Consumer Understanding of Prescription Drug Information: An Illustration Using an Antidepressant Medication

Public awareness regarding the manufacturer provided information about medicine usage, safety, and adverse drug reactions in Balochistan, Pakistan

Objectives: This study aimed to analyze the general public's awareness of medicine information, safety, and adverse drug reactions in Quetta, Pakistan. Methods: A cross-sectional descriptive study was conducted using random sampling from April 2020 to April 2021 in Quetta. Samples were collected from respondents who met the inclusion criteria and had visited community pharmacies. The analysis was done using SPSS version 23. Bivariate and multivariate analyses were performed to assess factors associated with good knowledge. Results: Multivariate analysis revealed that purchase on prescription was a determining factor of knowledge regarding knowledge of pharmaceutical products and their provided information, medicines usage and safety, and Medication ADRs. Patients who bought medicines on prescriptions were more likely to have better knowledge. Patients having education were more likely to have better knowledge. Conclusion: Public awareness about medicine information, safety, and the information provided by manufacturers is crucial to ensuring that patients have access to accurate information about their medications and can make informed decisions about their health. Healthcare providers and regulatory bodies must work together to improve access to information and promote safe medication practices.

What do patients on methotrexate need and expect at the clinic? An online patient survey

To verify, via a survey, the experience and needs of patients receiving methotrexate (MTX), their general management and the quality of the information provided by the rheumatologist. We conducted a 51-item online survey between May and July 2020 addressed to persons diagnosed with an immune-mediated disease and treated with MTX (regardless of the route of administration). Recruitment was done via Twitter. We obtained 294 responses, of which 283 were complete and could be analysed. Almost 82% of the respondents were women, 80% resided in Spain, 75% were between 31 and 60 years old, and 57% were active workers. Diseases included psoriasis (41%), lupus, Sjögren's or vasculitides (33%), and rheumatoid arthritis (16%), among others. Eighty per cent had read the leaflet inserted in the package, of whom 62% found it helpful. Only 15% of the respondents reported having been offered additional written material, which was considered barely functional (33 out of 100). Most patients (88%) responded that they had not received advice on any reliable sources to consult on the internet, and those who received it considered it unhelpful (24 out of 100). Patients receiving MTX due to an autoimmune disease demand more and better-quality written or web-based information than what is currently offered at their clinics.

Utility of patient information leaflet and perceived impact of its use on medication adherence

BACKGROUND

Although patients frequently use patient information leaflets (PILs) to obtain information about medicine, their confidence in using it may be diminished after reading it. This study aimed to assess the public perception of PIL's quality and the perceived impact of its use on medication adherence.

METHODS

A community-based cross-sectional study of 1,138 adult individuals in Saudi Arabia, April-May 2020, was conducted via Survey Monkey using an anonymous validated e-questionnaire. Data were collected on personal characteristics, PIL readership and preferences, perception towards PIL quality and impact of its use on taking medication, and reasons for not reading PIL. In addition, logistic regression analysis was performed to identify the significant predictors of reading PIL. Significance was considered at p < 0.05.

RESULTS

Nearly all participants (91.1%) reported reading PIL. The more read PIL's sections were directions of use (52.7%) and side effects (30.3%). Female gender (OR = 5.64, 95%CI: 3.53,9.02), age over 40 years (OR = 2.80, 95%CI: 1.69,4.64), and secondary education or more (OR = 1.74, 95%CI: 1.06,2.85) were the significant predictors of reading PIL. The majority of PIL readers reported their preference for verbal information (65.8%), hard copy presentation (77%), adding graphics (71.1%), and concise content of PIL (68.8%). In addition, most participants reported PIL always/usually adds to their knowledge of medicines (70.6%) and said that PIL reading positively impacted their medication adherence (64.9%). For only 8.8%, PIL reading negatively impacted their adherence, primarily because of reading information on medicine's side effects and complications (74.4%). More than one-half of participants perceived the PIL quality as good/excellent in terms of; font size (51.3%), language comprehensiveness (64.9%), paper quality (68.0%), and general appearance (64.9%). Getting sufficient information from doctors and pharmacists was the main reason for not reading the PIL (59.2%). Most participants (92.5%) agreed on standardizing how information is displayed in the PIL among all PILs of all companies.

CONCLUSION

PIL is read by nearly all the study sample, especially females, older, and educated subjects. It was perceived as beneficial in upgrading medication adherence. Effective designing of PILs should focus on patients' literacy level and age. Standardization of the PIL structure in all pharmaceutical companies is recommended.

Worth the paper they're printed on? Findings from an independent evaluation of how understandable patient information leaflets for antiseizure medications are

OBJECTIVE

The Patient Information Leaflet (PIL) is an authoritative document that all people with epilepsy (PWE) in the European Union receive when prescribed anti-seizure medication (ASM). We undertook the first independent, comprehensive assessment to determine how understandable they are. Regulators state that when patients are asked comprehension questions about them, ≥80% should answer correctly. Also recommended PILs have a maximum reading requirement of US Grade 8.

METHODS

Study 1: Obtained 140 current ASM PILs written in English. 'Readability' assessed using 4 tests, with and without adjustment for influence of familiar, polysyllabic words. 179 online materials on epilepsy also assessed. Study 2: Two PILs from Study 1 randomly selected (Pregabalin Focus; Inovelon) and shown to 35 people from UK epilepsy population. Their comprehension was assessed. Study 3: To understand whether student population provides accessible alternative population for future examination of ASM PILs, Study 3 was completed. Used same methods as Study 2 but participants were 262 UK university students.

RESULTS

Study 1: No PIL had a reading level of Grade 8. Median was 11. Adjusting for context, the PILs were still at Grade 10.5. PILs for branded ASMs were most readable. PILs were no more readable than (unregulated) online materials. Study 2: Users struggled to comprehend the PILs key messages. The 8 questions asked about pregabalin were typically answered correctly by 54%. For Inovelon it was 62%. Study 3: Most student participants comprehend the PILs key messages. The questions about Inovelon were answered correctly by 90%; for pregabalin it was 86%.

SIGNIFICANCE

This is the first independent and comprehensive examination of ASM PILs. Found PILs being used fail to meet recommendations and regulatory requirements and risk not being understandable to substantial proportion of users. In finding that people from epilepsy population differ markedly in comprehension of PILs compared to students, study highlights importance of completing user testing with the target population.

Chaos to Clarity: Pragmatic Approaches to Overcome Challenges for Successful Implementation of Additional Risk Minimisation Measures in the European Union and the UK by a Marketing Authorisation Holder

BACKGROUND

Most national competent authorities issue guidance on the dissemination and implementation of additional risk minimisation measures (aRMMs), like the European Medicines Agency. However, national competent authorities guidance includes additional regulatory requirements, the reasons for which are unclear.

OBJECTIVES

The purpose of this study was to identify significant barriers to risk management implementation and methodological challenges encountered by local safety managers in the European Union and the UK owing to differences in country-specific regulations and regional national competent authorities guidance.

METHODS

The European Medicines Agency and national competent authorities guidance for each of the aRMM programme's formative components were compared. A survey was conducted to ascertain the challenges encountered by local safety managers throughout the implementation phases and the responses analysed.

RESULTS

Twenty-seven national guidance documents were compared with the European Medicines Agency's guidance, and it was observed that national competent authorities provide additional aRMM dissemination and implementation parameters for the format and layout of aRMM, translation requirements, guidance on aRMM content, submission requirements, monitoring parameters and aRMM update requirements, among others. The survey was completed by 11 out of 21 local safety managers (52.38%). Eight local safety managers rated submission of an implementation plan as the most challenging aspect. Multiple national competent authorities requests, frequent updates, and delayed approval impacted planning and implementation, resulting in modifications and delays. Moreover, the study discovered that managing frequent version updates of digital aRMMs was challenging, and most national competent authorities neglected the post-implementation phase activities. Further, most local safety managers followed both the local and global processes to maintain documentation of aRMM implementation.

CONCLUSIONS

It was evident that the European Medicines Agency and national competent authorities empower marketing authorisation holders to implement and disseminate aRMM materials tailored to their local healthcare settings. However, this poses a challenge for marketing authorisation holders because of a lack of clarity in guidance in executing an aRMM programme and an added burden of complying with both European Medicines Agency and national competent authority requirements.

Thai Patients' Drug Safety Knowledge and Perceptions Relating to Different Forms of Written Medicine Information: A Comparative Study

PURPOSE

The aim of the study was to evaluate the medication safety knowledge, quality of the written medicine information (WMI), and perceptions of taking the medicines in patients receiving package inserts (PIs) in comparison with patient information leaflets (PILs).

METHODS

A cross-sectional, comparative study was conducted from December 2020 to May 2021 at two university hospitals in Thailand. Outpatients who visited the pharmacy departments and were prescribed one of the three medicines: atorvastatin, celecoxib, or metformin were randomly selected by a permuted block randomization. The medication safety knowledge was measured using a set of validated and closed questions. The quality of the WMI was measured by the Consumer Information Rating Form (CIRF). Satisfaction with information and perceptions of the benefits and risks of medications were rated by the participants using a visual analog scale (0 to 10).

RESULTS

Of the 1150 invited patients, 750 completed the questionnaires (65.2%). A higher proportion of respondents with high level of medication safety knowledge was found in those reading the PILs than the PIs (44.5% and 20.8%, respectively). The type of leaflet received was a significant predictor of the high knowledge level (p < 0.001). The mean CIRF scores were significantly higher among those reading the PILs than the PIs (p < 0.001). Patients reading the PILs were also more satisfied with the information and had more positive perceptions of the benefits from taking medicines and intention to adhere than those reading the PIs. Patients' perceptions of risks after reading both leaflets were moderate (median score = 5.0), with the PIL group having slightly more concern about risks than the PI group.

CONCLUSION

The PILs showed superior effectiveness to the PIs in enhancing knowledge about medication safety, providing greater satisfaction with the information, and positive perceptions of benefit and intention to comply with the medications. PILs should be provided more frequently to patients receiving medicines than PIs.

Patient literacy and awareness of medicine safety

Objective

To assess public understanding of medicine safety, approach to risks and preferences in accessing safety information.

Methods

Qualitative data were obtained from an online survey (n = 1079) covering four major themes around side effects and risks of medicines: willingness to accept side effects of medications, information seeking, sufficiency of information and understanding pharmacovigilance process. Comparisons were made for age, gender and social/financial status.

Key findings

Most respondents acknowledged medications were associated with side effects. If side effects were experienced, most (73%) would seek advice from their doctor or pharmacist. Four in 10 respondents felt doctors and pharmacists do not provide sufficient information about medications, even though many (47%) relied on their doctor to provide this. Although 51% felt that pharmaceutical companies were already providing enough information to patients, 95% responded that extra effort could still be made. Two-thirds of the respondents felt it was the companies’ responsibility to educate doctors and pharmacists so they could pass the information on, even though younger respondents preferred direct communication to patients compared to older respondents (&lt;24 years, 36% versus &gt;65 years, 10%; P &lt; 0.001). Men were more willing to accept risks, while women were more likely to seek information about their medicines. Understanding of the role of pharmaceutical companies and government in maintaining the safety of medicines was generally poor.

Conclusions

There is an ongoing need for consumer education regarding medicine safety. Doctors and pharmacists remain the more trusted source of information. Pharmaceutical companies play an important role in ensuring such information is both accessible and accurate.

Enhancing Patient Understanding of Medication Risks and Benefits

Objective

To evaluate the effectiveness of 2 interventions, including the DrugFactsBox format for presenting written medication information and the SMART (Strategic Memory Advanced Reasoning Training) program designed to enhance gist (i.e., “bottom‐line” meaning) reasoning ability.

Methods

We used a 2 × 2 factorial research design. A total of 286 patients with rheumatoid arthritis were randomly assigned to 1 of 4 groups, including DrugFactsBox with the SMART program, DrugFactsBox without the SMART program, other consumer medication information (CMI) with the SMART program, and other CMI without the SMART program. Data were collected via telephone interviews and online questionnaires at 4 time points, including baseline and 6‐week, 3‐month, and 6‐month time points following baseline. The primary outcome variable was informed decision‐making, which was defined as making a value‐consistent decision concerning use of disease‐modifying antirheumatic drugs based on adequate knowledge.

Results

We found no main effects for the 2 interventions, either alone or in combination. However, there was a significant interaction between assignment to the SMART/no SMART groups and informed decision‐making at baseline. Among participants in the SMART groups who did not meet the criteria for informed decision‐making at baseline, 42.5% met the criteria at the 6‐month follow‐up, compared to 23.6% of participants in the no SMART groups (mean difference 18.9 [95% confidence interval 5.6, 32.2]; P = 0.007). This difference was driven by increased knowledge in the SMART groups. Among participants who met the criteria for informed decision‐making at baseline, the difference between the SMART and no SMART groups was not statistically significant.

Conclusion

Participation in a theory‐driven program to enhance gist reasoning may have a beneficial effect on informed decision‐making among patients with inadequate knowledge concerning therapeutic options.

Assessing comprehension and perceptions of modified-risk information for snus among adult current cigarette smokers, former tobacco users, and never tobacco users

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Comprehension and risk perceptions of modified-risk messages for snus were tested.

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Modified-risk information communicated reduced risk of snus compared to cigarettes.

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The modified-risk information was understood by majorities of respondents.

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Most perceived snus to have considerable risk, although less risk than cigarettes.

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Providing modified-risk information about snus could facilitate smokers switching.

Introduction

Snus, a low nitrosamine smokeless tobacco product, presents less risks to health than cigarettes. Effectively communicating such risk information could facilitate smokers switching completely to snus, thereby benefiting public health.

Methods

This study assessed comprehension and perceptions of modified-risk information regarding snus. Adult cigarette smokers, former tobacco users, and never tobacco users (N = 3,922) from a US internet panel viewed an advertisement stating that smokers who switched completely to snus could greatly reduce risk of lung cancer, respiratory disease, heart disease, and oral cancer. Respondents answered questions regarding the modified-risk information and rated perceived risks of snus relative to cigarettes and other smokeless tobacco products.

Results

Across the four diseases mentioned in the advertisement, most respondents (49.7%–68.6%, across tobacco user groups) understood that snus presents less risk than cigarettes but is not completely safe. Some indicated snus presents the same risk as cigarettes; this was highest for oral cancer (33.7%–42.02%) and lowest for lung cancer (15.4%–23.1%) and respiratory disease (15.6%–23.4%). Majorities understood snus is addictive (77.7%–87.9%), quitting all tobacco is the best option for smokers (83.6%–93.1%), and non-users of tobacco should not use snus (80.4%–87.8%). Only 2.1%–5.8% indicated smokers would receive a health benefit if they continued to smoke while using snus.

Conclusions

The modified-risk information, conveying that snus presents less risk than cigarettes but is not completely safe, was understood by majorities of respondents. Differential risk beliefs across diseases suggest responses were shaped not only by the modified-risk information, but also by intuitions and pre-existing beliefs about tobacco products.

An investigation on patient attitudes toward package inserts and their accessibility in Iran

Background:

Package inserts (PIs) can be a source of information for patients, especially when clinicians do not provide adequate consultations to the patients. Therefore, for the first time, we investigated the state of PIs in Iran and evaluated patients’ attitude toward PI.

Materials and Methods:

In this descriptive study, conducted in a major teaching pharmacy in Isfahan, Iran, in 2016, 100 patients who presented a prescription were interviewed randomly and all medications in their medication bags were examined. The main outcome measures were whether or not the dispensed medications were accompanied by a PI and the behavior of patients in reading these PIs.

Results:

From the 237 medication items investigated, 129 (54.4%) were dispensed with a PI. Eighty-four percent of patients read the PIs and only 19% stated reading a non-Farsi PI. The level of education was the only significant factor related to reading the PI (P = 0.02). Reading the side effects was the main reason for reading the PI (64%). PIs were considered useful by 83% while 25% kept PIs as a source of drug information. Experience of fear to take the medication after reading the PI was reported by 47%.

Conclusion:

About half of medications were dispensed along with the PI. Although the majority of patients report reading the PIs and consider them useful, confidence in using the medicine may be diminished after reading the PI. Patients with higher education read the PIs the most.

Assessing the Understanding of Pediatric-Oriented Medication Education Materials Versus Standard Available Education Materials

OBJECTIVES

The objective of this study was to determine if education material targeting children would improve understanding of medication indication, administration, and common side effects in pediatric subjects.

METHODS

This cross-sectional pilot study included students 7 to 11 years old from a suburban elementary school. Study participants were read either the US Food and Drug Administration-approved adult medication leaflet or a pediatric medication leaflet created at a first-grade reading level for levetiracetam (Keppra, UCB, Inc, Atlanta, GA). Students were asked a set of standardized survey questions to evaluate comprehension of side effects, medication indication, dosing frequency, administration, and overall impression of the leaflet.

RESULTS

Fifty-eight children were included. Fifty percent of the children were male, 79% were Caucasian, and the average age was 9 years. There was no statistical difference for demographics in the adult leaflet versus the pediatric leaflet group. Children correctly stated the indication for the medication in 30% of participants (9/30) in the adult leaflet group and 79% of participants (22/28) in the pediatric leaflet group, p = 0.002. The administration frequency question was answered correctly in 93% of the pediatric leaflet group (26/28) as compared to 73% in the adult leaflet group (22/30), p = 0.05. For questions about side effects and how to administer the medication, there was no difference between the groups. The responses regarding readability and understanding of the leaflets were significantly different in the pediatric leaflet group compared to the adult leaflet group, p = 0.001 and p = 0.001, respectively.

CONCLUSIONS

Leaflets designed for pediatric patients resulted in an improvement in the understanding of the indication for levetiracetam.

What is the quality of drug safety information for patients: An analysis of REMS educational materials

Background

Poor‐quality patient drug information has been identified as a major cause of preventable medication errors in the United States. The US Food and Drug Administration (FDA) has the authority to require marketing authorization holders of medicinal products to implement risk evaluation and mitigation strategies (REMS) to ensure that the benefits of a drug or biological product outweigh its risks. Aside from medication guides, no research has been conducted to assess the quality of patient‐targeted REMS materials, including whether, and to what extent, patients find these materials understandable and actionable.

Purpose

To describe the readability, understandability, and actionability of patient educational materials in currently approved REMS programs, and to highlight opportunities for improving both the quality and effectiveness of these important drug safety tools.

Methods

Seventy‐seven REMS programs were identified from the FDA REMS database. We excluded medication guides (MGs) from our analysis because of the fact that there is a mandatory MG template. Based on this, we identified a total of 27 (non‐MG) REMS patient materials on the FDA REMS website for analysis purposes. The materials were tested for readability using the Lexile Measure, the Gunning Fog Index, and Flesch Kincaid and then assessed using the Patient Education Materials Assessment Tool for printable materials, for understandability and actionability.

Results

Twenty‐three of 77 (30%) REMS programs used educational materials to communicate serious risks to patients, yielding a total of 27 REMS patient materials for analysis. The median readability score for these materials was at a ninth‐grade reading level or higher. While most (89%) of these patient education materials met established criteria for being understandable, less than half (49%) were deemed actionable.

Discussion

Currently approved REMS patient materials fell short in terms of recommended reading level, and over half did not meet recommended standards for actionability. Developers of these materials should apply plain language principles when design these materials to improve their readability and to assess both understandability and actionability in order to increase the effectiveness when distributed to patients.

Role of Information Anxiety and Information Load on Processing of Prescription Drug Information Leaflets

In this study, we evaluate the role of information anxiety and information load on the intention to read information from prescription drug information leaflets (PILs). These PILs were developed based on the principals of information load and consumer information processing. This was an experimental prospective repeated measures study conducted in the United States where 360 (62% response rate) university students (>18 years old) participated. Participants were presented with a scenario followed by exposure to the three drug product information sources used to operationalize information load. The three sources were: (i) current practice; (ii) pre-existing one-page text only; and (iii) interventional one-page prototype PILs designed for the study. Information anxiety was measured as anxiety experienced by the individual when encountering information. The outcome variable of intention to read PILs was defined as the likelihood that the patient will read the information provided in the leaflets. A survey questionnaire was used to capture the data and the objectives were analyzed by performing a repeated measures MANOVA using SAS version 9.3. When compared to current practice and one-page text only leaflets, one-page PILs had significantly lower scores on information anxiety (p < 0.001) and information load (p < 0.001). The intention to read was highest and significantly different (p < 0.001) for PILs as compared to current practice or text only leaflets. Information anxiety and information load significantly impacted intention to read (p < 0.001). Newly developed PILs increased patient’s intention to read and can help in improving the counseling services provided by pharmacists.

Consumer confusion between prescription drug precautions and side effects

OBJECTIVE

Multiple studies have identified consumers' difficulty correctly interpreting risk information provided about prescription drugs, whether in printed format or online. This study's purpose was to explore whether consumers can distinguish between prescription drug precautions and side effects presented on brand-name drug websites.

METHODS

Participants (n=873) viewed fictitious drug websites that presented both precautions and side effects for one of four drugs, and they completed a survey assessing recall and comprehension. We coded open-ended recall data to identify whether drug precautions were mentioned and, if so, how they were interpreted.

RESULTS

Approximately 15% of participants mentioned at least one drug precaution. The majority (59.7%) misinterpreted precautions as potential side effects. Participants who misinterpreted precautions rated the drugs as significantly more likely to cause side effects than participants who accurately interpreted the precautions. Age, education, literacy, and other factors did not appear to predict precaution interpretation.

CONCLUSION

At least some consumers are likely to interpret precautions on drug websites as potential side effects, which might affect consumer preferences, treatment decisions, and medication safety.

PRACTICE IMPLICATIONS

Healthcare providers should be aware of this potential confusion, assess patients' understanding of precautions and potential side effects, and address any misunderstandings.

Communicating information concerning potential medication harms and benefits: What gist do numbers convey?

OBJECTIVES

Fuzzy trace theory was used to examine the effect of information concerning medication benefits and side-effects on willingness to use a hypothetical medication.

METHODS

Participants (N=999) were recruited via Amazon Mechanical Turk. Using 3×5 experimental research design, each participant viewed information about medication side effects in 1 of 3 formats and information about medication benefits in 1 of 5 formats. For both side-effects and benefits, one format presented only non-numeric information and the remaining formats presented numeric information.

RESULTS

Individuals in the non-numeric side-effect condition were less likely to take the medication than those in the numeric conditions (p<0.0001). In contrast, individuals in the non-numeric benefit condition were more likely to take the medication than those in the numeric conditions (p<0.0001).

CONCLUSIONS

Our findings suggest that non-numeric side-effect information conveys the gist that the medication can cause harm, decreasing willingness to use the medication; whereas non-numeric benefit information has the opposite effect.

PRACTICE IMPLICATIONS

Presenting side-effect and benefit information in non-numeric format appears to bias decision-making in opposite directions. Providing numeric information for both benefits and side-effects may enhance decision-making. However, providing numeric benefit information may decrease adherence, creating ethical dilemmas for providers.

[Compliance and leaflet's reading, which link and which media? Results from a French population with chronic kidney disease]

Leaflets inside drug boxes are complex and often poorly understood. Patients consulting in nephrology are mostly old and often suffer from multiple comorbidities. As so, they are often subject to various contra-indications and drug interactions. This paper aims to evaluate if patients actually read leaflets or other medical information on others medias such as Internet and whether this could, potentially, interfere with their observance. Results showed that leaflets were read by 65.1% of patients, leading to 12% of withdrawal or not taking drugs. Furthermore, compliance to medical guidance was deemed e-read by 65.1% of patients, leading to 12% of withdrawal or not taken drugs. Furthermore, this study showed no clear profile for non-compliant patients. Even the youngest patients (under 50 years old) have had a good compliance, with not more withdrawal or not taking pills. Nonetheless, youngest patients used more often to consult alternative medias and did not read much of the leaflets' information. Patients who were reading leaflets however, tended to search further information on other medias. This situation would create new challenges in health care, as it seems that data available on new medias are not systematically validated or adapted to the needs of the patients.

Addressing low health literacy with "Talking Pill Bottles": A pilot study in a community pharmacy setting

OBJECTIVES

To test the effect of "Talking Pill Bottles" on medication self-efficacy, knowledge, adherence, and blood pressure readings among hypertensive patients with low health literacy and to assess patients' acceptance of this innovation.

DESIGN

Longitudinal nonblinded randomized trial with standard treatment and intervention arms.

SETTING AND PARTICIPANTS

Two community pharmacies serving an ethnically diverse population in the Pacific Northwest. Participants were consented patients with antihypertension prescriptions who screened positive for low health literacy based on the Test of Functional Health Literacy Short Form. Participants in the intervention arm received antihypertensive medications and recordings of pharmacists' counseling in Talking Pill Bottles at baseline. Control arm participants received antihypertensive medications and usual care instructions.

MAIN OUTCOME MEASURES

Comparison and score changes between baseline and day 90 for medication knowledge test, Self-Efficacy for Appropriate Medication Use Scale (SEAMS), Morisky Medication Adherence Scale (MMAS-8), blood pressure, and responses to semistructured exit interviews and Technology Acceptance Model surveys.

RESULTS

Of 871 patients screened for health literacy, 134 eligible participants were enrolled in the trial. The sample was elderly, ethnically diverse, of low income, and experienced regarding hypertension and medication history. In both arms, we found high baseline scores in medication knowledge test, SEAMS, and MMAS-8 and minimal changes in these measures over the 90-day study period. Blood pressure decreased significantly in the intervention arm. Acceptability scores for the Talking Pill Bottle technology were high.

CONCLUSION

Our results suggest that providing audio-assisted medication instructions in Talking Pill Bottles positively affected blood pressure control and was well accepted by patients with low health literacy. Further research involving newly diagnosed patients is needed to mitigate possible ceiling effects that we observed in an experienced population.

Patient Evaluation of Medication Package Leaflets in Al Kharj City, Saudi Arabia

OBJECTIVE

The purpose of this study was to determine how well patients could correctly recognize and comprehend the various information items in over-the-counter (OTC) medications package leaflets in Saudi Arabia.

METHODS

Leaflets from 20 most commonly sold OTC medications were examined by experts to evaluate the leaflet layout, language, and content. The same leaflets were also evaluated by patients who had their medicines dispensed at 2 hospitals and 8 community pharmacies in Al Kharj, Saudi Arabia. A questionnaire was used for the patients' examination.

RESULTS

A total of 479 questionnaires were included in the study. Each package leaflet was examined by at least 20 participants. The results indicate poor comprehensibility, for many items, particularly items regarding "drug interactions" and "contraindications."

CONCLUSION

The participants had some difficulty recognizing and comprehending certain information items in the package leaflets that are supplied with OTC medications in Saudi Arabia.

Consumers' Understanding of FDA Approval Requirements and Composite Scores in Direct-to-Consumer Prescription Drug Print Ads

In 2 studies, we investigated how laypersons perceive the Food and Drug Administration (FDA) approval process, FDA authority, and the presentation of composite scores in direct-to-consumer (DTC) prescription drug print ads. The 1st study consisted of 4 focus groups (N = 38) in 2 cities. Using a semi-structured guide, a moderator led participants through the viewing of 3 existing DTC print ads that differed in the presence or absence of composite score information, and participants discussed their views of the ads and their understanding of composite scores. The 2nd study surveyed a nationally representative sample of 1,629 individuals from the general population who saw a fictitious DTC print ad and answered closed-ended questions about the same topics. Results showed that knowledge of FDA approval and authority was mixed, with several misconceptions apparent. Many consumers were not familiar with the use of composite scores in a medical context or in advertising and, in the 1st study, expressed distrust of the product and the ad after learning about how composite scores are used. In the 2nd study, receiving composite score information changed the perceived clarity of the ad but not the perceived risk or benefits. Implications for the presentation of complex medical information are discussed.

23 years of toxicology testing fatally injured pilots: Implications for aviation and other modes of transportation

Use of over-the-counter, prescription, and illicit drugs is increasing in the United States (US). Many of these drugs are psychoactive and can affect the user's ability to safely operate a vehicle. However, data about drug use by vehicle operators is typically limited to a small proportion of operators and a short list of drugs. For instance, required testing for commercial vehicle operators following most accidents is limited to a urine test for 11 drugs. By comparison, the Federal Aviation Administration (FAA), routinely tests fatally injured pilots' blood and tissues for hundreds of compounds. This study used the results from these tests to assess drug use in aviation.

METHODS

Using matched data from the FAA's Civil Aerospace Medical Institute toxicology database and the National Transportation Safety Board's (NTSB's) aviation accident database, this study examined trends in the prevalence of over-the-counter, prescription, and illicit drugs identified in toxicology tests of fatally injured pilots between 1990 and 2012. Cases that failed to match or where toxicology testing had not been performed were excluded. Pilots identified by the NTSB investigation as being the "flying pilot" at the time of the accident and results from blood or tissues were included. Toxicology results for ethanol and other alcohols were not included. Positive test results were categorized by drug type and potential for causing impairment. Analysis used SPSS Version 19.1 to perform linear by linear chi-squared statistics.

RESULTS

The study included 6677 pilots or 87% of the eligible subjects. The large majority were male (98%) and flying general aviation operations (96%) at the time of their fatal accident. There were increasing trends in pilots' use of all drugs, potentially impairing drugs, drugs used to treat potentially impairing conditions, drugs designated as controlled substances, and illicit drugs. The most common potentially impairing drug pilots had used was diphenhydramine, a sedating antihistamine that is an active ingredient in many over-the-counter allergy formulations, cold medicines, and sleep aids in the US. Although evidence of illicit drug use was found only in a small number of cases, the percentage of pilots testing positive for marijuana use increased during the study period, mostly in the last 10 years.

Factors influencing subjects' comprehension of a set of medicine package inserts

Background Package inserts (PIs) should promote the safe and effective use of medicines. The comprehension of PIs is related to socio-demographic features, such as education. Objectives To evaluate the participants' comprehension of a sample of PIs and to build an explanatory model of subjects' understanding of the content of these documents. Setting The data were collected from municipalities, city halls, firefighters, the military, schools and charities from two Portuguese regions. Methods Cross-sectional descriptive survey: 503 participants, homogeneously distributed by education and gender. The self-administered tool comprised questions on socio-demographic data, literacy tasks and comprehension evaluation of 12 purposively selected PIs. A logistic regression analysis was used. Main outcome measures Scores of numeracy tasks and comprehension. Results The average comprehension score for the PIs was 63 % (±32 %), with 48 % (n = 239) of the participants scoring <75 %. The most important predictors in explaining a comprehension score ≥75 % were having >12 years of education and correctly performing a numeracy task [respectively, OR 49.6 (CI 95 %: 22.8-108) and OR 2.48 (CI 95 %: 1.5-4.2)]. Conclusion An explanatory model of subjects' knowledge about the content of the tested PIs was built. Given that a high level of education and literacy were found to be the most relevant predictors for acceptable comprehension rates, PIs should be clearly written to assure that they are understood by all potential users, including the less educated. The evaluated PIs may thus need to be simplified.

Building Trust and Relationships Between Patients and Providers: An Essential Complement to Health Literacy in HIV Care

Health literacy is important for access to and quality of HIV care. While most models of health literacy acknowledge the importance of the patient-provider relationship to disease management, a more nuanced understanding of this relationship is needed. Thematic analysis from 28 focus groups with HIV-experienced patients (n = 135) and providers (n = 71) identified a long-term and trusting relationship as an essential part of HIV treatment over the continuum of HIV care. We found that trust and relationship building over time were important for patients with HIV as well as for their providers. An expanded definition of health literacy that includes gaining a patient's trust and engaging in a process of health education and information sharing over time could improve HIV care. Expanding clinical perspectives to include trust and the importance of the patient-provider relationship to a shared understanding of health literacy may improve patient experiences and engagement in care.

Extending FDA guidance to include consumer medication information (CMI) delivery on mobile devices

This paper describes the current state of consumer-focused mobile health application use and the current U.S. Food and Drug Administration (FDA) guidance on the distribution of consumer medication information (CMI), and discusses recommendations and considerations for the FDA to expand CMI guidance to include CMI in mobile applications. Smartphone-based health interventions have been linked to increased medication adherence and improved health outcomes. Trends in smartphone ownership present opportunities to more effectively communicate and disseminate medication information; however, current FDA guidance for CMI does not outline how to effectively communicate CMI on a mobile platform, particularly in regards to user-centered design and information sourcing. As evidence supporting the potential effectiveness of mobile communication in health care continues to increase, CMI developers, regulating entities, and researchers should take note. Although mobile-based CMI offers an innovative mechanism to deliver medication information, caution should be exercised. Specifically, considerations for developing mobile CMI include consumers' digital literacy, user experience (e.g., usability), and the quality and accuracy of new widely used sources of information (e.g., crowd-sourced reviews and ratings). Recommended changes to FDA guidance for CMI include altering the language about scientific accuracy to address more novel methods of information gathering (e.g., anecdotal experiences and Google Consumer Surveys) and including guidance for usability testing of mobile health applications.

Future Challenges and Opportunities in Online Prescription Drug Promotion Research Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

Despite increased availability of online promotional tools for prescription drug marketers, evidence on online prescription drug promotion is far from settled or conclusive. We highlight ways in which online prescription drug promotion is similar to conventional broadcast and print advertising and ways in which it differs. We also highlight five key areas for future research: branded drug website influence on consumer knowledge and behavior, interactive features on branded drug websites, mobile viewing of branded websites and mobile advertisements, online promotion and non-US audiences, and social media and medication decisions.

Medication Guide Reading Behaviors and Attitudes Among Subjects With Migraine, Asthma, or COPD

BACKGROUND

This cross-sectional survey describes attitudes and reading behaviors toward medication guides among 785 subjects with migraine, asthma, or COPD who reported recent use of Treximet (sumatriptan/naproxen sodium) or Advair (fluticasone propionate/salmeterol).

RESULTS

The survey demonstrated that the majority (82%) of subjects had read their medication guide, but most read it exactly once and did not read it thoroughly. Patients did not read medication guides with each refill, with the most frequent reasons being that they did not expect the information to have changed and that a doctor would tell them what they needed to know. Factors significantly associated with patients hypothetically being more likely to read medication guides associated with their new prescription included increasing age, simplification to format and content of the medication guide, and where subjects typically received their medication safety information. Patients reported acquiring medication safety from doctors or pharmacists more frequently than from medication guides.

CONCLUSIONS

The results provide insights into potential revisions to the medication guides that may improve reading behaviors.

Assessment of online patient materials for breast reconstruction

BACKGROUND

Limited health literacy affects nearly half of American adults and adversely affects patient participation, satisfaction, health care costs, and overall outcomes. As patients increasingly search the Internet for health information, accessibility of online material is critical. Previous studies examining this topic have focused on the readability of these materials. This study evaluates online breast reconstruction resources with regard to reading level, however, adds new metrics to assess degree of complexity, and suitability for the intended audience.

METHODS

The 10 most popular patient Web sites for "breast reconstruction" were identified using the largest Internet search engine. The content of each site was assessed for readability using the simple measure of gobbledygook analysis, complexity using the PMOSE/iKIRSCH formula, and suitability using the suitability assessment of materials instrument. Resulting scores were analyzed overall and by Web site.

RESULTS

Readability analysis revealed an overall average grade level of 13.4 (range 10.7-15.8). All sites exceeded the recommended sixth grade level. Complexity evaluation revealed a mean PMOSE/iKIRSCH score of 6.3, consistent with "low" complexity and requiring an 8th-12th grade education; individual sites ranged from "very low" to "high" complexity. Suitability assessment overall produced a mean 41.2% score, interpreted as "adequate" for the intended patient audience. Five of the 10 sites were found to be "not suitable" when examined individually; the remaining five were "adequate."

CONCLUSIONS

Available online patient material for breast reconstruction is often too difficult for many patients to understand based on readability, complexity, and suitability metrics. Comprehensive assessment is needed to design appropriate patient material and minimize disparities related to limited health literacy.

Patient understanding of drug risks: an evaluation of medication guide assessments

PURPOSE

When a Medication Guide (MG) is part of Risk Evaluation and Mitigation Strategy (REMS), manufacturers assess the effectiveness of MGs through patient surveys, which have not undergone systematic evaluation. We aimed to characterize knowledge rates from these patient surveys, describe their design and respondent characteristics, and explore predictors of acceptable knowledge rates.

METHODS

We analyzed MG assessments submitted to the Food and Drug Administration from September 2008 through June 2012. We evaluated the prevalence of specific characteristics, and calculated knowledge rates, whereby we defined "acceptable knowledge" when ≥ 80% of respondents correctly answered questions about the primary drug risk. Univariate logistic models were used to investigate the predictors of acceptable knowledge rates.

RESULTS

We analyzed the first completed MG assessment for each drug with a patient survey, resulting in 66 unique MG assessments. The mean knowledge rate was 63.8%, with 20 MG assessments (30.3%) achieving the 80% threshold. Compared to assessments that did not reach acceptable knowledge rates, those that did were more likely associated with additional REMS elements (e.g. Elements to Assure Safe Use or Communication Plans). Other factors, including mean age, reading or understanding the MG, and being offered or accepting counseling were not associated with knowledge rates. There was considerable variation in the design of MG assessments.

CONCLUSIONS

Most MG assessments did not reach the 80% knowledge threshold, but those associated with additional interventions were more likely to achieve it. Our study highlights the need to improve patient-directed information and the methods of assessing it.

Package leaflets of the most consumed medicines in Portugal: safety and regulatory compliance issues. A descriptive study

CONTEXT AND OBJECTIVES

Package leaflets are necessary for safe use of medicines. The aims of the present study were: 1) to assess the compliance between the content of the package leaflets and the specifications of the pharmaceutical regulations; and 2) to identify potential safety issues for patients.

DESIGN AND SETTING

Qualitative descriptive study, involving all the package leaflets of branded medicines from the three most consumed therapeutic groups in Portugal, analyzed in the Department of Pharmacoepidemiology, School of Pharmacy, University of Lisbon.

METHODS

A checklist validated through an expert consensus process was used to gather the data. The content of each package leaflet in the sample was classified as compliant or non-compliant with compulsory regulatory issues (i.e. stated dosage and descriptions of adverse reactions) and optional regulatory issues (i.e. adverse reaction frequency, symptoms and procedures in cases of overdose).

RESULTS

A total of 651 package leaflets were identified. Overall, the package leaflets were found to be compliant with the compulsory regulatory issues. However, the optional regulatory issues were only addressed in around half of the sample of package leaflets, which made it possible to identify some situations of potentially compromised drug safety.

CONCLUSION

Ideally, the methodologies for package leaflet approval should be reviewed and optimized as a way of ensuring the inclusion of the minimum essential information for safe use of medicines.

Readability of medicinal package leaflets: a systematic review

OBJECTIVE

To review studies on the readability of package leaflets of medicinal products for human use.

METHODS

We conducted a systematic literature review between 2008 and 2013 using the keywords “Readability and Package Leaflet” and “Readability and Package Insert” in the academic search engine Biblioteca do Conhecimento Online, comprising different bibliographic resources/databases. The preferred reporting items for systematic reviews and meta-analyses criteria were applied to prepare the draft of the report. Quantitative and qualitative original studies were included. Opinion or review studies not written in English, Portuguese, Italian, French, or Spanish were excluded.

RESULTS

We identified 202 studies, of which 180 were excluded and 22 were enrolled [two enrolling healthcare professionals, 10 enrolling other type of participants (including patients), three focused on adverse reactions, and 7 descriptive studies]. The package leaflets presented various readability problems, such as complex and difficult to understand texts, small font size, or few illustrations. The main methods to assess the readability of the package leaflet were usability tests or legibility formulae. Limitations with these methods included reduced number of participants; lack of readability formulas specifically validated for specific languages (e.g., Portuguese); and absence of an assessment on patients literacy, health knowledge, cognitive skills, levels of satisfaction, and opinions.

CONCLUSIONS

Overall, the package leaflets presented various readability problems. In this review, some methodological limitations were identified, including the participation of a limited number of patients and healthcare professionals, the absence of prior assessments of participant literacy, humor or sense of satisfaction, or the predominance of studies not based on role-plays about the use of medicines. These limitations should be avoided in future studies and be considered when interpreting the results.

Essential Medication Information for Patients: Ensuring Access

The US Food and Drug Administration (FDA) is developing a new framework to provide patients with quality, up-to-date prescription product information that will promote the safe use of prescribed medication. The goal of this new Patient Medication Information is to provide patient-oriented information for each prescription product. Described in this article are the efforts of the FDA to help ensure that patients receive essential prescription medication information.

Patient Comprehension of Medication Guides for Asthma and Chronic Obstructive Pulmonary Disease Medications

PURPOSE

This study assessed patients' comprehension of the Advair and Serevent medication guides (MGs) and MG reading behaviors with the goal to improve risk communication.

METHODS

After reading their assigned MGs, 452 adults with asthma or chronic obstructive pulmonary disease participated in structured interviews to assess comprehension of safety risks in the Advair MG (asthma, n = 150; chronic obstructive pulmonary disease, n = 153) and Serevent MG (asthma, n = 149). Generalized estimating equations for correlated binary data were used to identify factors associated with correct responses.

RESULTS

For 10 of 12 individual risk questions, ≥75% of patients reported correct responses. After adjusting for patient characteristics, health literacy was significantly associated with correct responses (odds ratio = 1.03, 95% confidence interval = 1.02-1.05 per 1-point increase in the Rapid Estimate of Adult Literacy in Medicine). MG reading behaviors were inconsistent, with many patients reading MGs only once (40%) despite multiple prescriptions.

CONCLUSIONS

Comprehension of safety risks in the Advair and Serevent MGs was adequate for most patients in the study but decreased with health literacy. Initiatives to improve patient-directed risk communication should consider health literacy and reasons for inconsistent reading behaviors.

Pharmacogenetic information for patients on drug labels

Advances in pharmacogenetic research have improved our understanding of adverse drug responses and have led to the development of pharmacogenetic tests and targeted drugs. However, the extent of the communication process and provision of information to patients about pharmacogenetics is unclear. Pharmacogenetic information may be included in sections of a drug's package insert intended for patients, which is provided directly to patients or communicated via the health provider. To determine what pharmacogenetic information, if any, is included in patient-targeted sections of the drug label, we reviewed the labels listed in the US Food and Drug Administration's Table of Pharmacogenomic Biomarkers in Drug Labels. To date, 140 drugs include pharmacogenetic-related information in the approved label. Our analysis revealed that pharmacogenetic information is included in patient-targeted sections for a minority (n=29; 21%) of drug labels, with no obvious pattern associated with the inclusion of pharmacogenetic information. Therefore, patients are unlikely to learn about pharmacogenetics through written materials dispensed with the drug. Given that there are also inconsistencies with regard to inclusion of pharmacogenetic information in the patient counseling information section, it is also unlikely that patients are receiving adequate pharmacogenetic information from their provider. The inconsistent presence of pharmacogenetic information in patient-targeted sections of drug labels suggests a need to review the criteria for inclusion of information in patient-targeted sections in order to increase consistency and patient knowledge of pharmacogenetic information.

Methodological gaps in the assessment of risk minimization interventions: a systematic review

INTRODUCTION

Since the introduction of therapeutic risk management regulatory guidance, an increase in the number of risk minimization interventions (RMIs) published in the literature has been observed. Methods used to evaluate their effectiveness remain, however, poorly examined.

OBJECTIVE

This paper aimed to conduct a literature review on the methods of evaluation of effectiveness of RMIs and to identify methodological gaps.

METHODS

The search was conducted using MEDLINE and Embase between 1 January 2000 and 31 December 2010, and updated on 1 April 2013. The following characteristics were extracted from each study: target population for the RMI, target population for the assessment of effectiveness, study design, data sources, and effectiveness outcome(s).

RESULTS

A total of 188 unique RMIs were identified in the literature, of which effectiveness was evaluated in only 65 (34.6%) at the time of publication. The largest proportion of studies reviewed (n = 49, 75.4%) attempted to evaluate changes in behavior through prescribing or laboratory test practices. One quarter of studies evaluated the effect of RMIs on the occurrence of adverse events. Only a minority of studies used robust designs, such as randomized controlled trials (n = 6, 9.2%) or a quasi-experimental design with a parallel comparison group (n = 8, 12.3%).

CONCLUSION

Lack of robust methodological design used in published studies on RMI effectiveness evaluation is an important methodological gap in the evaluation of RMI effectiveness. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.

A randomized, controlled study of an educational intervention to improve recall of auxiliary medication labeling and adherence to antibiotics

PURPOSE

To evaluate whether medication counseling with emphasis on auxiliary labels improves recall of auxiliary label information and adherence to medication schedules.

METHODS

A prospective, randomized study of an educational intervention in community pharmacies near Baltimore, Maryland. Fifty literate, English-speaking adults receiving one of the 18 commonly dispensed antibiotics were randomized to receive a counseling session or no counseling. Five to seven days after medication pickup, a structured phone interview was conducted to capture data on recall of auxiliary labels and adherence.

RESULTS

A total of 39 subjects completed the phone interview (78%). The rate of correct recall was high: 77% correct recall for all three labels. Among those with incorrect recall, 7 out of 9 subjects received no counseling (p = 0.11). The auxiliary labels incorrectly recalled were all related to dietary restrictions.

CONCLUSION

The findings from this study suggest that medication counseling emphasizing auxiliary label information may lead to improved recall and adherence to antibiotics. Additional studies are required to confirm the preliminary findings and determine whether they correspond to improved adherence. Information most commonly misunderstood were related to dietary restrictions. Additional research focusing on counseling related to dietary restrictions is recommended.

Reducing drug self-injection errors: a randomized trial comparing a "standard" versus "plain language" version of Patient Instructions for Use

BACKGROUND

Many American adults struggle to use and interpret medical-related instructions. Plain language materials have been shown to improve patient understanding and adherence.

OBJECTIVE

The study objective was to compare the effectiveness of a "standard" Patient Instructions for Use (PIFU-standard) with a "plain language" Patient Instructions for Use (PIFU-PL) by testing user comprehension and ability to administer a biologic agent with an auto-injector ("pen").

METHODS

A trained research assistant administered sociodemographic items and the Rapid Estimate of Adult Literacy in Medicine to study participants (n = 50). Next, using a priori random assignment, participants received either PIFU-PL or PIFU-standard. Participants' knowledge of preparation (6 steps) and pre-injection (3 steps) procedures, and demonstrated correctness of self-administration (15 steps) were then evaluated.

RESULTS

Participants receiving the PIFU-PL were more likely to correctly describe a greater number of both preparation (4.5 ± 1.3 versus 3.1 ± 1.5, P = 0.01) and pre-injection steps (2.4 ± 0.8 versus 1.6 ± 0.6, P = 0.01), and demonstrated more correct self-injection steps (13.1 ± 2.1 versus 10.8 ± 4.4, P = 0.05) as compared to participants receiving the PIFU-standard.

CONCLUSION

Participants given "plain language" instructions had a significantly better understanding of how to prepare for and self-administer medication with a pen and were consistently more accurate in demonstrating how to self-inject.