Medication Action Research Articles

Evaluation and Sustainability of the Healthy Learners Asthma Initiative

The Healthy Learners Asthma Initiative (HLAI) involved collaboration between Minneapolis Public Schools (MPS), local health care providers/payors, parents, and other partners. The intervention included development of enhanced asthma care in school health offices and clinic performance improvement projects to foster adoption of National Institutes of Health asthma guidelines. Goals were to improve asthma management among school children and reduce asthma-related school absences, hospitalizations, and emergency department visits. The effectiveness evaluation utilized a randomized community trial design with 16 elementary and middle schools matched and randomly assigned to either an intervention or a control group. Outcomes investigated were (a) school health office impacts and (b) school attendance. Data sources included school health office records, district attendance, enrollment, and demographics files. Following implementation of the HLAI, asthma visits to health offices were significantly lower in intervention schools compared to control schools (91 vs 121 visits per 100 students with asthma per month), and intervention schools had greater availability of medication and asthma action plans and more peakflow measurements, asthma education, and parent communication. Clinics initiated significantly more asthma action plans and sent them to MPS. Attendance differences between groups were limited to students who received asthma care through the school health office. Monitoring of asthma management activities provided through school health offices from 2002 to 2005 indicates sustained implementation of enhanced asthma care in schools and increased asthma communication between school, parents, and health care providers.

A Randomized Trial of Primary Care Provider Prompting to Enhance Preventive Asthma Therapy

Purpose of the Study. To determine if systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, would prompt providers to prescribe a new preventive medication or change a current dose. Study Population. The study included 151 children (aged 3–7 years) with mild persistent to severe asthma living in an urban setting. Methods. A routine school health-and-development form was sent to parents of schoolchildren. When asthma was indicated on this form, the parents were contacted by telephone. To be eligible for the trial, the child’s parent needed to report that a physician had diagnosed their child as having asthma, and the child’s symptoms needed to be consistent with mild persistent asthma or worse according to National Heart, Lung, and Blood Institute guidelines. The intervention arm of the study involved notification of the primary care providers via fax of the child’s symptoms and recommendations for action on the basis of national criteria. Confirmation of receipt was received from 90% of providers. In the control arm of the study, primary care providers were not contacted. Interviewers then contacted the parents 3 to 6 months later to determine if preventive actions were taken. Results. Children in the provider-notification group were not more likely to receive a preventive medication action than children in the control group (21.9% vs 26%). Additional preventive measures such as encouraging compliance with medications, recommending environmental modifications, and referrals to specialty care also did not differ between the 2 groups. The only factors that significantly predicted the occurrence of a preventive action were acute visits for asthma and baseline use of preventive medications. At the end of the study, 52.4% of children in both groups with no medications change were still experiencing symptoms. Conclusions. School-based asthma screening identified many symptomatic children in need of medication modification, but notification of their primary care providers did not improve preventive care. Reviewer Comments. Asthma is a complex disease, and there are many barriers to effective care. These barriers include steroid phobia, cost of medication, denial of the presence or severity of the disease, access to health care, exposure to asthma triggers, and poor adherence to treatment. It is concerning that another barrier to effective care of asthma, as illustrated by this study, is a poor response of health care providers to supportive education, such as treatment guidelines. In an effort to better understand this deficit, the authors queried the providers: “Was the information in the original notification helpful?” Only 27 of 73 providers responded: 10 said the information was helpful (7 changed medications); 9 replied that their patients had mild, intermittent asthma and did not need changes; 4 replied that their patients already were on preventive medications; and 4 replied that they were unable to contact their patients for follow-up.

A randomized trial of primary care provider prompting to enhance preventive asthma therapy

Context Urban children often receive inadequate therapy for asthma. One reason may be that primary care providers are unaware of the severity of their patients' symptoms. Objective To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to prescribe a new preventive medication or modify a current dose. Design Randomized controlled trial. Setting Rochester, New York. Participants Children age 3 to 7 years with mild persistent to severe persistent asthma. Interventions Children were assigned randomly to a provider notification group (child's primary care provider notified of asthma severity) or a control group (provider not notified of asthma severity). Primary care providers of children in the intervention group were sent a facsimile indicating the child's symptoms and recommending medication action based on national criteria. Interviewers blinded to the child's group assignment called parents 3 to 6 months later to determine whether preventive actions had been taken. Main Outcome Measures Number of children who received a preventive medication action. Results Of 164 eligible children, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P=.57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P =.85), recommending environmental modifications (39.3% vs 42.4%; P =.86), and making referrals for specialty care (6.6% vs 6.0%; P =.99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. Conclusions School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification did not improve preventive care, however. The findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

A Randomized Trial of Primary Care Provider Prompting to Enhance Preventive Asthma Therapy

Guidelines recommend preventive medications for all children with persistent asthma, yet young urban children often receive inadequate therapy. This may occur in part because primary care providers are unaware of the severity of their patients' symptoms. To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to take preventive medication action (prescribe a new preventive medication or change a current dose). Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2002-2003 school year in Rochester. Children were assigned randomly to a provider notification group (child's primary care provider notified of asthma severity) or a control group (provider not notified of severity). Primary care providers of children in the provider notification group were sent a facsimile indicating the child's symptoms and recommending medication action based on national criteria. Interviewers blinded to the child's group assignment called parents 3 to 6 months later to determine if preventive actions were taken. Of 164 eligible children with mild persistent or more severe asthma, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P = .57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P = .85), recommending environmental modifications (39.3% vs 42.4%; P = .86), and referrals for specialty care (6.6% vs 6.0%; P > .99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification, however, did not improve preventive care. Findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

How We Think About Medication Errors

physicians and pharmacists are generally the ones defining practice as it relates to preventing medication errors, without involving nurses. It’s imperative that nurses develop theoretical models, undertake research, and incorporate the findings into practices and processes that improve patient safety. It’s also paramount in the nursing profession that investment be made in both independent and multidisciplinary research. Nurses must investigate why so many medical errors involve medication administration and determine what can be done about it. Research into the state of the science on patient safety presents a relatively uncharted course to nurses. From the nursing perspective, models can be developed that explore medication actions and interactions as well as outcomes. The role of the patient and the nurse‐patient interaction in medication error, such as compliance with discharge instructions, should be investigated as well. Patient-safety research that is directed by nurses would afford opportunities to investigate various age-specific populations, disease states, and medical settings. In the National Quality Forum a number of factors associated with a greater risk of medication errors were identified, any of which would serve as an excellent subject of nursing research, including the impact of diagnostic technologies, patient acuity, and clinical environments on patient safety. 11

How We Think About Medication Errors

physicians and pharmacists are generally the ones defining practice as it relates to preventing medication errors, without involving nurses. It’s imperative that nurses develop theoretical models, undertake research, and incorporate the findings into practices and processes that improve patient safety. It’s also paramount in the nursing profession that investment be made in both independent and multidisciplinary research. Nurses must investigate why so many medical errors involve medication administration and determine what can be done about it. Research into the state of the science on patient safety presents a relatively uncharted course to nurses. From the nursing perspective, models can be developed that explore medication actions and interactions as well as outcomes. The role of the patient and the nurse‐patient interaction in medication error, such as compliance with discharge instructions, should be investigated as well. Patient-safety research that is directed by nurses would afford opportunities to investigate various age-specific populations, disease states, and medical settings. In the National Quality Forum a number of factors associated with a greater risk of medication errors were identified, any of which would serve as an excellent subject of nursing research, including the impact of diagnostic technologies, patient acuity, and clinical environments on patient safety. 11

Pharmacotherapy of neuropathic low back pain.

Neuropathic low back pain is examined from a structural standpoint, distinguishing processes that start from chronic inflammation and mechanical compromise and cross into the realm of neuropathy with primary neurogenic pathophysiology. The disease of chronic pain is discussed, examining peripheral and central changes in neuroanatomy, neurophysiology, and neuromolecular dynamics. The limitations of inadequate random controlled trials regarding long-term pharmacologic interventions are contrasted with excellent work in the basic science of chronic pain. Complex rational pharmacologic strategies for structural pathology, central pain processes, sites of medication action, and differing routes of administration are delineated.

Helping Teens Navigate a Safe Passage From Childhood to Adulthood

Helping Teens Navigate a Safe Passage From Childhood to Adulthood

Our Understanding of Drug Interactions Becomes Even More Complex

Clinicians must keep track of the factors that determine medication action and the nonprescription substances that influence it. For example, some

And the Complications Continue

Oxidative (phase-I) metabolism by cytochrome P450 enzymes is a well-known influence on medication action, but phase-II metabolism by glucuronidation

Policies on documentation and disciplinary action in hospital pharmacies after a medication error.

Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.

Pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients

The present study examines the correlations between pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients. The three variables were obtained with the Ulm Pain Diary (Ulmer Schmerztagebuch, UST). Thirty-eight patients with low back pain described pain intensity, effect of pain on mood and medication as well as other therapies over a 3-week period (21 days). The patients had a history of pain for between 6 weeks and 6 months. Clinical and orthopedic examinations revealed no relevant organic findings explaining the pain process. Pain occurred on 18.1 (of 21) days. Half of the patients (n=19) used medication or took other actions against their pain. Correlations between the three variables demonstrated that all three were significantly related. Partial correlations showed in addition to a high correlation between pain intensity and mood, that the frequency of pain-relieving actions was far less related to pain intensity than to mood. The group that took actions against their pain had a higher level of pain intensity than the no-action group. Furthermore, the effect of pain on mood was significantly greater in this group than in the no-action group. The findings indicate that pain intensity, mood and actions against pain are highly correlated. When pain intensity is statistically controlled, the influence of mood on taking medication or other actions against pain becomes more pronounced. It can be concluded that self-initiated actions against pain depend much more on mood than on pain intensity in pre-chronic low back pain patients.

Clinical profile of clozapine: adverse reactions and agranulocytosis.

The arrival of clozapine has been one of the most significant developments in antipsychotic drug treatment since the advent of chlorpromazine ushered in the psychopharmacologic era. However, its utilization has been significantly limited and complicated by its potential to cause adverse effects and agranulocytosis in particular. It must be emphasized that clozapine has a side effect profile that is in many ways distinct from standard typical antipsychotic drugs. Side effects with clozapine are common and range from the benign to the potentially lethal. The most common side effects include sedation, dizziness, and sialorrhea during sleep; the most serious are agranulocytosis, seizures and respiratory depression. Although side effects from clozapine are not necessarily preventable, they are for the most part manageable. Even with the most serious adverse effects, proper knowledge of the medication's actions, clinical vigilance, and prompt intervention can prevent the occurrence of significant morbidity and mortality as a consequence of clozapine treatment.

Pediatric asthma, a qualitative and quantitative approach to needs assessment

This article describes an approach to needs assessment in a specific location using both focus group interviews and a written questionnaire. In this case study, the target population consists of parents of asthmatic children (0–4 years of age). Six focus group interviews were conducted with the purpose of discussing parents' experiences with health care for asthma, their beliefs and knowledge of general aspects of asthma, medication and preventive actions. As a supplement, parents completed a written questionnaire providing additional quantitative information on parental knowledge and misconceptions. Results indicated that parental knowledge of asthma in general was not adequate, especially with respect to medication, preceding signs and preventive activities. Important misconceptions, which might contribute to noncompliance with self-management behaviors, were revealed during discussions with the parents. Several differences were found between results of the interviews and the questionnaire, for instance regarding parental knowledge about preventive measures, medication and perceived parental satisfaction with health care for asthma. These differences indicate the value of using both a survey and a focus group.

Geropharmacology treatment: behavioral problems extend nursing responsibility.

1. Assessment of older adults with behavior problems considers factors contributing to the behavior; potential psychosocial interventions; patient characteristics influencing medication action; and medication characteristics influencing therapeutic and adverse effects. 2. Anxiety, agitation, and other behavioral problems in demented patients might arise from their inability to verbally express complaints such as pain and discomfort. 3. Although constant blood levels of medication are most effective for ongoing management of behavior problems, as needed doses can be used to establish the optimal dosing schedule. 4. Medications in low doses can be used to improve the patient's response to psychosocial interventions for behaviors such as anxiety, agitation, depression, and sleep disorders; but they should not be used as the only intervention.

Psychiatric consultation to geriatric medically ill inpatients in a university hospital.

Using hospital admissions data, medical records, and the Consultation-Liaison Outcome Evaluation System, we studied psychiatric consultation to hospitalized medical-surgical patients who were aged 60 years or older. In comparison with younger patients, the geriatric population was less often referred for psychiatric consultation. Those referred had less prior psychiatric history than the group aged less than 60 years. They received a different distribution of psychiatric diagnoses. Consultants recommended psychotropic medication and diagnostic actions more often for the elderly; the former was related to the presence of organic mental disorder. Concordance with consultants' recommendations and diagnoses did not vary with patients' age. Certain aspects of the consultation process are thus modified when geriatric patients are involved, and specific features of "geriatric consultation" are unique.

Requests for outpatient mental health services: A comparison of whites and blacks

Service requests by 267 whites and 42 blacks registering through an outpatient psychiatric clinic were compared. Blacks requested relatively more direct and immediate types of services including medication and administrative action. The larger patterns of requests by whites and blacks bore a high similarity.

Compliance With Psychiatric Consultant's Recommendations-Reply

In the continued development of a Consultation Liaison Outcome Evaluation System (CLOES), we have now examined consultee responses to a number of consultant actions and identified variables critical to the respective outcomes. Concordance rates in these additional studies have been either lower or comparable to those we reported in response to consultants' recommendations for psychotropic medication. Kramer et al ask if consultants in other medical specialties elicit comparable consultee responses to their interventions. Preliminary results from companion studies of the cardiology consultation service in our hospital indicate that cardiology consultants elicit significantly greater overall concordance than their psychiatric counterparts in both recommendations for medication and diagnostic action.