Getting the Foundations Right for the Measurement of Medication Safety: the Need for a Meaningful Conceptual Frame
Ng, J; Scahill, S; Harrison, J (2017)
NZ Medical Journal 2017; 130(1452):54-62View abstract
A number of initiatives aimed at improving medication safety in and across New Zealand public hospitals have been introduced over recent years. Clinicians, policymakers and patients now want to know whether patients are safer today from medicine use than they have been in the past.
The challenge has been determining exactly what should be measured. In this viewpoint, we critically examine the suitability of adverse drug events (ADE) as a primary metric for assessing the progress of medication safety improvement. We provide an overview of contemporary dialogue on medication safety measurement and highlight the emergent challenges.
Finally, we reflect on how New Zealand has approached medication safety measurement so far and argue the need for a multi-stakeholder informed conceptual framework with a view to further enhancing meaningful assessment of medication safety.
Effectiveness of the YourCall™ Text Message Intervention to Reduce Harmful Drinking in Patients Discharged from Trauma Wards: Protocol for a Randomised Controlled Trial
Ameratunga, S; Kool, B; Sharpe, S; Reid, P; Lee, A; Civil, I; Smith, G; Thornton, V; Walekr, M; Whittaker, R (2017)
BMC Public Health 2017; 17:48. DOI:10.1186/s12889-016-3967-zView abstract
BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care.
METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Māori compared with non-Māori).
DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking.
Text Message-Based Diabetes Self-Management Support (SMS4BG): A Randomized Controlled Trial Protocol
Dobson, R; Whittaker, R; Jiang, Y; Maddison, R; Shepherd, M; Carter, K; Cutfield, R; McNamara, C; Khanolkar, M; Murphy, R (2016)
Trials Journal 2016; 17:179. DOI:10.1186/s13063-016-1305-5View abstract
BACKGROUND: Addressing the increasing prevalence, and associated disease burden, of diabetes is a priority of health services internationally. Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications. The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment. Self-Management Support for Blood Glucose (SMS4BG) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences, demographics, clinical characteristics, and culture. This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes. This paper outlines the rationale and methods of the trial.
METHODS/DESIGN: A two-arm, parallel, randomised controlled trial will be conducted across New Zealand health districts. One thousand participants will be randomised at a 1:1 ratio to receive SMS4BG, a theoretically based and individually tailored automated text message-based diabetes self-management support programme (intervention) in addition to usual care, or usual care alone (control). The primary outcome is change in glycaemic control (HbA1c) at 9 months. Secondary outcomes include glycaemic control at 3 and 6 months, self-efficacy, self-care behaviours, diabetes distress, health-related quality of life, perceived social support, and illness perceptions. Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction.
DISCUSSION: This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes. If found to be effective it has the potential to provide individualised support to people with diabetes across New Zealand (and internationally), thus extending care outside the clinic environment.
Assessing a Hospital Medication System for Patient Safety: Findings and Lessons Learnt from Trialling an Australian Modified Tool at Waitemata District Health Board
Ng, J; Andrew, P; Crawley, M; Pevreal, W; Peach, J (2016)
NZ Medical Journal 2016; 129(1430)View abstract
AIM: To undertake a review of Waitemata District Health Board’s (WDHB) hospital medication system for patient safety assessment and improvement purposes.
METHODS: A multidisciplinary group rated current WDHB hospital medication systems against the Medication Safety Self-Assessment for Australian Hospitals (MSSA®-AH) criterion of 247 aspirational practices using a five point scale ("no" to "fully implemented"). Items with a lesser extent of implementation represented practice gaps. The MSSA®-AH database and weighted adjustment scoring system generated an overall hospital score.
RESULTS: Of the maximum possible score that could be obtained had all MSSA®-AH practices been implemented, WDHB scored 63% and this was comparable to other demographically similar hospitals in Australia. Lowest scoring practices needing improvement related to staffing. Conflict resolution was a previously unidentified practice gap. Previously identified gaps, such as those relating to electronic medication systems suggested ongoing implementation was required.
CONCLUSION: This was the first documented use of the MSSA®-AH's in a New Zealand hospital setting and helped WDHB identify areas in need of further improvement. The unique generation of a percentage score helped simplify understanding for non-technical stakeholders. Future repeated assessments would help WDHB track progress. Implicit benefits, such as stakeholder engagement, were observed. The MSSA®-AH may be useful in other hospital settings.
Text Message and Internet Support for Coronary Heart Disease Self-Management: Results from the Text4Heart Randomised Controlled Trial
Pfaeffli-Dale, L; Whittaker, R; Jiang, Y; Stewart, R; Rolleston, A; Maddison, R (2015)
JMIR Oct 2015; 17(10)e237. DOI:10.2196/jmir.4944View abstract
BACKGROUND: Mobile technology has the potential to deliver behavior change interventions (mHealth) to reduce coronary heart disease (CHD) at modest cost. Previous studies have focused on single behaviors; however, cardiac rehabilitation (CR), a component of CHD self-management, needs to address multiple risk factors.
OBJECTIVE: The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program (Text4Heart) to improve adherence to recommended lifestyle behaviors (smoking cessation, physical activity, healthy diet, and nonharmful alcohol use) in addition to usual care (traditional CR).
METHODS: A 2-arm, parallel, randomized controlled trial was conducted in New Zealand adults diagnosed with CHD. Participants were recruited in-hospital and were encouraged to attend center-based CR (usual care control). In addition, the intervention group received a personalized 24-week mHealth program, framed in social cognitive theory, sent by fully automated daily short message service (SMS) text messages and a supporting website. The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score (≥3) at 3 and 6 months. Secondary outcomes included clinical outcomes, medication adherence score, self-efficacy, illness perceptions, and anxiety and/or depression at 6 months. Baseline and 6-month follow-up assessments (unblinded) were conducted in person.
RESULTS: Eligible patients (N=123) recruited from 2 large metropolitan hospitals were randomized to the intervention (n=61) or the control (n=62) group. Participants were predominantly male (100/123, 81.3%), New Zealand European (73/123, 59.3%), with a mean age of 59.5 (SD 11.1) years. A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months (AOR 2.55, 95% CI 1.12-5.84; P=.03), but not at 6 months (AOR 1.93, 95% CI 0.83-4.53; P=.13). The intervention group reported significantly greater medication adherence score (mean difference: 0.58, 95% CI 0.19-0.97; P=.004). The majority of intervention participants reported reading all their text messages (52/61, 85%). The number of visits to the website per person ranged from zero to 100 (median 3) over the 6-month intervention period.
CONCLUSIONS: A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zealand adults with CHD compared to usual care alone. The effect was not sustained to the end of the 6-month intervention. A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events.
A Mobile Phone Intervention Increases Physical Activity in People with Cardiovascular Disease: Results from the HEART Randomised Controlled Trial
Maddison, R; Pfaeffli, L; Whittaker, R; Stewart, R; Kerr, A; Jiang, Y; Kira, G; Leung, W; Dalleck, L; Carter, K; Rawstorn, J; (2014)
European Journal of Preventive Cardiology Jun 2015; 22(6):701-9. DOI:10.1177/2047487314535076. Epub May 2014View abstract
AIM: To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease (IHD).
METHODS/RESULTS: In this single-blind, parallel, two-arm, randomized controlled trial adults (n = 171) with IHD were randomized to receive a mobile phone delivered intervention (HEART; n = 85) plus usual care, or usual care alone (n = 86). Adult participants aged 18 years or more, with a diagnosis of IHD, were clinically stable as outpatients, able to perform exercise, able to understand and write English, and had access to the Internet. The HEART (Heart Exercise And Remote Technologies) intervention involved a personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behaviour, delivered over 24 weeks. All participants were able to access usual community-based cardiac rehabilitation, which involves encouragement of physical activity and an offer to join a local cardiac support club.
All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake (PVO2; primary outcome), self-reported physical activity, health-related quality of life, self-efficacy and motivation (secondary outcomes). Results showed no differences in PVO2 between the two groups (difference −0.21 ml kg−1 min−1, 95% CI: −1.1, 0.7; p = 0.65) at 24 weeks. However significant treatment effects were observed for selected secondary outcomes, including leisure time physical activity (difference 110.2 min/week, 95% CI: −0.8, 221.3; p = 0.05) and walking (difference 151.4 min/week, 95% CI: 27.6, 275.2; p = 0.02). There were also significant improvements in self-efficacy to be active (difference 6.2%, 95% CI: 0.2, 12.2; p = 0.04) and the general health domain of the SF36 (difference 2.1, 95% CI: 0.1, 4.1; p = 0.03) at 24 weeks. The HEART programme was considered likely to be cost-effective for leisure time activity and walking.
CONCLUSIONS: A mobile phone intervention was not effective at increasing exercise capacity over and above usual care. The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services.
The Remote Exercise Monitoring Trial for Exercise-Based Cardiac Rehabilitation (REMOTE-CR): a Randomised Controlled Trial Protocol
BMC Public Health Nov 2014; 14:1236. DOI:10.1186/1471-2458-14-1236View abstract
BACKGROUND: Exercise is an essential component of contemporary cardiac rehabilitation programs for the secondary prevention of coronary heart disease. Despite the benefits associated with regular exercise, adherence with supervised exercise-based cardiac rehabilitation remains low. Increasingly powerful mobile technologies, such as smartphones and wireless physiological sensors, may extend the capability of exercise-based cardiac rehabilitation by enabling real-time exercise monitoring for those with coronary heart disease. This study compares the effectiveness of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (REMOTE) to standard supervised exercise-based cardiac rehabilitation in New Zealand adults with a diagnosis of coronary heart disease.
METHODS/DESIGN: A two-arm, parallel, non-inferiority, randomised controlled trial will be conducted at two sites in New Zealand. One hundred and sixty two participants will be randomised at a 1:1 ratio to receive a 12-week program of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (intervention), or an 8-12 program of standard supervised exercise-based cardiac rehabilitation (control).
The primary outcome is post-treatment maximal oxygen uptake (V̇O2max). Secondary outcomes include cardiovascular risk factors (blood lipid and glucose concentrations, blood pressure, anthropometry), self-efficacy, intentions and motivation to be active, objectively measured physical activity, self-reported leisure time exercise and health-related quality of life. Cost information will also be collected to compare the two modes of delivery. All outcomes are assessed at baseline, post-treatment, and 6 months, except for V̇O2max, blood lipid and glucose concentrations, which are assessed at baseline and post-treatment only.
DISCUSSION: This novel study will compare the effectiveness of technology-supported exercise-based cardiac rehabilitation to a traditional supervised approach. If the REMOTE program proves to be as effective as traditional cardiac rehabilitation, it has potential to augment current practice by increasing access for those who cannot utilise existing services.
Implementing an Electronic Clinical Activity Capture System for a Hospital Pharmacy Department - a Case Report in New Zealand
Ng, J (2009)
Health Care and Informatics Review Online 13(3):16-26View abstract
AIM: To implement an electronic clinical activity capture system for a hospital clinical pharmacy department.
INTRODUCTION: organisations Health service departments are increasingly being held accountable for providing high quality, efficient yet cost effective care. In order to do this, there must be robust information systems in place to capture relevant and measurable data on service workflow and activities.
CASE REPORT: This case report discusses the implementation process of such a system at the Middlemore Hospital Clinical Pharmacy Department from the period of January 2008 through to July 2009, highlighting key steps and barriers during this process. Selected examples of data and reports produced are also described showing the types of information that can be generated for the purpose of quality improvement and administration.
DISCUSSION: Implementation of a new electronic clinical activity capture system requires a multifaceted approach which must address legal, privacy, security, technological and human factors. This case report describes key steps in the implementation process and may help other departments which are undergoing such processes.