Disease-Related Knowledge and Practices of Tuberculosis Patients

BACKGROUND: Tuberculosis (TB) is a major public health problem. World Health Organization (WHO) recommends the use of directly observed treatment, short course (DOTS) strategy for effective control of TB. Disease-related knowledge, beliefs and practices need to be recognized to tailor the DOTS strategy into the local norms. This study was performed with two objectives: i) to assess TB-related knowledge among TB patients in two rural hospitals in Ethiopia, ii) to assess the practices that contribute to delay in the initiation of anti-TB treatment. METHODS: The study was conducted between June 2000 and May 2001.Two hundred twenty two known adult TB patients attending TB clinics in Jimma and Hossana hospitals were interviewed on their knowledge, attitude and practice related to TB using pre-tested structured questionnaire. Patients belonged to 14 ethnic groups. RESULTS: Sixty percent (134/222) were female. The average family size of patients was 5.3. The number of illiterate female patients was greater than that of males (p = 0.002). Only 36% (80/222) of patients gave a correct response on the transmission of TB. Similarly, only 34 % (76/222) knew about symptoms indicative of TB. Hundred and fifty (67.5 %) patients sought medical help after experiencing TB indicative symptoms for more than one month. Age, sex, education, occupation, and religion did not affect TBrelated knowledge. Thirty-seven (16.7 %) patients used traditional medicine for at least one week before they came to a health institution. The diagnosis of TB had a negative social impact. Forty-eight (21.6 %) patients were either divorced, expelled from their family, abandoned by friends, or lost job. CONCLUSION: Health education targeting basic concepts on the transmission of TB and also targeting the need for early diagnosis is important in TB control. TB control programs may need to include traditional healers into the control strategy to refer patients with specific symptoms.Ethiop J Health Sci. Vol. 13, No. 1 January 72 200

Incorporating Medication Indications into the Prescribing Process

Purpose The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Summary Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, including avoiding look-alike/sound-alike errors, facilitating selection of drugs of choice, aiding in communication among the healthcare team, bolstering patient understanding and adherence, and organizing medication lists to facilitate medication reconciliation. Although strongly supported by pharmacists, multiple prior attempts to encourage prescribers to include the indication on prescriptions have not been successful. We convened 6 expert panels to consult high-level stakeholders on system design considerations and requirements necessary for building and implementing an indications-based computerized prescriber order-entry (CPOE) system. We summarize our findings from the 6 expert stakeholder panels, including rationale, literature findings, potential benefits, and challenges of incorporating indications into the prescribing process. Based on this stakeholder input, design requirements for a new CPOE interface and workflow have been identified. Conclusion The emergence of universal electronic prescribing and content knowledge vendors has laid the groundwork for incorporating indications into the CPOE prescribing process. As medication prescribing moves in the direction of inclusion of the indication, it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished

Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies

<p>Abstract</p> <p>Background</p> <p>Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services.</p> <p>Methods</p> <p>Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada.</p> <p>Results</p> <p>Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains.</p> <p>Conclusions</p> <p>Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.</p

Novel use of electronic health record (EHR) to estimate the prevalence of off-label prescribing, determinants and its association with adverse drug events (ADE)

Background Adverse drug events (ADE) are leading cause of death. Current pharmacosurveillance methods rely on passive reporting to monitor drug safety, but this is slow and many ADEs are unreported. Moreover, physicians regularly prescribe drugs for indications for which they were never tested (off-label use), despite some highly-publicized associations with ADEs. We urgently need timely pharmacosurveillance methods to monitor drug safety and effectiveness for on- and off-label uses. Electronic health records (EHR) may help fill this void if they document the reasons for drug prescription (treatment indications) and discontinuation (e.g. adverse drug event, ineffectiveness). Objectives 1) To determine the accuracy of an EHR system in documenting orders for drug discontinuation and dose changes of prescription drugs. 2) To determine the sensitivity and positive predictive value of using an EHR to document treatment indications at the time of prescribing. 3) To evaluate the prevalence of off-label prescribing and its drug, patient and physician determinants in primary care. 4) To determine the association between off-label use and ADEs. Methods I conducted four studies using the Medical Office of the XXI century (MOXXI) EHR system, developed by the McGill clinical and health informatics research group. First, I conducted a validation study to assess the sensitivity, specificity, positive and negative predictive value of the MOXXI EHR system in documenting prescription drug discontinuation and dose-change orders by comparing with information from physician-facilitated chart review. Second, I assessed the sensitivity and the positive predictive value of MOXXI EHR in documenting treatment indications. Third, I estimated the prevalence of off-label prescribing and assessed the strength of scientific evidence for off-label use. Moreover, the drug, patient and physician determinants of off-label prescribing were assessed. Fourth, I assessed the association between off-label use and ADE using incident drug prescriptions, treatment indications and ADE data collected using an EHR. Results Manuscript 1 The sensitivity of the EHR in identifying physician-initiated drug discontinuations and dose-changes was 67.0% (95% CI: 54.1, 77.7), the specificity was 99.7% (95% CI: 99.5, 99.9), and the positive predictive value was 97.3% (95% CI: 95.6, 98.7). Manuscript 2 The sensitivity of the EHR treatment indication was 98.5% (95% CI; 96.5%, 99.5%) and the PPV of the system in identifying the treatment indication was 97.0% (95% CI; 94.2%, 98.6%). Manuscript 3 The prevalence of off-label use was 11.0% of 253,347 prescriptions written to 50,823 patients. 79.0% of off-label prescriptions lacked strong scientific evidence. Off-label use was highest for CNS drugs (26.3%), including anticonvulsants (67%), antipsychotics (44%), and antidepressants (33%). Higher risk of off-label use was demonstrated in drugs with 1-2 approved indications, older drugs, in women and in physicians with less evidence-based orientation. Manuscript 4 Off-label use and off-label use without strong scientific evidence had higher risk of ADE compared to on-label use [HR, 1.43 (95% CI, 1.29, 1.59) and HR, 1.53 (95% CI, 1.37, 1.72), respectively]. Younger patients, women, and patients who received ≥8 drugs or anti-infective drugs had increased ADE risk. Conclusion I have shown for the first time that an EHR system can accurately document physician-identified treatment indications and adverse drug events and other treatment outcomes. The treatment indication data could measure prevalence of off-label use. In addition, the treatment indication data, combined with drug treatment outcome data, could create a novel pharmacosurveillance tool. Moreover, I demonstrated that off-label prescribing is an independent determinant of ADEs. Future EHRs should incorporate treatment indication and treatment outcome features to monitor the safety and effectiveness of on- and off-label uses of drugs.Contexte Les effets indésirables des médicaments (EIM) sont une cause importante de mortalité. Les méthodes actuelles de pharmacovigilance sous-estiment l'incidence des EIM et sont inefficientes. De plus, les médecins prescrivent souvent des médicaments pour des indications pour lesquelles ils n'ont pas été approuvés (usage non indiqué), une pratique associée à des EIM hautement médiatisés. Il y a donc un urgent besoin de développer de nouvelles méthodes de pharmacovigilance. À cette fin, les dossiers de santé électroniques (DSE) pourraient être utiles, notamment si l'indication de traitement et la raison justifiant l'arrêt d'un médicament y sont documentées.Objectifs1) Déterminer l'exactitude d'un DSE à documenter les arrêts de traitement médicamenteux; 2) Déterminer la sensibilité et la valeur prédictive positive d'un DSE à documenter les indications de traitement; 3) Évaluer la prévalence des prescriptions non indiquées en soins primaires et les déterminants y étant associées. 4) Déterminer l'association entre l'utilisation non indiquée des médicaments et les EIM. Méthodes Pour atteindre ces objectifs de recherche, j'ai réalisé quatre études en utilisant le DSE Medical Office of the XXI century (MOXXI). Premièrement, j'ai mené une étude de validation afin d'évaluer la sensibilité, la spécificité et les valeurs prédictives positive (VPP) et négative (VPN) du DSE MOXXI à documenter les ordonnance d'arrêt de traitement. Deuxièmement, j'ai mené une étude de validation afin d'évaluer la sensibilité et la VPP de MOXXI à documenter les indications de traitement. Troisièmement, j'ai estimé la prévalence de l'usage non indiqué des médicaments en soins primaires, ainsi que la robustesse des données supportant ce type d'usage. Quatrièmement, j'ai utilisé MOXXI afin d'évaluer l'association entre l'usage non indiqué des médicaments et les EIM. Résultats Manuscrit 1 La sensibilité de MOXXI à identifier des arrêts de traitements est de 67,0% (IC à 95%: 54,1 - 77,7), la spécificité est de 99,7% (IC 95%: 99,5, 99,9), la VPP est de 97,3% (IC à 95%: 95,6 - 98,7). Manuscrit 2 La sensibilité de l'indication de traitement documentée dans MOXXI était de 98,5% (IC à 95%; 96,5% - 99,5%) et sa VPP était de 97,0% (IC à 95%, 94,2% - 98,6%). Manuscrit 3 La prévalence de l'usage non indiqué des médicaments est de 11,0% parmi 253 347 prescriptions reçues par 50 823 patients. On estime que 79,0% des prescriptions non indiquées ne sont pas justifiées empiriquement. L'usage non indiqué des médicaments est le plus élevé pour les médicaments du système nerveux central (26,3%), dont les anticonvulsivants (66,6%), les antipsychotiques (43,8%) et les antidépresseurs (33,4%). Des taux élevés d'usages non indiqués des médicaments ont été démontrés pour les médicaments n'ayant que 1 ou 2 indications approuvées, les médicaments plus anciens, chez les femmes et pour les médecins plus empiristes. Manuscrit 4 Le taux d'EIM associé à un usage non indiqué des médicaments (19.8/10 000 personnes-mois) est plus élevé que celui pour les usages indiqués (12,5 pour 10.000 personnes-mois) [HR : 1,43; IC à 95% : 1,29 - 1,59)]. Les usages non indiqués, non justifiés empiriquement, ont un taux encore plus élevé d'EIM (21,8 pour 10.000 personnes-mois) par rapport aux usages indiqués [HR : 1,53; IC à 95% : 1,37 - 1,72]). Les patients plus jeunes, les femmes et les patients ayant reçu ≥8 médicaments ou des agents anti-infectieux ont un risque accru d'EIM. Conclusion Un DSE peut documenter avec précision les indications de traitement, les EIM et d'autres résultats de traitement. Les données relatives à l'indication de traitement pourraient être combinées à celles relatives aux résultats cliniques afin de créer un nouvel outil de pharmacosurveillance. L'usage non indiqué des médicaments est un déterminant indépendant des EIM. Les DSE devront intégrer les indications et les résultats de traitements afin de faciliter l'évaluation de la sécurité et de l'efficacité des médicaments

The role of candidate genes in purified protein derivative (PPD) responsiveness in pediatric tuberculosis patients /

Background. Tuberculin skin testing is an important tool for diagnosis and control of tuberculosis. The role of host genetics in responsiveness of pediatric tuberculosis patients to purified protein derivatives (PPD) has rarely been investigated.Objective. To determine the impact of the candidate genes - Natural Resistance Associated Macrophage Protein 1 (NRAMP1), Vitamin D Receptor (VDR) and Interleukin 4 Receptor (IL4R) with other covariates on PPD reaction size in pediatric tuberculosis patients.Methods. A family-based association study was conducted using eighty-three parent-child trios from a database of tuberculosis patients and their families from Texas, USA.Results. Marker IL4Rrs1805010_GA was in linkage disequilibrium with PPD size (R2 = 16%; p = 0.0017). PPD size was a predictor of transmission of allele 1 ("G") of IL4Rrs1805010_GA with an OR (95% CI) of 1.9 (1.16, 3.14) per five millimeter average increase in PPD size adjusted for age of diagnosis.Conclusions. This thesis provides evidence for the role of host genetics in PPD responsiveness in pediatric tuberculosis patients

Important Factors in Remote Experiential Education

Onsite and in-person experiential education has been well established to prepare practice-ready healthcare professionals, such as pharmacists. From COVID-19, the integration of remote educational delivery has occurred. As healthcare disciplines adjust to new experiential styles and innovate traditional methods, this paper highlights key areas for remote experiential education that can influence student experiences. Factors that are of importance to continuous quality improvement are described. A survey, utilizing the cloud-based software platform Qualtrics&reg; headquartered in the United States, was developed to evaluate whether remote rotation delivery was comparable to traditional onsite experiential education, to assist with quality improvement for virtual experiential education, and to ensure the redesigned educational model meets accreditation standards for two schools of pharmacy. Numerous factors including work, time zone, Office of Experiential Education and preceptor responsiveness, and technology, were examined. Chi-Square test, t-test for proportions and odds ratios were utilized to evaluate results. Students with technology concerns throughout a remote rotation had a more than two-fold increase in identifying the virtual experience as worse than most/all other in-person rotations (p = 0.01). Preceptor responsiveness to questions and concerns significantly impact student perceptions of educational quality (p &lt; 0.05). The majority of students perceived remote experiential education is equal to onsite experiences. Since continuous quality improvement is required by pharmacy accreditors and many other healthcare programs offering clinical opportunities, identifying factors is of importance to make future interventions in the remote experiential education delivery. This type of experiential learning became essential with COVID-19 impacting onsite clinical placements, and information can be used across health science disciplines at large