The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study.

OBJECTIVE: Completion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy. METHODS: A randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months. RESULTS: Five hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups. CONCLUSION: A brief intervention had no impact on AD completion for subjects of adequate or limited health literacy. PRACTICE IMPLICATIONS: Our intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids. TRIAL REGISTRATION NUMBER: NCT02702284, Protocol ID IRB201500776.

Design and Early Implementation Successes and Challenges of a Pharmacogenetics Consult Clinic.

Pharmacogenetic testing (PGT) is increasingly being used as a tool to guide clinical decisions. This article describes the development of an outpatient, pharmacist-led, pharmacogenetics consult clinic within internal medicine, its workflow, and early results, along with successes and challenges. A pharmacogenetics-trained pharmacist encouraged primary care physicians (PCPs) to refer patients who were experiencing side effects/ineffectiveness from certain antidepressants, opioids, and/or proton pump inhibitors. In clinic, the pharmacist confirmed the need for and ordered CYP2C19 and/or CYP2D6 testing, provided evidence-based pharmacogenetic recommendations to PCPs, and educated PCPs and patients on the results. Operational and clinical metrics were analyzed. In two years, 91 referred patients were seen in clinic (mean age 57, 67% women, 91% European-American). Of patients who received PGT, 77% had at least one CYP2C19 and/or CYP2D6 phenotype that would make conventional prescribing unfavorable. Recommendations suggested that physicians change a medication/dose for 59% of patients; excluding two patients lost to follow-up, 87% of recommendations were accepted. Challenges included PGT reimbursement and referral maintenance. High frequency of actionable results suggests physician education on who to refer was successful and illustrates the potential to reduce trial-and-error prescribing. High recommendation acceptance rate demonstrates the pharmacist's effectiveness in providing genotype-guided recommendations, emphasizing a successful pharmacist-physician collaboration.

Case of Serotonin Syndrome Initially Presenting as Diffuse Body Pain.

BACKGROUND Serotonin syndrome is a common yet potentially life-threatening condition caused by increased serotonergic activity, usually from serotonergic pharmaceutical agents. Primary features of serotonin syndrome include mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. However, the presentation of serotonin syndrome is often quite variable, leading to its under-diagnosis. CASE REPORT A 50-year-old female with chronic kidney disease on peritoneal dialysis presented to the Emergency Department with severe, diffuse body pain. Over the course of her hospital stay, she developed severe nausea, vomiting, and diarrhea followed by hyperreflexia and inducible clonus. Laboratory studies were remarkable for elevated liver transaminases. Review of her medications revealed several serotonergic agents, including duloxetine, tramadol, and ondansetron. Given her symptoms and the multiple serotonergic agents she was taking, she was diagnosed with serotonin syndrome. Discontinuation of the serotonergic agents led to resolution of her symptoms over the course of 4 days. CONCLUSIONS Our patient's initial presentation of diffuse body pain highlights the variable presentation of serotonin syndrome. Our case also demonstrates the importance of recognizing serotonin syndrome, as the supportive ondansetron we gave to alleviate her nausea and vomiting likely exacerbated her serotonin syndrome.