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Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies

Quality and Safety in Health Care Journal -

Background

Medication non-adherence in ambulatory care has received substantial attention in the literature, but less so as it affects acute care. Accordingly, we aimed to estimate the frequency with which non-adherence to medication contributes to hospital admissions.

Methods

We searched the Cochrane Library, EMBASE, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts and PubMed (until December 2017) to identify prospective observational studies that examined prevalence rates of hospital admissions associated with medication non-adherence. A quality assessment was performed using an expanded Crombie checklist. Data extraction covered patterns, circumstances, and patient and other key characteristics of non-adherence. Pooled estimates were obtained using a random-effect model.

Results

Of 24 included studies, 8 were undertaken in North America, 7 from Europe, 6 from Asia and 3 from Australia. Most studies (79%) were rated as low risk of bias. All but three studies used combination measures to detect non-adherence, but approaches to assess preventability varied considerably. Across the studies, there was high heterogeneity among prevalence estimates (2=548, df 23, p<0.001, I2=95.8%). The median prevalence rate of hospital admissions associated with non-adherence was 4.29% (IQR 3.22%–7.49%), with prevalence rates ranging from 0.72% to 10.79%. By definition, almost all of these admissions were considered preventable. The underlying causes contributing to these admissions included medication cost and side effects, and non-adherence most often involved cardiovascular medicines.

Conclusions

Hospital admissions associated with non-adherence to medication are a common problem. This systematic review highlights important targets for intervention. Greater attention could be focused on adherence to medication during the hospital stay as part of an enhanced medication reconciliation process. Standardisation in study methods and definitions is needed to allow future comparisons among settings; future studies should also encompass emerging economies.

Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers

Quality and Safety in Health Care Journal -

Background

Many intensive care (ICU) survivors experience early unplanned hospital readmission, but the reasons and potential prevention strategies are poorly understood. We aimed to understand contributors to readmissions from the patient/carer perspective.

Methods

This is a mixed methods study with qualitative data taking precedence. Fifty-eight ICU survivors and carers who experienced early unplanned rehospitalisation were interviewed. Thematic analysis was used to identify factors contributing to readmissions, and supplemented with questionnaire data measuring patient comorbidity and carer strain, and importance rating scales for factors that contribute to readmissions in other patient groups. Data were integrated iteratively to identify patterns, which were discussed in five focus groups with different patients/carers who also experienced readmissions. Major patterns and contexts in which unplanned early rehospitalisation occurred in ICU survivors were described.

Results

Interviews suggested 10 themes comprising patient-level and system-level issues. Integration with questionnaire data, pattern exploration and discussion at focus groups suggested two major readmission contexts. A ‘complex health and psychosocial needs’ context occurred in patients with multimorbidity and polypharmacy, who frequently also had significant psychological problems, mobility issues, problems with specialist aids/equipment and fragile social support. These patients typically described inadequate preparation for hospital discharge, poor communication between secondary/primary care, and inadequate support with psychological care, medications and goal setting. This complex multidimensional situation contrasted markedly with the alternative ‘medically unavoidable’ readmission context. In these patients medical issues/complications primarily resulted in hospital readmission, and the other issues were absent or not considered important.

Conclusions

Although some readmissions are medically unavoidable, for many ICU survivors complex health and psychosocial issues contribute concurrently to early rehospitalisation. Care pathways that anticipate and institute anticipatory multifaceted support for these patients merit further development and evaluation.

Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers

Quality and Safety in Health Care Journal -

Background

Little is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up.

Methods

In collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience.

Results

105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%–70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a ‘troublemaker’, ‘team is too busy’ or ‘I don’t know how’. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up.

Conclusion

Speaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create ‘trouble’ may help promote open discussions about care concerns and possible errors in the ICU.

Using a network organisational architecture to support the development of Learning Healthcare Systems

Quality and Safety in Health Care Journal -

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision. The network framework aligns participants around a common goal of improving health outcomes, transparency of outcome measures and a flexible and adaptive collaborative learning system. Team collaboration is promoted by using standardised processes, protocols and policies, including communication policies, data sharing, privacy protection and regulatory compliance. Learning methods include collaborative quality improvement using a modified Breakthrough Series approach and statistical process control methods. Participants observe their own results and learn from the experience of others. A common repository (a ‘commons’) is used to share resources that are created by participants. Standardised technology approaches reduce the burden of data entry, facilitate care and result in data useful for research and learning. We describe how this organisational framework has been replicated in four conditions, resulting in substantial improvements in outcomes, at scale across a variety of conditions.

QI Project Charter

Institute for Healthcare Improvement -

The QI project charter provides a rationale and roadmap for the team’s improvement work that can be used to clarify thinking about what needs to be done and why. The charter helps keep the focus on a specific opportunity or problem and identifies the members of the improvement team.

QI Project Charter

Institute for Healthcare Improvement -

The QI project charter provides a rationale and roadmap for the team’s improvement work that can be used to clarify thinking about what needs to be done and why. The charter helps keep the focus on a specific opportunity or problem and identifies the members of the improvement team.

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