Participatory healthcare-provider orientation to improve artemether-lumefantrine-based drug treatment of uncomplicated malaria: a cluster quasi-experimental study.

OBJECTIVES: To assess the effect of participatory healthcare-provider orientation in enhancing patient knowledge, appropriate prescribing and dispensing of artemether-lumefantrine, during drug treatment of uncomplicated malaria. METHODS: A cluster quasi-experimental study. The authors developed strategies to address challenges encountered by healthcare providers during clinical management of malaria. The primary outcome was patient knowledge on prescribed malaria drug treatment. Secondary outcomes were appropriate prescribing and provision of adequate drug dispensing information. The authors used generalised estimating equation logistic regression to investigate correlates of appropriate use of artemether-lumefantrine. RESULTS: The proportion of patients or caretakers of paediatric patients sufficiently knowledgeable about malaria treatment increased from 16/85 (18.8%) at baseline to 33/96 (34.4%) at evaluation, OR 2.26 (95% CI 1.13 to 4.49), p=0.020, in the intervention, and fell slightly from 49/134 (36.6%) to 35/114 (30.7%), OR 0.77, (95% CI 0.45 to 1.31), p=0.331 in the control district. This was enhanced by the existence of drug-dispensing standard operating procedures (adjusted OR 1.85, 95% CI 0.98 to 3.50; p=0.057). The proportion of appropriate prescriptions increased from 61/87 (70.1%) to 94/112 (83.9%) in the intervention district, OR 2.23 (95% CI 1.13 to 4.40), p=0.020 and reduced from 91/115 (79.1%) to 75/112 (67.0%) in the control district, OR 0.53, (95% CI 0.29 to 0.97), p=0.040. The frequency of adequately dispensed prescriptions increased in the intervention district (34(32.4%) to 53(45.3%), OR 1.73 (95% CI 1.00 to 2.99), p=0.050) but decreased in the control location (94 (69.6%) to 71 (52.6%), OR 0.48 (95% CI 0.29 to 0.80), p=0.004). CONCLUSIONS: Participatory healthcare-provider orientation enhanced patient knowledge, healthcare provider prescribing and dispensing of artemether-lumefantrine, bolstered by adequate medication counselling and use of drug-dispensing standard operating procedures.

Association of 9-hydroxy risperidone concentrations with risk of switching or discontinuation in the clinical antipsychotic trial of intervention effectiveness-Alzheimer's disease trial.

Risperidone has been used to treat behavioral symptoms, such as delusions and agitation, in people with Alzheimer's disease. The relationship between magnitude and variability of risperidone and 9-hydroxy risperidone exposure and the relationship with time to discontinuation of the medication were explored. Sixty-five subjects from the Clinical Antipsychotic Trial of Intervention Effectiveness-Alzheimer's Disease Trial that received risperidone were included in this study. Eighteen subjects completed the study without switching medication (completers on risperidone), whereas 47 discontinued the medication. Those who discontinued were divided into 2 groups according to responsiveness to therapy. Using Cox proportional survival regression analysis, we estimated time to discontinuation and factors associated with treatment discontinuation including age, dose, body mass index, neuropsychiatric inventory baseline score, and average exposure (area under the curve [AUC]) to risperidone and 9-hydroxy risperidone. Twenty-four and 17 subjects discontinued therapy because of inadequate therapeutic effect and side effects, respectively (6 subjects were excluded because of missing information about reason for switching or discontinuation). Discontinuation hazards for those with a higher than median AUC of the metabolite were 2.54 (P = 0.029; inadequate and side effect group combined) and 3.48 (P = 0.025; inadequate effect group) times that of those in the lower than median AUC group. None of the other covariates contributed significantly to the switching hazard. Risperidone metabolite, 9-hydroxy risperidone concentrations, correlated with the risk of switching or discontinuing the medication, suggesting that 9-hydroxy risperidone contributes to adverse events and intolerability in dementia patients.