A narrative review on do's and don'ts in prescription label writing - lessons for pharmacists

Association of Health Literacy and Health Care Utilization Among Glaucoma Patients

PRCIS

Among 7846 adults with self-reported glaucoma, low health literacy (LHL) was associated with fewer outpatient ophthalmological follow-up visits, utilization of a greater number of ocular hypotensive medication classes, and higher costs for glaucoma medications.

PURPOSE

Previous studies found LHL is associated with increased difficulty with treatment adherence among adults with glaucoma, which can lead to poor outcomes. This study examined patterns of glaucoma health care utilization associated with LHL.

METHODS

We analyzed 7846 adults with self-reported glaucoma enrolled in the 1996-2017 Medical Expenditure Panel Survey. Adult glaucoma patients with LHL (defined by National Assessment of Adult Literacy score <226) were the compared with those with high health literacy. Multivariable regression models were constructed to examine the association of LHL with number of outpatient glaucoma visits, prescription medications, polypharmacy (≥2 ocular hypotensive classes prescribed), and associated costs.

RESULTS

Self-reported glaucoma diagnosis was associated with higher rates of LHL [23.9% vs. 9.7%, odds ratio (95% CI): 2.43 (2.25-2.62), P <0.0001]. Among those with glaucoma, LHL was associated with fewer glaucoma outpatient visits [risk ratio: 0.94 (0.89-0.99), P =0.02] and the use of a greater number of ocular hypotensive medications [1.06 (1.01-1.12), P =0.03]. Moreover, those with LHL had higher health care spending on prescription medications [mean: $556.40 vs. $471.87, β (95% CI): $57.05 ($30.22-$83.87)]. Adult glaucoma patients with LHL were also more likely to have polypharmacy [odds ratio (95% CI): 1.26 (1.01-1.59)].

CONCLUSION

LHL was more prevalent in patients with glaucoma, compared with those without. Glaucoma patients with LHL were prescribed more medications and had higher medication costs, however, they had fewer outpatient glaucoma visits. Improved glaucoma patient education to address LHL is needed, in addition to studies to understand the impact of these findings on treatment outcomes.

Comprehensibility of a personalized medication overview compared to usual-care prescription drug labels

Poor understanding of prescription drug label (PDL) instructions can lead to medication errors, suboptimal treatment (side) effects, and non-adherence. A personalized medication hard-copy overview listing PDL instructions and visual information may support patients in their medication use. This study aimed to investigate the comprehensibility of PDL instructions on a personalized medication overview compared to usual-care PDL instructions presented on a medication box. A hypothetical-online-experiment was set up, comparing groups of respondents exposed vs not exposed to the medication overview and who received PDL instructions for three, five, or eight medications. Participants were divided randomly in six groups. Online questionnaires were sent to a stratified sample of 900 members from the Nivel Dutch Healthcare Consumer Panel. Outcome measures included comprehension of instructions for medication use, e.g. how often, dose timing, usage advice and warnings for a medication with simple use instructions (omeprazol) and more complex use instructions (levodopa/carbidopa (L/C)). To analyze differences between experimental conditions ANOVA testing was used. 604 respondents (net response 67%) completed the questionnaires. Respondents exposed (E) to the overview gave a higher proportion of correct answers compared to non-exposed (NE) respondents for usage advice (L/C: mean 0.83, SD 0.4 E; 0.03, SD 0.2 NE, p &lt; 0.001; omeprazol: mean 0.85, SD 0.4 E; 0.10, SD 0.3 NE, p &lt; 0.001). Both groups gave the same proportion of correct answers (mean 0.80, SD 0.4, p = 1.0) for dose timing of omeprazol. More NE respondents gave correct answers for how often (mean 0.85, SD 0.4 NE; mean 0.76, SD 0.4 E, p = 0.02) and dose timing (mean 0.92, SD 0.3 NE; mean 0.86, SD 0.4 E, p = 0.04) of L/C. No differences were found regarding number of medications nor were interaction effects found between the number of medications and information type. As a medication overview contains additional information, it can be a good addition in supporting patients in their medication use compared to usual-care PDLs. Future research should focus on identifying patient groups who might benefit more from a medication overview, by testing the effect of such overview on this group.

Older adult and family caregiver experiences with prescription medication labels and their suggestions for label improvement

Background

Prescription medication labels (PMLs) are an important source of written medication information for patients. However, real-world PMLs do not entirely conform with available labelling best practices and guidelines. Given this disconnect, older adults remain particularly at risk of misinterpreting their PMLs. Past studies have commonly assessed hypothetical PMLs, warranting studies that explore the lived experiences of older adults with real-world PMLs. Furthermore, the perspective of family caregivers of older adults is yet to be studied.

Objective(s)

This qualitative study documented the challenges faced by older adults and their family caregivers in using real-world PMLs, their strategies to cope with these challenges, and their suggestions to improve existing PMLs.

Methods

We conducted two focus group discussions (n = 17) and 30 in-depth interviews with older adults (n = 20; including those who can read in English and those with limited English proficiency) and caregivers (n = 10) in Singapore. The data were systematically assigned to codes that were continuously refined to accommodate emergent themes.

Results

Challenges, coping strategies and suggested improvements were related to the comprehensibility, availability, readability and consistency of medication information on PMLs.

Conclusions

Real-world PMLs continue to pose challenges for older adults and their caregivers, necessitating them to seek unique and personal coping strategies. The identified PML improvements, desired by older adults and their caregivers, urge healthcare systems to implement improved PMLs. Future research should explore system-level logistical, financial, and administrative barriers (or opportunities) that hinder (or facilitate) this implementation.

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Older adults and caregivers still face challenges with English medicine labels.

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Small font and lack of desired information were also enduring challenges.

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Inconsistency in label format and content confused older adults and caregivers.

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Caregivers and pharmacy staff adopted unique strategies to help older adults.

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Challenges and ad-hoc strategies necessitate real-world, systemic change to labels.

The impact of textual elements on the comprehensibility of drug label instructions (DLIs): A systematic review

INTRODUCTION

Correct interpretation of drug labels instructions (DLIs) is needed for safe use and better adherence to prescribed drugs. DLIs are often too difficult for patients, especially for those with limited health literacy. What is yet unknown, is how specific textual elements in DLIs (e.g., the presentation of numbers, or use of medical jargon) and patients' health literacy skills are related to the comprehension of DLIs. In order to provide concrete directions for health professionals on how to optimize drug prescriptions, we performed a systematic review to summarize the available research findings on which textual elements facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

METHOD

A systematic search was performed in PubMed, EMBASE, PsychINFO, and Smartcat (until April 2019) to identify studies investigating textual elements that facilitate or hinder the correct interpretation of DLIs in relation to patients' health literacy.

RESULTS

A total of 434 studies were identified of which 28 studies met our inclusion criteria. We found that textual elements contributing to the correct interpretation of DLIs were: using explicit time periods in dosage instructions, using plain language, presenting numbers in a numerical format, and providing DLIs in patients' native language. Multistep instructions per instruction line, using abbreviations and medical jargon seem to hinder the correct interpretation of DLIs. Although health literacy was taken into account in a majority of the studies, none of them assessed the effectiveness of specific textual elements on patients' comprehensibility of DLIs.

CONCLUSION

Based on our findings, we provide an overview of textual elements that contribute to the correct interpretation of DLIs. Optimizing the textual instruction on drug labels may increase the safety and adherence to prescribed drugs, taking into account that a significant proportion of patients has low health literacy.

Development of Comprehensible Prescription Label Instructions: A Study Protocol for a Mixed-Methods Approach

Introduction

Patients receive information about their medication from different sources, including prescription labels. These labels are physically attached to each package dispensed to patients and contain the most important instructions on how to use the medication correctly. However, many patients experience difficulties in understanding and applying the instructions on these labels correctly, especially patients with limited health literacy. The aim of this study is to investigate the comprehensibility of prescription label instructions among patients with adequate and limited health literacy skills, and to implement improvements in primary health care.

Methods

We used a mixed-methods approach, which consisted of four phases. Phase 1 (desk research) was divided into a systematic literature review on the comprehensibility of prescription label instructions (1a) and a content analysis of the textual elements in Dutch prescription label instructions (1b). In phase 2 (patient studies), semi-structured interviews were conducted to investigate the comprehensibility of seven prescription labels among patients with different health literacy skills (2a), and a quantitative study in which the comprehensibility of six optimized prescription labels was compared among patients with different health literacy skills (2b). Patient studies were conducted in eight Dutch pharmacies. In phase 3 optimized prescription label instructions were implemented in national medication databases which has been supported by a guideline (3a), and education of pharmacy workers (3b). Phase 4 consists of evaluating the optimized prescription label instructions by experiences from patients and pharmacists.

Anticipated Results

This mixed-methods approach will result in scientific publications of the individual studies, and a guideline on how to compose comprehensible prescription label instructions to be put on medication packages. Optimized prescription label instructions will be implemented in national medication databases.

Discussion

This protocol describes a mixed-method research to compose and implement comprehensible prescription label instructions and will lead to knowledge about the comprehensibility of textual elements in these labels, with specific attention for patients with limited health literacy. Implementation of optimized prescription label instructions will lead to a better understanding of them, which may contribute to improved medication adherence. A limitation is that non-textual aspects of prescription labels are not investigated.