Beers标准和STOPP/START标准再评价老年住院患者医嘱点评情况

目的：探讨Beers标准、STOPP/START标准两种方法在对我院老年住院患者医嘱点评进行再评价中筛查出的潜在不适当用药情况,为老年患者合理用药提供参考。方法：选取2013年3月~2015年2月医嘱点评的549份老年患者病历,分别以Beers标准、STOPP/START标准为依据,判断老年患者潜在不适当用药情况。结果：549份老年住院患者平均年龄为（77±7）岁,平均用药品种数（15±7）种。依照Beers标准,99例（18%）存在潜在不适当用药现象共104项;依照STOPP/START标准,104例（19%）存在潜在不适当用药现象共111项;155例（29%）存在处方遗漏现象共232项。结论：以Beers标准和STOPP/START标准可以筛查出大量老年住院患者潜在不适当用药情况,且两种标准筛查出的潜在不适当用药情况重复内容很少,可以形成互补对临床处方考量,促进老年人合理用药。     

Translation,cross-cultural adaptation and validation of the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire to Portuguese: Older adults version

BackgroundDeprescribing is a patient-centered approach to managing inappropriate polypharmacy that faces several barriers, including patients' attitudes and beliefs about medications that need to be considered. For this purpose, the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire is a helpful instrument, but until now, there is no Portuguese version.ObjectivesTo translate and validate the rPATD questionnaire (older adults version) to Portuguese.MethodsThe rPATD questionnaire was translated and cross-culturally adapted using forward-backward translation and pre-testing. A cross-sectional study with 192 older adults aged ≥65 years taking at least 1 regular medication was conducted for validity assessment. Participants were recruited by convenience sampling in 3 Portuguese outpatient rehabilitation medicine clinics. Psychometric properties were evaluated through face and content validity; construct validity, by assessing structural validity through exploratory factor analysis, hypotheses testing, including concurrent validity and cross cultural validity; reliability with internal consistency; and item-total correlation. Floor and ceiling effects were examined.ResultsThe exploratory factor analysis (EFA) revealed a 4-factor structure that explains 51.08% of the total variance, as in the original rPATD. These 4 factors are related to the level of involvement in medication management, beliefs in the appropriateness of medication, perceived burden of medication, and concerns about stopping medications. Factor loadings ranged from 0.226 to 0.800; 2 items scored <0.3, and no cross-loading was found. The exclusion of the 2 items loading <0.3 in the EFA showed no significant improvement in factor loading or internal consistency, so the item structure was maintained. In hypothesis testing, 78% of the correlations were correctly predicted. The 4 factors internal consistency was generally acceptable, with Cronbach's alpha ranging from 0.638 to 0.830. The item-total correlation ranged between 0.223 and 0.7.ConclusionThe Portuguese rPATD questionnaire for older adults presents globally good or acceptable psychometric properties.     

Addressing Adolescent Substance Use: Teaching Screening,Brief Intervention,and Referral to Treatment (SBIRT) and Motivational Interviewing (MI) to Residents

Background: The American Academy of Pediatrics Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every adolescent preventive and all appropriate urgent visits. We designed an SBIRT curriculum as part of the adolescent block of a pediatric residency that combined online modules with an in-person workshop, faculty feedback on resident interactions with patients, and resident self-reflection on their motivational interviewing (MI) skills. Methods: To evaluate the curriculum, we measured resident satisfaction and self-reported confidence in using SBIRT and MI with teens using a retrospective pre/post questionnaire. We used qualitative analysis to evaluate the written comments from faculty observations of patient-trainee interactions and comments from resident self-reflection(s) on patient interactions. Results: Thirty-two residents completed the curriculum. Residents reported high satisfaction with the training. Comparing retrospective pre/post scores on the survey of resident self-reported confidence, measures increased significantly in all domains, including for both alcohol and other drug use. Regarding self-reported MI, skillfulness also increased significantly. Analysis of specific faculty feedback to residents revealed subthemes such as normalizing confidentiality and focusing more on the patient's perspectives on substance use. Resident reflections on their own abilities with SBIRT/MI focused on using the ruler tool and on adapting the MI style of shared decision-making. Conclusions: A curriculum that combines online training, small-group practice, clinical observations, and self-reflection is valued by residents and can increase resident self-reported confidence in using SBIRT and MI in adolescent encounters. Future studies should examine to what extent confidence predicts performance using standardized measures of MI skillfulness in patient encounters.     

Readiness to change versus readiness to seek help for alcohol problems: the development of the Treatment Readiness Tool (TReaT)

OBJECTIVE: This study developed and psychometrically evaluated a short self-report measure for treatment readiness, a construct correlated with but distinct from general change readiness. This measure, the Treatment Readiness Tool (TReaT), was based on the transtheoretical model of behavior change. METHOD: A nontreatment-seeking sample of 748 patients from general hospitals who met criteria for at-risk or harmful drinking was recruited as part of an intervention study in Western Pomerania, Germany. RESULTS: Exploratory (n = 498) and confirmatory (n = 250) factor analyses supported the presence of a three-factor structure (Precontemplation, Contemplation and Preparation) among high-risk drinkers who were not seeking treatment. High internal item consistency was found for the three TReaT scales, and strong convergent validity was obtained with measures of alcohol use and consequences. Pearson correlations between the three TReaT scales and parallel scales collected by a measure of general change readiness indicated that the two constructs were relatively distinct (19% shared variance). CONCLUSIONS: The findings suggest that measurement of treatment readiness might have advantages in predicting treatment compliance, processes and outcome relative to measures of general behavior change readiness. The predictive validity of the measure needs to be investigated in future studies, however.     

Evaluating patient-perceived control of atopic dermatitis: design,validation, and scoring of the Atopic Dermatitis Control Tool (ADCT)

Abstract

Objectives: The Atopic Dermatitis Control Tool (ADCT) was designed to evaluate patient-perceived AD control and facilitate patient–physician discussion on long-term disease control.

Methods: The study was performed in adult patients with AD. Development of the ADCT followed US Food and Drug Administration (FDA) guidelines on patient-reported outcome measures (PROMs). Qualitative research, including targeted literature review, interviews with clinical experts, and combined concept elicitation/cognitive debriefing with patients with AD, was conducted to provide a list of comprehensive concepts capturing AD control per physician and patient perspectives. Quantitative methods assessed psychometric properties of the instrument and defined the threshold for AD control.

Results: The resulting pilot six-item ADCT, reflecting key concepts related to AD control, had 7-day recall and assessed symptoms and impacts on patients’ everyday lives by severity and/or frequency. The ADCT showed good content validity (well understood by adult patients with AD), and quick completion time (<2?min). Psychometric analysis indicated no floor/ceiling effects for response distributions, particularly strong (r?≥?0.80) inter-item correlations for the six ADCT items, robust construct validity (r?>?0.50), and item-level discriminating ability (p?<?.03); this supported the derivation of a total score based on responses to all items. ADCT total score showed evidence of strong internal consistency reliability (Cronbach’s alpha >0.80). A score ≥7 points was identified as an optimum threshold to identify patients whose AD is “not in control.”

Conclusions: No single validated instrument has been available to holistically evaluate patient-perceived AD control. The newly developed ADCT displays good-to-excellent content validity, construct validity, internal consistency, reliability, and discriminating ability.     

An Evidence-Based Alcohol Screening,Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization

SUMMARY

Objective: Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices.

Methods: ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program (www.ed.bmc.org/sbirt). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure.

Results: Among 402 ED providers, 74% reported <10 hours of prior professional alcohol-related education and 78% had <2 hours exposure in the previous year. At 3-month follow-up, scores for self-reported confidence in ability, responsibility to intervene, and actual utilization of SBIRT skills all improved significantly over baseline. Gains decreased somewhat at 12 months, but remained above baseline. Length of time in practice was positively associated with SBIRT utilization, controlling for gender, race and type of profession. Persistent barriers included time limitations and lack of referral resources.

Conclusions: ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.     

Implementing Adolescent Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education in a Pediatric Residency Curriculum

Background: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care for adolescents as well as adults. In an effort to promote universal SBIRT, the Substance Abuse and Mental Health Services Administration awarded funding to residency programs to develop and implement SBIRT education and training. Our project focused on creating scientifically based, developmentally appropriate strategies and teaching materials for the adolescent age range. This paper describes curriculum development and implementation and presents evaluation data. Methods: Pediatric and child psychiatry residents were trained. The training consisted of 4 activities: (1) case-based teaching modules, (2) role-play of motivational interviewing and brief interventions, (3) mock interviews with trained adolescents, and (4) supervised “hands-on” screening and brief interventions. Main outcome measures included trainee satisfaction, and SBIRT knowledge, perceived self-efficacy, and self- and observer report of use of the SBIRT algorithm. Results: Among 150 total participants completing the SBIRT training modules, nearly all (92.3%) were satisfied/very satisfied with the training modules. Knowledge accuracy immediately post training was high, but declined significantly by the end of the first residency year, with little change across subsequent years of residency. Confidence ratings also declined over time. Use of the SBIRT algorithm during the Adolescent Medicine rotation was high according to trainee self- and faculty observer report. Conclusions: We found evidence of training satisfaction, increased confidence in talking to adolescents about substance use, and widespread use of recommended practices immediately following training. Use of a highly structured algorithm to guide practice, and simple, highly structured brief interventions was a successful training approach, as residents self-reported accurate use of the SBIRT algorithm immediately after training. Knowledge and self-confidence declined over time. It is possible that “booster” sessions and ongoing opportunities to review materials could help residents retain knowledge and skills.     

South Texas Residency Screening,Brief Intervention,and Referral to Treatment (SBIRT) Training: 12-Month Outcomes

Background: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. Methods: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009–2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. Results: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. Conclusions: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.     

Patient Perspectives on Buprenorphine/Naloxone: A Qualitative Study of Retention During the Starting Treatment with Agonist Replacement Therapies (START) Study

This study examines the barriers and facilitators of retention among patients receiving buprenorphine/naloxone at eight community-based opioid treatment programs across the United States. Participants (n = 105) were recruited up to three and a half years after having participated in a randomized clinical trial comparing the effect of buprenorphine/naloxone and methadone on liver function. Semi-structured interviews were conducted with 67 patients provided with buprenorphine/naloxone who had terminated early and 38 patients who had completed at least 24 weeks of the trial. Qualitative data were analyzed using the constant comparison method. Barriers to buprenorphine/naloxone retention that emerged included factors associated with: (1) the design of the clinical trial; (2) negative medication or treatment experience; and (3) personal circumstances. The facilitators comprised: (1) positive experience with the medication; (2) personal determination and commitment to complete; and (3) staff encouragement and support. The themes drawn from interviews highlight the importance of considering patients’ prior experience with buprenorphine/naloxone and methadone, medication preference, personal circumstances, and motivation to abstain from illicit use or misuse of opioids, as these may influence retention. Ongoing education of patients and staff regarding buprenorphine/naloxone, especially in comparison to methadone, and support from staff and peers are essential.     

Developing and Implementing a Multispecialty Graduate Medical Education Curriculum on Screening,Brief Intervention,and Referral to Treatment (SBIRT)

ABSTRACT

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed.     

Facilitators and Barriers to Implementing Screening,Brief Intervention,and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings

Background: Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization. Methods: Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish. Results: All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. Conclusions: Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.     

Psychometric validation of a growth Mindset and Team Communication Tool to measure self-views of growth mindset and team communication skills

ObjectiveThe objective of this study was to develop and conduct psychometric validation of a tool to assess self-views of a growth mindset and team communication skills among pharmacists.DesignThe Mindset and Team Communication Tool was developed to assess self-views of growth mindset and team communication. The survey consisted of 2 parts: (1) 14 items on growth mindset and (2) 13 items on team communication; a 4-point Likert scale of agreement was used as an option to answer all items.Setting and participantsThe survey was administered to first-year student pharmacists from 2017 to 2019. The participants completed a presurvey at the beginning of the semester and a postsurvey at the end of the semester (3-month follow-up period).Outcome measuresPsychometric validation was performed by assessing the following properties: face and content validity, internal consistency reliability, construct validity, test-retest reliability, responsiveness validity, and convergent validity.ResultsA total of 174 participants completed both the pre- and postsurvey (response rate = 92.7%). Internal consistency reliability demonstrated a Cronbach alpha coefficient of 0.827. Construct validity showed that all measures, except for 6 items, loaded highly onto 2 components. Test-retest reliability revealed a statistically significantly positive relationship between the pre- and postsurvey scores. Responsiveness validity demonstrated a statistically significant improvement in the score when an intervention was provided. Convergent validity showed no correlation between the tool score and course grades.ConclusionThe Mindset and Team Communication Tool demonstrated validity and reliability across a robust set of psychometric values and provides a foundation to describe pharmacists’ self-views and explore associations of these views with behavior in teamwork-based environments.     

The role of Chinese clinical pharmacists in parenteral nutrition for children using the Screening Tool Risk on Nutrititional Status and Growth (STRONGkids)

International Journal of Clinical Pharmacy - Background The abuse and deficiency of nutritional support coexist in China, and clinical pharmacists have responsibilities to promote the rational use...     

Correlation and validation of alternative methods to the Draize eye irritation test (OPAL project)

A multicentre study of alternative methods to the Draize eye irritation test, involving six different laboratories was organized by OPAL (Oeuvre Pour l'Assistance aux Animaux de Laboratoire). Forty chemicals (including solvents, surfactants, acids, bases, and others) were selected for testing by three methods, namely Griffith's test (a low-volume eye irritation test on rabbits), the hen's egg chorioallantoic membrane (HET-CAM) assay for the evaluation of hyperaemia, haemorrhage and coagulation, and neutral red uptake by SIRC cells for the assessment of cytotoxicity. Each method was used in two or three laboratories. Intralaboratory reproducibility was good for each laboratory with values, for error, close to 10%. Interlaboratory agreement was also good, particularly for the cell culture method, a quantitative and objective technique. Griffith's test correlated well with the Draize test (r = 0.846; n = 37), while for the HET-CAM test (r = 0.670; n = 32) and the cell culture method (r = 0.579; n = 32) the correlation was satisfactory. A more complete statistical analysis is currently under way to confirm and extend these preliminary findings.     

Implementing a Statewide Screening,Brief Intervention,and Referral to Treatment (SBIRT) Service in Rural Health Settings: New Mexico SBIRT

ABSTRACT

This is a report on the New Mexico Screening, Brief Intervention, and Referral to Treatment (SBIRT) project conducted over 5 years as part of a national initiative launched by the Substance Abuse and Mental Health Services Administration with the aim of increasing integration of substance use services and medical care. Throughout the state, 53,238 adults were screened for alcohol and/or drug use problems in ambulatory settings, with 12.2% screening positive. Baseline substance use behaviors among 6,360 participants eligible for brief intervention, brief treatment, or referral for treatment are examined and the process of implementation and challenges for sustainability are discussed.     

An experimental validation of pharmacological agents to arrest the vestibulo-autonomic syndrome (motion sickness)

The results of development and experimental evaluation of the efficiency of pharmacological means of cupping the vestibulo-vegetative syndrome in man are presented. A model and procedure of evaluation of pharmacological cupping of the Vestibulo-vegetative syndrome are developed. The intramuscular injection of the mixture containing ephedrine, promethazine hydrochloride and strychnine (25, 50, and 1 mg, respectively) appeared most effective.