Coraline Claeys

Approaches for improving continuity of care in medication management: a systematic review

PURPOSE Medication-related problems frequently occur during transitions and lead to patient harm, increased use of healthcare resources and increased costs. The objective of this systematic review is to synthesize the impact of approaches to optimize the continuity of care in medication management upon hospital admission and/or discharge. DATA SOURCES MEDLINE, EMBASE, CINAHL, IPA and the Cochrane Database of Systematic Reviews from 1995 through December 2010. STUDY SELECTION Controlled, parallel-group trials. Data extraction Data were extracted by one researcher and checked by another. Both reviewers independently assessed the study quality. RESULTS Thirty studies met the inclusion criteria, but only 14 reached the predefined minimum quality score. Most studies focused on discharge and targeted the patients, sometimes together with primary care providers. The majority of studies found improvements in process measures. Patient education and counseling provided upon discharge and reinforced after discharge, sometimes together with improved communication with healthcare professionals, was shown to reduce the risk of adverse drug events and hospital re-admissions in some studies, but not all. Heterogeneity in study population as well as in intervention and outcome reporting precluded meta-analysis and limited interpretation. Most studies had important methodological limitations and were underpowered to show significant benefits on clinical outcomes. CONCLUSIONS The evidence for an impact of approaches on optimization of continuity of care in medication management remains limited. Further research should better target high-risk populations, use multicentered designs and have adequate sample size to evaluate the impact on process measures, clinical outcomes and cost-effectiveness.

Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies

BACKGROUND Medication discrepancies are medication-related problems (MRPs) that frequently occur when patients are transferred between settings of care. Older patients are at high risk for several reasons, including high consumption of medicines, and physical and cognitive deficiencies that can impair the communication process. Most previous studies that have evaluated medication discrepancies used instruments designed for clinical practice, but a well-validated and reliable instrument for clinical research is still lacking. OBJECTIVES The aims of this study were to (i) develop an instrument to characterize medication discrepancies that fulfils quality requirements for classification of MRPs related to continuity of care and (ii) assess its content validity and inter-rater reliability. METHODS The instrument was developed based on three main inputs: (i) a literature review to collect information about the quality requirements of instruments to characterize MRPs; (ii) another literature review to identify existing instruments to characterize MRPs and, more specifically, medication discrepancies; and (iii) previous experience from a pilot study on Belgian patients discharged from surgical and medical wards. Content validity was assessed using a modified Delphi technique with 11 healthcare professionals. Content validity indexes were calculated. For inter-rater reliability, three pharmacists (one experienced and two naive) were asked to identify and categorize (type and cause of) unintentional medication discrepancies for 21 patients discharged from hospital into the community. The intra-class correlation coefficient was calculated to compare the number of discrepancies identified, and a paradox-resistant index (AC1) was used to determine the inter-rater reliability for the type and cause of the discrepancy. RESULTS The instrument had 54 items classified in three sections (type of discrepancy, cause and intervention), with detailed specifications on how to use it. All evaluations relative to content validity met predefined cut-off values, except for two of them. Intra-class correlation coefficients of ≥0.76 and AC1 coefficients of ≥0.89 were found for the number and the type of discrepancies, respectively. Regarding evaluation of the specific causes of medication discrepancies, final AC1 results of ≥0.86 were obtained, except for three items (which had values between 0.62 and 0.79). CONCLUSION The validity and reliability of the instrument developed to assess unintentional medication discrepancies at patient transition from the hospital to the community setting was found to be satisfactory.

Initiatives promoting seamless care in medication management: an international review of the grey literature

Background Patients’ transition between hospital and community is a high-risk period for the occurrence of medication-related problems. Aim of the review The objective was to review initiatives, implemented at national and regional levels in seven selected countries, aiming at improving continuity in medication management upon admission and hospital discharge. Method We performed a structured search of grey literature, mainly through relevant websites (scientific, professional and governmental organizations). Regional or national initiatives were selected. For each initiative data on the characteristics, impact, success factors and barriers were extracted. National experts were asked to validate the initiatives identified and the data extracted. Results Most initiatives have been implemented since the early 2000 and are still ongoing. The principal actions include: development and implementation of guidelines for healthcare professionals, national information campaigns, education of healthcare professionals and development of information technologies to share data across settings of care. Positive results have been partially reported in terms of intake into practice or process measures. Critical success factors identified included: leadership and commitment to convey national and local forces, tailoring to local settings, development of a regulatory framework and information technology support. Barriers identified included: lack of human and financial resources, questions relative to responsibility and accountability, lack of training and lack of agreement on privacy issues. Conclusion Although not all initiatives are applicable as such to a particular healthcare setting, most of them convey very interesting data that should be used when drawing recommendations and implementing approaches to optimize continuity of care.