Development and external validation of a prognostic model for time to readmission or death in multimorbid patients.

OBJECTIVE: To develop and externally validate a prognostic model built on important factors predisposing multimorbid patients to all-cause readmission and/or death. In addition to identify patients who may benefit most from a comprehensive clinical pharmacist intervention. METHODS: A multivariable prognostic model was developed based on data from a randomised controlled trial investigating the effect of pharmacist-led medicines management on readmission rate in multimorbid, hospitalised patients. The derivation set comprised 386 patients randomised in a 1:1 manner to the intervention group, i.e. with a pharmacist included in their multidisciplinary treatment team, or the control group receiving standard care at the ward. External validation of the model was performed using data from an independent cohort, in which 100 patients were randomised to the same intervention, or standard care. The setting was an internal medicines ward at a university hospital in Norway. RESULTS: The number of patients who were readmitted or had died within 18 months after discharge was 297 (76.9 %) in the derivation set, i.e. the randomized controlled trial, and 69 (71.1 %) in the validation set, i.e. the independent cohort. Charlson comorbidity index (CCI; low, moderate or high), previous hospital admissions within the previous six months and heart failure were the strongest prognostic factors and were included in the final model. The efficacy of the pharmaceutical intervention did not prove significant in the model. A prognostic index (PI) was constructed to estimate the hazard of readmission or death (low, intermediate or high-risk groups). Overall, the external validation replicated the result. We were unable to identify a subgroup of the multimorbid patients with better efficacy of the intervention. CONCLUSIONS: A prognostic model including CCI, previous admissions and heart failure can be used to obtain valid estimates of risk of readmission and death in patients with multimorbidity.

'The way you talk, do I have a choice?' Patient narratives of medication decision-making during hospitalization.

OBJECTIVE: Based on the principle of the autonomy of the patient, shared decision-making (SDM) is the ideal approach in clinical encounters. In SDM, patients and healthcare professionals (HCPs) share knowledge and power when faced with the task of making decisions. However, patients are often not involved in the decision-making process. In this study, we explore medication decision-making during hospitalization and how power in the specific patient-HCP relationship is articulated, as analysed by Foucauldian theory. METHODS: A qualitative case study, comprising observations of patient-HCP encounters at an internal medicines ward at a university hospital in Norway, followed by semi-structured interviews. The narratives (n = 4 patients) were selected from a larger study (n = 15 patients). The rationale behind the choice of these patients was to include diverse and rich accounts. The four patients in their 40s-70s were included close to the day of presumed discharge. RESULTS: The narratives provide an insight into the patients as persons, their perspectives, including what mattered to them during their hospitalization, especially in relation to medications. Overall, SDM was not observed in this study. Even though all the participants actively tried to keep their autonomous capacity and to resist the HCPs' use of power, they were not able to change the established dynamics. Moreover, they were not allowed an equal voice to those of HCPs and thus not to escape the system's objectification and subjectification of them. CONCLUSION: There is a need for HCPs to get more familiarized with SDM. The healthcare system and the individual HCP need to make more room for dialogue with the patients about their preferences. A part of this is also how health care systems are structured and scheduled, thus, it is important to empower patients and HCPs alike.

Health literacy in medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway.

OBJECTIVE: When discharged from hospital patients are often assumed to have sufficient health literacy (HL) to participate in their medical treatment and manage medical self-care after discharge. However, limited HL is a widespread concern and patient participation during discharge is lacking. In this study, we explore how HL influences medication communication during hospital discharge. DESIGN: A qualitative case study, comprising unstructured observations of patient-healthcare personnel (HCP) encounters followed by semistructured interviews. Data were analysed using content analysis. SETTING: An internal medicines ward at a university hospital in Norway. PARTICIPANT: Fifteen patients aged 40-89 years were included close to the day of discharge. RESULTS: The following themes describing dimensions of HL emerged: (1) access, (2) understand, (3) appraise and (4) apply. Most patients sought access to medication information from HCP, while some felt dependent on HCP to provide it. However, their abilities to understand, evaluate and make informed decisions were challenged, partly because HCPs' ability to adapt their communication to the patient's knowledgebase varied. CONCLUSION: The results give a broader understanding of how HL influences medication communication during hospital discharge. To consider central dimensions of HL is important to achieve optimal medication communication, as the communication only can be exercised within the frames of the patient's HL. The findings in this study support that HL should be described as a shared responsibility between the patients and HCP. Attention should be focused to the HCP's responsibility to adapt the communication to the patient's knowledgebase.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway.

OBJECTIVE: Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge. DESIGN: This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis. SETTING: An internal medicines ward at a university hospital in Norway. PARTICIPANTS: Nine patients aged 49-90 years were included close to the day of discharge. RESULTS: The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued. CONCLUSIONS: The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

The observer effect in a hospital setting - Experiences from the observed and the observers.

BACKGROUND: Observation studies are used in health care research, e.g. to explore behaviors of patients or health care professionals in hospitals. A methodological challenge in observation studies is the observer effect, as it can jeopardize the quality of a study. OBJECTIVES: To capture different dimensions of the observer effect through health care professionals' and patients' experiences, and their reactions to being observed in a hospital setting, and in addition, observers' experiences from performing an observation study. METHOD: Four focus group interviews (health care professionals and observers) and 10 individual interviews (patients) were conducted with participants from a Norwegian observation study focusing on medication communication at a hospital ward. In all 26 persons were interviewed, whereof 3 were observers (pharmacist, pharmacy students). Data were collected between September 2019 and January 2020 and analyzed by an inductive, thematic analysis approach. RESULTS: Five main themes were identified; Experiencing being observed; Temporarily adapting medication communication behavior; Consequences for the patients; To interact or not - reflections on the relations and Observing the observers. Respondents reported some observer effects, but also that these diminished with time. Even though minimal interaction was used as a strategy, observers and the observed still built rapport. CONCLUSIONS: The observer effect in relation to medication communication seemed to be small and temporary in this specific hospital setting, among other things as staff and patients were used to extra persons (e.g. students) being around. Medication communication in hospital settings is a complex behavior, and appears to not be strongly impacted by the presence of observers, especially with a long observation time. It is important for researchers to monitor and record the observer effect in the specific setting of the study. This can be done by interviews with the observed and the observers by someone not connected to the observation study.

Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway.

BACKGROUND: Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective. METHODS: Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process. RESULTS: A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all. CONCLUSIONS: The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes.

Severity and management of drug-drug interactions in acute geriatric patients.

BACKGROUND: Previous studies have investigated the prevalence of drug-drug interactions (DDIs) among the elderly in different care settings, but data describing the frequency and management of DDIs among acute geriatric patients appear to be absent. OBJECTIVE: The aim of this study was to investigate the severity and interdisciplinary management of DDIs in patients admitted to an acute geriatric ward. METHODS: The study was conducted at Oslo University Hospital, Norway, over a period of 19 weeks in 2010/11. On admission and daily during the hospital stay, prescribed medications were reviewed by pharmacists to identify DDIs with the aid of web-based databases. DDIs defined to be of potential clinical relevance, i.e., those classified as "major" (generally avoid) or "moderate" (precautions recommended), were following assessments by pharmacists presented at interdisciplinary meetings with geriatricians and nurses, and discussed in relation to the possible implementation of monitoring actions or changes in prescribing. The odds for prescribing changes were compared in relation to DDI type ("pharmacokinetic" vs. "pharmacodynamic") and severity ("major" vs. "moderate"). The project group retrospectively assessed the possible causal relationships between hospitalizations and DDIs. RESULTS: The pharmacists identified 245 DDIs of major (n = 13) or moderate (n = 232) severity in 80 (63.5 %) of the 126 patients included on admission and/or during hospitalization. In 94 of 162 cases where the pharmacists alerted the geriatricians (58.0 %), prescribing changes or monitoring actions were implemented. Prescribing changes (n = 38) were performed significantly more often for major than for moderate DDIs [odds ratio (OR) 3.8; 95 % confidence interval (CI) 1.2-12.2, p = 0.03], and significantly more often for pharmacokinetic than for pharmacodynamic DDIs (OR 4.9; 95 % CI 2.2-10.9, p < 0.01). For 28 of 126 patients (22.2 %), a causal relationship between hospitalizations and DDIs was assessed as "possible". CONCLUSIONS: The present study shows that acute geriatric patients are frequently exposed to DDIs for which active management is recommended in order to avoid unfavorable clinical outcomes. The integration of pharmacists into interdisciplinary teams could prevent potentially severe DDIs in the elderly.