Self-assessment tool for screening patients at risk for drug therapy problems

Involving patients in medicines optimisation in general practice: a development study of the “PREparing Patients for Active Involvement in medication Review” (PREPAIR) tool

Background

Many patients have multiple health conditions and take multiple medications (polypharmacy). Active patient involvement may improve treatment outcomes and ensure patient-centred care. Yet, patient involvement remains a challenge in clinical practice. We aimed to develop and pilot test a questionnaire-based preparation and dialogue tool, the PREparing Patients for Active Involvement in medication Review (PREPAIR) tool, to encourage the involvement of patients with polypharmacy in medicines optimisation in general practice.

Methods

We conducted a literature review followed by a co-production process to develop the tool: a workshop with six GPs and pilot testing, including observations and interviews, with 22 patients, three GPs and three practice staff. During this process, we made continuous adaptations to the prototype. We analysed the qualitative data thematically, focusing on the development process and mechanisms of impact.

Findings

The final PREPAIR tool included five items concerning the patient’s experience of 1) adverse drug reactions, 2) excess medication, 3) unnecessary medication, 4) medication satisfaction and 5) medication-related topics to discuss with the GP (open-ended question). The applied workflow during testing was as follows; the patient completed the PREPAIR tool at home, to encourage reflection on the medication, and brought it to the GP consultation. During the consultation, the GP and the patient reviewed the patient’s responses and discussed potential medication-related problems. For some patients, the increased reflection led to worries about the medications. Still, the pilot testing showed that, when using the PREPAIR tool, the patients arrived at the clinic well prepared and empowered to speak. From the PREPAIR-supported dialogue, the GPs obtained a better understanding of patients’ perspectives and provided a more patient-centred consultation. For the patients, the PREPAIR-supported dialogue ultimately promoted an increased sense of security, satisfaction and insight into their medication, despite initial worries for some patients.

Conclusions

We developed a brief tool to support active patient involvement in medication review in general practice. The PREPAIR-tool was well received by both patients and GPs and fitted well into the existing clinical practice. Our findings suggest that the PREPAIR-tool can support patient involvement during consultations and facilitate patient-centred care.

INSAF-HAS: a tool to select patients with hypertension for pharmaceutical care

OBJECTIVE

To develop and validate the content of a tool aimed to select patients with hypertension for pharmaceutical care, based on identification of individuals in greater need of attention.

METHODS

The tool was developed and assessed for face and content validity, which was carried out in three stages. Phase I consisted of comprehensive literature review, which prompted the development of the first version of the tool. Phase II consisted of validation by an expert panel. Phase III consisted of a pilot study with hypertensive patients and preparation of the final version of the instrument.

RESULTS

Literature review yielded 30 studies, out of which 13 factors associated with hypertension and cardiovascular disease control and complications were selected. Once the initial version of the tool named INSAF-HAS was obtained, four expert meetings were held, each leading to instrument improvement until a final consensus was reached. In the pilot study, INSAF-HAS was applied to 30 patients with a diagnosis of hypertension for applicability pretest; adjustments were made and the final version of INSAF-HAS obtained.

CONCLUSION

The INSAF-HAS tool developed in this study has face and content validity, and may contribute to the selection of patients with hypertension in greater need of pharmaceutical care services.

Validation of the MedUseQ: A Self-Administered Screener for Older Adults to Assess Medication Use Problems

Background:

Older adults taking multiple prescription and nonprescription drugs are at risk for medication use problems, yet there are few brief, self-administered screening tools designed specifically for them.

Objective:

The study objective was to develop and validate a patient-centered screener for community-dwelling older adults.

Methods:

In phase 1, a convenience sample of 57 stakeholders (older adults, pharmacists, nurses, and physicians) participated in concept mapping, using Concept System® Global MAXTM, to identify items for a questionnaire. In phase 2, a 40-item questionnaire was tested with a convenience sample of 377 adults and a 24-item version was tested with 306 older adults, aged 55 and older, using Rasch methodology. In phase 3, stakeholder focus groups provided feedback on the format of questionnaire materials and recommended strategies for addressing problems.

Results:

The concept map contained 72 statements organized into 6 conceptual clusters or domains. The 24-item screener was unidimensional. Cronbach's alpha was .87, person reliability was acceptable (.74), and item reliability was high (.96).

Conclusion:

The MedUseQ is a validated, patient-centered tool targeting older adults that can be used to assess a wide range of medication use problems in clinical and community settings and to identify areas for education, intervention, or further assessment.

Drug-Associated Risk Tool: development and validation of a self-assessment questionnaire to screen for hospitalised patients at risk for drug-related problems

INTRODUCTION

Identifying patients with a high risk for drug-related problems (DRPs) might optimise the allocation of targeted pharmaceutical care during the hospital stay and on discharge.

OBJECTIVE

To develop a self-assessment screening tool to identify patients at risk for DRPs and validate the tool regarding feasibility, acceptability and the reliability of the patients' answers.

DESIGN

Prospective validation study.

SETTING

Two mid-sized hospitals (300-400 beds).

PARTICIPANTS

195 patients, exclusion criteria: under 18 years old, patients with a health status not allowing a meaningful communication (eg, delirium, acute psychosis, advanced dementia, aphasia, clouded consciousness state), palliative or terminally ill patients.

METHODS

Twenty-seven risk factors for the development of DRPs, identified in a previous study, provided the basis of the self-assessment questionnaire, the Drug-Associated Risk Tool (DART). Consenting patients filled in DART, and we compared their answers with objective patient data from medical records and laboratory data.

RESULTS

One hundred and sixty-four patients filled in DART V.1.0 in an average time of 7 min. After a first validation, we identified statements with a low sensitivity and revised the wording of the questions related to heart insufficiency, renal impairment or liver impairment. The revised DART (V.2.0) was validated in 31 patients presenting heart insufficiency, renal impairment or liver impairment as comorbidity and reached an average specificity of 88% (range 27-100) and an average sensitivity of 67% (range 21-100).

CONCLUSIONS

DART showed a satisfying feasibility and reliability. The specificity of the statements was mostly high. The sensitivity varied and was higher in statements concerning diseases that require regular disease control and attention to self-care and drug management. Asking patients about their conditions, medications and related problems can facilitate getting a first, broad picture of the risk for DRPs and possible pharmaceutical needs.

Exploring Electronic Medical Record and Self-Administered Medication Risk Screening Tools in a Primary Care Clinic

BACKGROUND

Electronic medical record (EMR) screening for indicators of medication risk could improve efficiency in identifying primary care clinic patients in need of clinical pharmacist care compared with patient self-reporting.

OBJECTIVES

To (a) compare the performance of an EMR medication risk assessment questionnaire (MRAQ) with a self-administered (SA) MRAQ and (b) explore each tool's ability to predict indicators of health behavior, health status, and health care utilization.

METHODS

A prospective cohort study was conducted with 143 adults who attended an academic family medicine center and were taking ≥ 2 medications. All participants completed the 10-item SA-MRAQ, Morisky Medication Adherence Scale, Chew's health literacy screener, Stanford Health Distress Scale, and SF-36 overall rating of health. A blinded investigator completed the EMR-MRAQ and a chart review to ascertain 6 months of health care utilization. Outcome measures included the following: (a) scores from the 5- and 10-item SA-MRAQs and 5-item EMR-MRAQ; (b) sensitivity and specificity to determine the accuracy of the 5-item EMR versus the 5-item SA risk scores; (c) correlations between risk assessments and health behavior/status scales; and (d) area under the receiver operator curve to determine how well a high-risk score predicted health care utilization.

RESULTS

The 5-item SA-MRAQ, the 5-item EMR-MRAQ, and the 10-item SA-MRAQ categorized 52.9% (55/104), 69.2% (99/143), and 17.6% (18/102) of participants as high risk, respectively. For the 104 participants who completed both 5-item MRAQ tools, the EMR-MRAQ had a sensitivity of 81.8% and specificity of 49.0% in detecting a high-risk SA-MRAQ score. Both 5-item risk assessments showed weak correlations with health distress and overall health, while the 10-item SA-MRAQ additionally showed weak correlations with medication adherence. The EMR-MRAQ was most effective in predicting all-cause emergency room visits/hospitalization (c-statistic = 0.69; 95% CI=0.57-0.81) and high clinic utilization (≥ 4 visits per 6 months; c-statistic = 0.77; 95% CI = 0.69-0.85). The EMR-MRAQ had high sensitivities but low specificities for these health care utilization outcomes, respectively (82.6% and 33.3%; 88.9% and 42.7%).

CONCLUSIONS

This pilot study suggests that EMR-MRAQ screening has high sensitivity but low specificity in comparison with self-reporting and was able to discriminate between those who would and would not experience health care utilization outcomes. These results justify further development and validation of an automated EMR-based tool to predict patient-important consequences of medication-related problems.

DISCLOSURES

This work was funded by the Canadian Society of Hospital Pharmacists Research and Education Foundation, which had no role in the analysis or interpretation of data or the decision to submit the manuscript for publication. The authors have no conflict of interests, potential or otherwise, to report. Makowsky had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Makowsky and Cor. Makowsky and Wong collected the data, and data interpretation was performed by Makowsky, Cor, and Wong. The manuscript was written by Makowsky and was critically reviewed for intellectual content by Makowsky, Cor, and Wong.

Utility of a brief screening tool for medication-related problems

BACKGROUND

Medication therapy management (MTM) services position pharmacists to prevent, detect, and resolve medication-related problems (MRPs.) However, selecting patients for MTM who are most at risk for MRPs is a challenge. Using self-administered scales that are practical for use in clinical practice are one approach.

OBJECTIVE

The objective of this study was to estimate the psychometric properties of a brief self-administered scale as a screening tool for MRPs.

METHODS

This was a non-randomized study utilizing questionnaires administered cross-sectionally. In Phase 1, patients (n = 394) at community pharmacies and outpatient clinics completed 78 items, provided to the study team by item authors, assessing perceived MRPs. These data were used to select items for further investigation as a brief, self-administered scale, and estimate the reliability and construct validity of the resulting instrument. In Phase 2, a convenience sample of patients (n = 200) at community pharmacies completed a nine-item, self-administered scale. After completion, they were engaged in a comprehensive medication review by their pharmacist who was blinded to questionnaire responses. The main outcome measure for estimating the criterion-related validity of the scale was the number of pharmacist-identified medication-related problems (MRPs.) Item statistics were computed as well as bivariate associations between scale scores and other variables with MRPs. A multivariate model was constructed to examine the influence of scale scores on MRPs after controlling for other significant variables.

RESULTS

Higher scores on the questionnaire were positively correlated with more pharmacist-identified MRPs (r = 0.24; P = 0.001) and scores remained as a significant predictor (P = 0.031) when controlling for other relevant variables in a multivariate regression model (R(2) = 0.21; P < 0.001).

CONCLUSIONS

Patient responses on the scale may have a modest role in predicting MRPs. The use of self-administered questionnaires such as this may supplement other available patient data in developing patient eligibility criteria for MTM, however, additional research is warranted.

Predictors of medication-related problems among medicaid patients participating in a pharmacist-provided telephonic medication therapy management program

STUDY OBJECTIVE

To identify predictors of medication-related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program.

DESIGN

Retrospective analysis of data from patients enrolled in a previously published study.

DATA SOURCES

Two Medicaid administrative claims file databases (for health care utilization and prescription dispensing information) and one pharmacy organization file for MTM program information.

PATIENTS

Seven hundred twelve adult Medicaid patients who participated in a statewide pharmacist-provided telephone-based MTM program and who received an initial medication therapy review.

MEASUREMENTS AND MAIN RESULTS

The primary dependent variable was the number of MRPs detected during the initial medication therapy review. Secondary dependent variables were the detection of one or more MRPs related to indication, effectiveness, safety, and adherence. Predictor variables were selected a priori that, from the literature and our own practice experiences, were hypothesized as being potentially associated with MRPs: demographics, comorbidities, medication use, and health care utilization. Bivariate analyses were performed, and multivariable models were constructed. All predictor variables with significant associations (defined a priori as p<0.1) with the median number of MRPs detected were then entered into a three-block multiple linear regression model. The overall model was significant (p<0.001, R(2)  = 0.064). Significant predictors of any MRPs (p<0.05) were total number of medications, obesity, dyslipidemia, and one or more emergency department visits in the past 3 months. For indication-related MRPs, the model was significant (p<0.001, R(2)  = 0.049), and predictors included female sex, obesity, dyslipidemia, and total number of medications (p<0.05). For effectiveness-related MRPs, the model was significant (p<0.001, R(2)  = 0.054), and predictors included bone disease and dyslipidemia (p<0.05). For safety-related MRPs, the model was significant (p<0.001, R(2)  = 0.046), and dyslipidemia was a predictor (p<0.05). No significant predictors of adherence-related MRPs were identified.

CONCLUSION

This analysis supports the relative importance of number of medications as a predictor of MRPs in the Medicaid population and identifies other predictors. However, given the models' low R(2) values, these findings indicate that other unknown factors are clearly important and that criteria commonly used for determining MTM eligibility may be inadequate in identifying appropriate patients for MTM in a Medicaid population.

Content validation of a tool for assessing risks for drug-related problems to be used by practical nurses caring for home-dwelling clients aged ≥65 years: a Delphi survey

PURPOSE

Home care services are becoming a critically important part of health care delivery as populations are aging. Those using home care services are increasingly older, more frail than previously, and use multiple medications, making them vulnerable to drug-related problems (DRPs). Practical nurses (PN) visit home-dwelling aged clients frequently and, thus, are ideally situated to identify potential DRPs and, if needed, to communicate them to physicians for resolution. This study developed and validated the content of a tool to be used by PNs for assessing DRP risks for their home-dwelling clients aged ≥65 years.

METHODS

The first draft of the tool was based on two systematic literature reviews and clinical experience of our research group. Content validity of the tool was determined by a three-round Delphi survey with a panel of 18 experts in geriatric care and pharmacotherapy. An agreement by ≥80% of the panel on an item was required.

RESULTS

The final tool consists of 18 items that assess risks for DRPs in home-dwelling aged clients. It is divided into four sections: (1) Basic Client Data, (2) Potential Risks for DRPs in Medication Use, (3) Characteristics of the Client's Care and Adherence, and (4) Recommendations for Actions to Resolve DRPs.

CONCLUSIONS

The Delphi process resulted in a structured DRP Risk Assessment Tool that is focused on the highest priority DRPs that should be identified and resolved. The tool also assists the PNs to identify solutions to these problems, which is a unique feature compared to similarly purposed prior tools.