Quality of life, daily functioning, and symptoms in hypothyroid patients on thyroid replacement therapy: A Dutch survey.

Objective: To explore the nature and extent of possible residual complaints among Dutch hypothyroid patients using thyroid replacement therapy, we initiated a comprehensive study measuring health-related quality of life (QoL), daily functioning, and hypothyroidism-associated symptoms in patients and control persons. Methods: An online survey measuring thyroid-specific QoL (ThyPRO), daily functioning, and hypothyroidism-associated symptoms (ThySHI) was distributed among treated hypothyroid patients and control individuals. The advertising text was formulated in an open-ended manner. Patients also provided their most recent thyroid blood values and their thyroid medication. Results: There was a large-sized impairment of QoL (Cohen's d = 1.04, +93 % ThyPRO score) in hypothyroid patients on thyroid replacement therapy (n = 1195) as compared to controls (n = 236). Daily functioning was significantly reduced i.e., general health (-38 %), problems with vigorous- (+64 %) and moderate activities (+77 %). Almost 80 % of patients reported having complaints despite thyroid medication and in-range thyroid blood values, with 75 % expressing a desire for improved treatment options for hypothyroidism (total n = 1194). Hypothyroid patients experienced 2.8 times more intense hypothyroidism-associated symptoms than controls (n = 865, n = 203 resp). Patients' median reported serum concentrations were: TSH 0.90 mU/L, FT4 17.0 pmol/L, and FT3 2.67 pmol/L, with 52 % having low T3 levels (<3.1 pmol/L). The QoL was not found to be related to age, sex, BMI, menopausal status, stress, serum thyroid parameters, the origin and duration of hypothyroidism, the type of thyroid medication, or the LT4 dose used. Conclusions: Our study revealed major reductions in quality of life and daily functioning, and nearly three times more intense hypothyroidism-associated symptoms in treated hypothyroid patients as compared to controls, despite treatment and largely in-range serum TSH/FT4 concentrations. The QoL was not associated with serum thyroid parameters. We recommend future research into the origin of persisting complaints and the development of improved treatment modalities for hypothyroidism.

Effects of the Proactive Interdisciplinary Self-Management (PRISMA) Program on Online Care Platform Usage in Patients with Type 2 Diabetes in Primary Care: A Randomized Controlled Trial.

Online care platforms can support patients with type 2 diabetes (T2DM) in managing their health. However, in the use of eHealth, a low participation rate is common. The Proactive Interdisciplinary Self-Management (PRISMA) program, aimed at improving patients' self-management skills, was expected to encourage patients to manage their disease through the use of an online platform. Therefore, the objective of the current study was to investigate whether a group education program can improve the use of an online care platform in patients with T2DM treated by primary care providers in the Netherlands. In a randomized controlled trial, patients with T2DM received either PRISMA with usual care or usual care only. During a six-month follow-up period in 2014-2015, usage (number of log-ons and time spent per session) of an online care platform (e-Vita) aimed at improving T2DM self-management was assessed. A training about the functionalities of e-Vita was offered. The sample consisted of 203 patients. No differences were found between the intervention and control groups in the number of patients who attended the platform training (interested patients) (X 2(1) = 0.58; p = 0.45), and the number of patients who logged on at least once (platform users) (X 2(1) = 0.46; p = 0.50). In addition, no differences were found between the groups in the type of users-patients who logged on twice or more (active users) or patients who logged on once (nonactive users) (X 2(1) = 0.56; p = 0.45). The PRISMA program did not change platform usage in patients with T2DM. In addition, only a small proportion of the patients logged on twice or more. Patients probably need other encouragements to manage their condition using an online platform.

Effects of a Proactive Interdisciplinary Self-Management Program on Patient Self-Efficacy and Participation During Practice Nurse Consultations: A Randomized Controlled Trial in Type 2 Diabetes.

BACKGROUND: Nowadays, patients with chronic conditions such as type 2 diabetes mellitus (T2DM) need and want to be more active participants in their health care. This study aimed to investigate the effects of the Proactive Interdisciplinary Self-Management (PRISMA) training program on participation during consultations with practice nurses and self-efficacy of patients with T2DM in general practice. METHODS: Within a randomized controlled trial, patients were followed for 6 months. They received either PRISMA in addition to usual care or usual care only. Self-efficacy was assessed using the 5-item Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) scale. Consultations were video-recorded and analyzed using the Roter interaction analysis system. Multilevel analysis was carried out. RESULTS: No differences in the PEPPI-5 were found between the intervention (n = 101) and control groups (n = 102) (U = 1,737.5, z = -0.2, P = 0.8). In addition, the groups did not differ in patient participation. However, patients who attended the PRISMA program expressed more counselling utterances (B = 0.22; standard error (SE) = 0.09). CONCLUSIONS: PRISMA did not result in higher self-efficacy or patient participation during the consultation with practice nurses at 6 months. Possibly, two training sessions are insufficient and a more powerful intervention might be needed. However, the study showed indications that patients counselled themselves more frequently during the consultation. Practice nurses could stimulate patients who are already engaged in self-counselling by further specifying their goals of behavior change.

Effects of the Proactive interdisciplinary self-management (PRISMA) program on self-reported and clinical outcomes in type 2 diabetes: a pragmatic randomized controlled trial.

BACKGROUND: Diabetes self-management education can be helpful for patients with type 2 diabetes in managing their condition. We aimed to study the effects of the group-based PRoactive Interdisciplinary Self-MAnagement (PRISMA) training program on self-reported and clinical outcomes in patients with type 2 diabetes treated in general practice. METHODS: Persons aged 18 years or older diagnosed with type 2 diabetes and treated in primary care were included. In a randomized controlled trial design (1:1), patients were followed for 6 months with an extension phase of 6 months. Block randomization was used. The patients with type 2 diabetes received either PRISMA in addition to usual care or usual care only. All patients completed a range of validated questionnaires (including knowledge, skills, and confidence for self-management [PAM], diabetes self-care behavior [SDSCA], health-related quality of life [EQ-5D], and emotional well-being [WHO-5]). In addition, clinical outcomes (HbA1c, body mass index, systolic blood pressure, and cholesterol levels) were collected during the routine diabetes checkups. RESULTS: Of the total sample (n = 193), 60.1% were men. The mean age was 69.9 years (SD = 9.1). No significant differences were found on self-reported outcomes between the groups at 0, 6, and 12 months. The clinical outcomes were not reported due to a large number of missing values. CONCLUSION: PRISMA did not improve self-reported outcomes in patients with type 2 diabetes treated in primary care. It was not possible to make a statement about the clinical effects. TRIAL REGISTRATION: date: 16/07/2014, number: NL4550 (https://www.trialregister.nl/trial/4550).

Effects of a Proactive Interdisciplinary Self-Management (PRISMA) program on medication adherence in patients with type 2 diabetes in primary care: a randomized controlled trial.

PURPOSE: The present study aims to investigate the effect of the group-based Proactive Interdisciplinary Self-Management (PRISMA) training program on medication adherence in patients with type 2 diabetes (T2DM) treated in primary care. PATIENTS AND METHODS: The current study is a two-arm, parallel group, randomized, open label trial (1:1) of 6-month duration with a 6-month extension period in which both groups received the intervention (wait-list control). People 18 years old or older who were diagnosed with T2DM were included. The intervention consisted of two group meetings about T2DM guided by care providers. The control group received usual care only (visits at the general practice). The primary outcome was adherence based on pharmacy refill data and was measured using medication possession ratio (MPR). The secondary outcomes were the number of drug holidays and self-reported adherence, measured by the 5-item Medication Adherence Rating Scale (MARS-5). RESULTS: Of the total sample (n=108), 66.6% were male. The mean age was 69.3 years (SD=9.1). In the 6-month period, patients were more adherent in the intervention group (n=56) (median MPR =100.0 [51.1-100.0]) than in the control group (n=52) (median MPR =97.7 [54.1-100.0]) (U=1,042, z=-2.783, P=0.005). The intervention group had less drug holidays than the control group (relative risk 0.55, 95% CI, 0.37-0.80). The sum scores of the MARS did not differ between the intervention group (median =23.98, SD=0.91) and the control group (median =24.00, SD=1.54). CONCLUSION: The PRISMA program resulted in a small improvement in MPR and fewer drug holidays, while no improvement has been found in self-reported adherence. However, health care providers and policy makers could take into account that adherence might be influenced by PRISMA.

Collaboration between hospital and community pharmacists to address drug-related problems: The HomeCoMe-program.

BACKGROUND: Hospital discharge poses a significant threat to the continuity of medication therapy and frequently results in drug-related problems post-discharge. Therefore, establishing continuity of care by realizing optimal collaboration between hospital and community pharmacists is of utmost importance. OBJECTIVE: To evaluate the collaboration between hospital and community pharmacists on addressing drug-related problems after hospital discharge. METHODS: A prospective follow-up study was conducted between November 2013-December 2014 in a general hospital and all affiliated community pharmacies. Adult patients, admitted for ≥48 h to the neurology or pulmonology ward were eligible if they used ≥3 chronic prescription drugs and lived in the community pharmacies' service area. The HomeCoMe intervention program was comprised of medication verification and counseling at admission, medication screening by the hospital pharmacist during admission, outpatient pharmacy discharge consultation and support, and a community pharmacist home visit within one week post-discharge. RESULTS: The mean age of the 152 included patients was 67.0 ±â€¯12.6 years and 56.6% were female. A total of 745 DRPs (4.9 ±â€¯2.2 DRPs per patient, range: 0-11) were identified with the need for additional "Education or information" (36.1%) and "Compliance" (16.4%) issues as most common DRP-types. This led to a total of 928 recommendations (6.1 ±â€¯3.0 per patient, range: 1-19) to solve the DRP. The majority of DRPs were identified (83.6%, n = 623) and solved (91.6%, n = 682) by the community pharmacist during the home visit. Furthermore, 52.5% (n = 64) of the DRPs identified during hospitalization were solved during the post-discharge home visit. CONCLUSIONS: Collaboration between hospital and community pharmacists from hospital admission to readmission to primary care is crucial to establish continuity of care. A post-discharge community pharmacist home visit is a valuable addition to in-hospital transitional care to identify and solve drug-related problems.

Patient-pharmacist communication during a post-discharge pharmacist home visit.

Background With the shifting role of community pharmacists towards patient education and counselling, they are well-positioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Setting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients' health were discussed most frequently, followed by medication logistics and medication effectiveness. Patients' beliefs about their medication and adherence were less frequently discussed. The pharmacist initiated the majority of these topics. Additional non-protocolled topics were scarce and consisted mainly of patient-initiated dissatisfaction regarding the community pharmacy or health insurers. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients' medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engagement in the consultation and providing training programs for pharmacists.

Pharmacists' barriers and facilitators on implementing a post-discharge home visit.

BACKGROUND: Introducing a post-discharge community pharmacist home visit can secure continuity of care and prevent drug-related problems. Currently, this type of pharmaceutical care is not standard practice and implementation is challenging. Mapping the factors influencing the implementation of this new form of care is crucial to ensure successful embedding. OBJECTIVE: To explore which barriers and facilitators influence community pharmacists' adoption of a post-discharge home visit. METHODS: A mixed methods study was conducted with community pharmacists who had recently participated in a study that evaluated the effectiveness of a post-discharge home visit in identifying drug-related problems. Four focus groups were held guided by a topic guide based on the framework of Greenhalgh et al. After the focus groups, major barriers and facilitators were formulated into statements and presented to all participants in a scoring list to rank for relevance and feasibility in daily practice. RESULTS: Twenty-two of the eligible 26 pharmacists participated in the focus groups. Twenty pharmacists (91%) returned the scoring list containing 21 statements. Most of these statements were perceived as both relevant and feasible by the responding pharmacists. A small number scored high on relevance but low on feasibility, making these potential important barriers to overcome for broad implementation. These were the necessity of dedicated time for performing pharmaceutical care, implementing the home visit in pharmacists' daily routine and an adequate reimbursement fee for the home visit. CONCLUSIONS: The key to successful implementation of a post-discharge home visit may lay in two facilitators which are partly interrelated: changing daily routine and reimbursement. Reimbursement will be a strong incentive, but additional efforts will be needed to reprioritize daily routines.

Identifying the Optimal Role for Pharmacists in Care Transitions: A Systematic Review.

BACKGROUND: A transition from one health care setting to another increases the risk of medication errors. Several strategies have been applied to improve care transitions and reduce adverse clinical outcomes. Pharmacist intervention during and after hospitalization has been frequently studied and show a variable effect on these outcomes. OBJECTIVE: To identify the components of pharmacist intervention that improve clinical outcomes during care transitions. METHODS: MEDLINE, EMBASE, International Pharmaceutical Abstracts, and Web of Science databases were searched for randomized controlled trials (RCTs) that studied pharmacist intervention with regard to hospitalization. Two reviewers independently screened all references published from inception to November 2014, extracted data, and assessed risk of bias. RESULTS: A total of 30 studies met the inclusion criteria. A model was created to categorize and cluster components of pharmacist intervention. The average number of components deployed, stages of hospitalization covered, and intervention targets were equally distributed between effective and ineffective studies. A best evidence synthesis of 15 studies revealed strong evidence for a clinical medication review in multifaceted programs (5 effective vs. 0 ineffective studies). Conflicting evidence was found for an isolated postdischarge intervention, admission medication reconciliation, combining postdischarge interventions with in-hospital interventions, and covering of multiple stages. Closely collaborating with other health care providers enhanced the effectiveness. CONCLUSIONS: Although there is a need for well-designed and well-reported RCTs, the study heterogeneity enabled a best evidence synthesis to elucidate effective components of pharmacist intervention. In isolated postdischarge intervention programs, evidence tends towards collaborating with nurses and tailoring to individual patient needs. In multifaceted intervention programs, performing medication reconciliation alone is insufficient in reducing postdischarge clinical outcomes and should be combined with active patient counseling and a clinical medication review. Furthermore, close collaboration between pharmacists and physicians is beneficial. Finally, it is important to secure continuity of care by integrating pharmacists in these multifaceted programs across health care settings. Ultimately, pharmacists need to know patient clinical background and previous hospital experience.

Bridging the gap between hospital and primary care: the pharmacist home visit.

Bridging the gap between hospital and primary care is important as transition from one healthcare setting to another increases the risk on drug-related problems and consequent readmissions. To reduce those risks, pharmacist interventions during and after hospitalization have been frequently studied, albeit with variable effects. Therefore, in this manuscript we propose a three phase approach to structurally address post-discharge drug-related problems. First, hospitals need to transfer up-todate medication information to community pharmacists. Second, the key phase of this approach consists of adequate follow-up at the patients' home. Pharmacists need to apply their clinical and communication skills to identify and analyze drug-related problems. Finally, to prevent and solve identified drug related problems a close collaboration within the primary care setting between pharmacists and general practitioners is of utmost importance. It is expected that such an approach results in improved quality of care and improved patient safety.