Improving Medication Knowledge Among Older Adults With Heart Failure: A Patient-Centered Approach to Instruction Design

Meeting the Challenge of Transmission Delay: Communication Protocols for Space Operations

OBJECTIVE

Several studies were conducted to assess media-specific communication protocols as a countermeasure to challenges of asynchronous space-ground communication.

BACKGROUND

Previous research demonstrated that transmission delay can negatively impact space-ground communication, collaboration, and task performance. We created media-specific protocols designed to mitigate identified problems associated with asynchronous communication and examined their effects on team communication and task performance.

METHODS

The lab study included 24 teams of three who collaborated remotely via voice or text on computer-based tasks simulating failures in a spacecraft's life support system. Training and availability of communication protocols was the between-groups variable. Perceived usability, criticality, and effectiveness of the communication protocols were also assessed in space-analog simulations.

RESULTS

Lab study data revealed that communication protocols facilitated some aspects of team communication; specifically, they reduced threats to common ground and information splitting but not instances of miscommunication. Analog data indicated that protocol compliance was high, participants evaluated most elements as highly important, and protocols maintained perceived communication effectiveness between space crews and mission control during time delay comparably to no-time-delay conditions.

CONCLUSION

Converging data attest to the feasibility, usability, and effectiveness of empirically derived communication protocols as a countermeasure to the negative impacts of transmission delay and also point to technological solutions.

APPLICATION

The communication protocols have been adopted for training in NASA analog simulations involving time-delayed communication. They could also support communication among remote team members in medical operations, command-and-control teams, or disaster response under asynchronous conditions or when time is limited and precise communication is critical.

Evaluation of Medicine Information Leaflets for Omeprazole, Safety Knowledge, and Perceptions of Taking the Medication in Thailand

PURPOSE

This study aimed to compare package inserts and patient information leaflets for omeprazole in terms of the quality of and satisfaction with the written medicine information, medication safety knowledge, and perceived benefits and risks.

PATIENTS AND METHODS

A cross-sectional, comparative study was conducted at a university hospital in Thailand. Outpatients visiting the pharmacy departments prescribed omeprazole were randomly selected to receive either a package insert or a patient information leaflet. Medication safety knowledge was measured using a set of eight questions. The quality of the written medicine information was measured by the Consumer Information Rating Form. Perceived benefits and risks of the medication were rated using a visual analog scale. Linear regression was used to determine factors associated with perceived benefits and risks.

RESULTS

Of the 645 patients, 293 agreed to answer the questionnaire. 157 and 136 patients were given patient information leaflets and package inserts, respectively. Most respondents were female (65.6%), over half had a degree (56.2%). Patients reading the patient information leaflets had slightly higher overall safety knowledge scores than those reading the package inserts (5.88 ± 2.25 vs 5.25 ± 1.84, p=0.01). Using the Consumer Information Rating Form, the patient information leaflets were given significantly higher scores compared to the package inserts for comprehensibility (19.34±3.92 vs 17.32±3.52, p<0.001) and design quality (29.25 ± 5.00 vs 23.81 ± 5.16, p<0.001). After reading the leaflets, patients receiving the patient information leaflets had significantly higher satisfaction with the information provided (p=0.003). In contrast, those receiving the package inserts rated the risks of omeprazole higher (p=0.007).

CONCLUSION

Demonstrable differences were found from the patient perspective between a package insert and a patient information leaflet for the same medicine, mostly in favour of patient information leaflets. Medicine safety knowledge after reading PI and PIL was similar. However, receiving package inserts provided higher perceived risks from taking the medicine.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Factors Affecting Engagement in Web-Based Health Care Patient Information: Narrative Review of the Literature

BACKGROUND

Web-based content is rapidly becoming the primary source of health care information. There is a pressing need for web-based health care content to not only be accurate but also be engaging. Improved engagement of people with web-based health care content has the potential to inform as well as influence behavioral change to enable people to make better health care choices. The factors associated with better engagement with web-based health care content have previously not been considered.

OBJECTIVE

The aims of this study are to identify the factors that affect engagement with web-based health care content and develop a framework to be considered when creating such content.

METHODS

A comprehensive search of the PubMed and MEDLINE database was performed from January 1, 1946, to January 5, 2020. The reference lists of all included studies were also searched. The Medical Subject Headings database was used to derive the following keywords: "patient information," "online," "internet," "web," and "content." All studies in English pertaining to the factors affecting engagement in web-based health care patient information were included. No restrictions were set on the study type. Analysis of the themes arising from the results was performed using inductive content analysis.

RESULTS

The search yielded 814 articles, of which 56 (6.9%) met our inclusion criteria. The studies ranged from observational and noncontrolled studies to quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments, which made quantitative assessment difficult. Consensus among all authors of this study resulted in six categories that formed the basis of a framework to assess the factors affecting engagement in web-based health care content: easy to understand, support, adaptability, accessibility, visuals and content, and credibility and completeness.

CONCLUSIONS

There is a paucity of high-quality data relating to the factors that improve the quality of engagement with web-based health care content. Our framework summarizes the reported studies, which may be useful to health care content creators. An evaluation of the utility of web-based content to engage users is of significant importance and may be accessible through tools such as the Net Promoter score. Web 3.0 technology and development of the field of psychographics for health care offer further potential for development. Future work may also involve improvement of the framework through a co-design process.

Evaluation of Patient's Knowledge of Atorvastatin Information in Patient Information Leaflets: A Pre-Post Intervention Study in Thailand

PURPOSE

This study aimed to evaluate the effect of using atorvastatin PIL on patients' medication knowledge, perceptions of the PIL usefulness, their anxiety about the medication, and factors related to these aspects.

PATIENTS AND METHODS

A pre-post intervention study was conducted in outpatients at a university hospital. Patients prescribed atorvastatin were enrolled using systematic random sampling. Participants were asked to complete Self-Administered Questionnaire to assess atorvastatin knowledge at baseline. An atorvastatin-PIL produced by the manufacturer was introduced to the participants as the intervention. One month after receiving the PIL, the participants were re-assessed. Ten questions were developed to assess atorvastatin knowledge and visual analog scale (VAS) was used to assess perceived benefits of using the PIL and patient anxiety about the medication. Multiple linear regression was used to assess the related factors.

RESULTS

Of 450 questionnaires distributed, 370 were returned. Atorvastatin knowledge significantly increased with mean score of 5.06±1.92 at baseline to 8.34±1.79 at 1-month after intervention. Reading all sections of the PIL (p=0.017) and working for civil service (p=0.006) were associated with higher knowledge scores at baseline and after intervention. Low educational level was associated with lower knowledge scores at baseline (p=0.002), but experience of allergy (p=0.042) was associated with higher knowledge scores after the intervention. Patients had high level of perceived usefulness from the PIL (average scores=8.87±1.83) and low level of anxiety (average scores=3.69±3.06). Reading all sections of the PIL (p=0.007) and taking more than 5 medications (p=0.012) were related to perceived usefulness of the PIL. Females (p<0.001) and herbal supplement users (p=0.048) were related to anxiety about the medication.

CONCLUSION

PILs could improve medication knowledge in patients. Patients' perceptions of benefits of PILs were high and anxiety about medication was low. Use of PILs should be encouraged to improve patients' knowledge and appropriate use of medications.

Immunomodulatory drugs in multiple myeloma: Impact of the SCARMET (Self CARe and MEdication Toxicity) educational intervention on outpatients' knowledge to manage adverse effects

Long-term multiple myeloma therapy by immunomodulatory drugs (IMiDs) raises the question of management of adverse effects. The aim of this study is to assess the impact of an educational session for patients on the acquisition of knowledge to manage hematologic and thromboembolic adverse effects of IMiDs. In this prospective single-center study, patients attended an educational session with a hospital clinical pharmacist and a nurse. The primary endpoint was the patient's level of knowledge for the management of IMiDs adverse effects, assess with a dedicated questionnaire administered before the session then 1 and 6 months after. Assessment of knowledge was combined with self-assessment of certainty. The secondary endpoints were adherence and IMiD treatment satisfaction. 50 patients were included. Patient knowledge increased at 1 month (p<0.001) despite a loss of knowledge at 6 months (p<0.05). Six months after the educational intervention, the number of patients with skills considered satisfactory by the pharmacist and nurse increased (p<0.01). Most patients showed satisfactory adherence, with medication possession ratio ≥ 80%. The Self CARe and MEdication Toxicity (SCARMET) study highlighted the impact of multidisciplinary follow-up in multiple myeloma patients to improve knowledge of toxicity self-management.

Differences in Memory, Perceptions, and Preferences of Multimedia Consumer Medication Information: Experimental Performance and Self-Report Study

Background

Electronic health resources are becoming prevalent. However, consumer medication information (CMI) is still predominantly text based. Incorporating multimedia into CMI (eg, images, narration) may improve consumers’ memory of the information as well as their perceptions and preferences of these materials.

Objective

This study examined whether adding images and narration to CMI impacted patients’ (1) memory, (2) perceptions of comprehensibility, utility, or design quality, and (3) overall preferences.

Methods

We presented 36 participants with CMI in 3 formats: (1) text, (2) text + images, and (3) narration + images, and subsequently asked them to recall information. After seeing all 3 CMI formats, participants rated the formats in terms of comprehensibility, utility, and design quality, and ranked them from most to least favorite.

Results

Interestingly, no significant differences in memory were observed (F_2,70=0.1, P=0.901). Thus, this study did not find evidence to support multimedia or modality principles in the context of CMI. Despite the absence of effects on memory, the CMI format significantly impacted perceptions of the materials. Specifically, participants rated the text + images format highest in terms of comprehensibility (χ²₂=26.5, P<.001) and design quality (χ²₂=35.69, P<.001). Although the omnibus test suggested a difference in utility ratings as well (χ²₂=8.21, P=.016), no significant differences were found after correcting for multiple comparisons. Consistent with perception findings, the preference ranks yielded a significant difference (χ²₂=26.00, P<.001), whereby participants preferred the text + images format overall. Indeed, 75% (27/36) of participants chose the text + images format as their most favorite. Thus, although there were no objective memory differences between the formats, we observed subjective differences in comprehensibility, design quality, and overall preferences.

Conclusions

This study revealed that although multimedia did not appear to influence memory of CMI, it did impact participants’ opinions about the materials. The lack of observed differences in memory may have been due to ceiling effects, memory rather than understanding as an index of learning, the fragmented nature of the information in CMI itself, or the size or characteristics of the sample (ie, young, educated subjects with adequate health literacy skills). The differences in the subjective (ie, perceptions and preferences) and objective (ie, memory) results highlight the value of using both types of measures. Moreover, findings from this study could be used to inform future research on how CMI could be designed to better suit the preferences of consumers and potentially increase the likelihood that CMI is used. Additional research is warranted to explore whether multimedia impacts memory of CMI under different conditions (eg, older participants, subjects with lower levels of health literacy, more difficult stimuli, or extended time for decay).

Agreement between self-reported morbidity and pharmacy claims data for prescribed medications in an older community based population

Background

Studies have indicated variability around prevalence estimates of multimorbidity due to poor consensus regarding its definition and measurement. Medication-based measures of morbidity may be valuable resources in the primary-care setting where access to medical data can be limited. We compare the agreement between patient self-reported and medication-based morbidity; and examine potential patient-level predictors of discordance between these two measures of morbidity in an older (≥ 50 years) community-based population.

Methods

A retrospective cohort study was performed using national pharmacy claims data linked to The Irish LongituDinal study on Ageing (TILDA). Morbidity was measured by patient self-report (TILDA) and two medication-based measures, the Rx-Risk (< 65 years) and Rx-Risk-V (≥65 years), which classify drug claims into chronic disease classes. The kappa statistic measured agreement between self-reported and medication-based morbidity at the individual patient-level. Multivariate logistic regression was used to examine patient-level characteristics associated with discordance between measures of morbidity.

Results

Two thousand nine hundred twenty-five patients were included (< 65 years: N = 1095, 37.44%; and ≥ 65 years: N = 1830 62.56%). Hypertension and high cholesterol were the most prevalent self-reported morbidities in both age cohorts. Agreement was good or very good (κ = 0.61–0.81) for diabetes, osteoporosis and glaucoma; and moderate for high cholesterol, asthma, Parkinson’s and angina (κ = 0.44–0.56). All other conditions had fair or poor agreement. Age, gender, marital status, education, poor-delayed recall, depression and polypharmacy were significantly associated with discordance between morbidity measures.

Conclusions

Most conditions achieved only moderate or fair agreement between self-reported and medication-based morbidity. In order to improve the accuracy in prevalence estimates of multimorbidity, multiple measures of multimorbidity may be necessary. Future research should update the current Rx-Risk algorithms in-line with current treatment guidelines, and re-assess the feasibility of using these indices alone, or in combination with other methods, to yield more accurate estimates of multimorbidity.

Hospital falls prevention with patient education: a scoping review

BACKGROUND

Hospital falls remain a frequent and debilitating problem worldwide. Most hospital falls prevention strategies have targeted clinician education, environmental modifications, assistive devices, hospital systems and medication reviews. The role that patients can play in preventing falls whilst in hospital has received less attention. This critical review scopes patient falls education interventions for hospitals. The quality of the educational designs under-pinning patient falls education programmes was also evaluated. The outcomes of patient-centred falls prevention programs were considered for a range of hospital settings and diagnoses.

METHODS

The Arksey and O'Malley (2005) framework for scoping reviews was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Eight databases, including grey literature, were searched from January 2008 until February 2020. Two reviewers independently screened the articles and data were extracted and summarised thematically. The quality of falls prevention education programs for patients was also appraised using a modified quality metric tool.

RESULTS

Forty-three articles were included in the final analysis. The interventions included: (i) direct face-to-face patient education about falls risks and mitigation; (ii) educational tools; (iii) patient-focussed consumer materials such as pamphlets, brochures and handouts; and (iv) hospital systems, policies and procedures to assist patients to prevent falls. The included studies assessed falls or education related outcomes before and after patient falls prevention education. Few studies reported incorporating education design principles or educational theories. When reported, most educational programs were of low to moderate quality from an educational design perspective.

CONCLUSIONS

There is emerging evidence that hospital falls prevention interventions that incorporate patient education can reduce falls and associated injuries such as bruising, lacerations or fractures. The design, mode of delivery and quality of educational design influence outcomes. Well-designed education programs can improve knowledge and self-perception of risk, empowering patients to reduce their risk of falling whilst in hospital.

Experiences and Views of Medicine Information Among the General Public in Thailand

PURPOSE

Written and electronic medicine information are important for improving patient knowledge and safe use of medicines. Written medicine information in Thailand is mostly in the form of printed package inserts (PIs), designed for health professionals, with few medicines having patient information leaflets (PILs). The aim of this study was to determine practices, needs and expectations of Thai general public about written and electronic medicine information and attitudes towards PILs.

PATIENTS AND METHODS

Cross-sectional survey, using self-completed questionnaires, was distributed directly to members of the general public in a large city, during January to March 2019. It explored experiences of using information, expectations, needs and attitudes, the latter measured using a 10-item scale. Differences between sub-groups were assessed, applying the Bonferroni correction to determine statistical significance.

RESULTS

Of the total 851 questionnaires distributed, 550 were returned (64.2%). The majority of respondents (88%) had received PIs, but only a quarter (26.2%) had received PILs. Most respondents (78.5%) had seen medicine information in online form. High educational level and income increased the likelihood of receiving PILs and electronic information. The majority of respondents (88.5%) perceived PILs as useful, but 70% considered they would still need information about medicines from health professionals. Indication, drug name and precautions were the most frequently read information in PIs and perceived as needed in PILs. Three-quarters of respondents would read electronic information if it were available, with more who had received a PIL having previously searched for such information compared to those who had not. All respondents had positive overall attitudes towards PILs.

CONCLUSION

Experiences of receiving PILs and electronic medicine information in Thailand are relatively limited. However, the general public considered PILs as a useful source of medicine information. Electronic medicine information was desired and should be developed to be an additional source of information for consumers.

Pharmacy-Based Approach to Improving Heart Failure Medication Use by Older Adults with Limited Health Literacy: Learning from Interdisciplinary Experience

Heart failure is a chronic disease requiring careful attention to self-care. Patients must follow instructions for diet and medication use to prevent or delay a decline in functional status, quality of life, and expensive care. However, there is considerable heterogeneity in heart failure patients' knowledge of important care routines, their cognition, and their health literacy, which predict the ability to implement self-care. Our interdisciplinary team of cognitive scientists with health literacy expertise, pharmacists, and physicians spent 18 years designing and testing protocols and materials to assist ambulatory heart failure patients with their care. Our approach is theory- as well as problem-driven, guided by our process-knowledge model of health literacy as it relates to self-care among older adult outpatients with either heart failure or hypertension. We used what we had learned from this model to develop a pharmacy-based protocol and tailored patient instruction materials that were the central component of a randomized clinical trial. Our results showed improved adherence to cardiovascular medications, improved health outcomes and patient satisfaction, and direct cost reductions. These results demonstrate the value of our interdisciplinary efforts for developing strategies to improve instruction and communication with attention to health literacy, which are core components of pharmacy and other ambulatory healthcare services. We believe attention to health literacy with medication use will result in improved health outcomes for older adult patients with heart failure and other complex chronic diseases.

A Multi-faceted Approach to Promote Comprehension of Online Health Information Among Older Adults

Purpose of the Study

Older adults' self-care often depends on understanding and utilizing health information. Inadequate health literacy among older adults poses a barrier to self-care because it hampers comprehension of this information, particularly when the information is not well-designed. Our goal was to improve comprehension of online health information among older adults with hypertension who varied in health literacy abilities.

Design and Methods

We identified passages about hypertension self-care from credible websites (typical passages). We used a multi-faceted approach to redesign these passages, revising their content, language, organization and format (revised passages). Older participants read both versions of the passages at their own pace. After each passage, they summarized the passage and then answered questions about the passage.

Results

Participants better remembered the revised than the typical passages, summarizing the passages more accurately and uptaking information more efficiently (less reading time needed per unit of information remembered). The benefits for reading efficiency were greater for older adults with more health knowledge, suggesting knowledge facilitated comprehension of information in the revised passages.

Implications

A systematic, multi-faceted approach to designing health documents can promote online learning among older adults with diverse health literacy abilities.

Readability and Comprehensibility of Patient Information Leaflets for Antidiabetic Medications in Qatar

Background:The readability and comprehensibility of the patient information leaflets (PILs) provided with antidiabetic medications are of questionable standards; this issue negatively affects adherence to drug therapy, especially in patients with limited literacy skills. Objective: To evaluate the readability and comprehensibility of PILs supplied with medications used for the treatment of type 2 diabetes mellitus in Qatar. Methods: All PILs of the antidiabetic medications in Qatar were evaluated using the Flesch Reading Ease (FRE) score for readability. The Flesch-Kincaid Grade Level, Gunning-Fog Index, and SMOG Grading were used to estimate the comprehensibility of PILs in terms of school grade levels. Results: A total of 45 PILs were evaluated: 32 (71.1%) PILs of brand-name products and 13 (28.9%) for generics. Nine (20%) of the PILs were in English only; 8 (17.8%) were in English, Arabic, and French; and 28 (62.2%) were in English and Arabic. The mean FRE score was 37.71 (±15.85), and the most readable PIL had FRE score of 62. The mean scores for the comprehensibility evaluations were 10.96 (±2.67), 15.02 (±2.52), and 11.41 (±1.6) for the Flesch-Kincaid Grade Level, Gunning-Fog Index, and SMOG Grading, respectively. The most commonly used antidiabetic medication was metformin with 1372.9 (±552.9) as PILs' mean number of words. Conclusion: Only 2.2% of PILs had acceptable readability scores. All PILs could be comprehended by at least an 11th grade student, which exceeds the recommended grade level for health-related materials. Approximately 20% of these PILs were in English only and were not readable by most patients.

Communication and patient participation influencing patient recall of treatment discussions

CONTEXT

Patient recall of treatment information is a key variable towards chronic disease (CD) management. It is unclear what communication and patient participation characteristics predict recall.

OBJECTIVES

To assess what aspects of doctor-patient communication predict patient recall of medication information. To describe lifestyle treatment recall, in CD primary care patients.

DESIGN

Observational study within a RCT.

SETTING & PARTICIPANTS

Community-based primary care (PC) practices. Family physicians (n=18): practicing >5 years, with a CD patient caseload. Patients (n=159): >40 years old, English speaking, computer literate, off-target hypertension, type II diabetes and/or dyslipidaemia.

MAIN VARIABLES

Patient characteristics: age, education, number of CDs. Information characteristics: length of encounter, medication status, medication class. Communication variables: socio-emotional utterances, physician dominance and communication control scores and PACE (ask, check and express) utterances, measured by RIAS. Number of medication themes, dialogue and initiative measured by MEDICODE.

MAIN OUTCOME MEASURES

Recall of CD, lifestyle treatment and medication information.

RESULTS

Frequency of lifestyle discussions varied by topic. Patients recalled 43% (alcohol), 52% (diet) to 70% (exercise) of discussions. Two and a half of six possible medication themes were broached per medication discussion. Less than one was recalled. Discussing more themes, greater dialogue and patient initiative were significant predictors of improved medication information recall.

DISCUSSION

Critical treatment information is infrequently exchanged. Active patient engagement and explicit conversations about medications are associated with improved treatment information recall in off-target CD patients followed in PC.

CONCLUSION

Providers cannot take for granted that long-term off-target CD patients recall information. They need to encourage patient participation to improve recall of treatment information.

Factors influencing the exit knowledge of patients for dispensed drugs at outpatient pharmacy of Hiwot Fana Specialized University Hospital, Eastern Ethiopia

BACKGROUND

A satisfactory counseling process between the patient and pharmacist is critical for rational use of dispensed drug(s) and is highly influenced by many factors including the experience of pharmacist in dispensing process. To improve patients' knowledge of dispensed drugs, it is necessary to understand the factors that optimize a pharmacist interaction with a patient in each activity of the dispensing process. Therefore, the aim of this study was to identify the pharmacist and patient factors that influence knowledge of dispensed drugs by ambulatory patients at Hiwot Fana Specialized University Hospital, Harar, Ethiopia.

MATERIALS AND METHODS

A cross-sectional study was conducted on 422 respondents. Data were collected by interviews using a structured questionnaire that measures "exit knowledge" of the ambulatory patients for dispensed drugs. The collected data were analyzed using SPSS Version 20.0. Potential covariates were identified using χ2 test, and logistic regression analyses were undertaken to adjust for the covariates.

RESULTS

Our findings showed significant proportions of the patients did not recall the name of their dispensed medication (53.6%), major side effects (66.4%), and what to do in case of missed doses (65.4%). Patients' knowledge of dispensed drugs was significantly associated with their educational level (adjusted odds ratio [AOR]: 1.97; 95% confidence interval [CI]: 1.01-3.84 [primary], AOR: 2.04; 95% CI: 1.04-4.04 [secondary], and AOR: 2.71; 95% CI: 1.35-5.46 [tertiary]); clear instruction from the pharmacist (AOR: 3.36; 95% CI: 1.16-9.72); and the politeness of the pharmacist (AOR: 2.02; 95% CI: 1.04-4.04).

CONCLUSION

We found that the majority of patients poorly understood the name of the dispensed medication, side effects, and what to do in case of missed doses. In addition, the formal educational level of the patient, clear instruction from the pharmacist, and the politeness of pharmacist were the factors significantly associated with improved exit knowledge of patients for dispensed drugs. Therefore, increased communication skills training for pharmacists would optimize patient-pharmacist interaction, which in turn would likely improve exit knowledge of ambulatory patients for dispensed drugs.

Communication Protocols to Support Collaboration in Distributed Teams Under Asynchronous Conditions

The safety and success of future space missions will depend on the ability of crewmembers and Mission Control to collaborate effectively, even when communication between them is delayed. Communication protocols—i.e., structured communication templates—were designed with the goal to facilitate space-ground collaboration under time-delayed conditions. Their effectiveness was assessed in several space-analog simulation studies. Method: Astronauts and astronaut-like volunteers received communication training prior to their missions. Missions included 2 to 4 days on which communication with Mission Control was delayed. Surveys were administered throughout the mission asking participants to rate the effectiveness of the protocols and their interactions with Mission Control and in a final survey to provide feedback on individual elements of the communication protocols. Results and Discussion: Participants rated the protocols as fairly effective. Their ratings also suggest that the protocols mitigated the negative impacts of communication delay. Participants’ ratings of individual protocol elements were generally high but also point to specific training needs and technology requirements.

Reducing and Mitigating Human Error in Medicine

Although precise definitions and models of human error in medicine remain elusive, there is little doubt that adverse events, sometimes involving human error, threaten patient safety and can be addressed by human factors approaches to error. In this chapter, we combine an information-processing framework that identifies perceptual, cognitive, and behavioral requirements of operators involved in health care activities with a system-based perspective that helps define when these needs are met by the health care context. We focus on errors and adverse events related to four broad areas of medical activities: medical device use, medication use, team collaboration, and diagnostic/decision support. For each area, we review evidence for specific error types, operator and system factors that contribute to these errors, and possible mitigating strategies related to design and training interventions that enable health care systems to better meet operators' perceptual, cognitive, and behavioral needs. This review reveals progress in identifying sources of human error and developing mitigating strategies in the areas of medical device and medication use, in part because of tools from human factors engineering that identify user needs and how to design environments to support them. Much less is known about how error emerges from work practices in complex settings, such as collaboration among team members. There is a need for theoretical frameworks to analyze error in the context of routine work practices. Such frameworks will bridge cognitive analyses of individual operators and tasks and more comprehensive theories of organizations, to guide interventions that target medical error at multiple levels.

Low literacy and written drug information: information-seeking, leaflet evaluation and preferences, and roles for images

Background Low-literate patients are at risk to misinterpret written drug information. For the (co-) design of targeted patient information, it is key to involve this group in determining their communication barriers and information needs. Objective To gain insight into how people with low literacy use and evaluate written drug information, and to identify ways in which they feel the patient leaflet can be improved, and in particular how images could be used. Setting Food banks and an education institution for Dutch language training in the Netherlands. Method Semi-structured focus groups and individual interviews were held with low-literate participants (n = 45). The thematic framework approach was used for analysis to identify themes in the data. Main outcome measure Low-literate people’s experience with patient information leaflets, ideas for improvements, and perceptions on possible uses for visuals. Results Patient information leaflets were considered discouraging to use, and information difficult to find and understand. Many rely on alternative information sources. The leaflet should be shorter, and improved in terms of organisation, legibility and readability. Participants thought images could increase the leaflet’s appeal, help ask questions, provide an overview, help understand textual information, aid recall, reassure, and even lead to increased confidence, empowerment and feeling of safety. Conclusion Already at the stages of paying attention to the leaflet and maintaining interest in the message, low-literate patients experience barriers in the communication process through written drug information. Short, structured, visual/textual explanations can lower the motivational threshold to use the leaflet, improve understanding, and empower the low-literate target group.

Integrative Medical Care Plus Mindfulness Training for Patients With Congestive Heart Failure

Congestive heart failure (CHF) has a high rate of morbidity and mortality. It is often accompanied by other medical and psychosocial comorbidities that complicate treatment and adherence. We conducted a proof of concept pilot project to determine the feasibility of providing integrative group medical visits plus mindfulness training for patients recently discharged with CHF. Patients were eligible if they had been discharged from an inpatient stay for CHF within the 12 months prior to the new program. The Compassionate Approach to Lifestyle and Mind–Body (CALM) Skills for Patients with CHF consisted of 8 weekly visits focusing on patient education about medications, diet, exercise, sleep, and stress management; group support; and training in mind–body skills such as mindfulness, self-compassion, and loving-kindness. Over two 8-week sessions, 8/11 (73%) patients completed at least 4 visits. The patients had an average age of 57 years. The most common comorbidities were weight gain, sleep problems, and fatigue. After the sessions, 100% of patients planned to make changes to their diet, exercise, and stress management practices. Over half of the patients who met with a pharmacist had a medication-related problem. Improvements were observed in depression, fatigue, and satisfaction with life. Integrative group visits focusing on healthy lifestyle, support, and skill-building are feasible even among CHF patients and should be evaluated in controlled trials as a patient-centered approach to improving outcomes related to improving medication management, depression, fatigue, and quality of life.

Health Literacy Mediates the Relationship Between Age and Health Outcomes in Patients With Heart Failure

BACKGROUND

Previous studies have linked frequent rehospitalizations for heart failure (HF) and increased mortality with older age, higher severity of HF, lack of an evidence-based medication regimen, and inadequate health literacy. However, the pathway between age and health outcomes in patients with HF remains unknown. Therefore, the purpose of this study was to test whether the association between age and health outcomes can be explained by severity of HF, evidence-based medication use, and health literacy in patients with HF.

METHODS AND RESULTS

This was a longitudinal study of 575 rural patients with HF recruited from outpatient clinics and hospitals. Demographics, clinical data, and health literacy were collected at baseline. HF readmissions and cardiac mortality were followed for 2 years; 57% of patients were ≥ 65 years of age. Older patients with HF were more likely to have low health literacy and less likely to be prescribed angiotensin-converting enzyme inhibitors or β-blockers. Using Kaplan-Meier survival curves with log-rank tests, health outcomes were significantly worse in patients who were ≥ 65 years and in those with low health literacy. Separate Cox regressions revealed that age and health literacy predicted worse health outcomes (P = 0.006 and < 0.001, respectively). When health literacy was entered into the model, the hazard ratio for age changed from 1.49 to 1.29 (a 41% reduction); age was no longer a significant predictor of health outcomes, but health literacy remained significant (P < 0.001), demonstrating mediation.

CONCLUSIONS

Health literacy mediates the relationship between age and health outcomes in adults with HF.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00415545.

Self-Management Skills in Chronic Disease Management: What Role Does Health Literacy Have?

BACKGROUND

Self-management-based interventions can lead to improved health outcomes in people with chronic diseases, and multiple patient characteristics are associated with the development of self-management behaviors. Low health literacy (HL) has been implicated in poorer self-management behaviors and increased costs to health services. However, the mechanisms behind this relationship remain unclear. Therefore, the aim of the current review is to assess the association between HL and patient characteristics related to self-management behaviors (i.e., disease-related knowledge, beliefs, and self-efficacy).

METHODS

The review comprised 3 phases: 1) database searches, 2) eligibility screening, and 3) study quality assessment and strength of evidence. Inclusion criteria specified that a valid HL screening tool was used, that at least one self-management behavior was assessed, and that patients had a chronic condition.

RESULTS

An initial search generated a total of 712 articles, of which 31 studies fulfilled the eligibility criteria. A consistent association was found between low HL and poorer disease-related knowledge in respiratory diseases, diabetes, and multiple disease categories. A significant association between low HL and poorer self-efficacy was reported in cardiovascular diseases, diabetes, human immunodeficiency virus, and multiple disease categories. HL was significantly associated with poorer beliefs in respiratory, musculoskeletal, and cardiovascular diseases.

DISCUSSION

The findings from the current review suggest that low HL may affect behaviors necessary for the development of self-management skills. Given that self-management strategies are core components for effective treatment of a range of chronic diseases, low HL poses a considerable health concern. Further research is needed to understand the mediating influence of HL on disease-related knowledge, self-efficacy, and beliefs. From this, HL-sensitive, self-management interventions ought to be devised and implemented.

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study

RATIONALE, AIMS AND OBJECTIVES

Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF).

METHODS

Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost.

RESULTS

The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions.

CONCLUSION

Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

The Effect of Health Literacy on Medication Knowledge and Medication Discrepancy in Chinese Americans

Background. Functional health literacy (FHL) is increasingly recognized as a useful predictor of health outcomes in different populations. However, the effect of FHL on medication knowledge and medication discrepancy in Chinese Americans is not well defined. Objectives. To examine the effects of FHL on medication knowledge and medication discrepancy in Chinese American patients. Methods. This was a cross-sectional study conducted at an academic internal medicine clinic. The Short Test of Functional Health Literacy in Adults was used to assess participants' FHL. Data for patients' demographic information, medication knowledge, and medication discrepancy (direction discrepancy and name discrepancy) were collected through patient interviews and chart reviews. The primary outcome was medication knowledge of purpose and the secondary outcomes included medication direction discrepancy and medication name discrepancy. Results. Of the 158 Chinese American patients who participated in the study, 54% had adequate FHL. More participants with adequate FHL had correct medication knowledge compared to participants with inadequate FHL (87% vs 56%, respectively, odds ratio = 3.4, 95% confidence interval = 1.2-9.7). Fewer participants with adequate FHL had medication direction discrepancy compared to those with inadequate FHL (42% vs 62%, odds ratio = 0.18, 95% confidence interval = 0.06-0.55). Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy (77% vs 89%) even though the between-group difference was insignificant. Conclusions. Adequate FHL among Chinese American patients is significantly associated with increased medication knowledge of purpose and decreased medication direction discrepancy. Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy.

Comprehensibility of Health-Related Documents for Older Adults with Different Levels of Health Literacy: A Systematic Review

A systematic review was conducted to assess the available evidence for the effectiveness of interventions aiming to improve the comprehensibility of health-related documents in older adults (≥50) with different levels of health literacy. Seven databases were searched (2005 forward), and references in relevant reviews were checked. The selection procedure was conducted by 2 independent reviewers. Data extraction and assessment of the quality of the resulting studies were conducted by 1 reviewer and checked for accuracy by a 2nd reviewer. A total of 38 intervention studies had a study population of older adults (n = 35) or made an explicit comparison between age groups, including older adults (n = 3). Inconsistent evidence was found for the importance of design features to enhance the comprehensibility of health-related documents. Only for narratives and multiple-feature revisions (e.g., combining revisions in textual and visual characteristics) did the included studies provide evidence that they may be effective for older adults. Using narrative formats and/or multiple-feature revisions of health-related documents seem to be promising strategies for enhancing the comprehensibility of health-related documents for older adults. The lack of consistent evidence for effective interventions stresses the importance of (a) replication and (b) the use of standardized research methodologies.

Advancing Best Practices for Prescription Drug Labeling

Objective: Problematic prescription drug labeling has been cited as a root cause of patient misunderstanding, medication errors, and nonadherence. Although numerous studies have recently been conducted to identify and test labeling best practices, the last systematic review on this topic was conducted a decade ago. The objective of this review was, therefore, to examine, summarize, and update best practices for conveying written prescription medication information and instructions to patients. Data Sources: English-language articles published from June 2005 to June 2015 were identified in MEDLINE and CINAHL by searching the following text words: ‘ medication OR prescription OR drug’ AND ‘label OR leaflet OR brochure OR pamphlet OR medication guide OR medication insert OR drug insert OR medication information OR drug information OR instructions’ AND ‘ patient OR consumer.’ Reference mining and secondary searches were also performed. Study Selection and Data Extraction: A total of 31 articles providing evidence on how to improve written, prescription drug labeling for patient use were selected. Two reviewers independently screened articles, rated their quality, and abstracted data. Data Synthesis: Identified best practices included the use of plain language, improved formatting and organization, and more explicit instructions to improve patient comprehension. The use of icons had conflicting findings, and few studies tested whether practices improved knowledge or behaviors with patients’ actual prescribed regimens. Conclusions: Future studies are needed to determine how specific modifications and improvements in drug labeling can enhance patient knowledge and behavior in actual use. Synthesizing best practices across all patient materials will create a more useful, coordinated system of prescription information.

The patient work system: an analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers

Human factors and ergonomics approaches have been successfully applied to study and improve the work performance of healthcare professionals. However, there has been relatively little work in "patient-engaged human factors," or the application of human factors to the health-related work of patients and other nonprofessionals. This study applied a foundational human factors tool, the systems model, to investigate the barriers to self-care performance among chronically ill elderly patients and their informal (family) caregivers. A Patient Work System model was developed to guide the collection and analysis of interviews, surveys, and observations of patients with heart failure (n = 30) and their informal caregivers (n = 14). Iterative analyses revealed the nature and prevalence of self-care barriers across components of the Patient Work System. Person-related barriers were common and stemmed from patients' biomedical conditions, limitations, knowledge deficits, preferences, and perceptions as well as the characteristics of informal caregivers and healthcare professionals. Task barriers were also highly prevalent and included task difficulty, timing, complexity, ambiguity, conflict, and undesirable consequences. Tool barriers were related to both availability and access of tools and technologies and their design, usability, and impact. Context barriers were found across three domains-physical-spatial, social-cultural, and organizational-and multiple "spaces" such as "at home," "on the go," and "in the community." Barriers often stemmed not from single factors but from the interaction of several work system components. Study findings suggest the need to further explore multiple actors, contexts, and interactions in the patient work system during research and intervention design, as well as the need to develop new models and measures for studying patient and family work.

Patients' preferences for visuals: differences in the preferred level of detail, type of background and type of frame of icons depicting organs between literate and low-literate people

OBJECTIVE

To evaluate icons of organs with systematic variations in design to provide directions for the development of pictograms that support patient leaflets targeted at a low-literate audience.

METHODS

In interview questionnaires, 191 pharmacy visitors (IJsselstein, The Netherlands), indicated for four organs in which image the organ was represented most clearly. The icons vary in level of detail of the depicted organ, in the organs that are shown in the background, and in how much of the body is shown as frame. Participants' literacy was determined through the Dutch Rapid Estimate of Adult Literacy in Medicine (REALM-D).

RESULTS

For the three internal organs, the intestines, lungs and kidneys, low-literate participants were more likely than literate participants to opt for less context in the form of the frame of the body.

CONCLUSION

When the meaning of the visual is given, low-literate people prefer organ icons with less context of the body over a depiction of the whole body.

PRACTICE IMPLICATIONS

Since literate and low-literate people differ in perceptual preferences, continued involvement of people with limited literacy skills in the design process is essential to target the visuals to their needs.

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients

Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.

Performance barriers among elderly chronic heart failure patients

Applications of the human factors and ergonomics (HFE) approach in the healthcare domain have largely targeted the work of healthcare professionals. Here, we argue for the importance of targeting the work of patients and their lay caregivers, a relatively underdeveloped approach we call patient-engaged HFE. A multi-method study of the barriers to the self-care work of elderly chronic heart failure patients (N=27) and caregivers (N=11) illustrates the approach. Analyses of interview data using a macroergonomic Work System framework revealed a large variety of barriers unique to patient work as well as to CHF self-care. The most common person-related barriers were physical limitations and knowledge gaps. Task-related barriers included medication complexity and side-effects. Tool and technology barriers included lack of or overdependence on aids. Context barriers were organizational (e.g., no indoor gyms), social (e.g., sodiumrich food culture), and physical-environmental (e.g., stairs). Findings motivate further applying HFE concepts and methods (e.g., workload, decision support, distributed cognition, resilience) to patient work.

Communicating Numerical Risk: Human Factors That Aid Understanding in Health Care

In this chapter, we review evidence from the human factors literature that verbal and visual formats can help increase the understanding of numerical risk information in health care. These visual representations of risk are grounded in empirically supported theory. As background, we first review research showing that people often have difficulty understanding numerical risks and benefits in health information. In particular, we discuss how understanding the meanings of numbers results in healthier decisions. Then, we discuss the processes that determine how communication of numerical risks can enhance (or degrade) health judgments and decisions. Specifically, we examine two different approaches to risk communication: a traditional approach and fuzzy-trace theory. Applying research on the complications of understanding and communicating risks, we then highlight how different visual representations are best suited to communicating different risk messages (i.e., their gist). In particular, we review verbal and visual messages that highlight gist representations that can better communicate health information and improve informed decision making. This discussion is informed by human factors theories and methods, which involve the study of how to maximize the interaction between humans and the tools they use. Finally, we present implications and recommendations for future research on human factors in health care.

Safeguarding the process of drug administration with an emphasis on electronic support tools

AIMS

The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety.

METHODS

To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention.

RESULTS

We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology.

CONCLUSIONS

A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Using Daily Routines to Promote Medication Adherence in Older Adults

PURPOSE. To understand the medication routines used by older adults taking four or more medications daily.

METHOD. One hundred forty-nine community-dwelling older adults were interviewed about the individual routines, storage locations, equipment, and assistance that enabled their adherence to a medication regimen. A subsample of 84 older adults was observed completing one medication routine in their home environments.

FINDINGS. Medication habits were embedded in mealtime, wake-up, and sleep routines for 91% of the sample. Participants developed unique, individualized behaviors for taking medications that were choreographed within broader daily routines. The primary locations for storing medications were the kitchen and bathroom. Equipment used to promote adherence was primarily pillboxes or self-made adaptations. More than 50% of the entire sample required some type of assistance related to medication adherence.

IMPLICATIONS. Findings support the role of occupational therapists in collaborating with clients to develop individualized medication routines to promote medication adherence.

Effect of health literacy on drug adherence in patients with heart failure

STUDY OBJECTIVE

To assess the effect of health literacy on drug adherence in the context of a pharmacist-based intervention for patients with heart failure.

DESIGN

Post hoc analysis of a randomized controlled trial.

SETTING

Inner-city ambulatory care practice affiliated with an academic medical center.

PATIENTS

The original trial enrolled 314 patients with heart failure who were aged 50 years or older and were taking at least one cardiovascular drug for heart failure; 122 patients received the pharmacist intervention (patient education, therapeutic monitoring, and communication with primary care providers), and 192 patients received usual care (regular follow-up with primary care providers). We analyzed the results of 281 patients who had available health literacy and adherence data.

MEASUREMENTS AND MAIN RESULTS

Drug adherence was assessed over 9 months using electronic prescription container monitors on cardiovascular drugs. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults (scores range from 0-36, with an adequate literacy score defined as ≥ 23). Taking adherence, defined as the percentage of prescribed drug doses taken by the patient compared with the number of doses prescribed by the physician, was assessed for each group. Patients were a mean ± SD of 63 ± 9 years old, 51% had less than 12 years of education, 29% had inadequate health literacy, and they received a mean ± SD of 11 ± 4 drugs. In the usual care group, taking adherence was greater among patients with adequate (69.4%) than those with inadequate (54.2%) health literacy (p=0.001). In the intervention group, the difference in taking adherence among patients with adequate (77.3%) and inadequate (65.3%) health literacy was not statistically significant (p=0.06). Among patients with inadequate health literacy, the intervention increased adherence (65%, 95% confidence interval [CI] 54-77%) by an order of magnitude similar to that of the baseline adherence of patients with adequate health literacy (69%, 95% CI 65-74%). Multivariable analysis supported the association between health literacy and adherence.

CONCLUSION

In patients with heart failure, those with adequate health literacy have better adherence to cardiovascular drugs than those with inadequate health literacy. The pharmacist intervention improved adherence in patients with adequate and inadequate health literacy. Health literacy may be an important consideration in drug adherence interventions.

Making healthy food choices using nutrition facts panels. The roles of knowledge, motivation, dietary modifications goals, and age

Nutrition facts panels (NFPs) contain a rich assortment of nutrition information and are available on most food packages. The importance of this information is potentially even greater among older adults due to their increased risk for diet-related diseases, as well as those with goals for dietary modifications that may impact food choice. Despite past work suggesting that knowledge and motivation impact attitudes surrounding and self-reported use of NFPs, we know little about how (i.e., strategies used) and how well (i.e., level of accuracy) younger and older individuals process NFP information when evaluating healthful qualities of foods. We manipulated the content of NFPs and, using eye tracking methodology, examined strategies associated with deciding which of two NFPs, presented side-by-side, was healthier. We examined associations among strategy use and accuracy as well as age, dietary modification status, knowledge, and motivation. Results showed that, across age groups, those with dietary modification goals made relatively more comparisons between NFPs with increasing knowledge and motivation; but that strategy effectiveness (relationship to accuracy) depended on age and motivation. Results also showed that knowledge and motivation may protect against declines in accuracy in later life and that, across age and dietary modification status, knowledge mediates the relationship between motivation and decision accuracy.

The influence of symbols on the short-term recall of pharmacy-generated prescription medication information in a low health literate sample

The effect of symbols on conveying health information has been studied in a variety of contexts and populations. This investigation assessed whether short-term recall of prescription medication information could be enhanced in a low health literate population through the use of symbols. Participants recruited from various nonpharmacy educational service locations were randomly assigned to receive a prescription medication information leaflet in either a text-only, text with symbols, or symbols-only format and then administered the Rapid Estimate of Adult Literacy in Medicine (REALM). Only those with REALM scores indicative of a sixth grade or lower reading level were included in data analysis. An 8-item, interviewer-administered questionnaire was used to assess participants' recall of information contained in the leaflet. A fictitious medication was used to control for participants' past experiences with medications. Results of statistical testing revealed that the three groups did not differ with respect to their ability to recall the medication information, F(2, 157) = 0.943, p = .392. The symbols used in this investigation were not found to enhance the short-term recall of the medication information presented. These findings should not be considered a wholesale indictment of the use of symbols within health care and in pharmacies. Rather, they should serve as a caution to their widespread use without careful consideration.

National study of prescription poisoning with psychoactive and nonpsychoactive medications in Medicare/Medicaid dual enrollees age 65 or over

The purpose of this study is to assess prescription medication poisoning among psychoactive and nonpsychoactive medications used by elderly (65 years or older) Medicare & Medicaid dual enrollees as well as examine contextual components associated with poisoning. Our primary research goal was to compare medication poisonings among psychoactive medications to nonpsychoactive medications. Our second research goal was to identify components influencing medication poisonings and how they interrelate. The approach used a cross-sectional retrospective review of calendar year 2003 Centers for Medicare & Medicaid Service's Medicaid Pharmacy claims data for elderly dual enrollees. Poisonings were identified based on ICD-9-CM categorizations. Poisonings associated with the psychoactive medications were proportionally over twice as high as compared to nonpsychoactive medications (14.3 per 100,000 enrollees and 6.6 per 100,000 enrollees, respectively). Additionally, the two contextual components of (a) use of many drugs and (b) familiarity with the medication have a direct, but competing impact on poisoning. The reasons behind unintentional poisoning in the elderly have been somewhat a mystery. This study is among the first to attempt to distinguish between poisoning events associated with psychoactive medications versus nonpsychoactive medications as well as assess the impact of differing contextual components on medication poisoning.

Linkages between anxiety and outcomes in heart failure

OBJECTIVE

We investigated the relationship between anxiety and event-free survival (ie, composite endpoint of death, emergency department visits, or hospitalizations) for patients with heart failure (HF), and examined whether behavioral and physiologic mechanisms mediate any association between anxiety and outcomes.

METHODS

In this longitudinal study, patients with HF completed the anxiety subscale of the Brief Symptom Inventory, and heart-rate variability and plasma norepinephrine levels were measured. Dietary adherence and medication adherence were measured according to 24-hour urine sodium level and the Medication Event Monitoring System, respectively. Patients were followed at least 1 year for event-free survival.

RESULTS

In total, 147 patients were enrolled. Patients with high anxiety had a shorter (hazard ratio, 2.2; 95% confidence interval, 1.1-4.3; P = .03) period of event-free survival than patients with lower anxiety. Anxiety independently predicted adherence to medication (P = .008), which in turn predicted event-free survival (hazard ratio, 2.0; 95% confidence interval, 1.2-3.3; P = .008). The effect of anxiety (P = .17) on event-free survival was less significant when the regression model included both anxiety and adherence to medication than when the model only included anxiety (P = .03), indicating that adherence to medication mediated the relationship between anxiety and event-free survival.

CONCLUSION

This is the first study to show that nonadherence to medication links anxiety and event-free survival for patients with HF. Interventions that reduce anxiety and improve adherence may benefit outcomes.