An electronic pillbox intervention designed to improve medication safety during care transitions: challenges and lessons learned regarding implementation and evaluation.

BACKGROUND: Adverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention. METHODS: Eligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research. RESULTS: Barriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them. CONCLUSIONS: In this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions. TRIAL REGISTRATION: Clinicaltrials.gov NCT03475030.

Produtos comercializados em cantinas escolares do município de Ribeirão Preto / Products sold in school canteens of the municipality of Ribeirão Preto / Productos del comercio de cafeterías de las escuelas del municipio de Ribeirão Preto

Objetivo: Avaliar os tipos de produtos comercializados em cantinas escolares do município de Ribeirão Preto, São Paulo. Métodos: Desenvolveu-se um estudo transversal e analítico, realizado de maio a dezembro de 2014, com amostra selecionada por conveniência, composta por cinco escolas estaduais e cinco escolas particulares de ensino fundamental. Aplicou-se, em cada uma das dez escolas, com o responsável pela cantina, um questionário estruturado contendo uma lista de alimentos e bebidas e variáveis relacionadas à implantação de uma cantina saudável. A classificação dos alimentos em saudáveis e não saudáveis baseou-se nos documentos "Os 10 Passos para a Promoção da Alimentação Saudável nas Escolas",do Ministério da Saúde e da Portaria do Estado de São Paulo sobre comercialização de alimentos saudáveis no ambiente escolar. Utilizou-se análise descritiva para tratamento dos dados. Resultados: Nas escolas particulares, observou-se maior apoio do profissional de Nutrição, disponibilidade de materiais educativos, propaganda de produtos industrializados e maior número de opções de alimentos saudáveis (81,7%). Nas escolas públicas, verificou-se a restrição de determinados alimentos não saudáveis, mas poucas opções de alimentos saudáveis (25,0%); entretanto, houve uma maior participação dos cantineiros em atividades de educação nutricional e conhecimento sobre legislação específica. Identificou-se o desinteresse de pais e alunos como limitador para a instalação e operacionalização da cantina saudável nas escolas. Conclusão: As cantinas investigadas, tanto de escolas públicas quanto de particulares, não seguiam integralmente as recomendações do Ministério da Saúde e da Portaria do Estado de São Paulo sobre comercialização de alimentos saudáveis no ambiente escolar, pois ofertavam alimentos considerados não saudáveis. Além disso, as escolas particulares oferecem mais opções de alimentos, tanto saudáveis quanto não saudáveis, para seus alunos.

Objective: To evaluate the types of products sold in school canteens of the municipality of Ribeirão Preto, São Paulo. Methods: Analytical cross-sectional study conducted from May to December 2014 with a convenience sample composed of five public primary schools and five private primary schools. A structured questionnaire containing a list of foods and beverages and variables related to the implementation of healthy canteens was applied to the person in charge of the canteen of each school. The classification of foods as healthy and unhealthy was based on the document "Os 10 Passos para a Promoção da Alimentação Saudável nas Escolas" (The 10 Steps to Promoting Healthy Eating in Schools) developed by the Ministry of Health and the São Paulo State Government. Results: In the private schools, there was greater support from a nutritionist, availability of education materials, advertising of processed foods and a greater number of healthy food options (81.7%). In the public schools, there was a restriction of certain unhealthy foods, but few options of healthy foods were available (25.0%); however, there was a greater participation of canteen workers in nutrition education activities and greater knowledge of specific legislation. The lack of interest of parents and students was identified as a hindrance to the implementation and operation of healthy canteens in schools. Conclusion: Both public and private school canteens did not fully follow the recommendations of the Ministry of Health and the São Paulo State Government regarding the selling of healthy foods in the school environment, as they offered unhealthy foods. In addition, private schools offer more food options ­ both healthy and unhealthy ­ to students.

Objetivo: Evaluar los tipos de productos del comercio de las cafeterías de las escuelas del municipio de Ribeirão Preto, São Paulo. Métodos: Se desarrolló un estudio transversal y analítico realizado entre mayo y diciembre de 2014 con una muestra seleccionada por conveniencia formada de cinco escuelas del estado y cinco escuelas privadas de la enseñanza básica. En cada una de las escuelas se aplicó al responsable de la cafetería un cuestionario estructurado con una lista de alimentos y bebidas y las variables relacionadas a la implantación de una cafetería saludable. La clasificación de los alimentos en saludables y no saludables estuvo basado en los documentos "Los 10 pasos para la Promoción de la Alimentación Saludable de las Escuelas", del Ministerio de la Salud y de la Portaría del Estado de São Paulo sobre el comercio de alimentos saludables en el ambiente de la escuela. Se utilizó un análisis descriptivo para el tratamiento de los datos. Resultados: Se observó en las escuelas privadas mayor apoyo del profesional de Nutrición, disponibilidad de materiales educativos, anuncios de productos industrializados y mayor número de opciones de alimentos saludables (81,7%). En las escuelas públicas se verificó la restricción para determinados alimentos no saludables pero pocas opciones de alimentos saludables (25,0%); sin embargo, hubo mayor participación de los cantineros en actividades de educación nutricional y conocimiento de la legislación específica. Se identificó la falta de interés de los padres y alumnos como limitación para la instalación y el funcionamiento de la cafetería saludable em las escuelas. Conclusión: Las cafeterías públicas y privadas investigadas no seguían en la íntegra las recomendaciones del Ministerio de la Salud y de la Portaría del Estado de São Paulo sobre el comercio de alimentos saludables en el ambiente de la escuela pues ofrecían alimentos considerados no saludables. Además, las escuelas privadas ofrecen más opciones de alimentos saludables y no saludables para los alumnos.