The Tracey Ullman Patient Compliance Videos

04-15-2008 | Categories:

Patient Education Goes Bollyhood




Once again, AlignMap takes patient education from the sad and drab ghetto of mainstream materials to the fab world of entertainment.

Check out Tracey Ullman’s conceptualization of patient counseling performed by the pharmacist.





Related Posts:

Another Reason The Personal Medication Record Is Essential

11-25-2007 | Categories:

The Safety Issue and The Personal Medication Record

While my recent posts on the Personal Medication Record focused on its utility as a tool to decrease unintentional noncompliance,1 the medication list also serves as an important safety function, as explained in What Medications Does Your Patient Take? Enhancing Medication Safety in the Outpatient Setting, an article published on the Institute for Healthcare Improvement web site.

I’ve included some excerpts to give a flavor of the essay:

… we recognized that the need for accurate information about a patient’s medication spans the continuum and shouldn’t be limited to the inpatient setting.
Indeed, inpatient and outpatient health care professionals rely on each other’s records as patients cross back and forth between care settings. It’s important, for example, for emergency department (ED) staff to know what medications a patient has been taking when he or she arrives for emergency care. And depending on the circumstances, patients arriving at the ED aren’t necessarily the best source. They may not be in a condition to communicate or remember accurately, and patients who do carry their medication lists with them may not have a list that is up to date.
Patients may assume all providers have access to the same information, regardless of the setting, and are often surprised to learn that this goal has yet to be realized. Records aren’t always immediately accessible, and clinicians who see a lot of patients may not have systems in place to quickly update and transmit large amounts of data.
While medication errors in the outpatient setting are harder to measure, in its 2006 report, Preventing Medication Errors, the IOM estimates that about 530,000 medication-related injuries occur annually just among Medicare recipients at outpatient clinics.
Launched in October 2006 after a pilot phase, the project seeks to improve communication about medications between patients and providers, and also among providers, through the use of a paper medication list (called the Med List) that patients maintain and regularly review with their providers.
Effie Brickman, Director of the Ambulatory Medication Safety Project at the Massachusetts Coalition for the Prevention of Medical Errors, says that the Med List helps improve medication safety in three ways.

First, the Med List gives patients a single place to write down all their medications, regardless of how many pharmacies they use. Space is provided to list both prescribed and over-the-counter medications, any herbal, vitamin or dietary supplements they are taking, along with start and stop dates, the purpose of each medication, possible danger signs, and if monitoring is required.

Second, because patients are encouraged to bring the list to each medical appointment, there’s a built in prompt and reference for discussing everything on it, including medications a patient used to take. And third, the Med List enables providers to reconcile the patient’s list with the information in the medical record, looking for omissions, duplications, and potentially problematic interactions.

Putting the patient in charge of creating and maintaining an accurate medication list reflects two things, one a problem, the other an opportunity: the difficulty that physicians’ offices have coordinating information in a fragmented system where electronic record-keeping and reliable communication is still not the norm, and the impact of the movement toward more patient-centered care that seeks to give patients more access to information and involvement in decision making.

Brickman says the practices that tested and helped refine the Med List during the pilot phase often revealed important information. “The biggest surprise for most doctors was how many patients thought the physician already knew all the medications the patient was taking, even those prescribed by other physicians. Physicians also learned how patients were thinking about and using their medications,” says Brickman. “One doctor learned that some patients didn’t consider birth control pills to be medication, for example. And other patients didn’t think it was important to report use of herbal and over-the-counter medications. Doctors do want to know this information because herbals and over-the-counter drugs sometimes negatively interact with prescription medications.”


Additional Sources

The Massachusetts Coalition has developed materials closely related to What Medications Does Your Patient Take? Enhancing Medication Safety in the Outpatient Setting. These include letters to patients, providers, and pharmacists to give patients and families useful tips for using medications wisely, and to inform providers and pharmacists about specific actions required to ensure patient health and medication safety:

Med List Letter to Patients
Med List Letter to Providers
Med List Letter to Pharmacists



Footnotes


  1. The Alignmap posts dealing with Personal Medication Record include

    [back]




Related Posts:

Many Losers In Patient Medication Quiz

10-15-2007 | Categories:


Patients Unable to Provide Names of Their Medications

This post started out as another of those How About That? items.

This news release version of a study to be published in the November issue of the Journal of General Internal Medicine resolves to a single punchline,

Almost 40% of 119 patients taking blood pressure medication
in three clinics could not accurately recall the drugs they were taking.


Commentary

Those familiar with AlignMap posts on health literacy1 will not find that result (nor the additional fact that the “number jumped to 60 percent for those with low health literacy”) surprising.

This is a specific area within patient compliance - noncompliance by error - that, it would seem, could be directly addressed by treatment plan presentation protocols, technology, and didactic efforts. And, in fact, I have come across some promising ideas lately.

Consequently, the next AlignMap posts will deal with pragmatic tips for decreasing medication noncompliance by error with methods now available.

How about that?



Source: Name that drug: Many patients can’t



Foonotes


  1. AlignMap posts focusing on health literacy include, among others, including Health Literacy , Medication Leaflets, and The Gap Betwixt, Persistent Themes: Health Literacy and Incentive Plans, Health Literacy: A Clear Problem Without A Clear Solution, and Healthcare Illiteracy Linked To Higher Mortality Among Elderly [back]



Related Posts:

Healthcare Illiteracy Linked To Higher Mortality Among Elderly

07-25-2007 | Categories:

Health Literacy and Mortality Among Elderly Persons
David W. Baker, MD, MPH; Michael S. Wolf, PhD, MPH; Joseph Feinglass, PhD; Jason A. Thompson, BA; Julie A. Gazmararian, PhD; Jenny Huang, PhD. Arch Intern Med. 2007;167:1503-1509.


The Study

The study looked prospectively at 3260 Medicare managed-care enrollees in 4 US metropolitan areas who were interviewed in 1997 to determine their demographic characteristics, chronic conditions, self-reported physical and mental health, and health behaviors. Participants also completed the shortened version of the Test of Functional Health Literacy in Adults. Main outcome measures included all-cause and cause-specific (cardiovascular, cancer, and other) mortality using data from the National Death Index through 2003.

Results

The crude mortality rates for participants with adequate (n = 2094), marginal (n = 366), and inadequate (n = 800) health literacy were 18.9%, 28.7%, and 39.4%, respectively (P less than .001). After adjusting for demographics, socioeconomic status, and baseline health, the hazard ratios for all-cause mortality were 1.52 (95% confidence interval, 1.26-1.83) and 1.13 (95% confidence interval, 0.90-1.41) for participants with inadequate and marginal health literacy, respectively, compared with participants with adequate health literacy. In contrast, years of school completed was only weakly associated with mortality in bivariate analyses and was not significant in multivariate models. Participants with inadequate health literacy had higher risk-adjusted rates of cardiovascular death but not of death due to cancer.


Commentary

Adherence to treatment for chronic illnesses such as asthma, diabetes and heart disease can be difficult in the best of circumstances. For those with literacy problems, following a treatment plan that goes beyond “take the blue pill twice a day” may prove impossible without extensive and expensive assistance. And, as this study indicates, the inability to follow treatment instructions is deadly.

While campaigns to end illiteracy may be a long term solution, the immediate problem of millions of individuals who today cannot comprehend written medical information should prompt further work in alternative means of communicating this information.





Related Posts:

Results Of Differing Methods Of Communicating Treatment Benefits To Patients

07-18-2007 | Categories:

Different Ways to Describe the Benefits of Risk-Reducing Treatments Peder A. Halvorsen, MD; Randi Selmer, PhD; and Ivar Sonbo Kristiansen, MD, PhD, MPH. Ann Intern Med, June 19, 2007; 146(12): 848-856

Knowing Number Needed to Treat May Help Patients Consent to Treatment Interventions News Author: Laurie Barclay, MD; CME Author: Charles Vega, MD; Medscape: June 20, 2007. CME1

The Study

Excerpted from abstract:

The survey presented scenarios regarding a hypothetical drug therapy to reduce the risk for heart attacks (1754 respondents) or hip fractures (1000 respondents). The data sources for both scenarios were clinical trials. Respondents were randomly assigned to a scenario with 1 of 3 outcomes after 5 years of treatment. For the drug to prevent heart attacks, the outcomes were postponement by 2 months for all patients, postponement by 8 months for 1 of 4 patients, or an NNT of 13 patients to prevent 1 heart attack. For the drug to prevent hip fractures, the outcomes were postponement by 16 days for all patients, postponement by 16 months for 3 of 100 patients, or an NNT of 57 patients to prevent 1 fracture. … The overall rate of response to the survey was 81%. In the heart attack scenarios, 93% of respondents who were presented with the NNT outcome consented to drug therapy, 82% who were presented with the outcome of large postponement for some patients consented to therapy, and 69% who were presented with the outcome of short postponement for all patients consented to therapy (chi-square, 89.6; P less than 0.001). Corresponding consent rates for the hip fracture scenarios were 74%, 56%, and 34%, respectively (chi-square, 91.5, P less than 0.001). Respondents who said that they understood the treatment effect were more likely to consent to therapy.


Commentary

Summarizing their results, the study’s authors write

Treatment effects expressed in terms of NNT yielded higher consent rates than did those expressed as equivalent postponements. This result suggests that the description of the anticipated outcome may influence the patient’s willingness to accept a recommended intervention.

While the difficulty of communicating statistically valid information about possible outcomes to medical professionals as well as patients has long been recognized, this study is valuable for its emphasis on the impact this process has on treatment decisions made by the patient.

On the other hand, I am not convinced that the specific results (e.g., that using the number needed to treat results in higher consent rates than postponement of events) has been proven by this study’s use of hypothetical scenarios rather than actual clinical situations, especially when the patients’ understanding of the scenarios is unclear.

I do agree with the editorial by Harold C. Sox, MD, in the same issue of Annals of Internal Medicine,

Halvorsen and colleagues’ findings are welcome because they remind us about framing effects and show how they could affect decisions about preventative interventions. They show that it is hard to communicate the risk for events realistically and without biasing our patients. Hopefully, this reminder will stimulate researchers, medical students, and practicing physicians.

Because it is beyond the legitimate scope of the article, an important issue on which this editorial statement touches but does not elaborate is the ethics of framing information. It is by no means certain, for example, that increasing the proportion of patients agreeing to treatment is necessarily the “good outcome.”



Footnotes


  1. CME Valid for credit through June 20, 2008. Credits Available: Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians; Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians. See CME Information [back]



Related Posts:

HIV Treatment Adherence Resources

06-21-2007 | Categories:



HIV InSite:
HIV/AIDS Information Source



HIV InSite, developed by the Center for HIV Information at the University of California San Francisco, aspires to provide free, anonymous access to “comprehensive, in-depth HIV/AIDS information and knowledge,” including an extensive Knowledge Base and other on-site materials as well as thousands of links to to other web sites.


HIV InSite Treatment Adherence References Index

On a single web page, Adherence to HIV Antiretroviral Therapy: Related Resources, HIV InSite lists annotated links to selected pertinent

  • Knowledge Base Chapters
  • Journal Articles
  • Policy Reports, Papers, and Briefs
  • Presentations, Interviews, and Roundtable Discussion
  • Online Books and Chapters
  • Newsletter Articles
  • Slide Sets
  • Program Management Materials
  • Patient and Community Education
  • Patient Information Sites

This index is available at
~Adherence to HIV Antiretroviral Therapy: Related Resources~


Commentary

The resources listed are extensive and many are immediately recognizable as frequently cited and highly regarded references.

That said, some improvements could increase the value of this index.

  • Updating The Listing: This morning, the Resources web page carries the legend, “Content reviewed July 2005,” although many of the articles were published in 2006. That apparent discrepancy should be clarified. More significantly, an accurate “Last revised” date should be listed for the benefit of those using this index. If no articles published in the past year are listed, one shouldn’t have to guess whether that is the consequence of a judgment that older references serve the reader’s purpose better than more recent publications or the result of the list lying dormant for that time. Also, some links are broken (e.g., Adherence to Potent Antiretroviral Therapy, in: Guidelines for the Use of Antiretroviral Agents Among HIV-Infected Adults and Adolescents)
  • More useful annotations: Currently, many annotations are no more than citations. The reader should have at least enough information to know why a given article or reference is listed. For example, the first item is Antiretroviral Drug Profiles, a heading which leaves the information’s pertinence to adherence a matter of speculation. Do those profiles contain compliance rates? Are they provided to inform one of factors that might affect adherence, such as side-effects or dosing schedules?
  • Provision of criteria for selection: The range of material listed is so varied that the qualification standards are not apparent. Even if these were chosen based on a group’s personal preferences, that should be known to the reader.
  • Notice of special costs: While the mission of InSite specifies “free” access, some of the links connect to brief abstracts of limited utility while the full articles are available only to those with subscriptions or willing to pay extra fees (e.g., A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART).). That is acceptable, but it would be helpful if those fees were mentioned in the link’s annotation.
  • Differentiation of commercial vs academic sites: Some of the links are connected to for-profit web sites (e.g., The annotation of the link to e-pill.com is limited to “Offers a range of interesting medication adherence/compliance tools for patients”). Again, this is acceptable, but it would be helpful if that were indicated in the annotations.

None of these issues negate the value of the materials listed at ~Adherence to HIV Antiretroviral Therapy: Related Resources~; taking these relatively simple steps, however, would further enhance the utility of this resource page.




Related Posts:

Prescription Information Not Given In Patient's Language

05-01-2007 | Categories:

A Patient Compliance And Literacy Problem
Or A Failure In The Healthcare System?


Introduction

Despite federal mandates to translate prescriptions,1 the technical capacity to do so, and the rather obvious clinical need for prescription information in the language of non-English speaking patients , many pharmacies in New York City do not provide translated labels,according to an April 27, 2007 presentation by Linda Weiss, PhD, at the annual meeting of the Society for General Internal Medicine held in Toronto, Ontario, Canada.



As Dr. Weiss notes:

Inadequate comprehension of medical instructions is associated with poor adherence and negative health outcomes, which may include adverse events and drug resistance. Research suggests that limited English proficient (LEP) patients do have poorer knowledge of medication and dosing instructions and that they have significantly greater problems with medication adherence. The provision of oral and written medication information in the patients’ language has been linked to improvements in health outcomes.

Study Parameters and Results

Of the 2186 New York City pharmacies licensed in 2006, 200 pharmacies were surveyed.

Although 88% of surveyed New York City pharmacists reported serving LEP customers daily, and 80% reported that they had the capability to translate labels, only 34% reported translating labels daily, and an additional 26% reported never translating labels.

“Health literacy is the strongest predictor of a person’s health status,” Ann Zweber, RPh, director of assessment and senior instructor of pharmacy practice at Oregon State University in Corvallis, told Medscape in response to a request for independent commentary. She was not involved with this study.

“If patients do not understand their medical condition and how to manage it, including how to use their medications, they are more likely to suffer from poor health outcomes,” Dr. Zweber said.

Translation Capacities

Of the New York City pharmacists surveyed, 77% reported the ability to print labels in Spanish; 12% said they could print labels in Chinese, Russian, or other languages; and 52% acknowledged that they could provide translated patient information sheets. However, barriers to improved language access cited by pharmacists included the need for additional translation tools (24%), lack of bilingual personnel (20%), insufficient time (7%), and cost constraints (7%). Five percent reported legal concerns that they would be held liable if they printed medication information in a language foreign to them and failed to spot errors in translation.

Even those pharmacists who provided translated printed information did so only when they happened to notice a patient having difficulty with English (54%) or if specifically asked (33%). Less than 20% of the pharmacies surveyed had protocols to systematically identify patients who need might need translated labels; less than 10% had signs indicating that translated materials were available.


Commentary

First, I recommend reading the article, which also includes speculation about the reasons pharmacies appear less likely than other healthcare providers to offer translated information, thoughts about informal strategies by some pharmacies to provide patients information in their own language, and services being developed to provide more sophisticated and specialized translation services.

Although, as the authors note, the research has limitations,2 its revelation that a large proportion of a randomly selected sampling of pharmacies lacked a systematic means of providing clinical information to a patient in his or her own language is astounding. My contention, in fact, is that this problem transcends issues of patient compliance and patient literacy.

Conceptualizing a patient as noncompliant because of a failure to following instructions provided in a language that patient doesn’t comprehend may meet some technical definition of compliance but certainly has little in common, for example, with a patient who unilaterally changes a medication dose because of side-effects or another who never has a prescription filled because of distrust of doctors.

Similarly, a recent immigrant who speaks only Spanish may somehow be described as functionally illiterate in an environment dominated by users of the English language, but describing the problem in terms of “health illiteracy” risks misrepresenting the problem as a deficit on the part of the patient when, given the rather easy availability of translation software, the primary responsibility rests upon the pharmacies.

As one of those doctors who are reflexively resistant to government “interference,” I have fastidiously looked to - well, to anyone else but government solve problems in the healthcare system. In this case, however, I am foursquare in favor of an approach that first addresses enforcement of the altogether reasonable regulations that all healthcare providers, including pharmacies, provide materials translated into an language understood by the patients served.3



Source: Pharmacies May Not Always Translate Prescription Labels for Non-English Speaking Patients Laurie Barclay, MD Medscape Medical News 2007.


Footnotes


  1. All healthcare providers receiving federal funds are, by legislation, required to offer language services to limited English proficient patients [back]
  2. E.g., the data were collected “through a relatively brief telephone survey (shorter than 5 minutes), preventing probing any item in detail; and reliance on self-report, which most likely biases the findings toward overestimation of pharmacy translation practices.” [back]
  3. Yes, the regulations must be practical. Not every pharmacy in southwest Missouri can provide labels written in an obscure dialect spoken only by the last 83 members of an isolated tribe living on a tributary of the Amazon. That kind of exception, however, should not be confused with a New York pharmacy not offering prescription levels in Spanish. [back]



Related Posts:

Compliance With Brief Physician Interventions

04-25-2007 | Categories:



The Value of Brief Physician Interventions

Source: Kaner EFS, et al. Effectiveness of brief alcohol interventions in primary care populations (Review). The Cochrane Database of Systematic Reviews 2007, Issue 2.

As is often the case, this chief virtue of this Cochrane Review is its authoritative confirmation of a concept already verified by several studies.

After reviewing 21 randomized controlled trials with 7,286 participants, Eileen Kaner, the lead author, summarized the findings thusly:

The study confirms that relatively short and simple interventions can be quite significant in terms of reducing drinking in the general population

More specifically, the results indicated that a single, brief intervention, typically as short as five minutes, decreased alcohol intake by an average of four drinks per week.

The target group consisted of patients who were heavy drinkers but not alcoholics.


Commentary

While the Cochrane Review dealt with alcohol use, parallel studies (although not a Cochrane Review) have demonstrated that brief interventions can have positive effects on smoking.

My clinical stance, equally influenced by cynicism and pragmatism, has been that, given the catastrophic risks of smoking and excessive drinking and the brief amount of time required for such an intervention, even a success rate as small as, say, 5% justified, if not mandated, that these issues be addressed in the office. This Cochrane Review reaffirms that notion.

One result of patient compliance is rendering treatment outcome somewhat of a numbers game. Just as more sales calls result in more sales and more at-bats result in more base hits (assuming the participants are competent), the more patients to whom a clinician recommends a decrease in drinking or a cessation of tobacco use, the more successful clinical outcomes.

And, we now know that those recommendations can be made efficiently without sacrificing effectiveness.




Related Posts:

Connection Between Knowledge and Compliance Unclear

04-12-2007 | Categories:

Primary Source: Family history of diabetes, awareness of risk factors, and health behaviors among African Americans. Baptiste-Roberts et al. Am J Public Health. 2007 Mar 29

Secondary Source: Better Diabetes Awareness Doesn’t Equal Better Habits for Some Blacks
Glenda Fauntleroy Health Behavior News Service



The Study

The study population consisted of 1,122 African-American adults, none of who was diagnosed with diabetes but 36 percent of whom reported that an immediate family member had type 2 diabetes.

Among that subgroup with a family history of diabetes, “nearly 60 percent had a better-than-average awareness of the diabetes risk factors” compared to 47 percent of the the control group (no family history of diabetes) who history demonstrated that level of awareness.”1

This larger proportion of individuals with family histories positive for diabetes, aware of the risk factors was not reflected in positive health behaviors. For example,

More than 75 percent of the participants were aware that being overweight increases the risk of diabetes. But, of the 65 percent who were overweight, only 32 percent were trying to lose weight.

Possible reasons proffered for this discrepancy and corrective actions recommended included:

  • Some reasons for this difference could be that people may not be aware of national standards used to define overweight and obesity. Furthermore, it has been shown in several studies that there may be a greater acceptance of a heavier body size among African-Americans.
  • One approach would be to improve awareness of health risks associated with being overweight or obese and accurate perceptions of defining overweight and obesity. This could be accomplished by national campaigns, community activism and policy approaches.
  • People who are overweight are “definitely aware that being overweight is unhealthy, but may not be able to name a specific risk.
  • Education is part of the answer. But what we really have to do is make it environmentally and educationally appealing to change behaviors, not just for diabetes, but for most chronic health conditions.


On the other hand, those subjects with diabetic family members were more likely to consume 5 or more servings of fruits and vegetables per day and to have been screened for diabetes.

Commentary

This article is one more indication that informing a patient about his or her disorder and its treatment is insufficient to assure adherence to treatment.

It is notable that the conclusion of the primary article itself is African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease while the review of that article, using the same data, observed that a patient’s greater awareness didn’t necessarily translate into healthy behavior.

Perhaps the most useful take-home message is the observation of Kate Lorig, R.N., a professor at Stanford University’s Patient Education Research Center,

Education is part of the answer, but what we really have to do is make it environmentally and educationally appealing to change behaviors, not just for diabetes, but for most chronic health conditions.



Footnotes


  1. The awareness scored was based on participants being shown “a seven-item list and asked whether any of the factors increase a person’s risk of developing diabetes. All seven items on the list are risk factors for diabetes — minority race or ethnicity, overweight, family history of diabetes, sedentary lifestyle, older age, high-calorie diet and diabetes during pregnancy.” [back]



Related Posts:

Health Literacy, Medication Leaflets, and The Gap Betwixt

03-29-2007 | Categories:

A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines1

DK Raynor, A Blenkinsopp, P Knapp, J Grime, DJ Nicolson, K Pollock, G Dorer, S Gilbody, D Dickinson, AJ Maule and P Spoor. Health Technology Assessment 2007; Vol 11:number 5





Medication Information Leaflets Fail To Meet Patient Needs

This monograph is the culmination of a review of 70 studies2 concerning patient medication information published in the United Kingdom, Europe, Australia and the United States, two patient workshops convened specifically for this report, and a survey of the expert literature on information design.

Because the heterogeneity of the studies precluded data pooling and synthesis, the monograph elaborates on the primary source information for nearly 200 pages, but the findings can be summarized in a few lines:

  • Patients consistently report that leaflets provided with prescription medications do not meet their needs
  • The leaflets do not improve patient understanding of their medications
  • Patients express the desire for information that better helps them evaluate pros and cons of a specific medication
  • Patients value the idea of information that is tailored, set in the context of the particular illness of the individual patient
  • Patients want written information in addition to — not instead of — spoken instructions from their health care professionals
  • No evidence was found that the information affected patient satisfaction or affected compliance
  • Patients do not see improving compliance as a function of the leaflets (an informed decision not to take a medicine is an acceptable outcome); many healthcare professionals, in contrast, view increasing compliance as a primary goal of the leaflets

Further, according to the Partnership for Clear Health Communication, nearly half of all American adults have difficulty understanding and using health information. In fact, the organization says, literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level or racial/ethnic group.

An unanswered question is the means by which to convey the likelihood of benefits and adverse drug effects. Colloquial descriptors such as “rare” or “common” are viewed as too vague to be useful, but terminology more typical of the professional literature such as percentages or “numbers needed to treat” often proves confusing to patients.

Not only is the text faulty but, according to the studies, the design and layout make navigation problematic, especially in the United States.

Recommendations, primarily culled from information design textbooks, include

  • Use short, familiar words and short sentences
  • Use short headings that stand out
  • Use the largest possible type size
  • Leave plenty of white space
  • Use bullet points to organize lists


Commentary

I suspect that few individuals who have tried to read the information provided with medications will find any surprises in the conclusions of this review.

The only addition I suggest (and it may have been covered in some of those 200 pages that I haven’t read) is that the print on the leaflets should be large enough and contrast enough with the background for the typical over-50 individual  adult with just a tad of presbyopia to read without the necessity of finding his reading glasses.

It is a superfluous but irresistible observation that the recommendations are little different than my 9th grade English teacher’s instructions on writing essays and need to be applied in many other areas as well as drug leaflets (software Help dialogs, toy assembly directions, and blogging guidelines come to mind).


Implications For Patient Compliance

Finally, I am especially taken with this finding,

Patients do not see improving compliance as a function of the leaflets (an informed decision not to take a medicine is an acceptable outcome); many healthcare professionals, in contrast, view increasing compliance as a primary goal of the leaflets

I would maintain that this dichotomy of views speaks to the meaning of patient compliance as well as (or perhaps rather than) the purpose of medication leaflets.

This disparity resonates with what I’ve written before (for example, in How To (Correctly) Not Take Medications As Prescribed) about the problem of directly or indirectly coercing even “empowered patients” to follow instructions and the need to extend patient compliance to include the patient communicating to the clinician the decision not to take a prescribed medication.

Clarifying the purpose of medication leaflets as information for decision-making by the patient rather than propaganda to persuade the patient to follow orders seems an ideal step in redefining patient compliance into a clinically useful concept.

Just a thought.



Footnotes


  1. This is the link to the Executive Summary of this monograph. The PDF of the full monograph as well as the PDF of the Executive Summary can be viewed or downloaded from this site. [back]
  2. From over 50,000 citations, 413 were considered. Of these, 64 papers reporting 70 studies were included [back]



Related Posts:

Training Couples Improves Compliance With Melanoma Screening

03-28-2007 | Categories:


Examination of mediating variables in a partner assistance intervention designed to increase performance of skin self-examination

Robinson JK, Turrisi R, Stapleton J, Journal of the American Academy of Dermatology- 2007 03 (Vol. 56, Issue 3) Published online 12 December 2006.






Robinson and colleagues, who had previously demonstrated that patients at risk for melanomas who were trained together with their significant others to perform a skin self-examination (SSE) were more likely to perform the exams as scheduled than those who were trained alone, undertook this study to discover the reasons for that differentiation.

130 participants drawn from a melanoma hospital registry were randomly assigned to a solo-learning control group (n = 65) or a partner-learning group (n = 65). The intervention was a 10-minute educational presentation and skills training session based on the ABCDE rule of early melanoma detection. The main outcome measure was SSE performance as measured by use of a body map.

The mediators measured included

  • Attitudes toward SSE
  • Self-efficacy/confidence in the ability to effectively perform SSE
  • Comfort with having a partner help with SSE
  • Perceived melanoma/skin cancer risk
  • Concern about developing skin cancer/skin damage
  • Melanoma/skin cancer knowledge

Of these, the most significant mediators were found to be

  • Attitudes toward SSE
  • Self-efficacy
  • Comfort with having a partner help with SSE
  • Concern about developing sun-damaged skin

The conclusions, as excerpted from the abstract, follow:

Involvement of a partner in the SSE skills training was more effective than solo learning because of the changes in the above-mentioned mediators. Future SSE skills training programs could benefit through using approaches that produce changes in key variables such as increasing attitudes toward SSE, increasing self-efficacy beliefs in the ability to perform SSE, and making participants feel confident in their ability to examine their skin.


Commentary

That training in medical self-examination is enhanced by partner-oriented rather than solo instruction is intuitively appealing and has far-reaching implications.

Nonetheless, a more rigorous evaluation of the consequences of this improvement would seem to be in order; i.e., do these patients who are trained as couples actually find a higher percentage of potential lesions over time than those trained individually? The clinical trials thus far appear to be a good start, not a finished product.




Related Posts:

Using Pictoral Aids To Enhance Medication Compliance

03-26-2007 | Categories:

The PicturRx Prescription Picture Cards



Improving Patient Comprehension Of Medication Instructions

PictureRx1 has a simple solution to one possible cause of medication noncompliance: the inability of some patients to understand instructions about taking their prescribed drugs.

PictureRx produces graphical cards, such as the one pictured above, for each patient with a photo of each medication taken by that patient, instructions on the medication schedule and dosage, and an explanation of the purpose of that medication. While prose is included, the emphasis appears to be on conveying as much information as possible by the use of graphical elements.

This excerpt from the PictureRx web site identifies the rationale for this methodology.

Studies have found that low literacy contributes to poor or incorrect use of medications.
• Nearly half (47%) of adult Americans lack adequate literacy skills.
• Low literacy increases annual health care costs by over $1500 per person.
• Limited literacy skills lead to incorrect medication usage. 42% of patients in two public hospitals could not understand instructions to take medication on an empty stomach; the American Medical Association estimates that only 50% of patients take medication as directed.

This abstract elaborates the same concept:

Katz, Marra G.; Kripalani, Sunil; Weiss, Barry D. Use of pictorial aids in medication instructions: A review of the literature. American Journal of Health-System Pharmacy. 63(23):2391-2397, December 1, 2006.

[Note: At least one of the authors "serves as a consultant to and holds equity in PictureRx, LLC"]

Abstract:
Purpose: The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.

Summary: Many patients depend on medication labels and patient information leaflets for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients’ satisfaction with medication instructions.

Conclusion: The use of pictorial aids enhances patients’ understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.

Commentary

As previously noted in this blog (see Health Literacy: A Clear Problem Without A Clear Solution), health illiteracy is widespread and a significant contributor to noncompliance. The use of graphically enhanced instructions is an appealing response to the problem.

Questions do, however, arise. It is unclear, for example, who will be responsible for the additional cost of the picture card (e.g., the patient, the third party payer, the pharmaceutical industry). How will the logistics be managed (e.g., Will new cards be issued with every medication change? What if the patient becomes confused about which picture card is the currently valid one?) If, as the abstract states, there is research “suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration,” who will provide and pay for that training? And the notion that individuals must be trained to use a simpler protocol is itself somewhat disconcerting. None of these potential problems appear irresolvable, but the solutions implemented could be key to this product’s clinical usefulness and commercial success.

At the risk of nitpicking, I also suggest the company’s promotion should clearly point out that health literacy deficits may be a significant cause of noncompliance but is hardly the only cause. Consider these two sentences placed adjacent to each other on the web site, implying a cause-effect relationship:

Limited literacy skills lead to incorrect medication usage. 42% of patients in two public hospitals could not understand instructions to take medication on an empty stomach; the American Medical Association estimates that only 50% of patients take medication as directed.

If this were a test asking how these two statements are related, the correct answer would be “True, True, and Unrelated.” I.e., both statements are accurate but “limited literacy skills” are not the sole cause of “only 50% of patients tak(ing) medication as directed.”

Nonetheless, if a system for efficient management of the economics and logistics of the picture cards have been or can be developed, they could well prove one step toward improved adherence to medication regimens.



Footnotes


  1. According to the LinkIn Profile of Arun Moran, the company’s Director, PictureRx is a privately held startup company “focused on improving medication compliance by simplifying prescription information.” [back]



Related Posts: