1
|
Ong SW, Jassal SV, Porter EC, Min KK, Uddin A, Cafazzo JA, Rac VE, Tomlinson G, Logan AG. Digital Applications Targeting Medication Safety in Ambulatory High-Risk CKD Patients: Randomized Controlled Clinical Trial. Clin J Am Soc Nephrol 2021; 16:532-542. [PMID: 33737321 PMCID: PMC8092059 DOI: 10.2215/cjn.15020920] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/13/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD are at risk for adverse drug reactions, but effective community-based preventive programs remain elusive. In this study, we compared the effectiveness of two digital applications designed to improve outpatient medication safety. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a 1-year randomized controlled trial, 182 outpatients with advanced CKD were randomly assigned to receive a smartphone preloaded with either eKidneyCare (n=89) or MyMedRec (n=93). The experimental intervention, eKidneyCare, includes a medication feature that prompted patients to review medications monthly and report changes, additions, or medication problems to clinicians for reconciliation and early intervention. The active comparator was MyMedRec, a commercially available, standalone application for storing medication and other health information that can be shared with patients' providers. The primary outcome was the rate of medication discrepancy, defined as differences between the patient's reported history and the clinic's medication record, at exit. RESULTS At exit, the eKidneyCare group had fewer total medication discrepancies compared with MyMedRec (median, 0.45; interquartile range, 0.33-0.63 versus 0.67; interquartile range, 0.40-1.00; P=0.001), and the change from baseline was 0.13±0.27 in eKidneyCare and 0.30±0.41 in MyMedRec (P=0.007). eKidneyCare use also reduced the severity of clinically relevant medication discrepancies in all categories, including those with the potential to cause serious harm (estimated rate ratio, 0.40; 95% confidence interval, 0.27 to 0.63). Usage data revealed that 72% of patients randomized to eKidneyCare completed one or more medication reviews per month, whereas only 30% of patients in the MyMedRec group (adjusted for dropouts) kept their medication profile on their phone. CONCLUSIONS In patients who are high risk and have CKD, eKidneyCare significantly reduced the rate and severity of medication discrepancies, the proximal cause of medication errors, compared with the active comparator. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: www.ClinicalTrials.gov, NCT:02905474.
Collapse
Affiliation(s)
- Stephanie W. Ong
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada,Division of Nephrology, University Health Network, Toronto, Ontario, Canada,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Sarbjit V. Jassal
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada,Department of Medicine, University Health Network, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eveline C. Porter
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada,Department of Nursing, University Health Network, Toronto, Ontario, Canada
| | - Kyoyoon K. Min
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Akib Uddin
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Joseph A. Cafazzo
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Ontario, Canada,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Valeria E. Rac
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, Toronto, Ontario, Canada,Program for Health System and Technology Evaluation, Toronto, Ontario, Canada,Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada,Diabetes Action Canada, Canadian Institutes of Health Research Strategy for Patient-Oriented Research Network, Toronto, Ontario, Canada
| | - George Tomlinson
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada,Department of Medicine, University Health Network, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Toronto Health Economics and Technology Assessment Collaborative, Toronto, Ontario, Canada
| | - Alexander G. Logan
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada,Department of Medicine, University Health Network, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada,Department of Medicine, Sinai Health, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Cheraghi-Sohi S, Panagioti M, Daker-White G, Giles S, Riste L, Kirk S, Ong BN, Poppleton A, Campbell S, Sanders C. Patient safety in marginalised groups: a narrative scoping review. Int J Equity Health 2020; 19:26. [PMID: 32050976 PMCID: PMC7014732 DOI: 10.1186/s12939-019-1103-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/27/2019] [Indexed: 12/05/2022] Open
Abstract
Background Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. Methods Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day. Results The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors. Conclusions This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks. Trial registration Not applicable for a scoping review.
Collapse
Affiliation(s)
- Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England. .,Centre for Primary Care, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL, England.
| | - Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England
| | - Gavin Daker-White
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England.,Centre for Primary Care, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL, England
| | - Sally Giles
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England.,Centre for Primary Care, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL, England
| | - Lisa Riste
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England
| | - Sue Kirk
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England
| | - Bie Nio Ong
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England.,Keele University, Citylabs, Nelson St, Manchester, M13 9NQ, England
| | - Aaron Poppleton
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England.,Centre for Primary Care, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL, England
| | - Caroline Sanders
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL,, England.,Centre for Primary Care, The University of Manchester, Williamson Building, Oxford Rd, Manchester, M13 9PL, England.,NIHR School for Primary Care Research, Citylabs, Nelson St, Manchester, M13 9NQ, England.,Health Innvoation Manchester, Citylabs, Nelson St, Manchester, M13 9NQ, England
| |
Collapse
|
3
|
Timely Interventions for Children with ADHD through Web-Based Monitoring Algorithms. Diseases 2019; 7:diseases7010020. [PMID: 30736492 PMCID: PMC6473761 DOI: 10.3390/diseases7010020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 01/27/2023] Open
Abstract
The aim of this study was to evaluate an automated trigger algorithm designed to detect potentially adverse events in children with Attention-Deficit/Hyperactivity Disorder (ADHD), who were monitored remotely between visits. We embedded a trigger algorithm derived from parent-reported ADHD rating scales within an electronic patient monitoring system. We categorized clinicians’ alert resolution outcomes and compared Vanderbilt ADHD rating scale scores between patients who did or did not have triggered alerts. A total of 146 out of 1738 parent reports (8%) triggered alerts for 98 patients. One hundred and eleven alerts (76%) required immediate clinician review. Nurses successfully contacted parents for 68 (61%) of actionable alerts; 46% (31/68) led to a change in care plan prior to the next scheduled appointment. Compared to patients without alerts, patients with alerts demonstrated worsened ADHD severity (β = 5.8, 95% CI: 3.5–8.1 [p < 0.001] within 90 days prior to an alert. The trigger algorithm facilitated timely changes in the care plan in between face-to-face visits.
Collapse
|
4
|
Ratanawongsa N, Quan J, Handley MA, Sarkar U, Schillinger D. Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims. BMC Health Serv Res 2018; 18:254. [PMID: 29625571 PMCID: PMC5889590 DOI: 10.1186/s12913-018-3071-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/28/2018] [Indexed: 12/15/2022] Open
Abstract
Background Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the validity of assessing adherence using automated telephone self-management (ATSM) queries, when compared with non-adherence using continuous medication gap (CMG) on pharmacy claims. We hypothesized that patients reporting greater days of missed pills to ATSM queries would have higher rates of non-adherence as measured by CMG, and that ATSM adherence assessments would perform as well as structured interview assessments. Methods As part of an ATSM-facilitated diabetes self-management program, low-income health plan members typed numeric responses to rotating weekly ATSM queries: “In the last 7 days, how many days did you MISS taking your …” diabetes, blood pressure, or cholesterol pill. Research assistants asked similar questions in computer-assisted structured telephone interviews. We measured continuous medication gap (CMG) by claims over 12 preceding months. To evaluate convergent validity, we compared rates of optimal adherence (CMG ≤ 20%) across respondents reporting 0, 1, and ≥ 2 missed pill days on ATSM and on structured interview. Results Among 210 participants, 46% had limited health literacy, 57% spoke Cantonese, and 19% Spanish. ATSM respondents reported ≥1 missed day for diabetes (33%), blood pressure (19%), and cholesterol (36%) pills. Interview respondents reported ≥1 missed day for diabetes (28%), blood pressure (21%), and cholesterol (26%) pills. Optimal adherence rates by CMG were lower among ATSM respondents reporting more missed days for blood pressure (p = 0.02) and cholesterol (p < 0.01); by interview, differences were significant for cholesterol (p = 0.01). Conclusions Language-concordant ATSM demonstrated modest potential for assessing adherence. Studies should evaluate HIT assessments of medication beliefs and concerns in diverse populations. Trial registration NCT00683020, registered May 21, 2008. Electronic supplementary material The online version of this article (10.1186/s12913-018-3071-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA.
| | - Judy Quan
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Margaret A Handley
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA.,Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Urmimala Sarkar
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| | - Dean Schillinger
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, USA
| |
Collapse
|
5
|
Bernhard G, Mahler C, Seidling HM, Stützle M, Ose D, Baudendistel I, Wensing M, Szecsenyi J. Developing a Shared Patient-Centered, Web-Based Medication Platform for Type 2 Diabetes Patients and Their Health Care Providers: Qualitative Study on User Requirements. J Med Internet Res 2018; 20:e105. [PMID: 29588269 PMCID: PMC5893891 DOI: 10.2196/jmir.8666] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/24/2017] [Accepted: 12/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Information technology tools such as shared patient-centered, Web-based medication platforms hold promise to support safe medication use by strengthening patient participation, enhancing patients’ knowledge, helping patients to improve self-management of their medications, and improving communication on medications among patients and health care professionals (HCPs). However, the uptake of such platforms remains a challenge also due to inadequate user involvement in the development process. Employing a user-centered design (UCD) approach is therefore critical to ensure that user’ adoption is optimal. Objective The purpose of this study was to identify what patients with type 2 diabetes mellitus (T2DM) and their HCPs regard necessary requirements in terms of functionalities and usability of a shared patient-centered, Web-based medication platform for patients with T2DM. Methods This qualitative study included focus groups with purposeful samples of patients with T2DM (n=25), general practitioners (n=13), and health care assistants (n=10) recruited from regional health care settings in southwestern Germany. In total, 8 semistructured focus groups were conducted. Sessions were audio- and video-recorded, transcribed verbatim, and subjected to a computer-aided qualitative content analysis. Results Appropriate security and access methods, supported data entry, printing, and sending information electronically, and tracking medication history were perceived as the essential functionalities. Although patients wanted automatic interaction checks and safety alerts, HCPs on the contrary were concerned that unspecific alerts confuse patients and lead to nonadherence. Furthermore, HCPs were opposed to patients’ ability to withhold or restrict access to information in the platform. To optimize usability, there was consensus among participants to display information in a structured, chronological format, to provide information in lay language, to use visual aids and customize information content, and align the platform to users’ workflow. Conclusions By employing a UCD, this study provides insight into the desired functionalities and usability of patients and HCPs regarding a shared patient-centered, Web-based medication platform, thus increasing the likelihood to achieve a functional and useful system. Substantial and ongoing engagement by all intended user groups is necessary to reconcile differences in requirements of patients and HCPs, especially regarding medication safety alerts and access control. Moreover, effective training of patients and HCPs on medication self-management (support) and optimal use of the tool will be a prerequisite to unfold the platform’s full potential.
Collapse
Affiliation(s)
- Gerda Bernhard
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelia Mahler
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Hanna Marita Seidling
- Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Heidelberg, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marion Stützle
- Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Heidelberg, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik Ose
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany.,Division of Cancer Population Sciences, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, United States
| | - Ines Baudendistel
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
6
|
Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department. J Patient Saf 2017; 12:119-24. [PMID: 24583958 DOI: 10.1097/pts.0000000000000072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. STUDY OBJECTIVES To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events. METHODS Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE. RESULTS From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event. CONCLUSION Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.
Collapse
|
7
|
Sellappans R, Lai PSM, Ng CJ. Challenges faced by primary care physicians when prescribing for patients with chronic diseases in a teaching hospital in Malaysia: a qualitative study. BMJ Open 2015; 5:e007817. [PMID: 26316648 PMCID: PMC4554910 DOI: 10.1136/bmjopen-2015-007817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify the challenges faced by primary care physicians (PCPs) when prescribing medications for patients with chronic diseases in a teaching hospital in Malaysia. DESIGN/SETTING 3 focus group discussions were conducted between July and August 2012 in a teaching primary care clinic in Malaysia. A topic guide was used to facilitate the discussions which were audio-recorded, transcribed verbatim and analysed using a thematic approach. PARTICIPANTS PCPs affiliated to the primary care clinic were purposively sampled to include a range of clinical experience. Sample size was determined by thematic saturation of the data. RESULTS 14 family medicine trainees and 5 service medical officers participated in this study. PCPs faced difficulties in prescribing for patients with chronic diseases due to a lack of communication among different healthcare providers. Medication changes made by hospital specialists, for example, were often not communicated to the PCPs leading to drug duplications and interactions. The use of paper-based medical records and electronic prescribing created a dual record system for patients' medications and became a problem when the 2 records did not tally. Patients sometimes visited different doctors and pharmacies for their medications and this resulted in the lack of continuity of care. PCPs also faced difficulties in addressing patients' concerns, and dealing with patients' medication requests and adherence issues. Some PCPs lacked time and knowledge to advise patients about their medications and faced difficulties in managing side effects caused by the patients' complex medication regimen. CONCLUSIONS PCPs faced prescribing challenges related to patients, their own practice and the local health system when prescribing for patients with chronic diseases. These challenges must be addressed in order to improve chronic disease management in primary care and, more importantly, patient safety.
Collapse
Affiliation(s)
- Renukha Sellappans
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, University of Malaya Primary Care Research Group (UMPCRG), University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
8
|
Mira JJ, Lorenzo S, Guilabert M, Navarro I, Pérez-Jover V. A systematic review of patient medication error on self-administering medication at home. Expert Opin Drug Saf 2015; 14:815-38. [PMID: 25774444 DOI: 10.1517/14740338.2015.1026326] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems. AREAS COVERED This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus. EXPERT OPINION The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.
Collapse
Affiliation(s)
- José Joaquín Mira
- Departamento de Salud Alicante-Sant Joan d'Alacant , Alicante , Spain
| | | | | | | | | |
Collapse
|
9
|
Sarkar U, Simchowitz B, Bonacum D, Strull W, Lopez A, Rotteau L, Shojania KG. A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors. Jt Comm J Qual Patient Saf 2014; 40:461-1. [PMID: 26111306 DOI: 10.1016/s1553-7250(14)40059-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis. METHODS As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis. RESULTS A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors. CONCLUSIONS Multiple themes relating to each of the participants in the diagnostic process-health system, provider, and patient-emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.
Collapse
Affiliation(s)
- Urmimala Sarkar
- Center for Vulnerable Populations, Division of General Internal Medicine, University of California, San Francisco, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Mira JJ, Navarro I, Botella F, Borrás F, Nuño-Solinís R, Orozco D, Iglesias-Alonso F, Pérez-Pérez P, Lorenzo S, Toro N. A Spanish pillbox app for elderly patients taking multiple medications: randomized controlled trial. J Med Internet Res 2014; 16:e99. [PMID: 24705022 PMCID: PMC4004137 DOI: 10.2196/jmir.3269] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/04/2014] [Accepted: 03/13/2014] [Indexed: 11/18/2022] Open
Abstract
Background Nonadherence and medication errors are common among patients with complex drug regimens. Apps for smartphones and tablets are effective for improving adherence, but they have not been tested in elderly patients with complex chronic conditions and who typically have less experience with this type of technology. Objective The objective of this study was to design, implement, and evaluate a medication self-management app (called ALICE) for elderly patients taking multiple medications with the intention of improving adherence and safe medication use. Methods A single-blind randomized controlled trial was conducted with a control and an experimental group (N=99) in Spain in 2013. The characteristics of ALICE were specified based on the suggestions of 3 nominal groups with a total of 23 patients and a focus group with 7 professionals. ALICE was designed for Android and iOS to allow for the personalization of prescriptions and medical advice, showing images of each of the medications (the packaging and the medication itself) together with alerts and multiple reminders for each alert. The randomly assigned patients in the control group received oral and written information on the safe use of their medications and the patients in the experimental group used ALICE for 3 months. Pre and post measures included rate of missed doses and medication errors reported by patients, scores from the 4-item Morisky Medication Adherence Scale (MMAS-4), level of independence, self-perceived health status, and biochemical test results. In the experimental group, data were collected on their previous experience with information and communication technologies, their rating of ALICE, and their perception of the level of independence they had achieved. The intergroup intervention effects were calculated by univariate linear models and ANOVA, with the pre to post intervention differences as the dependent variables. Results Data were obtained from 99 patients (48 and 51 in the control and experimental groups, respectively). Patients in the experimental group obtained better MMAS-4 scores (P<.001) and reported fewer missed doses of medication (P=.02). ALICE only helped to significantly reduce medication errors in patients with an initially higher rate of errors (P<.001). Patients with no experience with information and communication technologies reported better adherence (P<.001), fewer missed doses (P<.001), and fewer medication errors (P=.02). The mean satisfaction score for ALICE was 8.5 out of 10. In all, 45 of 51 patients (88%) felt that ALICE improved their independence in managing their medications. Conclusions The ALICE app improves adherence, helps reduce rates of forgetting and of medication errors, and increases perceived independence in managing medication. Elderly patients with no previous experience with information and communication technologies are capable of effectively using an app designed to help them take their medicine more safely. Trial Registration Clinicaltrials.gov NCT02071498; http://clinicaltrials.gov/ct2/show/NCT02071498 (Archived by WebCite at http://www.webcitation.org/6OJjdHVhD).
Collapse
Affiliation(s)
- José Joaquín Mira
- Sant Joan-Alicante Health District, Consellería Sanidad, Alicante, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Ratanawongsa N, Handley MA, Sarkar U, Quan J, Pfeifer K, Soria C, Schillinger D. Diabetes health information technology innovation to improve quality of life for health plan members in urban safety net. J Ambul Care Manage 2014; 37:127-37. [PMID: 24594561 PMCID: PMC3990277 DOI: 10.1097/jac.0000000000000019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Safety net systems need innovative diabetes self-management programs for linguistically diverse patients. A low-income government-sponsored managed care plan implemented a 27-week automated telephone self-management support/health coaching intervention for English-, Spanish-, and Cantonese-speaking members from 4 publicly funded clinics in a practice-based research network. Compared to waitlist, immediate intervention participants had greater 6-month improvements in overall diabetes self-care behaviors (standardized effect size [ES] = 0.29, P < .01) and 12-Item Short Form Health Survey physical scores (ES = 0.25, P = .03); changes in patient-centered processes of care and cardiometabolic outcomes did not differ. Automated telephone self-management is a strategy for improving patient-reported self-management and may also improve some outcomes.
Collapse
Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
| | - Margaret A. Handley
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
- Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, University of California, San Francisco, CA
| | - Urmimala Sarkar
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
| | - Judy Quan
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
| | - Kelly Pfeifer
- San Francisco Health Plan, 201 3rd Street, 7th Floor, San Francisco, CA 94103
| | - Catalina Soria
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
| | - Dean Schillinger
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94110
- California Diabetes Program, California Department of Public Health, PO Box 997377, MS 7211, Sacramento, CA 95899-7377
| |
Collapse
|
12
|
Patient Safety in Outpatient Care. PATIENT SAFETY 2014. [DOI: 10.1007/978-1-4614-7419-7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
13
|
Lyles CR, Schillinger D, Lopez A, Handley M, Ratanawongsa N, Sarkar U. Safety events during an automated telephone self-management support intervention. J Diabetes Sci Technol 2013; 7:596-601. [PMID: 23759391 PMCID: PMC3869126 DOI: 10.1177/193229681300700303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Interactive health information technology (HIT) can support the complex self-management tasks for diabetes. However, less is known about between-visit interactions and patient safety among chronic illness patients treated in the outpatient setting. METHODS We classified 13 categories for safety events and potential safety events within a larger trial evaluating a multilingual automated telephone self-management support system for diabetes using interactive voice response. Participants could trigger safety concerns by reporting hyperglycemia or hypoglycemia, inability to obtain medications, medication nonadherence and side effects, and needing appointments and/or supplies. We then examined these triggers across patient demographic and health characteristics to determine which patients were most likely to experience safety events. RESULTS Overall, there were 360 safety triggers that occurred among 155 participants, which represented 53% of individuals and 7.6% of all automated calls over the 27-week intervention. The most common triggers were for pain or medication side effects (22%) and not checking blood sugars (13%). In adjusted models, race/ethnicity and language were related to safety triggers; Spanish-speaking participants were significantly (p = .02) more likely than English-speaking participants to experience a safety trigger, and black participants were marginally more likely (p = .09) than white participants to experience a safety trigger. CONCLUSION About half of patients enrolled in a self-management technology intervention triggered at least one potential safety event over the course of the trial, and this was more frequent among some patients. Systems implementing HIT strategies to improve self-care and remote monitoring should consider specific program design elements to address these potential safety events.
Collapse
Affiliation(s)
- Courtney R. Lyles
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| | - Dean Schillinger
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| | - Andrea Lopez
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| | - Margaret Handley
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, University of California, San Francisco, San Francisco, California
| | - Neda Ratanawongsa
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| | - Urmimala Sarkar
- Division of General Internal Medicine at San Francisco General Hospital, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California
| |
Collapse
|
14
|
Davison KM, Kaplan BJ. Nutrient- and non-nutrient-based natural health product (NHP) use in adults with mood disorders: prevalence, characteristics and potential for exposure to adverse events. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 13:80. [PMID: 23570306 PMCID: PMC3626531 DOI: 10.1186/1472-6882-13-80] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 03/27/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND To address knowledge gaps regarding natural health product (NHP) usage in mental health populations, we examined their use in adults with mood disorders, and explored the potential for adverse events. METHODS Food and NHP intake was obtained from 97 adults with mood disorders. NHP data was used to compare prevalence with population norms (British Columbia Nutrition Survey; BCNS). Bivariate and regression analyses examined factors associated with NHP use. Assessment of potential adverse effects of NHP use was based on comparing nutrient intakes from food plus supplements with the Dietary Reference Intakes and by reviewing databases for reported adverse health effects. RESULTS Two-thirds (66%; 95% CI 56 to 75) were taking at least one NHP; 58% (95% CI 47 to 68) were taking NHPs in combination with psychiatric medications. The proportion of each type of NHP used was generally higher than the BCNS (range of p's < 0.05 to 0.0001). When intakes from food and NHP sources were combined, a small proportion exceeded any Lowest-Observed-Adverse-Effect-Levels: only for niacin (n = 17) and magnesium (n = 6), two nutrients for which the potential for adverse effects is minimal. Conversely, about 38% (95% CI 28 to 49) of the sample were taking a non-nutrient based NHP for which previous adverse events had been documented. CONCLUSIONS The prevalent use of NHPs in this population suggests that health care providers need to be knowledgeable about their characteristics. The efficacy and safety of NHPs in relation to mental health warrants further investigation.
Collapse
Affiliation(s)
- Karen M Davison
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- University of British Columbia, School of Population and Public Health, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Bonnie J Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Paediatrics, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
15
|
Mira JJ, Orozco-Beltrán D, Pérez-Jover V, Martínez-Jimeno L, Gil-Guillén VF, Carratala-Munuera C, Sánchez-Molla M, Pertusa-Martínez S, Asencio-Aznar A. Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Fam Pract 2013; 30:56-63. [PMID: 22904014 DOI: 10.1093/fampra/cms046] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To analyse the frequency of mistakes in communication between the physician and the patient and their incidence in errors in self-administered drugs. METHODS We undertook a descriptive, cross-sectional study based on interviews with a random sample of patients older than 65 years who were polymedicated (five or more drugs) and had multiple comorbidities. Data were analysed about the patients' reports of what the physician said, medication mistakes by the patients and their consequences. RESULTS Responses were provided by 382 patients. A medication error in the last year was reported by 287 patients (75%), and 16 patients (4%) reported four or more errors. Most cases concerned the dosage, a similar appearance of the medication or a lack of understanding of the physician's instructions. Very severe consequences occurred in 19 cases (5%). Multiple comorbidities (P = 0.006) and a greater number of treatments (P = 0.002) were associated with making mistakes. Frequent changes in prescription (P = 0.02), not considering the prescriptions of other physicians (P = 0.01), inconsistency in the messages (P = 0.01), being treated by various different physicians at the same time (P = 0.03), a feeling of not being listened to (P < 0.001) or loss of trust in the physician (P < 0.001) were associated with making medication mistakes. CONCLUSIONS Mistakes by polymedicated patients with multiple comorbidities represent a real risk that should be addressed by the professionals. A review should be made of the routine control questions that the physician asks the patient to identify what other drugs the patient may be taking that have been indicated by another physician.
Collapse
|
16
|
Mira JJ, Lorenzo S, Vitaller J, Ignacio-García E, Aranaz J. [What do diabetic patients and what should they do to avoid errors in the course of treatment?]. ACTA ACUST UNITED AC 2012; 59:416-22. [PMID: 22789153 DOI: 10.1016/j.endonu.2012.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/03/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To report the precautions taken by diabetic patients to avoid treatment errors and to provide advice to increase their safety. METHODS A descriptive study of patients' behaviors to minimize errors and tips by professionals to improve safety. Ninety-nine insulin-treated patients were randomly recruited from 3 primary healthcare centers and 2 hospitals. An opportunity sample of 33 doctors and nurses was also surveyed. RESULTS Information of all prescriptions (p = 0.005), review of doubts before the visit (p = 0,009), and diet adherence (p = 0.02) were the only precautions reported by patients that related to a lower number of patient errors. Female patients better follow at home instructions for blood glucose monitoring (odds ratio 0.07; 95% confidence interval (CI) 0.1-0.6) and use pillboxes to avoid errors (odds ratio 0.23; 95% CI 0.1-0.6) more frequently than male patients. Male patients more commonly carry with them a card with information about allergies (odds ratio 5.03; 95% CI 1.4-17.5). Patients with a longer course of disease tend to withhold information about other treatments from their doctors (β -15.8; 95% CI -23.2-8.4). For healthcare professionals, safety may increase if patients: play a more active role in their treatment (91%), and inform their doctors about their different treatments (88%). CONCLUSIONS Promotion of patient autonomy, improved communication to patients, and systematic information about the most common medication errors may contribute to patient safety.
Collapse
Affiliation(s)
- José Joaquín Mira
- Departamento de Psicología de la Salud, Universidad Miguel Hernández, Elche, España.
| | | | | | | | | |
Collapse
|
17
|
Brenner S, Detz A, López A, Horton C, Sarkar U. Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients. BMJ Qual Saf 2012; 21:670-5. [PMID: 22626736 PMCID: PMC3402751 DOI: 10.1136/bmjqs-2011-000643] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear. Methods The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers. Results The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers. Conclusions The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.
Collapse
Affiliation(s)
- Stacey Brenner
- Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA 94110, USA
| | | | | | | | | |
Collapse
|
18
|
Ratanawongsa N, Handley MA, Quan J, Sarkar U, Pfeifer K, Soria C, Schillinger D. Quasi-experimental trial of diabetes Self-Management Automated and Real-Time Telephonic Support (SMARTSteps) in a Medicaid managed care plan: study protocol. BMC Health Serv Res 2012; 12:22. [PMID: 22280514 PMCID: PMC3276419 DOI: 10.1186/1472-6963-12-22] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 01/26/2012] [Indexed: 12/11/2022] Open
Abstract
Background Health information technology can enhance self-management and quality of life for patients with chronic disease and overcome healthcare barriers for patients with limited English proficiency. After a randomized controlled trial of a multilingual automated telephone self-management support program (ATSM) improved patient-centered dimensions of diabetes care in safety net clinics, we collaborated with a nonprofit Medicaid managed care plan to translate research into practice, offering ATSM as a covered benefit and augmenting ATSM to promote medication activation. This paper describes the protocol of the Self-Management Automated and Real-Time Telephonic Support Project (SMARTSteps). Methods/Design This controlled quasi-experimental trial used a wait-list variant of a stepped wedge design to enroll 362 adult health plan members with diabetes who speak English, Cantonese, or Spanish and receive care at 4 publicly-funded clinics. Through language-stratified randomization, participants were assigned to four intervention statuses: SMARTSteps-ONLY, SMARTSteps-PLUS, or wait-list for either intervention. In addition to usual primary care, intervention participants received 27 weekly calls in their preferred language with rotating queries and response-triggered education about self-care, medication adherence, safety concerns, psychological issues, and preventive services. Health coaches from the health plan called patients with out-of-range responses for collaborative goal setting and action planning. SMARTSteps-PLUS also included health coach calls to promote medication activation, adherence and intensification, if triggered by ATSM-reported non-adherence, refill non-adherence from pharmacy claims, or suboptimal cardiometabolic indicators. Wait-list patients crossed-over to SMARTSteps-ONLY or -PLUS at 6 months. For participants who agreed to structured telephone interviews at baseline and 6 months (n = 252), primary outcomes will be changes in quality of life and functional status with secondary outcomes of 6-month changes in self-management behaviors/efficacy and patient-centered processes of care. We will also evaluate 6-month changes in cardiometabolic (HbA1c, blood pressure, and LDL) and utilization indicators for all participants. Discussion Outcomes will provide evidence regarding real-world implementation of ATSM within a Medicaid managed care plan serving safety net settings. The evaluation trial will provide insight into translating and scaling up health information technology interventions for linguistically and culturally diverse vulnerable populations with chronic disease. Trial Registration ClinicalTrials.gov: NCT00683020
Collapse
Affiliation(s)
- Neda Ratanawongsa
- General Internal Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, University of California, 94110, USA.
| | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
OBJECTIVE To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. DATA SOURCE We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. STUDY DESIGN Secondary data analysis. PRINCIPAL FINDINGS An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). CONCLUSIONS Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.
Collapse
Affiliation(s)
- Urmimala Sarkar
- Department of Medicine, UCSF Center for Vulnerable Populations, San Francisco General Hospital Medical Services, Division of General Internal Medicine, University of California, San Francisco (UCSF), Box 1364, 1001 Potrero, Bldg 10, 3rd Floor, San Francisco, CA 94143-1364, USA.
| | | | | | | |
Collapse
|