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Riaz A, Cambaco O, Ellington LE, Lenahan JL, Munguambe K, Mehmood U, Lamorte A, Qaisar S, Baloch B, Kanth N, Nisar MI, Volpicelli G, Bassat Q, Jehan F, Ginsburg AS. Feasibility, usability and acceptability of paediatric lung ultrasound among healthcare providers and caregivers for the diagnosis of childhood pneumonia in resource-constrained settings: a qualitative study. BMJ Open 2021; 11:e042547. [PMID: 33707268 PMCID: PMC7957133 DOI: 10.1136/bmjopen-2020-042547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Paediatric pneumonia burden and mortality are highest in low-income and middle-income countries (LMIC). Paediatric lung ultrasound (LUS) has emerged as a promising diagnostic tool for pneumonia in LMIC. Despite a growing evidence base for LUS use in paediatric pneumonia diagnosis, little is known about its potential for successful implementation in LMIC. Our objectives were to evaluate the feasibility, usability and acceptability of LUS in the diagnosis of paediatric pneumonia. DESIGN Prospective qualitative study using semistructured interviews SETTING: Two referral hospitals in Mozambique and Pakistan PARTICIPANTS: A total of 21 healthcare providers (HCPs) and 20 caregivers were enrolled. RESULTS HCPs highlighted themes of limited resource availability for the feasibility of LUS implementation, including perceived high cost of equipment, maintenance demands, time constraints and limited trained staff. HCPs emphasised the importance of policymaker support and caregiver acceptance for long-term success. HCP perspectives of usability highlighted ease of use and integration into existing workflow. HCPs and caregivers had positive attitudes towards LUS with few exceptions. Both HCPs and caregivers emphasised the potential for rapid, improved diagnosis of paediatric respiratory conditions using LUS. CONCLUSIONS This was the first study to evaluate HCP and caregiver perspectives of paediatric LUS through qualitative analysis. Critical components impacting feasibility, usability and acceptability of LUS for paediatric pneumonia diagnosis in LMIC were identified for initial deployment. Future research should explore LUS sustainability, with a particular focus on quality control, device maintenance and functionality and adoption of the new technology within the health system. This study highlights the need to engage both users and recipients of new technology early in order to adapt future interventions to the local context for successful implementation. TRIAL REGISTRATION NUMBER NCT03187067.
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Affiliation(s)
- Atif Riaz
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Olga Cambaco
- Centro de Investigação em Saúde de Manhiça, Manhica, Maputo, Mozambique
| | | | | | - Khatia Munguambe
- Centro de Investigacao em Saude de Manhica, Manhica, Maputo, Mozambique
| | - Usma Mehmood
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Alessandro Lamorte
- Emergency Medicine, Umberto Parini Hospital, Aosta, Valle d'Aosta, Italy
| | - Sana Qaisar
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Benazir Baloch
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Neel Kanth
- Children's Hospital-Poverty Eradication Initiative, Sindh Government Hospital Karachi, Karachi, Sindh, Pakistan
| | | | | | - Quique Bassat
- ISGLOBAL, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Fyezah Jehan
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amy Sarah Ginsburg
- Clinical Trial Center, University of Washington, Seattle, Washington, USA
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Ginsburg AS, Vitorino P, Qasim Z, Lenahan JL, Hwang J, Lamorte A, Valente M, Balouch B, Muñoz Almagro C, Nisar MI, May S, Jehan F, Bassat Q, Volpicelli G. Lung ultrasound patterns in paediatric pneumonia in Mozambique and Pakistan. ERJ Open Res 2021; 7:00518-2020. [PMID: 33569493 PMCID: PMC7861021 DOI: 10.1183/23120541.00518-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/04/2020] [Indexed: 11/12/2022] Open
Abstract
Objective Improved pneumonia diagnostics are needed, particularly in resource-constrained settings. Lung ultrasound (LUS) is a promising point-of-care imaging technology for diagnosing pneumonia. The objective was to explore LUS patterns associated with paediatric pneumonia. Methods We conducted a prospective, observational study among children aged 2 to 23 months with World Health Organization Integrated Management of Childhood Illness chest-indrawing pneumonia and among children without fast breathing, chest indrawing or fever (no pneumonia cohort) at two district hospitals in Mozambique and Pakistan. We assessed LUS and chest radiograph (CXR) examinations, and viral and bacterial nasopharyngeal carriage, and performed a secondary analysis of LUS patterns. Results LUS demonstrated a range of distinctive patterns that differed between children with and without pneumonia and between children in Mozambique versus Pakistan. The presence of LUS consolidation or interstitial patterns was more common in children with chest-indrawing pneumonia than in those without pneumonia. Consolidations were also more common among those with only bacterial but no viral carriage detected (50.0%) than among those with both (13.0%) and those with only virus detected (8.3%; p=0.03). LUS showed high interrater reliability among expert LUS interpreters for overall determination of pneumonia (κ=0.915), consolidation (κ=0.915) and interstitial patterns (κ=0.901), but interrater reliability between LUS and CXR for detecting consolidations was poor (κ=0.159, Pakistan) to fair (κ=0.453, Mozambique). Discussion Pattern recognition was discordant between LUS and CXR imaging modalities. Further research is needed to define and standardise LUS patterns associated with paediatric pneumonia and to evaluate the potential value of LUS as a reference standard. This study explored distinctive lung ultrasound patterns associated with paediatric community-acquired pneumonia in Mozambique and Pakistan, and found reliable pattern recognition critical to identifying pneumoniahttps://bit.ly/3eWWvXr
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Affiliation(s)
| | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Zunera Qasim
- Dept of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Jun Hwang
- Dept of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Marta Valente
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Benazir Balouch
- Dept of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - M Imran Nisar
- Dept of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Susanne May
- Dept of Biostatistics, University of Washington, Seattle, WA, USA
| | - Fyezah Jehan
- Dept of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Instituto de Recerca Pediatrica, Hospital Sant Joan de Déu, Barcelona, Spain.,ICREA, Barcelona, Spain.,Consorcio de Investigacion Biomedica en Red de Epidemiologia y Salud Publica (CIBERESP), Madrid, Spain
| | - Giovanni Volpicelli
- Dept of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Italy
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Ginsburg AS, Lenahan JL, Jehan F, Bila R, Lamorte A, Hwang J, Madrid L, Nisar MI, Vitorino P, Kanth N, Balcells R, Baloch B, May S, Valente M, Varo R, Nadeem N, Bassat Q, Volpicelli G. Performance of lung ultrasound in the diagnosis of pediatric pneumonia in Mozambique and Pakistan. Pediatr Pulmonol 2021; 56:551-560. [PMID: 33205892 PMCID: PMC7898329 DOI: 10.1002/ppul.25176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/28/2020] [Accepted: 11/05/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Improved pneumonia diagnostics are needed in low-resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. The objective was to compare LUS versus chest radiograph (CXR), and among LUS interpreters, to compare expert versus limited training with respect to interrater reliability. METHODS We conducted a prospective, observational study among children with World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) chest-indrawing pneumonia at two district hospitals in Mozambique and Pakistan, and assessed LUS and CXR examinations. The primary endpoint was interrater reliability between LUS and CXR interpreters for pneumonia diagnosis among children with WHO IMCI chest-indrawing pneumonia. RESULTS Interrater reliability was excellent for expert LUS interpreters, but poor to moderate for expert CXR interpreters and onsite LUS interpreters with limited training. CONCLUSIONS Among children with WHO IMCI chest-indrawing pneumonia, expert interpreters may achieve substantially higher interrater reliability for LUS compared to CXR, and LUS showed potential as a preferred reference standard. For point-of-care LUS to be successfully implemented for the diagnosis and management of pneumonia in LRS, the clinical environment and amount of appropriate user training will need to be understood and addressed.
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Affiliation(s)
| | | | - Fyezah Jehan
- Department of Pediatrics and Child HealthAga Khan UniversityKarachiPakistan
| | - Rubao Bila
- Centro de Investigação em Saúde de Manhiça (CISM)MaputoMozambique
| | | | - Jun Hwang
- Clinical Trial CenterUniversity of WashingtonSeattleWashingtonUSA
| | - Lola Madrid
- ISGlobal, Hospital Clínic, Universitat de BarcelonaBarcelonaSpain
| | | | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça (CISM)MaputoMozambique
| | - Neel Kanth
- Sindh Government Children's Hospital–Poverty Eradication InitiativeKarachiPakistan
| | - Reyes Balcells
- ISGlobal, Hospital Clínic, Universitat de BarcelonaBarcelonaSpain
| | - Benazir Baloch
- Department of Pediatrics and Child HealthAga Khan UniversityKarachiPakistan
| | - Susanne May
- Clinical Trial CenterUniversity of WashingtonSeattleWashingtonUSA
| | - Marta Valente
- ISGlobal, Hospital Clínic, Universitat de BarcelonaBarcelonaSpain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de BarcelonaBarcelonaSpain
| | - Naila Nadeem
- Department of RadiologyAga Khan UniversityKarachiPakistan
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM)MaputoMozambique
- ISGlobal, Hospital Clínic, Universitat de BarcelonaBarcelonaSpain
- Institució Catalana de Recerca i Estudis Avançats (ICREA)BarcelonaSpain
- Department of Pediatrics, Hospital Sant Joan de DeuUniversitat de BarcelonaBarcelonaSpain
- Consorcio de Investigacion Biomedica en Red de Epidemiologia y Salud Publica (CIBERESP)MadridSpain
| | - Giovanni Volpicelli
- Department of Emergency MedicineSan Luigi Gonzaga University HospitalOrbassanoItaly
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Lenahan JL, Nkwopara E, Phiri M, Mvalo T, Couasnon MT, Turner K, Ndamala C, McCollum ED, May S, Ginsburg AS. Repeat assessment of examination signs among children in Malawi with fast-breathing pneumonia. ERJ Open Res 2020; 6:00275-2019. [PMID: 32494572 PMCID: PMC7248340 DOI: 10.1183/23120541.00275-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/04/2020] [Indexed: 01/04/2023] Open
Abstract
Background As part of a randomised controlled trial of treatment with placebo versus 3 days of amoxicillin for nonsevere fast-breathing pneumonia among Malawian children aged 2–59 months, a subset of children was hospitalised for observation. We sought to characterise the progression of fast-breathing pneumonia among children undergoing repeat assessments to better understand which children do and do not deteriorate. Methods Vital signs and physical examination findings, including respiratory rate, arterial oxygen saturation measured by pulse oximetry (SpO2), chest indrawing and temperature were assessed every 3 h for the duration of hospitalisation. Children were assessed for treatment failure during study visits on days 1, 2, 3 and 4. Results Hospital monitoring data from 436 children were included. While no children had SpO2 90–93% at baseline, 7.4% (16 of 215) of children receiving amoxicillin and 9.5% (21 of 221) receiving placebo developed SpO2 90–93% during monitoring. Similarly, no children had chest indrawing at enrolment, but 6.6% (14 of 215) in the amoxicillin group and 7.2% (16 of 221) in the placebo group went on to develop chest indrawing during hospitalisation. Conclusion Repeat monitoring of children with fast-breathing pneumonia identified vital and physical examination signs not present at baseline, including SpO2 90–93% and chest indrawing. This information may support providers and policymakers in developing guidance for care of children with nonsevere pneumonia. This study characterised the progression of fast-breathing pneumonia among children in Malawi. Repeat monitoring of children identified vital and physical exam signs not present at baseline, including oxygen saturation of 90–93% and chest indrawing.http://bit.ly/2vUlckS
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Affiliation(s)
- Jennifer L Lenahan
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Evangelyn Nkwopara
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Melda Phiri
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Tisungane Mvalo
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Mari T Couasnon
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Kali Turner
- International Programs, Save the Children Federation Inc., Westport, CT, USA
| | - Chifundo Ndamala
- Dept of Pediatrics, University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Eric D McCollum
- Dept of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susanne May
- Dept of Biostatistics, University of Washington, Seattle, WA, USA
| | - Amy Sarah Ginsburg
- International Programs, Save the Children Federation Inc., Westport, CT, USA
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Ginsburg AS, Lenahan JL, Izadnegahdar R, Ansermino JM. A Systematic Review of Tools to Measure Respiratory Rate in Order to Identify Childhood Pneumonia. Am J Respir Crit Care Med 2019; 197:1116-1127. [PMID: 29474107 DOI: 10.1164/rccm.201711-2233ci] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pneumonia is the leading infectious cause of death in children worldwide, with most deaths occurring in developing countries. Measuring respiratory rate is critical to the World Health Organization's guidelines for diagnosing childhood pneumonia in low-resource settings, yet it is difficult to accurately measure. We conducted a systematic review to landscape existing respiratory rate measurement technologies. We searched PubMed, Embase, and Compendex for studies published through September 2017 assessing the accuracy of respiratory rate measurement technologies in children. We identified 16 studies: 2 describing manual devices and 14 describing automated devices. Although both studies describing manual devices took place in low-resource settings, all studies describing automated devices were conducted in well-resourced settings. Direct comparison between studies was complicated by small sample size, absence of a consistent reference standard, and variations in comparison methodology. There is an urgent need for affordable and appropriate innovations that can reliably measure a child's respiratory rate in low-resource settings. Accelerating development or scale-up of these technologies could have the potential to advance childhood pneumonia diagnosis worldwide.
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Affiliation(s)
- Amy Sarah Ginsburg
- 1 Department of Global Health, Save the Children Federation, Inc., Fairfield, Connecticut
| | - Jennifer L Lenahan
- 1 Department of Global Health, Save the Children Federation, Inc., Fairfield, Connecticut
| | - Rasa Izadnegahdar
- 2 Department of Pediatrics, University of Washington, Seattle, Washington.,3 Seattle Children's Hospital, Seattle, Washington; and
| | - J Mark Ansermino
- 4 Department of Anesthesiology, Pharmacology, and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
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Lenahan JL, Volpicelli G, Lamorte A, Jehan F, Bassat Q, Ginsburg AS. Multicentre pilot study evaluation of lung ultrasound for the management of paediatric pneumonia in low-resource settings: a study protocol. BMJ Open Respir Res 2018; 5:e000340. [PMID: 30622716 PMCID: PMC6307622 DOI: 10.1136/bmjresp-2018-000340] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/22/2018] [Accepted: 10/19/2018] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Pneumonia is the leading infectious cause of death among children under 5 years of age worldwide. However, pneumonia is challenging to diagnose. Lung ultrasound (LUS) is a promising diagnostic technology. Further evidence is needed to better understand the role of LUS as a tool for the diagnosis of childhood pneumonia in low-resource settings. METHODS AND ANALYSIS This study aims to pilot LUS in Mozambique and Pakistan and to generate evidence regarding the use of LUS as a diagnostic tool for childhood pneumonia. Children with cough <14 days with chest indrawing (n=230) and without chest indrawing (n=40) are enrolled. World Health Organization Integrated Management of Childhood Illness assessment is performed at enrolment, along with a chest radiograph and LUS examination. Respiratory and blood specimens are collected for viral and bacterial testing and biomarker assessment. Enrolled children are followed for 14 days (in person) and 30 days (phone call) post-enrolment with LUS examinations performed on Days 2, 6 and 14. Qualitative and quantitative data are also collected to assess feasibility, usability and acceptability of LUS among healthcare providers and caregivers. The primary outcome is LUS findings at enrolment with secondary outcomes including patient outcomes, repeat LUS findings, viral and bacterial test results, and patient status after 14 and 30 days of follow-up. ETHICS AND DISSEMINATION This trial was approved by the Western Institutional Review Board as well as local ethics review committees at each site. We plan to disseminate study results in peer-reviewed journals and international conferences. TRIAL REGISTRATION NUMBER NCT03187067.
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Affiliation(s)
- Jennifer L Lenahan
- International Programs, Save the Children Federation Inc, Fairfield, Connecticut, USA
| | | | | | - Fyezah Jehan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Amy Sarah Ginsburg
- International Programs, Save the Children Federation Inc, Fairfield, Connecticut, USA
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Lenahan JL, Englund JA, Katz J, Kuypers J, Wald A, Magaret A, Tielsch JM, Khatry SK, LeClerq SC, Shrestha L, Steinhoff MC, Chu HY. Human Metapneumovirus and Other Respiratory Viral Infections during Pregnancy and Birth, Nepal. Emerg Infect Dis 2018; 23. [PMID: 28726613 PMCID: PMC5547777 DOI: 10.3201/eid2308.161358] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Human metapneumovirus (HMPV) is a respiratory virus that can cause severe lower respiratory tract disease and even death, primarily in young children. The incidence and characteristics of HMPV have not been well described in pregnant women. As part of a trial of maternal influenza immunization in rural southern Nepal, we conducted prospective, longitudinal, home-based active surveillance for febrile respiratory illness during pregnancy through 6 months postpartum. During 2011-2014, HMPV was detected in 55 of 3,693 women (16.4 cases/1,000 person-years). Twenty-five women were infected with HMPV during pregnancy, compared with 98 pregnant women who contracted rhinovirus and 7 who contracted respiratory syncytial virus. Women with HMPV during pregnancy had an increased risk of giving birth to infants who were small for gestational age. An intervention to reduce HMPV febrile respiratory illness in pregnant women may have the potential to decrease risk of adverse birth outcomes in developing countries.
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Lenahan JL, Englund J, Tielsch J, Katz J, Khatry S, Leclerq SC, Kuypers J, Steinhoff MC, Chu HY. Human Metapneumovirus Infection in Pregnant and Postpartum Women. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lenahan JL, McCarthy DM, Davis TC, Curtis LM, Serper M, Wolf MS. A drug by any other name: patients' ability to identify medication regimens and its association with adherence and health outcomes. J Health Commun 2013; 18 Suppl 1:31-39. [PMID: 24093343 PMCID: PMC3815114 DOI: 10.1080/10810730.2013.825671] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Understanding and organizing medication regimens can be challenging, and many patients struggle to properly dose prescribed medicine, potentially leading to less effective treatment or even harm. Generic prescriptions are increasingly common and may change in appearance, adding further complexity. The authors aimed to investigate familiarity with the drug regimen among a cohort of patients with diagnosed hypertension. Specifically, they determined the prevalence of patients' knowledge of their prescribed drug names and dosages compared to those who relied only on physical characteristics (size, shape, color) of their medications. The relationship between patients' identification strategies, self-reported adherence, and health outcomes (blood pressure control, hospitalization) were investigated. Patients who were dependent on the visual identification of their prescription medicine reported worse adherence. In addition, they had significantly lower rates of blood pressure control and greater risk of hospitalization. The ability to identify prescribed medicines by name may be helpful for screening and responding to patients at greater risk of making medication errors or being less engaged with their regimen for adherence purposes.
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Affiliation(s)
- Jennifer L. Lenahan
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Danielle M. McCarthy
- Department of Emergency Medicine, and Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Terry C. Davis
- Department of Medicine–Pediatrics, Louisiana State University Health Sciences Center–Shreveport, Shreveport, Louisiana, USA
| | - Laura M. Curtis
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marina Serper
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael S. Wolf
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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