The federal standard medication plan in practice: An observational cross-sectional study on prevalence and quality

BackgroundMedication plans are instruments used to document drug therapies, guide patients, and ensure medication safety. In Germany, patients who take at least 3 long-term medications are eligible to receive a medication plan. It has been statutory to use the federal standard layout (German: “Bundeseinheitlicher Medikationsplan”) since April 2017.ObjectivesThis study explores the prevalence, availability, medication discrepancies, and conformance with statutory regulations of medication plans since the introduction of the format of the federal standard medication plan in Germany.MethodsMedication reconciliation was performed for hospitalized patients according to the Best Possible Medication History principle. The collected medication lists were analyzed for medication discrepancies and conformance with the statutory regulations. The medication discrepancies were (1) omitted drugs, (2) additional drugs, and (3) dosing errors.ResultsAfter hospitalization, 524 patients taking drugs were included. The majority (n = 424 patients) were eligible for a medication plan. While 241 medication lists were present, only 24.1% (n = 58) matched the federal standard format. The mean number of drugs was 6.3 ± 3.6, with 3315 medications (3046 long-term and 269 as needed) reconciled totally. The 84 medication lists with omitted or additional drugs included 166 medication discrepancies upon 774 drugs listed. Of the 253 patients with dosing errors, 146 had a medication list. Inappropriate dosages were due to single dose (n = 195), daily dose (n = 225) or frequency of application (n = 255).ConclusionMedication plans are valuable tools for patients and health care providers. This study shows that the introduced paper-based federal standard medication plan in Germany falls short of its expectations regarding availability and correctness. Switching to an electronic patient record system may overcome some of the current pitfalls.     

Integrating pharmacists into Aboriginal Community Controlled Health Services (IPAC project): Protocol for an interventional,non-randomised study to improve chronic disease outcomes

BackgroundAboriginal and Torres Strait Islander peoples experience a higher burden of chronic disease yet have poorer access to needed medicines than other Australians. Adverse health outcomes from these illnesses can be minimised with improved prescribing quality. This project aims to improve quality of care outcomes for Aboriginal and Torres Strait Islander adult patients with chronic disease by integrating a pharmacist within primary health care teams in Aboriginal Community Controlled Health Services (ACCHSs).MethodologyThis non-randomised, prospective, pre and post quasi-experimental study, will be pragmatic, community-based and participatory, comparing outcomes and costs using paired patient data. Pharmacists will be integrated at 22 sites for approximately 15 months to conduct patient-related and practice-related activities through 10 core roles: providing medication management reviews, assessing adherence and medication appropriateness, providing medicines information and education and training, collaborating with healthcare teams, delivering preventive care, liaising with stakeholders, providing trnsitional care, and undertaking a drug utilisation review. With patients’ consent, de-identified client-level data will be extracted from clinical information systems and pharmacists will record deidentified activity in an electronic logbook. Primary expected outcomes include improvements in biometric indices (glycated haemoglobin, systolic and diastolic blood pressure, lipids, cardiovascular risk, albumin-creatinine ratio) from baseline to end of study. Expected secondary outcomes include improvements in estimated glomerular filtration rate, prescribing indices (appropriateness, overuse and underuse), medication adherence, self-assessed health, and health service utilisation indices. A qualitative assessment of stakeholder and patient perceptions and a cost-effectiveness analysis will be undertaken.DiscussionNumerous inquiries have recommended evaluating the impact of pharmacists integrated within primary health care settings. This study is the first to explore this impact on the health of Aboriginal and Torres Strait Islander peoples who are medically underserved. Evaluation of innovative integrated workforce models is necessary to address the challenges of delivering quality care together with this population.     

临床药师参与治疗管理对门诊2型糖尿病合并高血压患者 血压控制的影响*

目的:探究临床药师参与治疗管理及对门诊Ⅱ型糖尿病合并高血压患者血压控制的作用。方法:纳入2017年6月至2018年6月500例心内科门诊Ⅱ型糖尿病合并高血压患者,随机分为对照组和药师干预组,各25例。对照组完成常规诊疗流程,每月电话咨询其药物使用情况;药师干预组现场记录患者一般情况,与医生讨论处方优化并决定是否执行,对患者进行用药指导。就诊后1个月内每2周随访1次,其后每4周随访1次,随访期间药师可根据情况与医生讨论是否调整降压方案并作出最终决定,患者根据药师建议或自己意愿回医院随诊,随访时间1年。主要终点事件为12个月后血压≤130/80 mmHg;次要终点事件为药物调整情况、药师建议采纳率、药物持有率(评估患者依从性)。结果:最终378例完成随访。对照组68名(36.4%)及干预组152名(79.6%)患者血压≤130/80 mmHg,P<0.01;干预组收缩压与舒张压降幅显著>对照组(P<0.01)。对照组药物调整35次,干预组调整129次,药师建议采纳率为85.18%。1年后,对照组药物持有率为0.22±0.04,干预组为0.77±0.11,P<0.01。结论:临床药师参与治疗管理有助于优化降压方案,提升用药依从性,提高了门诊Ⅱ型糖尿病合并高血压患者的血压控制达标率。     

Medication overuse headache: Updating of the French recommendations regarding the treatment strategies

Regular and frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic migraine or medication-overuse headache (MOH). The one-year prevalence of this condition is between 1% and 2% in Europe, provoking substantial burden. MOH is more prevalent in people with comorbid depression, anxiety, and other chronic pain conditions. This paper aims at presenting an updating of French recommendations regarding treatments strategies. Prior French recommendations, published in 2014, were written in French. A literature search in the major medical databases including the terms “medication overuse headache”, “symptomatic medication overuse”, published between 2010 and 2020 was carried out. Three main strategies can be recommended and conducted in parallel: education and explanations about the negative consequences of overusing acute antimigraine drugs, discontinuation of the overused medication, and finally, preventive drug therapy and non-pharmacological prevention. Medication overuse headache remains a debated problem and evidence for the most effective treatment strategy is needed.     

Learning to Synchronize: Midfrontal Theta Dynamics during Rule Switching

In recent years, several hierarchical extensions of well-known learning algorithms have been proposed. For example, when stimulus-action mappings vary across time or context, the brain may learn two or more stimulus-action mappings in separate modules, and additionally (at a hierarchically higher level) learn to appropriately switch between those modules. However, how the brain mechanistically coordinates neural communication to implement such hierarchical learning remains unknown. Therefore, the current study tests a recent computational model that proposed how midfrontal theta oscillations implement such hierarchical learning via the principle of binding by synchrony (Sync model). More specifically, the Sync model uses bursts at theta frequency to flexibly bind appropriate task modules by synchrony. The 64-channel EEG signal was recorded while 27 human subjects (female: 21, male: 6) performed a probabilistic reversal learning task. In line with the Sync model, postfeedback theta power showed a linear relationship with negative prediction errors, but not with positive prediction errors. This relationship was especially pronounced for subjects with better behavioral fit (measured via Akaike information criterion) of the Sync model. Also consistent with Sync model simulations, theta phase-coupling between midfrontal electrodes and temporoparietal electrodes was stronger after negative feedback. Our data suggest that the brain uses theta power and synchronization for flexibly switching between task rule modules, as is useful, for example, when multiple stimulus-action mappings must be retained and used.SIGNIFICANCE STATEMENT Everyday life requires flexibility in switching between several rules. A key question in understanding this ability is how the brain mechanistically coordinates such switches. The current study tests a recent computational framework (Sync model) that proposed how midfrontal theta oscillations coordinate activity in hierarchically lower task-related areas. In line with predictions of this Sync model, midfrontal theta power was stronger when rule switches were most likely (strong negative prediction error), especially in subjects who obtained a better model fit. Additionally, also theta phase connectivity between midfrontal and task-related areas was increased after negative feedback. Thus, the data provided support for the hypothesis that the brain uses theta power and synchronization for flexibly switching between rules.     

Exploring caregiver understanding of medications immediately after a pediatric primary care visit

Objective

Assess accuracy of caregiver understanding of children's prescribed medications and examine factors associated with accurate recall.

Methods

Cross-sectional, observational study of English- or Spanish-speaking caregivers of primary care patients aged 0–7 years. Child and visit characteristics and caregiver health literacy (Short Test of Health Literacy in Adults) were assessed. Post-visit, caregivers completed questionnaires on medications prescribed. Caregiver and medical record agreement on medication name and administration (dose and frequency) were examined using chi square and logistic regression.

Results

Analyses included 68 caregivers (28% low health literacy); 96% of children had public insurance. Caregivers indicated that the doctor provided clear medication information (100%) and they could follow instructions (98%). 101 medicines were prescribed; 6 were recalled by caregiver only. 71% of medications were accurately named; 37% of administration instructions were accurately recalled. Accurate naming was more often found for patients 3–7 years, without conditions requiring repeat visits, and new medications. Accurate administration responses were associated with having only 1 child at the visit.

Conclusion

Unperceived medication instruction understanding gaps exist at physician visits for caregivers of all literacy levels. Communication and care delivery practices need further evaluation.

Practice implications

Clinicians should be aware of the frequency of caregiver medication misunderstanding.     

Development and validation of the General Health Numeracy Test (GHNT)

Objective

Because existing numeracy measures may not optimally assess ‘health numeracy’, we developed and validated the General Health Numeracy Test (GHNT).

Methods

An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity.

Results

On average, participants were 55.0 ± 13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39 K with 14.4 ± 2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20 = 0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p < .001). Furthermore, both versions were associated with participants’ understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses.

Conclusions

The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy.

Practice implications

Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.