Adherence Aids Research Articles

Medication Self-Management for Home Care Users Receiving Multidose Drug Dispensing: Qualitative Interview Study.

Multidose drug dispensing (MDD) is an adherence aid where medicines are machine-dispensed in disposable unit bags, usually for a 14-day period. MDD replaces manually filled dosettes in many home care services in Norway. While evidence suggests that MDD can improve medication adherence and reduce errors, there are few studies on how patients manage MDD at home and how this affects their daily routines. The aim of the study is to identify factors influencing medication self-management behavior among MDD users living at home and explore how MDD affects medication self-management. We conducted semistructured interviews with 19 MDD users in Oslo between August 2019 and February 2020. The interviews were held at the participants' homes, and the interview transcripts were analyzed thematically. All participants in the study received some form of assistance with medication management from home care services. This assistance ranged from MDD delivery every other week to actual assistance with medication administration multiple times daily. However, regardless of the level of assistance received, participants primarily managed their MDD medications themselves. Daily medication routines and knowledge about medicines varied among the participants, with some taking an active role in their medication management, while others relied on others to take responsibility. The degree of involvement seemed determined by motivation rather than capability. MDD can support medication self-management, but its effectiveness varies among patients. The level of medication management by MDD users is not solely determined by their actual capabilities. Factors such as interest in self-care and independence, available support, information, and cognitive capacity all play a role in determining the degree of autonomy.

Disease-Agnostic Electronic Adherence Aid for Subcutaneous at-Home and Self-Administration Devices-The Lowest Common Denominator Based on a Cross-Indication Survey.

The value of connected devices and health apps with features such as adherence trackers, dosing reminders, and remote communication tools for users and healthcare providers has been assessed to support home-based subcutaneous administration. A comprehensive survey was conducted with 605 participants, including users and caregivers, from eight countries. Medical conditions encompassed ankylosing spondylitis, asthma, cerebral palsy, cluster headaches, Crohn's disease, hemophilia, lupus, migraine, multiple sclerosis, Parkinson's disease, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, spasticity, spondyloarthritis, and ulcerative colitis. Utilizing a maximum difference scaling methodology, the survey gauged participant preferences regarding specific attributes and features of connected drug delivery devices. Irrespective of demographic factors like age, gender, nationality, or the specific medical condition, the device's ability to verify a successful injection stood out as universally valued. The second and third most valued attributes pertained to temperature-related indicators or warnings. These features do not necessitate the use of a connected device and can be integrated into existing autoinjector platforms. The survey findings support the development of a universal adherence tool for at-home subcutaneous dosing, independent of a specific medical condition. This tool may be gradually improved with disease-specific features. Once established as a platform, manufacturers can launch any subcutaneous medication and later integrate real-world evidence for enhanced educational, treatment, and diagnostic capabilities. This approach is crucial for advancing connected adherence tools in decentralized healthcare, aligning with user and healthcare system needs while translating scientific innovation into practical solutions.

Toward the Design of Sensing-Based Medication Adherence Aids That Support Individualized Activities of Daily Living: Survey and Interviews With Patients and Providers

Background Nearly half of Americans taking prescription medications do not take them properly. The resulting implications have a broad impact. Nonadhering patients develop worsened medical conditions and increased comorbidity of disease or die. Objective Clinical studies have shown that the most effective strategies for addressing adherence are those that are individualized to the context that each patient and situation require. However, existing aids for adherence are relatively ridged and poorly support adaptation to individual behaviors and lifestyles. The aim of our study was to better understand this design tension. Methods A series of 3 qualitative studies was conducted: a web-based survey of 200 Americans that investigated existing adherence strategies and behaviors and perception of how hypothetical in-home tracking technologies would assist adherence; in-person semistructured interviews with 20 medication takers from Pittsburgh, PA, that investigated personal adherence behaviors, which included demonstration of medication locations and routines as well as an assessment of hypothetical technologies; and semistructured interviews with 6 pharmacists and 3 family physicians to gain a provider perspective on patient adherence strategies, which included feedback on hypothetical technologies in the context of their patient populations. Inductive thematic coding of all interview data was performed. Studies were conducted consecutively, with the results informing the subsequent studies. Results Synthesized, the studies identified key medication adherence behaviors amenable to technological interventions, distilled important home-sensing literacy considerations, and detailed critical privacy considerations. Specifically, 4 key insights were obtained: medication routines are heavily influenced and adapted by and through the physical location and placement of medications relative to activities of daily living, routines are chosen to be inconspicuous to maintain privacy, the value of provider-involved routines is motivated by a desire to build trust in shared decision-making, and the introduction of new technologies can create further burden on patients and providers. Conclusions There is considerable potential to improve individual medication adherence by creating behavior-focused interventions that leverage emerging artificial intelligence (AI), machine learning (ML), and in-home Internet of Things (IoT) sensing technologies. However, success will be dependent on the technology’s ability to learn effectively and accurately from individual behaviors, needs, and routines and tailor interventions accordingly. Patient routines and attitudes toward adherence will likely affect the use of proactive (eg, AI-assistant routine modification) versus reactive (eg, notification of associated behaviors with missed dosages) intervention strategies. Successful technological interventions must support the detection and tracking of patient routines that can adjust to variations in patient location, schedule, independence, and habituation.

Management of heart failure patients with systolic dysfunction in a real world setting-a physician-based survey

Background: The objective of this study was to understand cardiologists’ perspectives on heart failure (HF) management with an emphasis on heart rate (HR) optimization and practice patterns among different medical specialties. Methods: A digital, cross-sectional, questionnaire-based survey involving 149 Indian cardiologists who were experienced in the management of patients with HF in their clinical practice was conducted. The survey questionnaire included 53 items divided into five sections. Responses were analyzed and data were represented as summary statistics. Results: According to most cardiologists, majority of patients belong to the New York Heart Association (NYHA) categories II and III, with ischemia being the most prevalent cause of HF. For patients with HF with reduced ejection fraction (HFrEF), HR>70 beats per minute and sinus rhythm, 38.9% of clinicians strongly agreed to include ivabradine in the treatment regimen. According to 56.4% of clinicians, 26%-50% of patients with HFrEF were receiving ivabradine therapy at <50% guideline-directed target dose of β-blockers. At the highest therapeutic dosage of ivabradine, 46.3% of clinicians noticed a 6-10 bpm reduction in HR. Additionally, it was reported that a stable HFrEF patient consumed an average of 4-6 tablets daily (67.1%), which increased the pill burden. Overall, 58.4% and 67.1% of clinicians strongly believed that cutting back on medications will assist with therapy adherence and that improved therapy adherence and compliance aid with clinical outcomes, respectively. Majority of the clinicians strongly agreed or agreed that patients should be switched from twice-daily to once-daily ivabradine. Conclusions: Clinical outcomes of patients with HF could be improved by reducing the pill burden and improving compliance.

ANTIRETROVIRAL MEDICATION ADHERENCE AMONG PATIENTS WITH HIV/AIDS AT A COMMUNITY MEDICAL CENTER IN VIETNAM

Introduction: Non-adherence to antiretroviral (ARV) medications is a common issue worldwide and in Vietnam. Purpose: To assess patients’ adherence to ARV medications and to determine factors associated with adherence among patients with HIV/AIDS in Ho Chi Minh City (HCMC). Methods: A cross-sectional study was conducted on 360 outpatients being on ARV therapy at a community medical center in HCMC from 15th March to 20th June in 2020. We invited patients aged 18 or above who have been on ARV treatment for at least 6 months to participate in the study. Data was collected through patient interviews and medical records. Medication adherence was assessed regarding timing of medication administration and dosing adherence using Morisky Medication Adherence Scale-8-item Questionnaire (MMAS-8). Factors associated with optimal adherence were identified by multivariable logistic regression model. Results: The median age of 360 patients was 38 (33 - 43), 72.5% were male. The proportion of optimally adherent patients was 56.4%. Factors associated with better adherence were increased age, stronger belief in medications, and adherence aids use. Factors associated with poorer adherence were alcohol consumption in the previous 30 days, concerns about side effects, twice-daily ARV therapy, and undesirable effects in the previous 3 months. Conclusion: Optimal adherence to ARV medications among HIV/AIDS patients was relatively limited. To improve medication adherence, health workers may need to simplify ARV regimens and counsel patients more intensively (especially for the younger) about the effectiveness of ARV medications, alcohol intake reduction and the use of adherence aids.

208 Pharmacy Students Explore Use of an Electronic Medication Adherence Device

OBJECTIVES/GOALS: To examine pharmacy students’ and patients’ perspectives on use of an automatic pill dispenser (APD) and adherence device, and secondly, to identify patient characteristics impacting selection of an APD. This knowledge will assist pharmacists in making appropriate device recommendations that improve medication adherence and effectiveness. METHODS/STUDY POPULATION: One hundred fifty-three pharmacy students participated in a personal APD simulation, living the life as a person taking medication. Students then each identified an actual patient exhibiting medication nonadherence from pharmacy records at their work setting, provided them with an APD free of charge and instructed them on its use. The students later interviewed their patients and reported on their patients’ ability to use the APD, as well as their perspectives (likes and dislikes) on the features of the device. Students identified individual patient characteristics associated with successful use of the APD. This new knowledge will aid these future pharmacists in making recommendations for medication adherence devices for their patients. RESULTS/ANTICIPATED RESULTS: In general, patients perceived more difficulty with use of the 10 APD features than did students. Over half of the patients indicated that the following features were a distinct advantage in adherence: individual medication compartment size, method of loading medications, alarm, flashing light, ability to lock the dispenser, and method of retrieving the medication from the device. Patients felt that the biggest disadvantage was its bulky size and lack of portability. In spite of individual difficulties with use, the research findings showed that persons who are elderly, homebound, have memory problems, take multiple medications and/or have complex regimens are most likely to benefit from the device features and exhibit improved adherence to their prescribed medication regimen. DISCUSSION/SIGNIFICANCE: Medication adherence rates in the U.S are agreed upon to be about 50% - highly relevant to healthcare practitioners since several studies suggest a correlation between adherence and improved health outcomes. Pharmacists must be knowledgeable about non-adherence tools and consider patient characteristics when recommending an adherence aid.

Oral-care adherence. Service design for nursing homes - initial caregiver reactions and socio-economic analysis.

Background: Lack of proper oral care among elderly people in nursing homes is associated with increased morbidity and hospitalisation. The ability of the individual to maintain sufficient oral self-care is difficult for caregivers to assess, and thus, caregivers often risk providing suboptimal oral care. Sensor-based tools exist that can support the caregiving staff in achieving a better understanding of who among the elderly are able to perform proper self-care, and who cannot and thus need additional assistance from caregivers. How such systems should be designed and deployed in nursing homes, and how they will be perceived by caregivers has not been investigated sufficiently yet.Objectives: The aim of this study was to gain a better understanding of how caregiving staff perceives the introduction of sensor-based systems that allow the caregivers to automatically discover who among the elderly residents are able to adhere to the given recommendation on daily oral self-care, and who among them are in need of further assistance, as well as whether there is potential for saving costs.Methods: In a mixed methods qualitative study, we visited three nursing homes where we had recently deployed, or were about to deploy, electrical toothbrushes and a basic oral-care adherence aid system. Nursing home staff was interviewed during the field studies about their initial reactions to introducing such a system as part of their daily workflow. The field study was supported by a literature review.Results: Caregiving staff welcomed the introduction of a sensor-based oral-care adherence aid system, which would identify any elderly who could no longer achieve a sufficient level of oral self-care. Improving oral care for the elderly may not only prevent serious consequential diseases, but also generate considerable savings with a return on investment of at least 1:2.5.Conclusion: Sensor-based oral-care adherence aid systems that monitor oral-care adherence, meaning the ability of the individual elderly to properly perform teeth and/or denture brushing as part of normal self-care efforts, appear useful and relevant to introduce. More work is needed to provide a better understanding of the long-term user experience of both caregiving staff and elderly. There is also a need for more high-quality long-term clinical studies of further preventive effects of oral hygiene measures and their economic benefit.

Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD).

Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD).

Digital Medication Adherence Support: Could Healthcare Providers Recommend Mobile Health Apps?

Adherence to prescribed medication is suboptimal in 50% of the chronic population, resulting in negative medical and economic outcomes. With the widespread use of mobile phones worldwide, medication adherence apps for mobile phones become promising medication adherence aids thanks to simplicity, user-friendliness, and accessibility for the public. Yet, until today, there is insufficient evidence in favor of using mobile health (mHealth) apps to increase medication adherence. This study aims to develop a methodology for scientific and end-user (patient) mHealth evaluation (a) to identify medication adherence apps search terms, (b) to evaluate identified apps based on scientific criteria, and (c) to report best smartphone apps evaluated by patients. Search terms were identified via literature review and expertise. Firstly, an online questionnaire was developed to identify frequently used search terms by recruited patients. Related medication adherence apps were identified and selected using predefined inclusion criteria. Secondly, identified apps were evaluated thanks to a scientific evaluation method and a created online questionnaire for patient feedback. Recruited patients were invited to test and evaluate the selected apps. Out of 1,833 free-of-charge and 307 paid apps identified, only four free-of-charge and three paid apps remained included in the study after eligibility criteria. None of the selected app reached a high score. Looking at the overall scores, Medisafe (59%), MyTherapy (56%), and Meds on time (44%) received the highest scores in the scientific app evaluation. In the patient evaluation, Dosecast (3.83 out of five points), Medisafe (3.62), and SwissMeds (3.50) received the highest scores. None of the apps in this research has undergone a process for certification, for example, CE marking, through a notified body. Security and data protection aspects of existing apps highly contribute to these low evaluation scores through little information on patient's data processing and storage. This might be corrected through the introduction of General Data Protection Regulation (GDPR) in the European Economic Area (EEA) and more scrutiny through regulatory bodies in the EU/EEA and the USA. None of the applications should be recommended by healthcare providers. In addition, clinical studies with chronic patients are necessary to measure long-term app impacts.

From Paper to E-Prescribing of Multidose Drug Dispensing: A Qualitative Study of Workflow in a Community Care Setting.

E-prescribing is now widespread and, in some countries, has completely replaced paper prescriptions. In Norway, almost all prescribing is electronic, except for multidose drug dispensing (MDD), which is still sent to the pharmacy by fax or ordinary mail. MDD is an adherence aid used by one-third of all patients receiving home care services. In this paper, we present results from a qualitative study evaluating the introduction of e-prescribing for MDD in a community health care setting. The focus is on the work and workflow for the pharmacists and nurses involved in the medication-handling process. We used the pragmatic process evaluation framework and the systematic text condensation method to analyse the data. We conducted 12 interviews with 34 nurses and pharmacists. This study shows that the e-prescribing of MDD led to greater integration between systems, both within the existing MDD system and across care levels, potentially improving patient safety. However, the structured prescriptions increased the need for clarifications, resulting in an increased overall workload. A greater understanding of the roles and responsibilities of the different professionals in the medication management chain and their needs would improve the workflow of the nurses and pharmacists involved.

The Practice Guidelines for Multidose Drug Dispensing Need Revision-An Investigation of Prescription Problems and Interventions.

Multidose drug dispensing (MDD) is an adherence aid used by one-third of patients receiving home care services in Norway. The system can increase patient safety by reducing dispensing errors and increase adherence, however it has also been criticised for unclear routines and distribution of responsibilities. We investigated prescription problems which pharmacists have detected, and the responsibilities they adopt regarding MDD. For two consecutive weeks, 11 pharmacies used a self-completion form to register prescription problems identified with MDD. Of the 4121 MDD prescriptions, problems were identified on 424 (11%). The most common issues were expired prescriptions (29%), drug shortages (19%), missing prescriber signatures (10%) and unclear/missing medication names or strengths (10%). Compared to ordinary prescriptions, the pharmacist took on additional responsibility for renewing MDD prescriptions. However, because these patients received their medications via the home care service, there was limited patient counselling during dispensing. To increase the efficiency and patient safety of the MDD system, the roles and responsibilities of the pharmacist, GP, and home care nurses in the MDD system should be clearly defined. This seems most urgent for the renewal of prescriptions and patient counselling, where the responsibilities and work practice seem to differ from ordinary prescriptions.

Potentially inappropriate prescribing to older patients receiving multidose drug dispensing

BackgroundMultidose drug dispensing (MDD) is an adherence aid that provides patients with machine-dispensed medicines in disposable unit bags, usually for a 14 day period. Previous studies have suggested that the quality of prescribing, with time, is lower for MDD users, compared to patients receiving prescriptions dispensed as usual. This study aimed to examine the quality of prescribing to Norwegian elderly home care service patients receiving MDD.MethodsA cross-sectional study comprising 45,593 MDD patients aged ≥70 years was performed. The proportion of potentially inappropriate medications (PIMs) was assessed using the Norwegian General Practice Criteria, and drug-drug interactions (DDI) were investigated using the Norwegian Medicines Agency database.ResultsOn average, patients were prescribed 10.6 drugs (SD = 5.0), of which 6.1 were dispensed via MDD. Men used on average fewer drugs than women (10.7 vs 11.1), Twenty-seven percent of patients used at least one PIM. Concomitant use of three or more psychotropic drugs (10.8%), and prescribing of diazepam (6.4%) was the most commonly identified inappropriate prescribing. DDIs affected 59% of the patients, however, only 2.7% had serious interactions. Women were more frequently exposed to both PIMs and DDIs than men, with an odds ratio of 1.50 (95% CI: 1.43–1.58) and 1.43 (95% CI: 1.37–1.50), respectively.ConclusionsPolypharmacy is common in elderly Norwegian patients using MDD. About one-fourth of the patients were exposed to PIMs, and over half were exposed to DDI.

Challenges and Strategies in Managing Medication Adherence Among Elderly Patients: Insights from Pharmacists

This qualitative study investigates the challenges pharmacists face in managing medication adherence among elderly patients and the strategies they use to overcome these obstacles. Fifteen pharmacists were interviewed to explore barriers such as complex medication regimens, cognitive impairments, and socioeconomic constraints. The study also examined strategies employed by pharmacists, including regimen simplification, patient education, use of adherence aids, and interprofessional collaboration. Findings reveal that while complexity and cognitive issues are significant barriers, pharmacists utilize various approaches to improve adherence and support elderly patients. This research highlights the critical role of pharmacists in enhancing medication adherence and offers insights into effective practices for addressing adherence challenges.

Efficacy of a medication management service in improving adherence to tyrosine kinase inhibitors and clinical outcomes of patients with chronic myeloid leukaemia: a randomised controlled trial.

Suboptimal adherence to tyrosine kinase inhibitors (TKIs) contributes to poor clinical outcomes in chronic myeloid leukemia (CML). This randomised controlled trial (RCT) aimed to evaluate the impact of a medication management service (MMS) on adherence to TKIs and clinical outcomes. A parallel RCT was conducted in two hospitals in Malaysia, where 129 CML patients were randomised to MMS or control (usual care) groups using a stratified 1:1 block randomisation method. The 6-month MMS included three face-to-face medication use reviews, CML and TKI-related education, two follow-up telephone conversations, a printed information booklet and two adherence aids. Medication adherence (primary outcome), molecular responses and health-related quality of life (HRQoL) scores were assessed at baseline, 6th and 12th month. Medication adherence and HRQoL were assessed using medication possession ratio and the European Organisation for Research and Treatment in Cancer questionnaire (EORTC_QLQ30_CML24) respectively. The MMS group (n = 65) showed significantly higher adherence to TKIs than the control group (n = 64) at 6th month (81.5% vs 56.3%; p = 0.002), but not at 12th month (72.6% vs 60.3%; p = 0.147). In addition, a significantly higher proportion of participants in the MMS group achieved major molecular response at 6th month (58.5% vs 35.9%; p = 0.010), but not at 12th month (66.2% vs 51.6%; p = 0.092). Significant deep molecular response was also obtained at 12th month (24.6% vs 10.9%; p = 0.042). Six out of 20 subscales of EORTC-QLQ30-CML24 were significantly better in the MMS group. The MMS improved CML patients' adherence to TKI as well as achieved better clinical outcomes. Clinicaltrial.gov (ID: NCT03090477).

Exploring variables associated with medication non-adherence in patients with COPD.

Research has indicated that medication adherence is low and represents a barrier to achieve the desired health outcome in patients with Chronic Obstructive Pulmonary Disease (COPD). The aim of the study was to investigate the factors that are significantly associated with self-reported medication non-adherence in patients with COPD. Patients attending the outpatient respiratory clinic at the Royal Medical Services (RMS) Hospital in Amman. In addition to socio-demographics, validated measures including COPD knowledge questionnaire, the 4-item self-reported Morisky medication adherence scale, St George respiratory questionnaire and Health Anxiety and Depression scale were used in the present study. The stepwise logistic regression analysis was performed in order to identify variables that independently and significantly predicted medication non-adherence. Predictors of medication non-adherence. A total of 133 patients participated in the study. Results indicated that majority of the patients (61.7%) were non-adherent. According to the model, patients were four times more likely to be non-adherent if they reported having depression (OR 0.251, CI 0.24-0.76) and approximately eight times to have medication non-adherence if they suffered from comorbid illness (OR 0.119, CI 0.11-0.80). Study participants were found to have a double risk of medication nonadherence if they received an increase in the frequency of administration of their COPD medication (OR 0.524, CI 0.08-0.69) and being concerned about side effects (OR 0.515, CI 0.36-0.92). Depression, dosage regimen complexity, the presence of co-morbidities and therapy side effects have significantly influenced adherence to COPD therapy in the present study. Clinical pharmacists should provide emotional support, simplify dosage regimen, use adherence aids, elicit patients' concerns about their illness comorbidities, select treatments with less side effect and help the patients coping with side effects in order to enhance adherence and health outcomes in patients with COPD.

E-health and its Impact on Indian Health Care: An Analysis

Healthcare sector is progressing towards digitalization in every aspect such as e-consultations, health surveillance, health education and various other healthcare services. Developing countries like India lacks infrastructure to conduct studies to evaluate impact of these e-health services on patient outcomes. Various developed countries have electronic health records which makes evaluation of patient outcomes much easier. This paper aims to evaluate effect of e-health on patient outcomes in Indian healthcare scenario and future consequences of these e-health services. The integrative literature searches were conducted using various databases such as pubmed, google scholar and SCC web edition using keywords such as ‘e-health’, ‘telemedicine’, ‘mhealth’, ‘electronic health records’, ‘patient outcomes’ and ‘data protection laws’. From the papers retrieved only few papers studied impact of e health services in patient outcomes. Other papers assessed e-health on basis of accessibility, feasibility and medium of education in clinical practice. It was concluded that e-health services such as diagnostic services like teleopthalmology and tele ECG, distant consultation with specialist through telemedicine and adherence aids like automated voice reminder and pictorial messaging have positive impact on patient outcomes. Though e-health services can help us in various ways but it will also open the new Pandora box of problems in handling personal information. The information technology rules in India have certain grey areas in protection of digital data. In future, besides improving the data content of information system to analyse the impact of various services provided to the patients, we will have to relook the legal system to protect the data.

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT.

Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI. To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds. Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved. Usual NHS care. Patients undergoing elective/non-elective abdominal surgery, including caesarean section. Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'. Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers. Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals. Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments. Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres. A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks. Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).

Characterization of clinical pharmacy services in a pediatric HIV clinic

ObjectivesThe objectives of this study were to characterize and analyze clinical pharmacists' interventions in a pediatric human immunodeficiency virus clinic.MethodsThis retrospective review assesses interventions documented by pediatric pharmacists. The percent of patients with an undetectable viral load at baseline, prior to implementation of pharmacy services, was compared with the viral load at a 7‐year follow‐up visit. Mean log10 viral loads at years 1 and 7 were compared to baseline and the mean change in viral load was compared.ResultsPharmacists were involved with the care of 53 patients at 2257 visits documenting 8893 interventions. Recommendations to physicians accounted for 1316 (14.8%) of the interventions. Pharmacists documented 3176 (35.7%) interventions to patients/caregivers. One‐thousand and twenty‐eight (11.6%) interventions were educational concepts taught to patients/caregivers. Pharmacists provided 1107 (12.4%) adherence aids and conducted 669 (7.5%) adherence assessments. The percentage of patients with undetectable viral loads increased from 12.1% (4/33) to 65.8% (25/38) (P = 0.0094). The mean log10 viral load at years 1 and 7 were lower than those obtained prior to the first clinical pharmacy visit (year 1:3.95 ± 1.22 copies/mL vs 4.37 ± 1.09 copies/mL; P = 0.0042; year 7:2.88 ± 1.21 copies/mL vs 4.42 ± 1.11 copies/mL; P < 0.0001).The decrease in mean log10 viral load (viral load change) was significantly greater in year 7 compared with year 1 (P = 0.04). A clinically significant mean viral load decrease occurred each year from years 2 to 7.ConclusionsIn 7 years of pediatric clinical pharmacy services, thousands of interventions were documented. An increase in the number of patients with an undetectable viral load and improvements in mean log10 viral load occurred. These findings suggest that interventions by pediatric clinical pharmacists contributed to overall improvements in viral loads observed in this study. This analysis provides insight into the essential role of a clinical pharmacist in a pediatric HIV clinic.

Efficiency, Efficacy, and Power in the Implementation of a Medication Adherence Aid.

Nonadherence to medication regimens is common, with approximately 50% of patients not taking their medications as prescribed. The Universal Medication Schedule (UMS) is a set of standardized, evidence-based, and patient-centered instructions for pill-form medications that has demonstrated improvements in adherence by promoting patient comprehension. An urban, publicly funded, integrated health care system attempted to adopt UMS labeling but had limited success at its largest pilot site, which was a safety-net health care system's outpatient pharmacy. To assess barriers to implementation, we engaged pharmacists at this site in group interviews. We thematically analyzed transcripts by integrating sociological work on standardization with grounded theory methodologies. In addition to lacking technological infrastructure, tensions among efficiency, efficacy, and effectiveness, and tension between individual/biomedical versus population health perspectives emerged as barriers to implementation. Additionally, we discovered that hierarchies of professional power impeded uptake. For successful implementation of evidence-based practices for vulnerable populations in resource-poor settings, efforts must anticipate and reconcile the tensions among conflicting demands, professional hierarchies, and divergent orientations to patient care. [HLRP: Health Literacy Research and Practice. 2018;2(3):e128–e131.]

Integration of clinical pharmacists into an ambulatory, pediatric hematology/oncology/transplant clinic.

To describe key activities performed by a newly deployed clinical pharmacist in an outpatient pediatric hematology, oncology, transplant clinic. To demonstrate how utilization of the pharmacist evolved, as indicated by changes in frequency of key activities, during the first four months of integration. Clinical pharmacists were made consistently available in an outpatient clinic serving hematology, oncology, transplant patients and their families. A list of key activities, based on provincial clinical pharmacist standards, was created to provide a framework for the role. Over a four-month period, the pharmacists recorded the number of times activities were performed. Over the data collection period, obtaining best possible medication histories (203), providing medication counseling (150), and creating adherence aids (144) were the most commonly performed activities. In comparison to the first month, key activities increased by 73% in the fourth month. Notably, providing recommendations for drug therapy (156%), assessments of adherence (122%), and best possible medication history collection (88%) increased considerably. The integration of a pharmacist into an outpatient pediatric hematology, oncology, transplant clinic resulted in the provision of several key clinical pharmacy services. As the role developed, activities were performed more frequently, demonstrating growth in utilization of the pharmacist.