OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

OBJECTIVE: To review the relationship between literacy and health outcomes DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003 STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes Two abstractors reviewed each study for inclusion and resolved disagreements by discussion DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry The whole study team reconciled disagreements about information in evidence tables Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources Patients with low literacy were generally 15 to 3 times more likely to experience a given poor outcome The average quality of the articles was fair to good Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons CONCLUSIONS: Low literacy is associated with several adverse health outcomes Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions

/pdf/literacy-and-health-outcomes-4pmopsjgz6.pdf

Literacy and health outcomes

The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence

BACKGROUND AND OBJECTIVES Patients' health literacy is increasingly recognized as a critical factor affecting patient-physician communication and health outcomes We reviewed research on health literacy, examined its impact on patient-physician communication, and offer recommendations to enhance communication with patients who have poor health literacy METHODS We conducted a literature review using the MEDLINE database for January 1966 through July 2001 The keywords "literacy" and "health literacy" were searched independently and in combination with the medical subject headings (MeSH) "physician-patient communication," "communication," and "reading" RESULTS Poor health literacy is common, especially among elderly patients More than 33% of patients ages 65 and older have inadequate or marginal health literacy, as do up to 80% of patients in public hospital settings Patients with poor health literacy have a complex array of communication difficulties, which may affect health outcomes Such patients report worse health status and have less understanding about their medical conditions and treatment; they may have increased hospitalization rates Professional and public awareness of the health literacy issue must be increased, beginning with education of medical students and physicians and improved patient-physician communication skills CONCLUSIONS Future research needs to address identification of optimal methods for communicating with patients who have low literacy skills This should focus on the effect of poor health literacy on patients' ability to communicate their history and physicians' ability to solicit information, as well as identifying the most-effective techniques to educate patients

The role of health literacy in patient-physician communication.

Objectives To present a summary of the existing literature on medication nonadherence, health literacy, and use of written patient information in health care and pharmacy in particular. Data sources Searches of Medline, PubMed, and International Pharmaceutical Abstracts databases were conducted using one or more of the following terms adherence/nonadherence, compliance/noncompliance, printed/written information, literacy, patient education, communication , and health literacy . These terms were combined with the following search terms: drug information, readability, medication/drug, patient, pharmacy/pharmacist , and prescription . References of pertinent articles were hand searched to retrieve additional articles. Data extraction By the author. Data synthesis Articles were grouped and summarized into three broad categories (nonadherence, health literacy, and communicating health information to patients), with an emphasis on the use of written patient information in health care and pharmacy practice in particular. The complexities inherent in nonadherence behavior, health literacy, and patient education are summarized, and suggestions for enhancing medication adherence, especially for patients with low health literacy skills, are provided. Conclusion The health literacy skills of American adults have not changed considerably during the previous decade. This makes use of written patient medication information in pharmacy practice problematic for some patients. Limited health literacy has been associated with poorer health, medication nonadherence, medication errors, higher medical expenses, and increased hospitalization. A need exists for identifying patients with limited health literacy and tailoring medication counseling to their needs.

http://apha.imirus.com/pdf/2009/Aug_CE_exam.pdf

Health literacy: A barrier to pharmacist–patient communication and medication adherence

Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon

Erratum: Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon (Patient Education and Counseling (1997) 30 (257-270))

Lucy Nkukuma Ngoh

Papers

Health literacy: A barrier to pharmacist–patient communication and medication adherence

Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon

Erratum: Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon (Patient Education and Counseling (1997) 30 (257-270))