Pilot evaluation of the psychometric properties of a self-medication Risk Assessment Tool among elderly patients in a community setting

<p>Abstract</p> <p>Background</p> <p>Although community pharmacists in the United Kingdom are expected to assess elderly patients' needs for additional support in managing their medicines, there is limited data on potentially useful assessment tools. We sought to evaluate a 13-item assessment instrument among community dwelling elderly patients, 65 years and above. The instrument is composed of a cognitive risk sub-scale of 6 items and a physical risk sub-scale of 7 items.</p> <p>Findings</p> <p>The instrument was administered to elderly patients in a survey performed in a community to the west of Glasgow, Scotland. The survey recruited 37 participants, 31 from 4 community pharmacies and 6 patients whose medication management tasks were managed by the West Glasgow Community Health and Care Partnership (managed patients). Community pharmacists independently rated 29 of the 37 participants' comprehension of, and dexterity in handling their medicines. We assessed scale reliability, convergent validity and criterion validity. In sub-analyses, we assessed differences in scores between the managed patients and those recruited from the community pharmacies, and between multi-compartment compliance aid users and non-users. The instrument showed satisfactory internal consistency (Cronbach's alpha of 0.792 for 13-item scale). There was significant strong negative correlation between the cognitive risk sub-scores and community pharmacists' assessment of comprehension (ρ = -0.546, p = 0.0038); and physical risk sub-scores and community pharmacists' assessment of dexterity (ρ = -0.491, p = 0.0093). The Area Under the Receiver Operator Characteristic Curve (AUC ± SE; 95%CI) showed that the instrument had good discriminatory capacity (0.86 ± 0.07; 0.68, 0.96). The best cut-off (sensitivity, specificity) was ≥4 (65%, 100%). In the sub-analyses, managed patients had significantly higher cognitive risk sub-scores (6.5 versus 4.0, p = 0.0461) compared to non-managed patients. There was a significant difference in total risk score (4 versus 2, p = 0.0135) and cognitive risk sub-score (4 versus 1.5, p = 0.0029) between users and non-users of multi-compartment compliance aids.</p> <p>Conclusions</p> <p>This instrument shows potential for use in identifying elderly patients who may have problems managing their own medicines in the community setting. However, more robust validity and reliability assessments are needed prior to introduction of the tool into routine practice.</p

Potential Cost-Effectiveness of Prenatal Distribution of Misoprostol for Prevention of Postpartum Hemorrhage in Uganda

<div><p>Background</p><p>In settings where home birth rates are high, prenatal distribution of misoprostol has been advocated as a strategy to increase access to uterotonics during the third stage of labor to prevent postpartum hemorrhage (PPH). Our objective was to project the potential cost-effectiveness of this strategy in Uganda from both governmental (the relevant payer) and modified societal perspectives.</p><p>Methods and Findings</p><p>To compare prenatal misoprostol distribution to status quo (no misoprostol distribution), we developed a decision analytic model that tracked the delivery pathways of a cohort of pregnant women from the prenatal period, labor to delivery without complications or delivery with PPH, and successful treatment or death. Delivery pathway parameters were derived from the Uganda Demographic and Health Survey. Incidence of PPH, treatment efficacy, adverse event and case fatality rates, access to misoprostol, and health resource use and cost data were obtained from published literature and supplemented with expert opinion where necessary. We computed the expected incidence of PPH, mortality, disability adjusted life years (DALYs), costs and incremental cost effectiveness ratios (ICERs). We conducted univariate and probabilistic sensitivity analyses to examine robustness of our results. In the base-case analysis, misoprostol distribution lowered the expected incidence of PPH by 1.0% (95% credibility interval (CrI): 0.55%, 1.95%), mortality by 0.08% (95% CrI: 0.04%, 0.13%) and DALYs by 0.02 (95% CrI: 0.01, 0.03). Mean costs were higher with prenatal misoprostol distribution from governmental by US$3.3 (95$1.3; 95% CrI: -1.6, 2.8) perspectives. ICERs were US$191 (95$73 (95% CI: -86, 256) per DALY averted from a modified societal perspective.</p><p>Conclusions</p><p>Prenatal distribution of misoprostol is potentially cost-effective in Uganda and should be considered for national-level scale up for prevention of PPH.</p></div

Tornado diagram of univariate sensitivity analysis.

<p>The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a modified societal perspective</p

Parameters to compute a woman’s probable delivery pathway trajectory: base case probabilities (sensitivity ranges) by wealth quintile, UDHS 2011[5].

<p>¹ conditioned on wealth quintile</p><p>² conditioned on delivery in health facility</p><p>³ Joint probabilities of non-health facility delivery and either unassisted or assisted by TBA</p><p>^†TBA = Traditional Birth Attendant</p><p>Parameters to compute a woman’s probable delivery pathway trajectory: base case probabilities (sensitivity ranges) by wealth quintile, UDHS 2011[<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142550#pone.0142550.ref005" target="_blank">5</a>].</p

Results of the cost-effectiveness analysis (cost per life saved and cost per DALYs averted).

<p>Values in brackets are 95% Credibility Intervals for incremental costs and outcomes from the PSA.</p

Probabilities of PPH, treatment efficacy of uterotonics and case fatality rate of PPH.

<p>^a Computed by multiplying the baseline probability of PPH in unskilled delivery by the ratio of the relative risk of PPH comparing active to expectant management of the third stage of labor</p><p>^b A random effects meta-analysis of incidence of PPH in the non-interventional arms of clinical studies comparing a uterotonic to no uterotonic</p><p>^c A random effects meta-analysis of trials that compared the risk of PPH with misoprostol versus placebo in a setting of skilled assistance at delivery</p><p>Probabilities of PPH, treatment efficacy of uterotonics and case fatality rate of PPH.</p

Tornado diagram of univariate sensitivity analysis.

<p>The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a governmental perspective</p

Probabilities of receiving uterotonics and probabilities of accessing emergency obstetric care by delivery pathway trajectory.

<p>Probabilities of receiving uterotonics and probabilities of accessing emergency obstetric care by delivery pathway trajectory.</p