Michelle Howard

Interventions to Improve Medication Reconciliation in Primary Care

Objective: To systematically review all primary care intervention studies designed to implement medication reconciliation for effects on medication discrepancies, clinical outcomes, and patient knowledge of their medications. Data Sources: We searched MEDLINE (1988–March 2008); Healthstar (1966–March 2008): CINAHL (1982–March 2008); EMBASE (1980–March 2008); Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, and Health Technology Assessments; and unpublished material. No language restrictions were applied. Search terms included medication reconciliation, medication errors, prescribing error, medication systems, adverse drug events, drug utilization review, medication list, medication record, and medications management. Study Selection And Data Abstraction: Randomized controlled trials or before-and-after studies that examined the effect of various interventions on medication discrepancies either in ambulatory settings or at hospital discharge among community-dwelling adults were included. Two reviewers independently assessed studies to determine inclusion. Level of agreement between the reviewers was good, with unweighted Cohens κ of 0.71. Two of 3 independent reviewers abstracted data and evaluated validity from included studies. Disagreements between reviewers were resolved by consensus. Data Synthesis: Four trials met the inclusion criteria. Two before-and-after studies (n = 275) in ambulatory care examining systematic medication reconciliation at each visit produced conflicting results. One study showed a reduction in the proportion of medication discrepancies from 88.5% to 49.1% (OR 0.13; 95% CI 0.07 to 0.21); the other showed no benefit. One randomized controlled trial and one before-and-after study (n = 202) evaluated pharmacist medication review at hospital discharge. Neither showed a benefit. Heterogeneity precluded pooling of studies. All included studies had significant design flaws. Conclusions: There is no good quality evidence demonstrating the effectiveness of medication reconciliation in the primary care setting. Further research is needed.

Regional Distribution of Antibodies to Herpes Simplex Virus Type 1 (HSV-1) and HSV-2 in Men and Women in Ontario, Canada

ABSTRACT This study estimated the regional and age- and gender-specific seroprevalences of herpes simplex virus type 1 (HSV-1) and HSV-2 in Ontario, Canada. Stored serum specimens from subjects aged 15 to 44 years, including men (n = 979), women not under prenatal care (n = 638), and women under prenatal care (n = 701) submitted for routine viral serology were randomly selected according to regional population size from public health laboratories. HSV-1 and HSV-2 testing was done with the MRL enzyme immunoassay (EIA) (Focus Technologies), and HSV-2 was also tested by the Gull/Meridian EIA. Specimens discordant for HSV-2 antibodies between the two EIAs were resolved by a recombinant immunoblot assay (Focus Technologies). The overall age- and gender-standardized seroprevalences of HSV-1 and HSV-2 were 51.1% (95% confidence interval [CI], 50.1 to 52.1) and 9.1% (95% CI, 8.6 to 9.7), respectively. The seroprevalence of HSV-1 antibodies increased from 26.9 to 54.7% in men between 15 to 16 and 40 to 44 years of age, from 32.0 to 88.7% in women not under prenatal care, and from 55.2 to 69.2% in women under prenatal care. The seroprevalence of HSV-2 increased from 3.8 to 21.3% in men between 15 to 16 and 40 to 44 years of age, from 0 to 18.9% in women not under prenatal care, and from 3.4 to 23.1% in women under prenatal care. HSV-2 results were discordant for 3.3% (76 of 2,318) of specimens. Both types of HSV antibodies appeared to be acquired earlier among women under prenatal care than among men and women not under prenatal care. Antibodies were more prevalent among people in northern Ontario (72.9% of subjects [range, 68.4 to 77.4%] for HSV-1 and 13.7% of subjects [95% CI, 10.2 to 17.2%] for HSV-2) than elsewhere.

Prevalence of Chlamydia trachomatis Infections and Specimen Collection Preference Among Women, Using Self-Collected Vaginal Swabs in Community Settings

Background Chlamydia trachomatis is a common, often asymptomatic sexually transmitted infection. Goal The goal was to estimate the prevalence and predictors of C. trachomatis among young women using self-collected vaginal swabs, and the preferences of women and physicians for self-testing. Study Design A total of 514 attendees of university/college health clinics, adolescent birth control clinics, centers providing health services to homeless youth and adults (street health centers), a sexually transmitted diseases clinic, and family practices were tested by ligase chain reaction. Preference for self- versus provider-testing was examined. Results Prevalence was 6.0% and was highest (18.2%) in the street health centers. In multivariate analysis, only recent contact with someone with C. trachomatis infection was significantly associated with infection (odds ratio, 7.1; 95% confidence interval, 2.5–20.0). Most women (54.2%; 256 of 472) preferred self-sampling compared with physician sampling (15.9%; 75 of 472). The majority of physicians (75.0%; 9 of 12) reported at the start and end of the study that they would use vaginal swab self-sampling if available. Conclusions Prevalence of infection in young women attending homeless youth organizations was high. Self-sampling was acceptable and could facilitate screening in high-risk women who do not regularly access health services.

Vaginal self sampling versus physician cervical sampling for HPV among younger and older women.

Objectives: To estimate the agreement between self collected vaginal swabs and physician collected cervical brush samples for detection of oncogenic human papillomavirus infection (HPV) by the hybrid capture 2 (HC-2) test among women younger and older than 50 years, and to assess women’s preference for sample collection method based on age. Methods: Consecutive women aged 15–49 years due for a 1 year visit in a prevalence study of carcinogenic HPV and a new sample of women aged 50 years and older attending their family physicians for cervical screening, in Ontario, Canada, performed vaginal self sampling and underwent physician cervical sampling and cervical cytology. Women completed a self administered questionnaire on demographics and preference for sampling method. Results: Among the 307 women aged 15–49 years, the prevalence of HPV was 20.8% (64/307) and 17.6% (54/307) in the vaginal and cervical specimens, respectively. Among the women aged 50 years and older, prevalence was 9.9% (15/152) and 8.6% (13/152), respectively. Kappa for agreement between sample collection methods was 0.54 for the younger and 0.37 for the older women (both p<0.001). Nearly half of the women preferred self sampling or had no preference. Conclusions: There was fair agreement between self collected vaginal and physician collected cervical specimens for detecting carcinogenic HPV in younger and older women. Vaginal sampling for HPV appears to be promising as a primary screening strategy for cervical cancer prevention programmes in low resource settings in developed and developing countries.

Optimizing the hybrid capture II human papillomavirus test to detect cervical intraepithelial neoplasia

OBJECTIVE To estimate the optimal relative light unit ratio, and correspondingly viral load, of the hybrid capture II oncogenic human papillomavirus deoxyribonucleic acid test for detecting cervical intraepithelial neoplasia (CIN). METHODS Women with abnormal cytology were referred for colposcopy, and a cervical swab or brush specimen was obtained for human papillomavirus testing. Sensitivities, specificities, and likelihood ratios of different relative light unit ratio cutoffs were calculated using a reference standard of colposcopy or biopsy of either CIN II+ (CIN II, III, or carcinoma), or CIN I+ (CIN I, CIN II+). The receiver operating characteristic curve was used to estimate optimal test‐positive cutoff points for the hybrid capture II test. RESULTS CIN II+ was found in 18.7% (98 of 524) and CIN I in 10.5% (55 of 524) of the women. The optimal relative light unit ratio was 15.56, giving a sensitivity and specificity of 82.7% and 73.2% for CIN II+, and 74.2% and 77.8% for CIN I+. In a stratified analysis, a higher relative light unit cutoff (15.19) optimized sensitivity and specificity for CIN II+ (sensitivity 81.8%, specificity 51.5%) for women with low‐grade squamous intraepithelial lesions cytology, whereas the optimal cutoff was 2.36 (sensitivity 100%, specificity 73.0%) for women with atypical squamous cells of undetermined significance, yielding referral rates of 53.3% and 28.7%, respectively. Use of a swab or brush was not associated with the level of human papillomavirus detected (P > .05). CONCLUSION Use of a higher cutoff for the relative light unit ratio (higher viral load) of the hybrid capture II test may improve the management of women, especially those with low‐grade squamous intraepithelial lesions cytology.

Self-collection for vaginal human papillomavirus testing: systematic review of studies asking women their perceptions.

Objectives. To systematically review literature on womens acceptance, preference, willingness, and attitudes toward human papillomavirus DNA vaginal self-sampling and assess study validity using the STROBE statement. Materials and Methods. From September to October 2008, Ovid MEDLINE, EMBASE, and CINAHL databases were searched systematically over all years available. Participants were women who either completed vaginal self-sampling or were described the procedure. Studies were required to report womens acceptance, preference, willingness or attitudes toward self-sampling. Two independent reviewers assessed abstracts and articles for inclusion and collected study data. Disagreements were resolved by consensus. Results. Twenty studies were included. Of 8 studies, 7 reported that women found self-sampling acceptable. Of the 13 studies, 8 found that more women (63%-94%) preferred self-sampling to clinician-collected sampling. Most women were also receptive to self-sampling as part of future screening. Common opinions expressed by women included an uncertainty if they had or could perform the self-test properly and greater confidence in clinician sampling. Only 2 studies used questionnaires that had been validated, and selection bias favoring self-sampling could not be ruled out in most studies. Conclusions. Vaginal human papillomavirus DNA self-sampling is generally well received among women. However, the possibility of selection bias and survey instrument measurement error may have led to an overestimate of womens favorable opinions for self-sampling. A self-sampling option may increase screening coverage, but concerns of women must also be addressed.

Patient Satisfaction With Care for Urgent Health Problems: A Survey of Family Practice Patients

PURPOSE Patient satisfaction is an important health care outcome. This study compared patients’ satisfaction with care received for an urgent health problem from their family physician, at an after-hours clinic in which their physician participated, at a walk-in clinic, at the emergency department, from telephone health advisory services, or from more than 1 of those services. METHODS We mailed a questionnaire to a random sample of patients from 36 family practices in Thunder Bay, Ontario. We elicited satisfaction with care for the most recent urgent health problem in the past 6 months on a 7-point scale (very dissatisfied to very satisfied). RESULTS The response rate was 62.3% (5,884 of 9,397). Of the 5,722 eligible patients 1,342 (23.4%) reported an urgent health problem, and data were available for both services used and satisfaction for 1,227 patients. After adjusting for sociodemographic characteristics and self-reported health status, satisfaction with care received for most recent urgent health problem was significantly higher among patients who visited or spoke to their family physician (mean 6.1; 95% confidence interval [CI], 5.8–6.4) compared with all other services (all P <.004, adjusted for multiple comparisons), with the exception of patients who used the after-hours clinic affiliated with their physician, whose satisfaction was not significantly different (mean 5.6; 95% CI, 5.2–6.0). CONCLUSIONS Satisfaction was highest for patients receiving care from their own family physician or their physician’s after-hours clinic. These results are important for new primary care models that emphasize continuity and after-hours availability of family physicians.

Assessment of the cervix after acetic acid wash: inter-rater agreement using photographs.

OBJECTIVE To estimate the inter‐rater agreement on the assessment of cervical photographs after acetic acid wash, using visual inspection with acetic acid categories. METHODS Three raters individually assessed 144 photographs as negative, positive, or suspicious for cancer. The inter‐rater agreement was analyzed using the unweighted and weighted κ coefficient. To explore the reasons for concordancy and discordancy, photographs were compared on histologic evidence of cervical intraepithelial neoplasia and on testing for oncogenic types of human papillomavirus. RESULTS Overall raw agreement among the three raters was 66.7% (96 of 144) with a κ of 0.57 (95% confidence interval 0.48, 0.66). Pair‐wise agreement using unweighted and weighted κ was moderate to substantial: 0.54–0.60 and 0.56–0.63, respectively. There was concordance on negative in 25.7% (37 of 144) and on positive or suspicious for cancer in 41.0% (59 of 144). Cervical intraepithelial neoplasia II or III was not present on biopsy if photographs were concordant‐negative, and the human papillomavirus test was less likely to be positive (relative risk 0.3; 95% confidence interval 0.2, 0.6) in concordant‐negatives compared with concordant‐positives, including suspicious for cancer. Cervical intraepithelial neoplasia II or III was more common in photographs that were concordant‐positive, including suspicious for cancer, compared with discordants (relative risk 3.4, 95% confidence interval 1.5, 7.6). CONCLUSION Based on photographs of the cervix taken after acetic acid wash, the level of agreement among raters using visual inspection with acetic acid categories was moderate to substantial, consistent with other commonly used tests.

A Shared Care Model Pilot for Palliative Home Care in A Rural Area: Impact on Symptoms, Distress, and Place of Death

CONTEXT Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs. OBJECTIVES To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death. METHODS An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models. RESULTS Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed. CONCLUSION Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.

Understanding the Health of Refugee Women in Host Countries: Lessons from the Kosovar Re-Settlement in Canada

INTRODUCTION Refugees from Kosovo arrived in several Canadian cities after humanitarian evacuations in 1999. Approximately 500 arrived in Hamilton, Canada. Volunteer sponsors from community organizations assisted the families with settlement, which included providing them access to healthcare services. HYPOTHESIS/PROBLEM It was anticipated that women, in particular, would have unmet health needs relating to trauma and a lack of healthcare access after experiencing forced migration. METHODS This study describes the results of a self-administered survey regarding womens health issues and experiences with health services after the arrival of refugees. It also describes the sponsor groups experience related to womens health care. The survey was administered to a random sample of 85 women refugees, and focus groups with 14 sponsors. Women self-completed questionnaires about their health, which included the Harvard Trauma Questionnaire for post-traumatic stress disorder (PTSD) and use of preventive health services. Sponsor groups participated in a focus group discussing healthcare needs and experiences of their assigned refugee families. Themes pertaining to womens issues were identified from the focus groups. RESULTS Preventive screening rates were low, only 1/19 (5.3%) women > or = 50-years-old had ever received a mammogram; 34.1% (28/82) had ever received a Pap test); and PTSD was prevalent (25.9%, 22/85). Sponsor groups identified challenges relating to prenatal care needs, finding family physicians, language barriers to health care services, cultural influences ofwomens healthcare decision-making, mental health concerns, and difficulties accessing dental care, eye care, and prescriptions. CONCLUSIONS Many women refugees from Kosovo had unmet health needs. Culturally appropriate population level screening campaigns and integration of language and interpretation services into the healthcare sector on a permanent basis are important policy actions to be adequately prepared for newcomers and women in displaced situations. These needs should be anticipated during the evacuation period by host countries to aid in planning the provision of health resources more efficiently for refugees and displaced people going to host countries.