Impact of pre-packaging antimalarial drugs and counselling on compliance with malaria treatment at Port Moresby General Hospital Adult Outpatient Department. [Usefulness of a software package to reduce medication errors in neonatal care]. Improving adherence to family planning guidelines in Kenya: an experiment. Effect of value-added utilities on prescription refill compliance and Medicaid health care expenditures--a study of patients with non-insulin-dependent diabetes mellitus. Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study. Impact of medication packaging on adherence and treatment outcomes in older ambulatory patients. A randomized trial of special packaging of antihypertensive medications. The effect of drug packaging on patients' compliance with treatment for Plasmodium vivax malaria in China. Effect of value-added utilities on prescription refill compliance and health care expenditures for hypertension. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Prescribers' responses to alerts during medication ordering in the long term care setting.
We investigated the impact of pre-packaging antimalarial drugs and counselling on compliance with treatment of malaria at the Adult Outpatient Department of Port Moresby General Hospital. Adult patients who were prescribed standard antimalarial drugs following clinical and microscopic diagnosis of malaria were randomly assigned to one of three groups: an intervention group, where pre-packaging and counselling instructions were applied; control group A, with counselling but no pre-packaging; and control group B, with neither counselling nor pre-packaging. Patients were interviewed on two occasions, day 1 of treatment and day 4 post treatment. Of a total of 436 patients, 322 patients (179 males and 143 females) completed the study. Our data indicate an increase of 18% in compliance with treatment in the intervention group and 16% in control group A, when compared with control group B. While compliance with treatment was gender independent, the language spoken and used for giving instructions and counselling may have influenced patients' behaviour on prescribed medication. The results of our study indicate that a simple pre-packaging system and proper counselling could improve compliance with antimalarial drug treatment. As an additional beneficial observation, pre-packaging is likely to eliminate errors and possible contamination of the products during dispensing. Many treatment errors in neonatal intensive care units are caused by the need to carry out a sequence of calculations to determine the dose and dilution of the drugs used.
                To help in this task, we designed a spreadsheet (Neodosis) that helps clinicians and nurses to calculate the doses and standardize the dilutions of some of the drugs most commonly used in resuscitation and neonatal intensive care units. The aim of this study was to verify the usefulness and reliability of this software package.
                A randomized, cross-over, controlled trial was conducted through simulated clinical cases in which the number of errors in the prescription data and the amount of time spent in making calculations, with and without the program, were evaluated. Fifty-four tests were performed by pediatricians, third- and fourth-year pediatric residents, and nurses.
                Without computer support, all three groups made errors (residents, pediatricians and nurses in descending order). When Neodosis was used, all the medical staff made significantly fewer errors. The greatest reduction was found in errors made by pediatric residents: minor errors decreased from 16 % to 2 % and major errors from 1.6 % to zero. When using the spreadsheet, the time spent by all groups in making the calculations was reduced by between one-third and one-half.
                The tests performed with simulated clinical cases revealed that the number of errors made by the healthcare personnel who participated in this study was not inconsiderable. The use of Neodosis helped physicians and nurses to make markedly fewer errors and also saved them time. QUALITY PROBLEM: Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed.
                Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices.
                Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement.
                A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation.
                Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective.
                Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa. An estimated 20 million Americans suffer from diabetes. Patients with non-insulin-dependent diabetes mellitus (NIDDM) comprise approximately 90% of the diabetic population. An estimated 10-30% of patients with NIDDM withdraw from their prescribed regimen within 1 year of diagnosis, and of the remainder, nearly 20% administer insufficient medication to facilitate an adequate reduction in blood glucose. A randomized trial was undertaken to discern the effect of pharmacy-based value-added utilities on prescription-refill compliance with sulfonylurea therapy and health service utilization. The subjects were 258 Medicaid beneficiaries from the state of South Carolina, previously untreated for NIDDM, prescribed 5 mg of the second-generation sulfonylurea glyburide twice daily, and monitored with regard to prescription-refill compliance and health service utilization for 1 year. Subjects provided informed consent and were randomly assigned to one of four experimental groups: (i) the control cohort received standard pharmaceutical care with each dispensing of glyburide; (ii) the second cohort received standard pharmaceutical care and was mailed a medication-refill reminder 10 days prior to each sequential refill date; (iii) the third cohort received standard pharmaceutical care and was provided unit-of-use packaging with each prescription-refill request; (iv) the fourth cohort received standard pharmaceutical care, mailed medication-refill reminders, and unit-of-use packaging. Analysis of variance (ANOVA) procedures revealed that patients receiving mailed prescription-refill reminders, unit-of-use packaging, or a combination of both interventions achieved a significant (P < or = 0.05) increase in the Medication Possession Ratio (MPR) for sulfonylurea therapy relative to controls.(ABSTRACT TRUNCATED AT 250 WORDS) To determine whether an educational package could influence the management of menorrhagia, increase the appropriateness of choice of non-hormonal treatment, and reduce referral rates from primary to secondary care.
                Randomised controlled trial.
                General practices in East Anglia.
                100 practices (348 doctors) in primary care were recruited and randomised to intervention (54) and control (46). Interventions: An educational package based on principles of "academic detailing" with independent academics was given in small practice based interactive groups with a visual presentation, a printed evidence based summary, a graphic management flow chart, and a follow up meeting at 6 months.
                All practices recorded consultation details, treatments offered, and outcomes for women with regular heavy menstrual loss (menorrhagia) over 1 year.
                1001 consultation data sheets for menorrhagia were returned. There were significantly fewer referrals (20% v 29%; odds ratio 0. 64; 95% confidence interval 0.41 to 0.99) and a significantly higher use of tranexamic acid (odds ratio 2.38; 1.61 to 3.49) in the intervention group but no overall difference in norethisterone treatment compared with controls. There were more referrals when tranexamic acid was given with norethisterone than when it was given alone. Those practices reporting fewer than 10 cases showed the highest increase in prescribing of tranexamic acid.
                The educational package positively influenced referral for menorrhagia and treatment with appropriate non-hormonal drugs. To evaluate medication adherence and treatment outcomes in elderly outpatients using daily-dose blister packaging (Pill Calendar) compared with medications packaged in bottles of loose tablets.
                Randomized controlled trial.
                Ambulatory care clinics at Ohio State University Medical Center, Columbus; University of Arizona Health Science Center, Tucson; and Riverside Methodist Hospital Family Medicine Clinic, Columbus, Ohio, from July 1, 2002, to December 31, 2004.
                85 individuals 65 years of age or older being treated with lisinopril for hypertension.
                Patients were randomly assigned to receive lisinopril in either daily-dose blister packaging (Pill Calendar) or traditional bottles of loose tablets.
                Adherence was assessed by prescription refill regularity and medication possession ratio (MPR). Treatment outcome and use of medical services were assessed by medical record review of blood pressure and morbidity associated with poorly controlled hypertension.
                Patients receiving lisinopril in the daily-dose blister packaging (Pill Calendar) refilled their prescriptions on time more often (P = 0.01), had higher MPRs (P = 0.04), and had lower diastolic blood pressure (P = 0.01) than patients who had their medications packaged in traditional bottles of loose tablets.
                Providing medications in a package that identifies the day each dose is intended to be taken and provides information on proper self-administration can improve treatment regimen adherence and treatment outcomes in elderly patients. This article reports a randomized controlled trial designed to test the effects of special packaging of antihypertensive medication on compliance and blood pressure control. One hundred eighty subjects who had exhibited elevated blood pressure greater than 90 mmHg in the two years prior to the study were recruited from patients receiving care at a community hospital-based family medicine practice. After completing preenrollment interviews and blood pressure measurements, subjects were randomly assigned to receive their antihypertensive medications either in the usual vials or in special unit dose-reminder packaging. Follow-up interviews, pill counts, and blood pressure measurements were performed at three-month intervals. There were no statistically significant differences between the control and experimental groups with regard to age, sex, race, employment, education, marital status, insurance coverage, or blood pressure regimens. Prior to the intervention, the experimental group had slightly lower diastolic blood pressure and reported better compliance than the control group. Analyses performed on 165 subjects completing the first follow-up visit revealed no significant improvements in blood pressure control or compliance for patients receiving special medication packaging. While some patients found it easy to remember to take pills packaged using this format, they also found the packages somewhat more difficult and inconvenient to use. In contrast to previously reported work, this study did not demonstrate any significant improvement in compliance with special packaging of antihypertensive medications. A study conducted in 1994 showed that the use of blister packs containing antimalarial drugs significantly increased patients' compliance, compared with traditional means of dispensing drugs in a paper envelope. The present study assessed patients' compliance and compared the difference between 3-day chloroquine and 8-day primaquine courses of treatment for vivax malaria. The level of real compliance was determined by making the drugs with phenobarbital, and measuring its level in the blood following treatment. The results show that blister packaging significantly improved patients' compliance (p < 0.001) over traditional means of dispensing antimalarial drugs; there was no difference in treatment compliance between 3-day and 8-day courses when the drugs were in blister packs. However, with ordinary packaging the treatment compliance rate for an 8-day course was significantly less than for a 3-day course (P < 0.05). A randomised trial was undertaken to discern the effect of pharmacy-based value-added utilities on prescription refill compliance with antihypertensive therapy and subsequent health care expenditures. The subjects were 304 Medicaid beneficiaries from the state of Florida, previously untreated for mild to moderate hypertension, prescribed 240 mg of calcium channel antagonist verapamil once daily and monitored regarding prescription refill compliance and health service utilisation for one year. Subjects provided informed consent and were randomly assigned to one of four experimental groups: (1) the control cohort received standard pharmaceutical care with each dispensing of antihypertensive therapy, (2) the second cohort received standard pharmaceutical care and was mailed a medication-refill reminder ten days prior to each sequential refill date, (3) the third cohort received standard pharmaceutical care and was provided unit-of-use packaging with each prescription-refill request and (4) the fourth cohort received standard pharmaceutical care, mailed medication-refill reminders and unit-of-use packaging. Analysis of variance (ANOVA) procedures revealed that patients receiving mailed prescription-refill reminders, unit-of-use packaging or a combination of both interventions achieved a significant (P < or = 0.05) increase in the Medication Possession Ratio (MPR) for antihypertensive therapy relative to controls. Receipt of both interventions resulted in a significant (P < or = 0.05) improvement in the MPR for antihypertensive therapy relative to all other groups no significant difference was discerned between groups receiving either mailed prescription-refill reminders or unit-of-use packaging.(ABSTRACT TRUNCATED AT 250 WORDS) Few controlled clinical trials of psychological interventions for cancer pain relief exist in spite of frequent support for their importance as adjuncts to medical treatment. This study compared oral mucositis pain levels in 4 groups of cancer patients receiving bone marrow transplants (BMT): (1) treatment as usual control, (2) therapist support, (3) relaxation and imagery training, and (4) training in a package of cognitive-behavioral coping skills which included relaxation and imagery. A total of 94 patients completed the study which involved two training sessions prior to treatment and twice a week 'booster' sessions during the first 5 weeks of treatment. Results confirmed our hypothesis that patients who received either relaxation and imagery alone or patients who received the package of cognitive-behavioral coping skills would report less pain than patients in the other 2 groups. The hypothesis that the cognitive-behavioral skills package would have an additive effect beyond relaxation and imagery alone was not confirmed. Average visual analogue scale (VAS) report of pain within the therapist support group was not significantly lower than the control group (P = 0.103) nor significantly higher than the training groups. Patient reports of relative helpfulness of the interventions for managing pain and nausea matched the results of VAS reports. From these results, we conclude that relaxation and imagery training reduces cancer treatment-related pain; adding cognitive-behavioral skills to the relaxation with imagery does not, on average, further improve pain relief. Computerized physician order entry with clinical decision support has been shown to improve medication safety in adult inpatients, but few data are available regarding its usefulness in the long-term care setting. The objective of this study was to examine opportunities for improving medication safety in that clinical setting by determining the proportion of medication orders that would generate a warning message to the prescriber via a computerized clinical decision support system and assessing the extent to which these alerts would affect prescribers' actions.
                The study was set within a randomized controlled trial of computerized clinical decision support conducted in the long-stay units of a large, academically-affiliated long-term care facility. In March 2002, a computer-based clinical decision support system (CDSS) was added to an existing computerized physician order entry (CPOE) system. Over a subsequent one-year study period, prescribers ordering drugs for residents on three resident-care units of the facility were presented with alerts; these alerts were not displayed to prescribers in the four control units.
                We assessed the frequency of drug orders associated with various categories of alerts across all participating units of the facility. To assess the impact of actually receiving an alert on prescriber behavior during drug ordering, we calculated separately for the intervention and control units the proportion of the alerts, within each category, that were followed by an appropriate action and estimated the relative risk of an appropriate action in the intervention units compared to the control units.
                During the 12 months of the study, there were 445 residents on the participating units of the facility, contributing 3,726 resident-months of observation time. During this period, 47,997 medication orders were entered through the CPOE system-approximately 9 medication orders per resident per month. 9,414 alerts were triggered (2.5 alerts per resident-month). The alert categories most often triggered were related to risks of central nervous system side-effects such as over-sedation (20%). Alerts for risk of drug-associated constipation (13%) or renal insufficiency/electrolyte imbalance (12%) were also common. Twelve percent of the alerts were related to orders for warfarin. Overall, prescribers who received alerts were only slightly more likely to take an appropriate action (relative risk 1.11, 95% confidence interval 1.00, 1.22). Alerts related to orders for warfarin or central nervous system side effects were most likely to engender an appropriate action, such as ordering a recommended laboratory test or canceling an ordered drug.
                Long-term care facilities must implement new system-level approaches with the potential to improve medication safety for their residents. The number of medication orders that triggered a warning message in this study suggests that CPOE with a clinical decision support system may represent one such tool. However, the relatively low rate of response to these alerts suggests that further refinements to such systems are required, and that their impact on medication errors and adverse drug events must be carefully assessed.
There is insufficient evidence to know if the effects of unit-dose packaged antimalarial drugs reduce treatment failure. Unit-dose packaging, supported by prescriber training and patient information, appears to improve participant-reported treatment adherence, but these data come from trials with methodological limitations.