Patients' knowledge of the indications for their medications - a scoping review.

BACKGROUND: Inadequate medication knowledge may contribute to inappropriate medication use and treatment harms. We aimed to map and synthesise the existing evidence on patients' knowledge of the indications for their medications. METHOD: We searched MEDLINE, Embase, CINAHL, PsychInfo and the Cochrane Library for studies that assessed patients' knowledge of the indications for their medications from inception to June 16, 2022. A pair of reviewers independently screened and extracted data on study characteristics, aims, and methods used to assess and report patients' knowledge of the indications for their medications. RESULTS: We included 99 studies conducted in 33 countries, published between 1979 and 2021, with 42,377 participants in total (median 126 participants [Interquartile range: 63-338]). Studies were observational (n = 77), experimental (n = 18), or qualitative interviews (n = 4). The exact question used to assess knowledge of the indications was reported in 27 studies and was phrased in 25 different ways. Knowledge of the indications was reported as a proportion of either 1) all participants (n = 65) or 2) the total number of medications used by all patients (n = 13). Sixteen studies used both reporting methods, while five only reported a proportion without specifying the denominator. Fourteen studies in various populations reported the number of participants with correct knowledge of all their medications, ranging from 19% (long-term psychiatric in-patients) to 87% (general practice patients). CONCLUSION: We did not identify any established scientific standard for assessing patients' knowledge of the indications for their medications. The wide range of study methodologies and reporting styles observed call for a methodological consensus in this research field. Estimates of correct knowledge varied widely between studies, but whether this was due to differences in study populations or study methodology could not be determined. Furthermore, we did not identify any study investigating whether participants' knowledge of the indications for their medications was associated with the quality, e.g. appropriateness, of their treatment.

Medication review in hospitalised patients to reduce morbidity and mortality.

BACKGROUND: A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients. OBJECTIVES: We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life. SEARCH METHODS: In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts. SELECTION CRITERIA: We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence. MAIN RESULTS: In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.

Disentangling concepts of inappropriate polypharmacy in old age: a scoping review.

INTRODUCTION: Polypharmacy is a common concern, especially in the older population. In some countries more that 50% of all individuals over 60 receive five or more drugs, most often due to multimorbidity and increased longevity. However, polypharmacy is associated with multiple adverse events, and more medication may not always be the answer. The terms "appropriate" and "inappropriate" are often used to distinguish between "much" and "too much" medications in relation to polypharmacy in research and practice, but no explicit definition exists to describe what these terms encompass. The aim of this review is to unfold the different understandings of and perspectives on (in)appropriate polypharmacy and suggest a framework for further research and practice. METHOD: A scoping review was conducted using the framework of Arksey and O'Malley and Levac et al. Pubmed, Embase, PsycINFO, CINAHL, Cochrane database, Scopus and Web of Science were searched for references in English, Danish, Norwegian and Swedish using the search string "Polypharmacy" AND "Appropriate" OR "Inappropriate". Data was extracted on author information, aims and objectives, methodology, study population and setting, country of origin, main findings and implications, and all text including the words "appropriate," "inappropriate," and "polypharmacy." Qualitative meaning condensation analysis was used and data charted using descriptive and thematic analysis. RESULTS: Of 3982 references, a total of 92 references were included in the review. Most references were from 2016-2021, from fields related to medicine or pharmacy, and occurred within primary and secondary healthcare settings. Based on the qualitative analysis, a framework were assembled consisting of Context, three domains (Standardization, Practices and Values & Concerns) and Patient Perspective. CONCLUSION: Inappropriate polypharmacy is a concept loaded by its heterogeneity and the usefulness of a single definition is doubtful. Instead, the framework suggested in this article representing different dimensions of inappropriate polypharmacy may serve as an initial strategy for focusing research and practice on polypharmacy in old age.

Two-year MRI-defined structural damage and patient-reported outcomes following surgery or exercise for meniscal tears in young adults.

OBJECTIVE: To investigate potential differences in structural knee joint damage assessed by MRI and patient-reported outcomes (PROMs) at 2-year follow-up between young adults randomised to early surgery or exercise and education with optional delayed surgery for a meniscal tear. METHODS: A secondary analysis of a multicentre randomised controlled trial including 121 patients (18-40 years) with an MRI-verified meniscal tear. For this study, only patients with 2-year follow-up were included. The main outcomes were the difference in worsening of structural knee damage, assessed by MRI using the Anterior Cruciate Ligament OsteoArthrits Score, and the difference in change in the mean score of four Knee Injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sport and recreation, and quality of life, from baseline to 2 years. RESULTS: In total, 82/121 (68%) patients completed the 2-year follow-up (39 from the surgical group and 43 from the exercise group). MRI-defined cartilage damage had developed or progressed in seven (9.1%) patients and osteophytes developed in two (2.6%) patients. The worsening of structural damage from baseline to 2-year follow-up was similar between groups. The mean (95% CI) adjusted differences in change in KOOS4 between intervention groups from baseline to 2 years was -1.4 (-9.1, 6.2) points. The mean improvement in KOOS4 was 16.4 (10.4, 22.4) in the surgical group and 21.5 (15.0, 28.0) in the exercise group. No between group differences in improvement were found in the KOOS subscales. CONCLUSIONS: The 2-year worsening of MRI-defined structural damage was limited and similar in young adult patients with a meniscal tear treated with surgery or exercise with optional delayed surgery. Both groups had similar clinically relevant improvements in KOOS4, suggesting the choice of treatment strategy does not impact 2-year structural knee damage or PROMs. TRIAL REGISTRATION NUMBER: NCT02995551.

Does group-based cognitive therapy improve functional ability, pain, catastrophic thoughts and quality of life in patients with persistent low back pain and psychological risk factors? A randomised controlled trial in a secondary care setting.

OBJECTIVE: To investigate the effects of a group-based cognitive behavioural intervention for patients with persistent low back pain (LBP) and psychological risk factors referred to secondary care. DESIGN: A randomised controlled trial. SETTING: Silkeborg Regional Hospital, Denmark. SUBJECTS: A total of 136 participants with chronic LBP and psychological risk factors. INTERVENTIONS: Participants were randomised to the standard care group, including examination by a rheumatologist and/or a physiotherapist, or the intervention group, including standard care plus a multidisciplinary group-based pain management programme. MAIN MEASURES: Patient-reported outcomes were collected at baseline and after 6 and 12 months. The primary outcome was disability (Roland Morris Disability Questionnaire). Secondary outcomes included low back pain intensity, pain catastrophising, health-related quality of life, and sick leave. RESULTS: Among 136 participants, 68 (mean age: 41.7 years (SD 11.8)) were randomised to standard care and 68 (mean age: 46.0 years (SD 10.8)) were randomised to the intervention group. Except for age, baseline characteristics were comparable between groups. 12-month follow-up was completed by 92.6% in the intervention group and 80.9% in the standard care group. Both groups achieved significant improvements on disability, with a reduction of -4.8 points (SD 6.1) in the intervention group compared to -3.7 points (SD 5.2), resulting in an insignificant difference between groups. No significant differences were found in the secondary outcomes. CONCLUSION: A group-based pain management programme was no more effective than standard care for patients with persistent LBP and psychological risk factors.

Description of content, structure and theoretical model of a group-based pain management programme in the treatment of patients with persistent non-specific low back pain and psychological risk factors in a secondary sector setting.

OBJECTIVE: To present the theoretical foundation and methodological considerations for a group-based pain management programme for patients with persistent non-specific low back pain and psychosocial risk factors. METHOD: The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework for describing the content, structure and context of the program. The theoretical rationale underlying the pain management programme was described using the first three steps of the Intervention Mapping framework. The Fear-avoidance model and the Self-efficacy Theory were identified as the two main theories. These were used to establish specific factors addressed by the pain management programme as well as expected outcomes. INTERVENTION DESCRIPTION: A multidisciplinary, group-based programme using a cognitive-behavioural approach was developed. The programme consisting of six sessions of two hours duration, took place at a spine clinic at a regional hospital in Denmark. Psychoeducation and cognitive restructuring were specific strategies hypothesised to induce changes in outcome measures. The outcomes expected to change as a result of the intervention were disability, quality of life, sick leave and physical activity. A pilot study was performed, subsequent adjustments made and the final content and educational materials completed by January 2017. CONCLUSION: The theoretical foundation and underlying evidence for the hypothesised change mechanisms in the use of a cognitive-behavioural approach was presented. A theoretically sound and practically feasible intervention has been developed and its effectiveness is being determined in a randomised controlled trial, including 130 low back pain patients, which is currently underway.

Video interpretation in a medical spine clinic: A descriptive study of a diverse population and intervention.

OBJECTIVES: Back pain is one of the most challenging health conditions to manage. Healthcare providers face additional challenges when managing back pain for patients with culturally diverse backgrounds including addressing linguistic barriers and understanding patients' cultural beliefs about pain and healthcare. Knowledge about patients with culturally diverse backgrounds experiencing back pain and the interventions available to them is limited. Therefore, this study aims to describe the characteristics of patients with culturally diverse backgrounds experiencing back pain and the video interpretation intervention offered to them and further to explore the clinician's perspective on this intervention. METHODS: Data were collected from the electronic medical records and the Interpreter Gateway. Four clinicians participated in a group interview, where they described and evaluated the video interpretation intervention in detail inspired by the template for intervention description and replication (TIDieR) checklist and guide. RESULTS: A total of 119 (68%) patients accepted the intervention (53% women, mean 44 years). These patients represent 24 different languages, with 50% having at least one hospital-registered diagnosis and a mean number of five outpatient contacts, 1 year before receiving the intervention. Fifty-seven patients did not accept the intervention and declined interpretation or opted to use relatives or through video conferencing equipment. The intervention was positively evaluated by the clinicians. CONCLUSIONS: The detailed description of the population and the intervention together with the clinician perspective provides a valuable foundation for developing and refining similar interventions, allocating resources, and designing future research studies. The intervention consisted of a consultation lasting up to 2 h delivered by a rheumatologist and a physiotherapist, with a remote interpreter connected.

Are Outcomes From an Exercise Therapy and Patient Education Program for Osteoarthritis Associated With Hip and Knee Replacement Within Two Years? A Register-Based Study of 9,339 Patients With Osteoarthritis.

OBJECTIVE: The objective of this study was to determine whether short-term outcomes from exercise therapy and patient education for osteoarthritis (OA) are associated with hip or knee replacement within two years. METHODS: Individual-level data from the Good Life with osteoArthritis in Denmark (GLA:D) Registry were linked to the Danish National Patient Registry and other national registries. Cox proportional hazards models were used to investigate associations between program outcomes (baseline to three-month changes) and time to primary hip or knee replacement. Patients who did not receive joint replacement were censored at two years, time of death, or emigration. RESULTS: A total of 2,304 and 7,035 patients with clinically diagnosed hip and knee OA, respectively, were included. Of these, 30% with hip OA and 10% with knee OA had joint replacement within two years. Postprogram improvements in hip-related quality of life and arthritis self-efficacy (pain subscale) were associated with a reduced hazard of hip replacement (adjusted hazard ratios [HRs] for a 10-unit improvement: 0.74 [95% confidence interval (CI) 0.69-0.80] and 0.90 [95% CI 0.85-0.96], respectively). Improvements in knee pain, knee-related quality of life, and arthritis self-efficacy (pain subscale) were associated with a lower hazard of knee replacement (adjusted HRs for 10-unit improvement: 0.81 [95% CI 0.76-0.86] to 0.90 [95% CI 0.86-0.95], 0.70 [95% CI 0.63-0.78] to 0.79 [95% CI 0.72-0.86], and 0.89 [95% CI 0.83-0.94], respectively). CONCLUSION: The magnitude of improvement in key measures after exercise therapy and education was significantly associated with the likelihood of surgery. Progression to hip replacement was three times higher than progression to knee replacement. This information can guide patient-clinician conversations around anticipated program outcomes.

Do imaging findings modify the effect of non-surgical treatment in patients with knee and hip osteoarthritis? A systematic literature review.

OBJECTIVES: To review the available evidence on diagnostic imaging findings in knee and hip osteoarthritis (OA) as treatment effect modifiers in non-surgical OA interventions. METHODS: MEDLINE, Embase and The Cochrane Central Register of Controlled Trials were searched from the earliest records published to 22 March 2022. Studies in knee and hip OA reporting subgroup analyses in randomised controlled trials with imaging findings as potential treatment effect modifiers were included. Studies were critically appraised using the Cochrane risk of bias tool and a subgroup analysis quality assessment. RESULTS: Of 10 014 titles and abstracts screened, eight studies met the inclusion criteria, six on knee OA and two on hip OA. The studies investigated effect modifiers in exercise therapy, intra-articular injections and unloading shoes. Imaging findings assessed as potential treatment effect modifiers were radiographic OA severity, hip effusion (ultrasound), bone marrow lesions and meniscal pathology (MRI). Two studies fulfilled the methodological quality criteria for assessing effect modification. One reported that radiographic knee OA severity modified the effect of unloading shoes on walking pain. Those with more severe radiographic knee OA had a greater response to shoe inserts. One reported no interaction between radiographic OA severity or joint effusion and the effect of intraarticular injections of corticosteroid or hyaluronic acid in hip OA, indicating no difference in response in people with greater hip joint effusion or radiographic OA severity compared with those with less severe joint disease. CONCLUSION: Overall, methodological limitations and very few studies do not permit conclusions on diagnostic imaging findings as effect modifiers in non-surgical interventions in knee and hip OA.Radiographic severity of knee OA potentially modifies the effect of unloading shoes. PROSPERO REGISTRATION NUMBER: CRD42020181934.

The association between cervical degenerative MRI findings and self-reported neck pain, disability and headache: a cross-sectional exploratory study.

BACKGROUND: Neck pain and headache are highly prevalent conditions and leading causes of disability worldwide. Although MRI is widely used in the management of these conditions, there is uncertainty about the clinical significance of cervical MRI findings in patients with neck pain or headache. Therefore, this study aims to investigate the association between cervical degenerative MRI findings and self-reported neck pain, neck disability, and headache. METHODS: This study was a secondary analysis of a cohort of patients with low back pain aged 18-40 years recruited from a non-surgical outpatient spine clinic. The cervical MRI and outcome measures used in this analysis were collected at a four-year follow-up (2014-2017). Self-reported outcome measures included neck pain intensity, neck disability as measured by the Neck Disability Index, and headache as measured by a single NDI item. Cervical MRI findings included disc degeneration, disc contour changes, and vertebral endplate signal changes (VESC). Multivariable logistic regression analyses, adjusted for age and sex, were used to analyse the associations between MRI findings and neck pain, neck disability, and headache. RESULTS: A total of 600 participants who underwent MRI and completed the relevant questionnaires at follow-up were included. The median age was 37 years (interquartile range 31-41) and 325 (54%) were female. Of the included participants, 181 (31%) had moderate or severe neck pain, 274 (59%) had moderate or severe neck disability, 193 (42%) reported headaches, and 211 (35%) had one or more cervical degenerative MRI findings. Cervical disc degeneration and disc contour changes were positively associated with moderate or severe neck pain with odds ratio 1.6 (95% CI 1.1-2.4) and 1.6 (1.1-2.3), respectively. VESC was associated with moderate or severe neck disability with odds ratio 3.3 (1.3-8.4). No statistically significant associations were found between the MRI findings assessed and headache. CONCLUSIONS: In this cross-sectional exploratory study, we found that cervical disc degeneration and disc contour changes were associated with neck pain, and VESC was associated with neck disability. None of the MRI findings were associated with headache. The results suggest that cervical degenerative changes may contribute to the aetiology of neck symptoms, but the associations are modest and cannot guide clinical decisions.

Nationally Shared Medication Lists - Describing Systems in the Nordic Countries.

This paper provides an overview of shared medication lists (SMLs) in four Nordic countries (Denmark, Finland, Norway and Sweden) with a focus on the type of information the list is based on. This is a structured comparison conducted in stages using an expert group, grey papers, unpublished materials, web pages, as well as scientific papers. Denmark and Finland have implemented their solutions for an SML and Norway and Sweden are working on the implementation of their solution. Denmark and Norway have or are aiming at a list based on medication orders, while Finland and Sweden have lists based on prescriptions.

Prognostic factors of total hip replacement during a 2-year period in participants enrolled in supervised education and exercise therapy: a prognostic study of 3657 participants with hip osteoarthritis.

BACKGROUND: Evidence on prognostic factors associated with progression to total hip replacement (THR) in hip osteoarthritis (OA) is for the most patient- and disease-specific characteristics either conflicting or inconclusive. Therefore, the objectives of this study of participants with hip OA enrolled in a structured program of supervised education and exercise therapy were to describe the rate of THR and to identify prognostic factors for receiving THR within the following 2 years. METHODS: Participants aged ≥ 45 years with hip OA enrolled in Good Life with osteoArthritis in Denmark (GLA:D®) from July 2014 to March 2017 were included. Potential prognostic factors included demographic and disease-specific baseline characteristics and measures of physical activity and quality of life (QoL). Information on THR was retrieved from The Danish National Patient Registry. A multivariable Cox proportional hazards model was developed. RESULTS: Of 3657 included participants, 30% received a THR within 2 years. Of the 100 participants already wait-listed for THR, 60% had the procedure. Of 22 candidate prognostic factors, 14 were statistically significant for receiving THR. Factors associated with a faster rate of THR included being "male" (HR 1.43), having "self-reported radiographic hip OA" (HR 2.32), being "wait-listed for THR" (HR 2.17), and having a higher "pain intensity" (HR 1.01). In contrast, faster "walking speed" (HR 0.64), better "hip-related QoL" (HR 0.98), and having "three or more comorbidities" (HR 0.62) were predictive of a slower rate of THR. CONCLUSION: During the 2-year follow-up period, 30% of the cohort received a THR. Notably, 40% of those wait-listed for THR when entering the program did not receive THR within 2 years. A number of baseline prognostic factors for receiving THR were identified.

Ultrasound imaging in patients with hip pain and suspected hip osteoarthritis: an inter-rater and intra-rater reliability study.

OBJECTIVES: The objectives of this study were to asses (1) inter-rater and intrarater reliability of ultrasound imaging in patients with hip osteoarthritis, and (2) agreement between ultrasound and X-ray findings of hip osteoarthritis using validated Outcome Measures in Rheumatology ultrasound definitions for pathology. DESIGN: An inter-rater and intrarater reliability study. SETTING: A single-centre study conducted at a regional hospital. PARTICIPANTS: 50 patients >39 years of age referred for radiography due to hip pain and suspected hip osteoarthritis were included. Exclusion criteria were previous hip surgery in the painful hip, suspected fracture or malignant changes in the hip. INTERVENTION: Bilateral ultrasound examinations (n=92) were performed continuously by two experienced operators blinded to clinical information and other imaging findings. After 4-6 weeks, one operator reassessed the images. X-rays were assessed by a third imaging specialist. PRIMARY AND SECONDARY OUTCOME MEASURES: Inter-rater and intrarater reliability and agreement between ultrasound imaging and X-ray were assessed using Cohen's ordinal kappa statistics for binary categorical variables and weighted kappa for ordered categorical variables. RESULTS: Kappa values (κ) for inter-rater reliability were 0.9 and 0.8 for hip effusion/synovitis and osteoarthritis grading, respectively. For acetabular and femoral osteophytes, femoral cartilage changes and labrum changes κ ranged from 0.4 to 0.7. Intrarater reliability had κ equal or higher compared with inter-rater reliability. Agreement between ultrasound and X-ray findings ranged from κ=0.2 to κ=0.5. CONCLUSION: This study demonstrated substantial to almost perfect reliability on the most common ultrasound findings related to hip osteoarthritis and osteoarthritis grading. Agreement on the grade of osteoarthritis between ultrasound and X-ray was moderate. Overall, these results support ultrasound imaging as a reliable tool in the assessment of hip osteoarthritis.