Basics of qualitative research: Grounded theory procedures and techniques

Objectives. People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring. Design. Feasibility “before-and-after” intervention study. Setting. Three care homes in Wales. Participants. Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine. Intervention. West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines. Outcome Measures. (1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants’ records before and after introduction of the profile, and one month later. Results. Nurses recruited and retained 11 of 29 eligible service users. The profile took 20–25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation. Conclusions. Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.

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Medication Monitoring for People with Dementia in Care Homes: The Feasibility and Clinical Impact of Nurse-Led Monitoring

Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time?

Objective: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. Methods: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference. Results: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment). Conclusion: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

https://ard.bmj.com/content/annrheumdis/66/12/1560.full.pdf

EULAR evidence based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases.

Unintentional non-adherence has been characterized as passively inconsistent medication-taking behavior (forgetfulness or carelessness). Our objectives were to: (1) study the prevalence and predictors of unintentional non-adherence; and (2) explore the interrelationship between intentional and unintentional non-adherence in relation to patients’ medication beliefs. We conducted a cross-sectional survey of adults with asthma, hypertension, diabetes, hyperlipidemia, osteoporosis, or depression from the Harris Interactive Chronic Illness Panel. The analytic sample for this study included 24,017 adults who self-identified themselves as persistent to prescription medications for their index disease. They answered three questions on unintentional non-adherence (forgot, ran out, being careless), 11 questions on intentional non-adherence, and three multi-item scales assessing perceived need for medication (k = 10), perceived medication concerns (k = 6), and perceived medication affordability (k = 4). Logistic regression was used to model predictors of each unintentional non-adherence behavior. Baron and Kenny’s regression approach was used to test the mediational effect of unintentional non-adherence on the relationship between medication beliefs and intentional non-adherence. Bootstrapping was employed to confirm the statistical significance of these results. For the index disease, 62% forgot to take a medication, 37% had run out of the medication, and 23% were careless about taking the medication. Common multivariate predictors (p < .001) of the three behaviors were: (1) lower perceived need for medications; (2) more medication affordability problems; (3) worse self-rated health; (4) diabetes or osteoporosis (relative to hypertension); and (5) younger age. Unique statistically-significant predictors of the three behaviors were: (a) ‘forgot to take medications’ - greater concerns about the index medication and male gender; (b) ‘run out of medications’ - non-white race, asthma, and higher number of total prescription medications; (c) ‘being careless’ - greater medication concerns. Mediational tests confirmed the hypothesis that the effect of medication beliefs (perceived need, concerns, and affordability) on intentional non-adherence is mediated through unintentional non-adherence. For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients’ suboptimal medication beliefs before they choose to discontinue therapy all together.

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Unintentional non-adherence to chronic prescription medications: How unintentional is it really?

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

https://qualitysafety.bmj.com/content/qhc/18/5/341.full.pdf

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

We are the experts: people with asthma talk about their medicine information needs.

BACKGROUND Metered dose inhalers (MDIs) are not easy to use well. Every MDI user receives a manufacturer's patient information leaflet (PIL). However, not everyone is able or willing to read written information. Multimedia offers an alternative method for teaching or reinforcing correct inhaler technique. OBJECTIVE The aim of this study was to compare the effects of brief exposure to the same key information, given by PIL and multimedia touchscreen computer (MTS). METHODS A single-blind randomized trial was conducted in 105 fluent English speakers (53% female; 93% White) aged 12-87 years in London general practices. All patients had had at least one repeat prescription for a bronchodilator MDI in the last 6 months. Inhaler technique was videotaped before and after viewing information from a PIL (n = 48) or MTS (n = 57). Key steps were rated blind using a checklist and videotape timings. The main outcome measures were a change in (i) global technique; (ii) co-ordination of inspiration and inhaler actuation; (iii) breathing-in time; and (iv) information acceptability. RESULTS Initially, over a third of both groups had poor technique. After information, 44% (MTS) and 19% (PIL) were rated as improved. Co-ordination improved significantly after viewing information via MTS, but not after PIL. Breathing-in time increased significantly in both groups. Half the subjects said they had learned 'something new'. The MTS group were more likely to mention co-ordination and breathing. CONCLUSIONS Short-term, multimedia is as least as effective as a good leaflet, and may have advantages for steps involving movement. MTS was acceptable to all age groups. The method could be used more widely in primary care.

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Providing information on metered dose inhaler technique: is multimedia as effective as print?

Dispensary workload is widely perceived by pharmacists as limiting the time available for customer contact. This study compared pharmacist work patterns at two neighbouring independent pharmacies, one without (A) and one with (B) a trained dispensing technician, using fixed interval activity sampling. Pharmacists were observed at work over two weeks; six half-day observation sessions (A = 1,181 observations; B=1,348) could be matched for incoming dispensing workload. Data on 505 prescription issues and 74 over-the-counter events (advice requests, advised sales, and health information) were collected. Pharmacy B dispensed a greater proportion of antibiotics (19 per cent v 11 per cent, P<0.02) but there were no other significant differences. Pharmacists at site B spent 20 per cent less of their time on dispensary activities, 14 per cent more of their time on the counter and had 6 per cent more time to rest and read, but they did not spend significantly longer talking to customers about medicines and health. Skilled dispensing help released over an hour of pharmacist time per day, but these savings were linked to prescription workload, which is unpredictable. The pharmacists could not plan to give this extra time to their customers because they did not know when it would be available, or when it would be needed.

Time for customer contact in pharmacies with and without a dispensing technician

Objectives — To determine whether the professional policy shift away from dispensing towards patient-focused care is reflected in the way community pharmacists actually use their time.



Method — Retrospective comparison, using data from five observational work sampling studies employing the same methodology. The percentage of time spent on manipulative dispensing (defined as creating labels and physically preparing prescription items) and health-related customer communication was monitored.



Setting — Fifteen independent practices (8.7 prescriptions/hour; London, England, 1993); 40 urban/rural pharmacies (7.8 prescriptions/hour; Dublin, Eire, 1985); 28 independents (9.1 prescriptions/hour; Sydney, Australia, 1985); one traditional multiple (9.6 prescriptions/hour; Nova Scotia, Canada, 1980); 20 traditional multiples (8.1 prescriptions/hour; eastern United States, 1973).



Key findings — Despite full computerisation, English pharmacists in 1993 spent as much time creating dispensing labels (8.8 per cent) as they did on health-related customer talk (7.2 per cent), and twice as much time preparing prescription items (14.2 per cent). Of their total time, 6.5 per cent was spent on simple redispensing (mostly counting tablets, pouring liquids and cutting blister strips). The time spent on extemporaneous preparation was extremely low. In Eire, pharmacists spent nearly twice as much time (5.8 per cent) on health-related talk as on counting, pouring and compounding (3.8 per cent) and in Australia nearly three times as much time (6.6 per cent vs 2.3 per cent). In Eire, two-thirds of pharmacists had qualified dispensing help of a type not found in other countries. In Australia, most products were ready to issue.



Conclusion — The proportion of pharmacist time spent on customer communication has increased three-fold since 1973. However, this has not been mirrored by a decline in time spent on manipulative dispensing. Keeping the study limitations in mind, it is suggested that, in Britain, the reprofessionalisation process may be hampered by the continued need for redispensing and the limited availability and use of trained support staff.

Imogen Savage

Papers

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

We are the experts: people with asthma talk about their medicine information needs.

Providing information on metered dose inhaler technique: is multimedia as effective as print?

Time for customer contact in pharmacies with and without a dispensing technician

The changing face of pharmacy practice — evidence from 20 years of work sampling studies