Patients' health literacy and experience with instructions: influence preferences for heart failure medication instructions

Self-management interventions for chronically ill patients with limited health literacy: A descriptive analysis

OBJECTIVES

To support patients with limited health literacy with the challenges they face in the day-to-day management of their disease(s), numerous self-management interventions (SMIs) have been developed. To date, it is unclear to what extent SMIs have been developed for chronically ill patients with limited health literacy. This study aims to provide a description of these SMIs and to provide insight in their methodological components.

METHODS

A secondary analysis of the COMPAR-EU database, consisting of SMIs addressing patients with diabetes, chronic obstructive pulmonary disease, obesity and heart failure, was conducted. The database was searched for SMIs addressing health literacy, including cognitive aspects and the capacity to act.

RESULTS

Of the 1681 SMIs in the COMPAR-EU database, 35 studies addressed health literacy, describing 39 SMIs. The overview yields a high variety in interventions given, with overlapping information, but also lacking of specific details.

DISCUSSION

This descriptive analysis shows that there was a large variety in the extensiveness of the description of intervention characteristics and their justification or explanation. A focus on the broad concept of health literacy, including functional skills, cognitive skills and the capacity to act could improve the effectiveness. This should be taken into account in the future development of SMIs.

Relationship between People's Interest in Medication Adherence, Health Literacy, and Self-Care: An Infodemiological Analysis in the Pre- and Post-COVID-19 Era

The prevalence of non-communicable diseases has risen sharply in recent years, particularly among older individuals who require complex drug regimens. Patients are increasingly required to manage their health through medication adherence and self-care, but about 50% of patients struggle to adhere to prescribed treatments. This study explored the relationship between interest in medication adherence, health literacy, and self-care and how it changed during the COVID-19 pandemic. We used Google Trends to measure relative search volumes (RSVs) for these three topics from 2012 to 2022. We found that interest in self-care increased the most over time, followed by health literacy and medication adherence. Direct correlations emerged between RSVs for medication adherence and health literacy (r = 0.674, p < 0.0001), medication adherence and self-care (r = 0.466, p < 0.0001), and health literacy and self-care (r = 0.545, p < 0.0001). After the COVID-19 pandemic outbreak, interest in self-care significantly increased, and Latin countries showed a greater interest in self-care than other geographical areas. This study suggests that people are increasingly interested in managing their health, especially in the context of the recent pandemic, and that infodemiology may provide interesting information about the attitudes of the population toward chronic disease management.

Health-related information needs and preferences for information of individuals with cardiovascular disease from underserved populations: A systematic review

OBJECTIVE

This systematic review aimed to identify the information needs and preferences of individuals with CVD from underserved populations.

METHODS

Five databases were searched from data inception to February 2022. Pilot and case report studies, non-peer-reviewed literature, and studies published in a language other than English, Portuguese, or Spanish were excluded. Structured and thematic analysis of all included studies were performed. The Critical Appraisal Skills Program and the Downs and Black Checklist were used to assess the quality of the qualitative and quantitative studies, respectively.

RESULTS

Of 35,698 initial records, 19 studies were included, most in observational design and classified as "fair" quality. Underserved populations - women, people living in rural areas, ethnic minority groups, older people, and those with low socioeconomic status - presented unique needs in four main groups, with some similarities across them: information about CVD, primary and secondary prevention of CVD, CVD management, and health care, policies and practices. Across the studies there was a lack of standardization on how individuals' needs were assessed and reported.

CONCLUSION

Underserved populations with CVD have unique information needs and preferences that should be address during their care.

PRACTICAL IMPLICATION

Information from this study may assist health care professionals with the development of comprehensive strategies to improve their provision of care for specific CVD patient groups.

Current Knowledge about Providing Drug-Drug Interaction Services for Patients-A Scoping Review

Drug-drug interactions (DDIs) pose a major problem to patient safety. eHealth solutions have the potential to address this problem and generally improve medication management by providing digital services for health care professionals and patients. Clinical decision support systems (CDSS) to alert physicians or pharmacists about DDIs are common, and there is an extensive body of research about CDSS for professionals. Information about DDIs is commonly requested by patients, but little is known about providing similar support to patients. The aim of this scoping review was to explore and describe current knowledge about providing digital DDI services for patients. Using a broad search strategy and an established framework for scoping reviews, 19 papers were included. The results show that although some patients want to check for DDIs themselves, there are differences between patients, in terms of demands and ability. There are numerous DDI services available, but the existence of large variations regarding service quality implies potential safety issues. The review includes suggestions about design features but also indicates a substantial knowledge gap highlighting the need for further research about how to best design and provide digital DDI to patients without risking patient safety or having other unintended consequences.

Patients' Use and Perceptions of a Drug-Drug Interaction Database: A Survey of Janusmed Interactions

Janusmed interactions is a drug-drug interactions (DDI) database available online for healthcare professionals (HCP) at all levels of the healthcare system including pharmacies. The database is aimed at HCP but is also open to the public for free, for those individuals who register for a personal account. The aim of this study was to investigate why and how patients use the database Janusmed interactions, how they perceive content and usability, and how they would react if they found an interaction. A web-based questionnaire was sent by email to all users who had registered for Janusmed interactions as a “patient” (n = 3219). A total of 406 patients completed the survey (response rate 12.6%). The study shows that there is an interest among patients to use a DDI database to check their own or a relative’s medication. The respondents found the database easy to use and perceive they understand the information aimed at HCP. Most patients stated they would talk to their HCP if they found an interaction and not adjust their treatment by themselves. However, the respondents in this study are actively searching for information and seem to have high health literacy. Thus, the findings are not generalizable for the general population.

Understood? Evaluating the readability and understandability of intranasal corticosteroid delivery instructions

BACKGROUND

Allergic rhinitis is a widespread disease that has significant quality-of-life ramifications. Symptoms include rhinorrhea, nasal obstruction, cough, and postnasal drip. Intranasal corticosteroids are a hallmark of treatment of allergic rhinitis. However, the benefits of treatment are dependent on correct nasal spray technique, of which many patients are not aware. Patient instructions are included with the purchase of these medications. The readability and understandability for these educational materials has been minimally assessed in the medical literature. The aim of this study was to evaluate the readability and understandability of commonly used intranasal steroids.

METHODS

Three readability measures (Gunning Fog, Simple Measure of Gobbledygook [SMOG], and FORCAST) and an understandability assessment (Patient Education Materials Assessment Tool for Printable Materials [PEMAT-P]) were used to evaluate the instructions for use of commonly prescribed intranasal steroids. Instructions with 6th grade readability level or lower were considered to meet health literacy experts' recommendations. Higher understandability values correlate to easier understandability.

RESULTS

Instructions for 10 intranasal corticosteroid brands were reviewed. Gunning Fog consistently estimated easiest readability, whereas FORCAST estimated most difficult readability. Twenty percent (20%) of analyzed instructions met National Institutes of Health and health literacy experts' recommended reading levels. Understandability of instructions ranged from 33% to 90%, with an average of 66%.

CONCLUSION

The benefit of intranasal corticosteroids is contingent on correct use by patients. However, the prepackaged instructions provided are most often above recommended reading levels and are difficult to understand. Future development of intranasal steroid instructions should meet recommended readability levels and be understandable to maximize their utility.

Social Support, Health Literacy, and Health Care Utilization Among Older Adults

The purpose of this study was to explore the relationship between social support, health literacy, and health care utilization in older Chinese adults. A cross-sectional survey design was employed. Data were collected from 32 nursing homes from Urumqi in Xinjiang of China. A total of 1486 respondents completed a pack of questionnaires. The average health literacy level of older adults in nursing homes was relatively low, only 73.68 ± 29.42 points; the average social support level was also relatively low, only 31.42 ± 7.12 points (lower than domestic norm of Chinese residents, P < .001). Both values were below the midpoint for the overall population, indicating a sample with below-average levels of healthy literacy and social support. Low social support levels are associated with poor health literacy and greater likelihood of hospital admission (P < .05). Social support was significantly associated with health literacy. Improving the quantity and quality of social support may be an effective means to obtain better health literacy and lower hospital admissions.

Transition From Hospital to Home: The Role of the Nurse Case Manager in Promoting Medication Adherence in the Medicare Population

Lack of adherence to medication plans is a factor in costly hospital readmissions. Adherence to medication plans in the home care setting in relation to hospital readmission is a major issue among the Medicare population. Nurse case managers are in a key position to provide care after hospital discharge to promote medication adherence and thus reduce the chance of hospital readmission. This article discusses barriers to taking medications as prescribed and directed, the importance of ongoing medication reconciliation at home, and strategies to promote adherence to medication plans.

Measurement of health literacy in patients with cardiovascular diseases: A systematic review

BACKGROUND

While many instruments have been developed, validated, and used to assess health literacy skills, their use and appropriateness among patients with cardiovascular diseases (CVDs) are not widely studied.

OBJECTIVE

To identify, appraise, and synthesize available health literacy assessment instruments used in patients with CVDs.

METHODS

Electronic databases were searched for studies that used validated measures to assess health literacy in patients with CVDs. Included studies were assessed for risk of bias and the identified instruments were evaluated based on their psychometric properties. Data were synthesized using a narrative approach.

RESULTS

Forty-three studies were included in the review, of which 20 were cross-sectional studies and 12 were randomized controlled trials. Eleven health literacy assessment instruments were identified, of which only one was disease-specific. The Abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA) (n = 19) and the Rapid Estimate of Adult Literacy in Medicine (REALM) (n = 13) were found to be the most commonly used instruments to assess health literacy in CVDs.

CONCLUSIONS

The S-TOFHLA and the REALM are the most widely used instruments to evaluate health literacy in CVD population. More CVD-specific health literacy screening instruments are warranted. Assessment of health literacy should be a standard of care in patients with CVDs and effective interventions should be developed to improve the impact of limited health literacy on health outcomes in this population.

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.

Functional health literacy and adherence to the medication in older adults: integrative review

Objective:

to characterize the national and international scientific production on the relationship of Functional Health Literacy and the adherence to the medication in older adults.

Method:

integrative review of literature, searching the following online databases: Scientific Electronic Library Online (SCIELO); Latin American and Caribbean Health Sciences Literature (LILACS); Medical Literature Analysis and Retrieval System Online (MEDLINE); and Cumulative Index to Nursing & Allied Health Literature (CINAHL), in June 2016. We selected 7 articles that obeyed the inclusion criteria.

Results:

all articles are from the USA. The inappropriate Functional Health Literacy affects the non-adherence to medication; however, there are several strategies and interventions that can be practiced to change this relationship.

Conclusion:

nursing needs to explorefurther this theme, since it can exert a differentiated care for adherence to medication in older adults, considering the literacy.

Objetivo:

caracterizar a produção científica nacional e internacional sobre a relação do Letramento Funcional em Saúde e a adesão à medicação em idosos.

Método:

revisão integrativa da literatura, com busca nas bases de dados on-line: Scientific Electronic Library Online (SCIELO); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); Medical Literature Analysis and Retrieval System Online (MEDLINE); e Cumulative Index to Nursing & Allied Health Literature (CINAHL), no mês de junho de 2016. Foram selecionados 7 artigos que obedeceram aos critérios de inclusão.

Resultados:

todos os artigos são internacionais e originários dos EUA. O Letramento Funcional em Saúde inadequado influencia para a não adesão à medicação, porém há diversas estratégias e intervenções que podem ser realizadas na prática para modificar essa relação.

Conclusão:

a enfermagem precisa explorar mais essa temática, visto que pode exercer um cuidado diferenciado para a adesão à medicação em idosos, levando em conta o letramento.

Cardiovascular disease risk and secondary prevention of cardiovascular disease among patients with low health literacy

OBJECTIVE

To explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of a nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD).

METHODS

Data were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D).

RESULTS

Among 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had a higher CVD risk [mean SCORE 5.2 (SD 4.8) versus 3.3 (SD 4.1), p < 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences.

CONCLUSION

Inadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse-coordinated care seems to be effective among patients with inadequate health literacy.

Health Literacy and Heart Failure: A Systematic Review

BACKGROUND

Low health literacy affects millions of Americans, putting those who are affected at a disadvantage and at risk for poorer health outcomes. Low health literacy can act as a barrier to effective disease self-management; this is especially true for chronic diseases such as heart failure (HF) that require complicated self-care regimens.

PURPOSE

This systematic review examined quantitative research literature published between 1999 and 2014 to explore the role of health literacy among HF patients. The specific aims of the systematic review are to (1) describe the prevalence of low health literacy among HF patients, (2) explore the predictors of low health literacy among HF patients, and (3) discuss the relationship between health literacy and HF self-care and common HF outcomes.

METHODS

A systematic search of the following databases was conducted, PubMed, CINAHL Plus, Embase, PsycINFO, and Scopus, using relevant keywords and clear inclusion and exclusion criteria.

CONCLUSIONS

An average of 39% of HF patients have low health literacy. Age, race/ethnicity, years of education, and cognitive function are predictors of health literacy. In addition, adequate health literacy is consistently correlated with higher HF knowledge and higher salt knowledge.

CLINICAL IMPLICATIONS

Considering the prevalence of low health literacy among in the HF population, nurses and healthcare professionals need to recognize the consequences of low health literacy and adopt strategies that could minimize its detrimental effect on the patient's health outcomes.

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.

Risk for Mild Cognitive Impairment Is Associated With Semantic Integration Deficits in Sentence Processing and Memory

OBJECTIVES

We examined the degree to which online sentence processing and offline sentence memory differed among older adults who showed risk for amnestic and nonamnestic varieties of mild cognitive impairment (MCI), based on psychometric classification.

METHOD

Participants (N = 439) read a series of sentences in a self-paced word-by-word reading paradigm for subsequent recall and completed a standardized cognitive test battery. Participants were classified into 3 groups: unimpaired controls (N = 281), amnestic MCI (N = 94), or nonamnestic MCI (N = 64).

RESULTS

Relative to controls, both MCI groups had poorer sentence memory and showed reduced sentence wrap-up effects, indicating reduced allocation to semantic integration processes. Wrap-up effects predicted subsequent recall in the control and nonamnestic groups. The amnestic MCI group showed poorer recall than the nonamnestic MCI group, and only the amnestic MCI group showed no relationship between sentence wrap-up and recall.

DISCUSSION

Our findings suggest that psychometrically defined sub-types of MCI are associated with unique deficits in sentence processing and can differentiate between the engagement of attentional resources during reading and the effectiveness of engaging attentional resources in producing improved memory.

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.

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.

eHealth literacy interventions for older adults: a systematic review of the literature

Background

eHealth resources offer new opportunities for older adults to access health information online, connect with others with shared health interests, and manage their health. However, older adults often lack sufficient eHealth literacy to maximize their benefit from these resources.

Objective

This review evaluates the research design, methods, and findings of eHealth literacy interventions for older adults.

Methods

A systematic review of peer-reviewed research articles from 28 databases in 9 fields was carried out in January 2013. Four rounds of screening of articles in these databases resulted in a final sample of 23 articles.

Results

Findings indicated a significant gap in the literature for eHealth literacy interventions evaluating health outcomes as the outcome of interest, a lack of theory-based interventions, and few studies applied high-quality research design.

Conclusions

Our findings emphasize the need for researchers to develop and assess theory-based interventions applying high-quality research design in eHealth literacy interventions targeting the older population.

Asthma outcomes are poor among older adults with low health literacy

OBJECTIVE

To examine the association of health literacy (HL) with asthma outcomes among older asthmatics.

METHODS

The study included adults ages ≥60 with moderate to severe asthma in New York City and Chicago. We assessed asthma control with the Asthma Control Questionnaire (ACQ) and the percent predicted forced expiratory volume at 1 s (FEV1) by spirometry, hospitalizations and emergency department (ED) visits in the past 6 months, and quality of life. HL was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multivariate logistic regression models controlled for age, sex, race, income, general health and years with asthma.

RESULTS

Among 433 individuals, 36% had low HL, 55% were over age 65, 38% were Hispanic and 22% were black. Poor asthma control was reported by 40% and 32% had FEV1 <70% of predicted; 9% had a hospital stay, 23% had an ED and 38% had poor quality of life. In multivariable analysis, individuals with low HL were more likely to have FEV1 <70% predicted (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39-3.94, p = 0.001), hospitalizations (OR 2.53, 95% CI 1.17-5.49, p = 0.02) and ED visits for asthma (OR 1.81, 95% CI 1.05-3.10, p = 0.03). There were no differences in self-reported asthma control and quality of life.

CONCLUSIONS

Low HL is associated with poor asthma control by objective measure, and greater likelihood of ED visits and hospitalization. HL is a modifiable target for interventions to improve asthma outcomes in the elderly.

Self-Management of Wellness and Illness in an Aging Population

In this chapter, we review the last 10 years of literature on self-management of illnesses (acute/episodic and chronic) and wellness (e.g., health promotion). We focus on health self-management in the context of an aging population, wherein middle-aged adults are more likely to be managing wellness activities and older adults are often managing both maintenance of health and chronic illnesses. The critical issues related to self-management of health are discussed, including those imposed by health care demands and those stemming from individual differences in general abilities (e.g., motor, perception, cognition) and socioemotional characteristics. The dynamic relationship between theory and practice is highlighted. Health care demands reflect the nature of the illness or wellness activity and include managing comorbidities, symptoms, and medications; engaging in health promotion activities (e.g., exercise, diet); the required use of health technologies; the need for health-related information; and coordination of the care network. Individual differences in motor, perceptual, and cognitive abilities, as well as in the severity and complexity of the illness and the consequent demands, also impact how a person self-manages health. Cognitive abilities, such as decision making, knowledge, literacy (i.e., general, health, and e-health literacy), and numeracy are particularly implicated in the process of managing one’s own health and are especially important in the context of an aging population; therefore we give these cognitive abilities special attention in this chapter. Socioemotional characteristics, and attitudes and beliefs about one’s health, impact an individual’s self-management of health as well, impacting his or her motivation and goal-setting behaviors. Moreover, we discuss literature on interventions that have been used to improve self-management of health, and we examine the potential for technology. We conclude with guidelines for technology design and instruction, and discuss emerging themes.

Development of a standardized knowledge base to generate individualized medication plans automatically with drug administration recommendations

AIMS

We aimed to develop a generic knowledge base with drug administration recommendations which allows the generation of a dynamic and comprehensive medication plan and to evaluate its comprehensibility and potential benefit in a qualitative pilot study with patients and physicians.

METHODS

Based on a literature search and previously published medication plans, a prototype was developed and iteratively refined through qualitative evaluation (interviews with patients and focus group discussions with physicians). To develop the recommendations for safe administration of specific drugs we screened the summary of product characteristics (SmPC) of different exemplary brands, allocated the generated advice to groups with brands potentially requiring the same advice, and reviewed these allocations regarding applicability and appropriateness of the recommendations.

RESULTS

For the recommendations, 411 SmPCs of 140 different active ingredients including all available galenic formulations, routes of administrations except infusions, and administration devices were screened. Finally, 515 distinct administration recommendations were included in the database. In 926 different generic groups, 29,879 allocations of brands to general advice, food advice, indications, step-by-step instructions, or combinations thereof were made. Thereby, 27,216 of the preselected allocations (91.1%) were confirmed as appropriate. In total, one third of the German drug market was labelled with information.

CONCLUSIONS

Generic grouping of brands according to their active ingredient and other drug characteristics and allocation of standardized administration recommendations is feasible for a large drug market and can be integrated in a medication plan.

Health literacy challenges in the aging population

PURPOSE

The purpose of this paper is to discuss the impact of low health literacy and discuss interventions to minimize its effect on the elderly population.

CONCLUSION

Low health literacy combined with the physiological changes of aging put the elderly in a vulnerable position. It can negatively affect health behaviors and health outcomes, and can lead to economic burden, not just on the individual but on the society as a whole.

PRACTICE IMPLICATION

Clinicians need to recognize the indicators of low health literacy and utilize the available assessment tools. To improve clinician-patient communication, interventions must be tailored to the patients' literacy level.

Thromboembolism and antithrombotic therapy for heart failure in sinus rhythm: an executive summary of a joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis

Chronic heart failure (HF) with either reduced or preserved left ventricular (LV) ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to heart failure can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thromboembolism and/or venous thromboembolism. This executive summary of a joint consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence, summarises 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is clearly recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thromboembolism prevention versus risk of bleeding) of oral anticoagulation. In HF patients with reduced LV ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Whilst there is the potential for a reduction in ischaemic stroke, there is currently no compelling reason to routinely use warfarin for these patients. Risk factors associated with increased risk of thromboembolic events should be identified and decisions regarding use of anticoagulation individualised. Patient values and preferences are important determinants when balancing the risk of thromboembolism against bleeding risk. Novel oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.

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.

Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis

Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA(2)DS(2)-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.

A review of the literature on heart failure and discharge education

The Centers for Medicare and Medicaid Services (CMS) have proposed changes in the health care reimbursement for patients diagnosed with heart failure (HF) if readmission to a hospital occurs within 30 days of their discharge. The Joint Commission (TJC) has identified 6 key education topics for HF patients with their families that can result in decreased readmissions. Though the patient may be too ill, critical care nurses have an opportunity to begin the discharge education process immediately with families or caregivers. This literature review discusses studies focused on discharge education in general and then those studies specific to HF discharge education. This review reports on what is known or supported by evidence within 8 major topics. Finally, the discussion section summarizes the evidence for discharge education by answering 6 questions that address the "who and when" as well as the "what" of discharge education.

Mechanisms underlying comprehension of health information in adulthood: the roles of prior knowledge and working memory capacity

Prior knowledge, working memory capacity (WMC), and conceptual integration (attention allocated to integrating concepts in text) are critical within many contexts; however, their impact on the acquisition of health information (i.e. learning) is relatively unexplored.We examined how these factors impact learning about nutrition within a cross-sectional study of adults ages 18 to 81. Results showed that conceptual integration mediated the effects of knowledge and WMC on learning, confirming that attention to concepts while reading is important for learning about health. We also found that when knowledge was controlled, age declines in learning increased, suggesting that knowledge mitigates the effects of age on learning about nutrition.

Psychosocial correlates of health literacy among older patients with coronary heart disease

This study examined psychosocial correlates of health literacy (HL) scores among older patients with coronary heart disease (CHD). A cross-sectional survey assessed psychosocial factors relating to the following: self-efficacy (i.e., perception of ability to perform a specified behavior) for diet, exercise, medication, and for a future attempt to quit smoking; social support; social stigma; appointment attendance; knowledge of heart problems; and understanding of health information. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM). Of 321 patients, 70 had a REALM score in the low HL range (<60). When adjusting for demographics, a lower REALM score was significantly associated with reports of increased difficulty understanding health information (p < .001), less knowledge of heart problems (p = .002), increased discomfort about asking for explanations of health information (p = .014), less support with discussing health problems (p = .020). Patients with CHD and low HL are likely to face psychosocial challenges when managing their health problems. In order to encourage these individuals to seek help, health professionals need to be aware of the psychosocial characteristics of patients with low HL. These individuals may need behavioral support to increase both their self-efficacy and their understanding of their medical condition.

Pharmacist Approach to Geriatrics

Pharmacists have traditionally focused on the appropriate use of medications to enhance the functional status of the elderly patient. However, in the proper provision of pharmaceutical care, the influence of lifestyle factors on the use and misuse of medications cannot be ignored. The pharmacist collaborates with other members of the health care team to ensure that drugs are dosed according to known changes occurring with age such as pharmacokinetic and pharmacodynamic alterations. Also, medications that may decrease cognitive function, impair gait/balance, or reduce sensory stimulation must be avoided. The appropriate use of medications can improve the functional status and reduce morbidity in the elderly patient, and drug adherence issues should be addressed to ensure that the elderly patient can receive the optimal benefit from his or her medication regimen. Pharmacists, in collaboration with physicians and other health care providers, can help to ensure that a comprehensive approach to patient care occurs, one that involves medications, diet, and exercise as it embraces the mind, body, and spirit.

Chemotherapy-induced nausea and vomiting: contemporary approaches to optimal management. Proceedings from a symposium at the 2008 Multinational Association of Supportive Care in Cancer (MASCC) Annual Meeting

INTRODUCTION

Chemotherapy-induced nausea and vomiting remains a significant problem for cancer patients.

DISCUSSION

Patient factors such as polypharmacy, medication costs, mucositis, and depression may hinder good antiemetic control, while high workloads, poor communication, and underestimation of the problem on the part of healthcare professionals also play a role. Improving outcomes requires accurate assessment of risk factors, use of guidelines, and better adherence to antiemetic regimens.

CONCLUSION

Extended-release formulations and new delivery systems such as transdermal patches, nasal sprays, and pumps provide a new strategy that may improve patient outcomes.

Assessment of preferences for treatment: validation of a measure

Systematic measurement of treatment preferences is needed to obtain well-informed preferences. Guided by a conceptualization of treatment preferences, a measure was developed to assess treatment acceptability and preference. The purpose of this study was to evaluate the psychometric properties of the treatment acceptability and preferences (TAP) measure. The TAP measure contains a description of each treatment under evaluation, items to rate its acceptability, and questions about participants' preferred treatment option. The items measuring treatment acceptability were internally consistent (alpha > .80) and demonstrated validity, evidenced by a one-factor structure and differences in the scores between participants with preferences for particular interventions. The TAP measure has the potential for the assessment of acceptability and preferences for various behavioral interventions.

Continuity of Health Care and the Pharmacist: Let's Keep It Simple

Pharmacists are a cornerstone of quality medication management. High-quality continuity of care involves patient-centered medication therapy management, which could be bolstered for 26 million Part D Medicare beneficiaries. Yet, many patients do not receive sufficient instruction about their prescription medications. Patient-centered aspects are important because of the heterogeneity in patient types and severity of disease, varying treatment requirements, lifestyle factors, and differences in health literacy. Although time constraints for all health professionals are apparent, a simple but crucial contribution by pharmacists to the continuity of care is to increase the emphasis on patient-centered medication instruction.

Health Literacy and Health Actions: A Review and a Framework From Health Psychology

The association between performance on health literacy measures and health outcomes is well established. The next step is to understand the processes through which health literacy affects health. This review introduces a framework drawing on ideas from health psychology and proposing that associations between health literacy and health outcomes could be mediated by a range of health actions involving access and use of health care, patient—provider interactions, and the management of health and illness. The framework outlines routes through which health literacy might affect either health actions themselves or the motivational and volitional determinants that have been identified in social cognition models. The implications of the framework for future research and intervention strategies are discussed.

What do we know about adherence and self-care?

Despite advances in healthcare, heart failure patients continue to experience complications that could have been prevented or treated. This occurs because the only way that a therapeutic or preventive regimen can be effective, assuming that the patient's condition has been accurately diagnosed and appropriately treated, is if the patient implements self-care behaviors and adheres to the treatment regimen. However, it is widely accepted that this does not occur in many or even most instances. This article provides an overview of the current evidence related to adherence and self-care behaviors among heart failure patients and describes the state of the science on interventions developed and tested to enhance self-care maintenance in this population. Our review of literature shows that effective interventions integrate strategies that motivate, empower, and encourage patients to make informed decisions and assume responsibility for self-care. Gaps in current evidence support the need for additional research on ways to improve adherence and self-care for patients who are at an increased risk of poor adherence, including those with cognitive and functional impairments and low health literacy.