patients had at least one laboratory test on initiation of (64.8 %) and during statin treatment (61.8 %). Patients taking atorvastatin or rosuvastatin, and patients with history of chronic renal diseases were more likely to have creatine kinase (CK) monitored on initiation of and during statin treatment. Additionally, taking drugs which could potentially increase muscle injury (OR 1.929, P < 0.01) and self-reporting of musculoskeletal symptoms (OR 1.805, P < 0.01) were associated with CK monitoring during statin treatment. Reporters of musculoskeletal symptoms also had significantly higher mean CK level than those not reporting any musculoskeletal symptoms (207.35 ± 155.40 vs. 143.95 ± 83.07 U/L, respectively; P = 0.037). Patient reporting of liver AEs was not related to alanine aminotransferase (ALT) level and monitoring, however, prior history of liver disorders was significantly associated with monitoring of ALT on initiation of and during statin treatment (OR 5.745 and OR 23.063, respectively; P < 0.01).

CONCLUSION

Many patients experienced at least one possible adverse effects on a statin. The findings suggest that laboratory monitoring is relatively selective in relation to risks and patient-reported adverse symptoms.

Survey of patients' experiences and their certainty of suspected adverse drug reactions

BACKGROUND

Patients are best placed to recognize and monitor their own experiences of adverse drug reactions (ADRs), however they may need medicines information to help them do so. In Thailand patients rarely receive information leaflets, but are permitted to report ADRs directly to the regulator.

OBJECTIVES

To determine frequency of ADRs reported by hospital out-patients, the information sources used to evaluate suspected ADRs and patients' confidence in ADR identification.

SETTING

Srinagarind hospital in Khon Kaen, the second-largest province of North-eastern Thailand.

METHODS

A questionnaire designed for self-completion and distributed to out-patients at this tertiary hospital using systematic random sampling over a 2-month period.

MAIN OUTCOME MEASURES

Frequency of reported ADRs, information sources confirming ADRs and degree of confidence in ADR identification.

RESULTS

Of 1,195 questionnaires distributed, 1,044 usable responses were obtained (87.4 %). The majority of respondents were female (57.1 %) with average age 39.6 ± 13.6 years. Of 1,044 valid questionnaires, 257 (24.7 %) patients indicated they had experienced an ADR with high (56.0 %) and moderate (31.9 %) degree of confidence in ADR identification. The most frequent causative agent was an anti-infective (19.1 % of the patients). Major sources of information used for ADR assessment were healthcare professionals (35.5 %) and past ADR experience (25.5 %), with information leaflets being used infrequently (14.6 %).

CONCLUSIONS

This study showed high frequency of ADRs among Thai patients who were mostly confident about casual relationships with medicines. Patients mostly used healthcare professionals as confirmation source to evaluate suspected ADRs. Reliable medicines information sources such as information leaflets should be made more widely available.

Comparison between patient-reported and clinician-observed symptoms in oncology

BACKGROUND

Symptom assessment is critical to understand the effectiveness of cancer treatment. Traditionally, clinicians have provided the information about cancer patients' symptoms. However, current research has shown that there are discrepancies on symptom assessment results reported by patients themselves and clinicians.

OBJECTIVE

The objective of this study was to present an integrative review on studies comparing patient-reported symptoms and clinician-observed symptoms in patients with a diagnosis of cancer.

METHODS

This was a review of published articles from PubMed, CINAHL, and the Cochrane Database, using the key words symptom or toxicity, and patient-reported, patient-rated, patient-assessed or patient-evaluated, which were combined with cancer, oncology, neoplasm, or tumor.

RESULTS

Clinicians have the propensity to underestimate the incidence, severity, or distress of symptoms experienced by cancer patients. These discrepancies appear to be consistently demonstrated over time and become even more apparent when symptoms are more severe and distressing to patients. In addition, patients report both symptom frequency and severity earlier than clinicians do; patients' symptom assessments are more predictable for daily health status, whereas clinicians' symptom measurements are more related to clinical outcomes.

CONCLUSIONS

Healthcare professionals must appreciate that there can be discordance between what they perceive and what patients experience and report. Further research needs to address methodological limitations and weaknesses of existing literature.

IMPLICATIONS FOR PRACTICE

Symptoms reported by patients themselves provide the necessary and different insight into cancer and its treatment, compared with those observed by clinicians. The use of patient-reported symptoms should be incorporated into routine clinical practice and not just research studies.

Construct and concurrent validity of a patient-reported adverse drug event questionnaire: a cross-sectional study

BACKGROUND

Direct patient-reported information about adverse drug events (ADEs) is important since it adds to healthcare professional-reported information about the safety of drugs. Previously, we developed an instrument to assess patient-reported ADEs in research settings. The aim of this study is to assess the construct and concurrent validity of the questionnaire.

METHODS

Patients on at least an oral glucose-lowering drug completed the ADE questionnaire, the World Health Organization Quality of Life-BREF, and the Treatment Satisfaction Questionnaire for Medication (TSQM). The ADE questionnaire assesses ADEs for any drug that the patient uses. Construct validity was assessed by testing whether patients reporting an ADE had a lower general quality of life and physical health than those not reporting an ADE, using Mann-Whitney U-tests and t-tests (significance level <0.05). For concurrent validity, we tested whether ADEs that patients associate with particular drugs in the ADE questionnaire are documented in the Summary of Product Characteristics (SPC) of those drugs, and whether patients who report an ADE with the use of metformin on the TSQM, mention metformin as a drug associated with an ADE on the ADE questionnaire. Agreement of 70% with the SPC was considered satisfactory. Sensitivity and positive predictive value (PPV) were calculated for the comparison with the TSQM, where 70% was used as the cut-off level for sufficient concurrent validity.

RESULTS

We included 135 patients (mean age 64 years, 35% women). Patients who reported an ADE (N = 37) had a lower general quality of life and physical health than those not reporting an ADE (P < 0.05). For 78 of the 146 reported ADEs (53%), patients mentioned at least 1 particular drug associated with the ADE. After clustering related ADEs, this resulted in 56 patient-reported ADE-drug associations. Of these, 41 (73%) were in agreement with information in the SPC. Finally, the questionnaire had a sensitivity of 38% and PPV of 79% for assessing ADEs associated with metformin.

CONCLUSIONS

The construct validity of the patient-reported ADE questionnaire was sufficient for reporting any versus no ADE, but the concurrent validity was only partly demonstrated. Therefore, the questionnaire needs to be adapted before it can be used.

Medication monitoring in a nurse-led respiratory outpatient clinic: pragmatic randomised trial of the West Wales Adverse Drug Reaction Profile

Objective

To assess the clinical effect of medication monitoring using the West Wales Adverse Drug Reaction (ADR) Profile for Respiratory Medicine.

Design

Single-site parallel-arm pragmatic trial using stratified randomisation.

Setting

Nurse-led respiratory outpatient clinic in general hospital in South Wales.

Participants

54 patients with chronic respiratory disease receiving bronchodilators, corticosteroids or leukotriene receptor antagonists.

Intervention

Following initial observation of usual nursing care, we allocated participants at random to receive at follow up: either the West Wales ADR Profile for Respiratory Medicine in addition to usual care (‘intervention arm’ with 26 participants); or usual care alone (‘control arm’ with 28 participants).

Main Outcome Measures

Problems reported and actions taken.

Results

We followed up all randomised participants, and analysed data in accordance with treatment allocated. The increase in numbers of problems per participant identified at follow up was significantly higher in the intervention arm, where the median increase was 20.5 [inter-quartile range (IQR) 13–26], while that in the control arm was −1 [−3 to +2] [Mann-Whitney U test: z = 6.28, p<0.001]. The increase in numbers of actions per participant taken at follow up was also significantly higher in the intervention arm, where the median increase was 2.5 [1]–[4] while that in the control arm was 0 [−1.75 to +1] [Mann-Whitney U test: z = 4.40, p<0.001].

Conclusion

When added to usual nursing care, the West Wales ADR Profile identified more problems and prompted more nursing actions. Our ADR Profile warrants further investigation as a strategy to optimise medication management.

Trial Registration

Controlled-trials.com ISRCTN10386209

PERSYVE - Design and validation of a questionnaire about adverse effects of antihypertensive drugs

OBJECTIVE

The aim of this study was to design and validate a questionnaire to measure perceived symptoms associated with antihypertensive drugs (PERSYVE).

METHODS

THE PERSYVE DEVELOPMENT AND VALIDATION INCLUDED FOUR STAGES: 1) item development (bibliographic review and questionnaire elaboration); 2) face and content validation; 3) field testing (pre-test); and 4) test-retest validation, assessment of internal consistency (Cronbach's alpha) and reproducibility over time (intraclass correlation coefficient and Cohen's kappa coefficient).

RESULTS

PERSYVE IS DIVIDED INTO SIX SECTIONS ACCORDING TO RESULTS OBTAINED FROM THE LITERATURE REVIEW: (1) drug adherence, (2) perceived symptoms and how they affect quality of life (five-point Likert scale), (3) communication with health professionals, (4) perception of symptoms as adverse reactions, (5) influence on therapy compliance, and (6) adoption of non-pharmacological methods for blood pressure control. Content and face validation of the questionnaire led to some vocabulary changes and the introduction of section 2.1. Field-testing (n=26) revealed high comprehensibility of the questions. The Cronbach's alpha, calculated for section 2 (five-point Likert scale) was 0.850. PERSYVE was reproducible (n=167): kappa values presented fair to substantial reproducibility and, in section 2, ICC values resulted in good to excellent reproducibility.

CONCLUSION

Results showed that PERSYVE is a well-structured, objective, patient-friendly, valid and reliable questionnaire. PERSYVE can be a very useful instrument in hypertensive patients' monitoring and in the screening of adverse effects.

A qualitative study to explore how patients identify and assess symptoms as adverse drug reactions

PURPOSE

To explore how Thai patients assess symptoms as adverse drug reactions (ADRs).

METHODS

Out-patients at two hospitals in Thailand previously reporting suspected ADRs to statins were purposively selected to cover factors relevant to the accuracy of ADR reports. Semi-structured interviews explored the mechanisms participants used to work out whether their symptoms were related to their statin. All interviews were audio-recorded, transcribed and independently thematically analyzed by two researchers.

RESULTS

One hundred interviews were suitable for analysis; 52 were male, age range was 36 to 77 years (mean ± S.D.: 59.83 ± 9.14) and most (92) were taking other medicines in addition to statins. Patient assessment of symptoms as ADRs fell into two major themes: medicine-related factors and external factors. Timing relationships were mentioned most frequently (74), followed by information received (55), seeing similar symptoms in others (7) and diagnosis through blood tests (4). Use of multiple medicines, consideration of the medicine versus diseases, symptoms occurring with more than one medicine or relieved through treatment reduced confidence in ADR attribution. Many participants proposed alternative explanations for symptoms, including old age. Lack of information and knowledge were obstacles to the assessment process.

CONCLUSIONS

Patients assessed possible ADRs most often by considering timing relationships. While they also used medicine information, Thai patients received inadequate information to help them assess their symptoms. Patients expressed uncertainty and difficulties in deciding attribution when concomitant medicines and diseases were involved. The findings could support the development of a patient-friendly systematic tool for identifying and assessing possible ADRs.

Adverse Drug Reactions in Children--International Surveillance and Evaluation (ADVISE): a multicentre cohort study

BACKGROUND

A previous meta-analysis reported that 9.5% of hospitalized children suffered from an adverse drug reaction (ADR); however, reported incidences among studies varied.

OBJECTIVE

To enhance the knowledge of ADRs in paediatric hospitalized patients at a global level we investigated the incidence and characteristics of ADRs in hospitalized children in European and non-European countries.

METHODS

A prospective observational cohort study was conducted in academic and non-academic hospitals in five countries: Australia, Germany, Hong Kong, Malaysia and the UK. Children aged 0-18 years admitted during a 3-month period (between 1 October 2008 and 31 December 2009) were recruited. The main outcome measures were incidence, causality and outcome of ADRs.

RESULTS

A total of 1278 patients (1340 admissions) were included [Australia n = 146 (149 admissions), Germany n = 376 (407), Hong Kong n = 143 (149), Malaysia n = 300 (314) and the UK n = 313 (321)]. The median age was 2 years (interquartile range [IQR] 0-7). Patients received a total of 5367 drugs (median 3; IQR 2-5) and median length of hospital stay was 4 days (IQR 3-7). A total of 380 ADRs were identified in 211 patients. The resultant ADR incidence of 16.5% (95% CI 14.5, 18.7) varied significantly between countries (p < 0.001). The highest incidences were observed in Malaysia and the UK. 65.3% (n = 248) of ADRs were found to be probable, and 24% of the ADRs were serious, with one being fatal.

CONCLUSIONS

By comparing data from five countries in Europe, Asia and Australia we have shown that the incidence of ADRs in hospitalized children is at least as high as incidences published in adults. However, the variation between countries was mainly due to different populations and treatment strategies. Particular attention should be given to opioid use in hospitalized children.

Patient reporting of suspected adverse drug reactions to antiepileptic drugs: factors affecting attribution accuracy

This study was aimed to assess the frequency and number of suspected ADRs reported by patients taking antiepileptic drugs (AEDs) and to explore the factors that may affect patients' symptom attribution accuracy. A validated questionnaire containing an extensively checklist of symptoms was distributed to outpatients prescribed one or more AEDs. Data on concomitant drugs and diseases were obtained from outpatient records. All symptoms identified were assessed for causality. Of 1388 questionnaires distributed to 1214 patients, 830 completed questionnaires were returned (59.8%) from 727 patients. In total, 7815 symptoms were identified on 757 questionnaires (91.2%). Symptom severity ratings were positively related to the number of symptoms reported (p=0.003). Causality assessment found that 71.9% of the symptoms were 'true' ADRs and 28.1% were 'false' ADRs. Attribution accuracy was primarily influenced by the number of symptoms identified and indication for AED therapy, fewer symptoms and use for non-epilepsy indications being associated with greater attribution accuracy.

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review

This systematic review identifies the factors that both support and deter patients from being willing and able to participate actively in reducing clinical errors. Specifically, we add to our understanding of the safety culture in healthcare by engaging with the call for more focus on the relational and subjective factors which enable patients' participation (Iedema, Jorm, & Lum, 2009; Ovretveit, 2009). A systematic search of six databases, ten journals and seven healthcare organisations' web sites resulted in the identification of 2714 studies of which 68 were included in the review. These studies investigated initiatives involving patients in safety or studies of patients' perspectives of being actively involved in the safety of their care. The factors explored varied considerably depending on the scope, setting and context of the study. Using thematic analysis we synthesized the data to build an explanation of why, when and how patients are likely to engage actively in helping to reduce clinical errors. The findings show that the main factors for engaging patients in their own safety can be summarised in four categories: illness; individual cognitive characteristics; the clinician-patient relationship; and organisational factors. We conclude that illness and patients' perceptions of their role and status as subordinate to that of clinicians are the most important barriers to their involvement in error reduction. In sum, patients' fear of being labelled "difficult" and a consequent desire for clinicians' approbation may cause them to assume a passive role as a means of actively protecting their personal safety.

Overview of medical errors and adverse events

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures.

The importance of direct patient reporting of suspected adverse drug reactions: a patient perspective

AIM

To explore the opinions of patient reporters to the UK Yellow Card Scheme (YCS) on the importance of the scheme.

METHODS

Postal questionnaires were distributed on our behalf to all patient reporters submitting a Yellow Card to the Medicines and Healthcare Regulatory Agency (MHRA) between March and December 2008, with one follow-up reminder to non-responders. Qualitative analysis was undertaken of responses to an open question asking why respondents felt patient reporting was important. This was followed up by telephone interviews with a purposive sample of selected respondents.

RESULTS

There were 1362 evaluable questionnaires returned from 2008 distributed (68%) and 1238 (91%) respondents provided a total of 1802 comments. Twenty-seven interviews were conducted, which supported and expanded the views expressed in the questionnaire. Four main themes emerged, indicating views that the YCS was of importance to pharmacovigilance in general, manufacturers and licensing authorities, patients and the public and health professionals. Reporters viewed the YCS as an important opportunity to describe their experiences for the benefit of others and to contribute to pharmacovigilance. The scheme's independence from health professionals was regarded as important, in part to provide the patient perspective to manufacturers and regulators, but also because of dismissive attitudes and under-reporting by health professionals.

CONCLUSION

Direct patient reporting through the YCS is viewed as important by those who have used the scheme, in order to provide the patient experience for the benefit of pharmacovigilance, as an independent perspective from those of health professionals.

A review of methods used in assessing non-serious adverse drug events in observational studies among type 2 diabetes mellitus patients

Clinical drug trials are often conducted in selective patient populations, with relatively small numbers of patients, and a short duration of follow-up. Observational studies are therefore important for collecting additional information on adverse drug events (ADEs). Currently, there is no guidance regarding the methodology for measuring ADEs in such studies. Our aim was to evaluate whether the methodology used to assess non-serious ADEs in observational studies is adequate for detecting these ADEs, and for addressing limitations from clinical trials in patients with type 2 diabetes mellitus. We systematically searched MEDLINE and EMBASE for observational studies reporting non-serious ADEs (1999-2008). Methods to assess ADEs were classified as: 1) medical record review; 2) surveillance by health care professionals (HCP); 3) patient survey; 4) administrative data; 5) laboratory/clinical values; 6) not specified. We compared the range of ADEs identified, number and selection of patients included, and duration of follow-up. Out of 10,125 publications, 68 studies met our inclusion criteria. The most common methods were based on laboratory/clinical values (n = 25) and medical record review (n = 18). Solicited surveillance by HCP (n = 17) revealed the largest diversity of ADEs. Patient surveys (n = 15) focused mostly on hypoglycaemia and gastrointestinal ADEs, laboratory values based studies on hepatic and metabolic ADEs, and administrative database studies (n = 5) on cardiovascular ADEs. Four studies presented ADEs that were identified with the use of more than one method. The patient population was restricted to a lower risk population in 19% of the studies. Less than one third of the studies exceeded pre-approval regulatory requirements for sample size and duration of follow-up. We conclude that the current assessment of ADEs is hampered by the choice of methods. Many observational studies rely on methods that are inadequate for identifying all possible ADEs. Patient-reported outcomes and combinations of methods are underutilized. Furthermore, while observational studies often include unselective patient populations, many do not adequately address other limitations of pre-approval trials. This implies that these studies will not provide sufficient information about ADEs to clinicians and patients. Better protocols are needed on how to assess adverse drug events not only in clinical trials but also in observational studies.

Incidence and cost estimate of treating pediatric adverse drug reactions in Lagos, Nigeria

CONTEXT AND OBJECTIVES

Adverse drug reactions (ADRs) may cause prolonged hospital admissions with high treatment costs. The burden of ADRs in children has never been evaluated in Nigeria. The incidence of pediatric ADRs and the estimated cost of treatment over an 18-month period were determined in this study.

DESIGN AND SETTING

Prospective observational study on children admitted to the pediatric wards of the Lagos State University Teaching Hospital (LASUTH) in Nigeria, between July 2006 and December 2007.

METHODS

Each patient was assessed for ADRs throughout admission. Medical and non-medical costs to the hospital and patient were estimated for each ADR by reviewing the medical and pharmacy bills, medical charts and diagnostic request forms and by interviewing the parents. Cost estimates were performed in 2007 naira (Nigeria currency) from the perspectives of the hospital (government), service users (patients) and society (bearers of the total costs attributable to treating ADRs). The total estimated cost was expressed in 2007 United States dollars (USD).

RESULTS

Two thousand and four children were admitted during the study; 12 (0.6%) were admitted because of ADRs and 23 (1.2%) developed ADR(s) during admission. Forty ADRs were suspected in these 35 patients and involved 53 medicines. Antibiotics (50%) were the most suspected medicines. Approximately 1.83 million naira (USD 15,466.60) was expended to manage all the patients admitted due to ADRs.

CONCLUSIONS

Treating pediatric ADRs was very expensive. Pediatric drug use policies in Nigeria need to be reviewed so as to discourage self-medication, polypharmacy prescription and sales of prescription medicines without prescription.

A classification system for issues identified in pharmaceutical care practice

Objective

To investigate the usefulness of a system for classifying pharmaceutical care issues (PCIs), defined in Scottish practice guidelines as “an element of a pharmaceutical need which is addressed by the pharmacist,” which were identified during the delivery of pharmaceutical care in a primary care setting.

Method

The classification system had 12 categories, each with a definition and examples reflecting the primary care setting to assist in assigning categories to individual PCIs. There was no category of “other” or “miscellaneous”. The system was used by two clinical pharmacists in a study involving 332 patients aged 65 years or over collecting four or more medicines regularly. The point at which PCIs were identified and resolved, the drugs involved and the actions required to resolve them were analysed for each type of PCI.

Setting

Six randomly selected medical practices in the Grampian region of Scotland.

Key findings

All 2,586 PCIs identified were successfully assigned one category within this classification system. The most commonly occurring types of PCI were “potential adverse drug reaction”, “need for monitoring”, “potentially ineffective therapy” and “need for education.” Most PCIs classed as “potential adverse drug reaction” and “need for monitoring” were identified from the prescription record. A third of “potentially ineffective therapy” PCIs, plus most PCIs classed as “drug use — no indication” and “indication — no treatment” were identified from medical records. Patient interview identified most of the PCIs categorised as “need for education,” “suspected adverse drug reaction” and “actual compliance issue.” Resolving the “need for education,” “suspected/actual compliance issue” and “out of date medicines” PCIs mostly involved the patient, whereas those involving changes to prescribed therapy or monitoring required contact with a health care professional.

Conclusion

The classification system was comprehensive in its coverage of PCIs arising from clinical pharmacists' direct patient care activities in a primary care setting. While the system requires further development and testing, it would appear to be a useful tool for researchers and practitioners to use in describing and comparing PCIs in different studies and using different practices.

Developing a patient safety surveillance system to identify adverse events in the intensive care unit

Aggregation of adverse drug event data has evolved in the last decade. Several approaches are available to augment the standard voluntary incident reporting system. Most of these methods are applicable to nonmedication adverse events as well. To identify appropriately system trends as well as process failures, intensive care units should participate in various collection methods. Several different methods are available for robust adverse drug event data collection, such as target chart review, nontargeted chart review, and direct observation. As the various methods usually capture different types of events, employing more than one technique will improve the assessment of intensive care unit care. Some of these surveillance methods offer real-time or near real-time identification of adverse drug events and potentially afford the practitioner time for intervention. Continued development of adverse drug event detection will allow for further quality improvement efforts and preventive strategies to be utilized.