Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study.

BACKGROUND: Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term. OBJECTIVE: The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery. METHODS: Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call-based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority. RESULTS: A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention's ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery. CONCLUSIONS: Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums.

BACKGROUND: The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support. OBJECTIVE: The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively. METHODS: A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery. RESULTS: A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals. CONCLUSIONS: Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.

Exploring Undergraduate Pharmacy Student Experiences of Learning Human Anatomy Using Cadaveric Specimens.

Objective. To gain insights into pharmacy students' experiences in learning human anatomy using qualitative interviews and thematic analysis. Methods. Participants included Master of Pharmacy students at the end of their first year or the beginning of their second year. The study used a transcendental phenomenological design. Data were collected using semi-structured individual interviews that were recorded and transcribed verbatim. Thematic analysis was used to identify structural and textural components of participants' experiences using data management software. Results. Sixteen participants were recruited and interviewed. Students described developing an understanding of anatomy that differed from their previous experiences, focusing on variation in anatomical structures between patients, and developing professional attributes such as empathy and respect. Students described haptic learning that acted as a hook on which to anchor additional learning from textbooks and lectures. Finally, students perceived the experience as valuable to their future careers as caring professionals. Conclusion. The results of this qualitative study demonstrate that the value of teaching anatomy to undergraduate students goes beyond developing a broad knowledge of anatomical structures, but also engages a deeper conceptual appreciation of professionalism, thereby inducting them into a community of professional practice.

Improving medication-related clinical decision support.

PURPOSE: Current uses of medication-related clinical decision support (CDS) and recommendations for improving these systems are reviewed. SUMMARY: Using a systematic approach, articles published from 2007 through 2014 were identified in MEDLINE and EMBASE using MeSH terms and keywords relating to the 5 basic medication-related CDS functionalities. A total of 156 full-text articles and 28 conference abstracts were reviewed across each of the 5 areas: drug-drug interaction (DDI) checks (n = 78), drug allergy checks (n = 20), drug dose support (n = 55), drug duplication checks (n = 11), and drug formulary support (n = 20). The success of medication-related CDS depends on users finding the alerts valuable and acting on the information received. Improving alert specificity and sensitivity is important for all domains. Tiering is important for improving the acceptance of DDI alerts. The ability to perform appropriate cross-sensitivity checks is key to producing appropriate drug allergy checks. Drug dosage alerts should be individualized and deliver practical recommendations. How the system is configured to identify certain drug duplications is important to prevent possible patient toxicity. Accurate knowledge databases are needed to produce relevant drug formulary alerts and encourage formulary adherence. Medication-related CDS is still relatively immature in some organizations and has substantial room for improvement. For example, decision support should consider more patient-specific factors, human factors principles should always be considered, and alert specificity must be improved in order to reduce alert fatigue. CONCLUSION: Standardization, integration of patient-specific parameters, and consideration of human factors design principles are central to realizing the potential benefits of medication-related CDS.

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.

Objective: To identify and understand the factors that contribute to medication errors associated with the use of computerized provider order entry (CPOE) in pediatrics and provide recommendations on how CPOE systems could be improved. Materials and Methods: We conducted a systematic literature review across 3 large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Three independent reviewers screened the titles, and 2 authors then independently reviewed all abstracts and full texts, with 1 author acting as a constant across all publications. Data were extracted onto a customized data extraction sheet, and a narrative synthesis of all eligible studies was undertaken. Results: A total of 47 articles were included in this review. We identified 5 factors that contributed to errors with the use of a CPOE system: (1) lack of drug dosing alerts, which failed to detect calculation errors; (2) generation of inappropriate dosing alerts, such as warnings based on incorrect drug indications; (3) inappropriate drug duplication alerts, as a result of the system failing to consider factors such as the route of administration; (4) dropdown menu selection errors; and (5) system design issues, such as a lack of suitable dosing options for a particular drug. Discussion and Conclusions: This review highlights 5 key factors that contributed to the occurrence of CPOE-related medication errors in pediatrics. Dosing support is the most important. More advanced clinical decision support that can suggest doses based on the drug indication is needed.

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

OBJECTIVE: To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. MATERIALS AND METHODS: We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. RESULTS: A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users' work processes, and clinical decision support systems. Displaying an incomplete list of a patient's medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users' misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. DISCUSSION AND CONCLUSIONS: Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users' workflow expectations.

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

OBJECTIVES: A key element of the implementation and ongoing use of an electronic prescribing (ePrescribing) system is ensuring that users are, and remain, sufficiently trained to use the system. Studies have suggested that insufficient training is associated with suboptimal use. However, it is not clear from these studies how clinicians are trained to use ePrescribing systems or the effectiveness of different approaches. We sought to describe the various approaches used to train qualified prescribers on ePrescribing systems and to identify whether users were educated about the pitfalls and challenges of using these systems. METHODS: We performed a literature review, using a systematic approach across three large databases: Cumulative Index Nursing and Allied Health Literature, Embase and Medline were searched for relevant English language articles. Articles that explored the training of qualified prescribers on ePrescribing systems in a hospital setting were included. KEY FINDINGS: Our search of 'all training' approaches returned 1155 publications, of which seven were included. A separate search of 'online' training found three relevant publications. Training methods in the 'all training' category included clinical scenarios, demonstrations and assessments. Regarding 'online' training approaches; a team at the University of Victoria in Canada developed a portal containing simulated versions of electronic health records, where individuals could prescribe for fictitious patients. Educating prescribers about the challenges and pitfalls of electronic systems was rarely discussed. CONCLUSIONS: A number of methods are used to train prescribers; however, the lack of papers retrieved suggests a need for additional studies to inform training methods.

Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation and weight management, including meta-analysis for smoking cessation.

OBJECTIVES: To systematically review the effectiveness of community pharmacy-delivered interventions for alcohol reduction, smoking cessation and weight management. DESIGN: Systematic review and meta-analyses. 10 electronic databases were searched from inception to May 2014. STUDY DESIGN: randomised and non-randomised controlled trials; controlled before/after studies, interrupted times series. INTERVENTION: any relevant intervention set in a community pharmacy, delivered by the pharmacy team. No restrictions on duration, country, age, or language. RESULTS: 19 studies were included: 2 alcohol reduction, 12 smoking cessation and 5 weight management. Study quality rating: 6 'strong', 4 'moderate' and 9 'weak'. 8 studies were conducted in the UK, 4 in the USA, 2 in Australia, 1 each in 5 other countries. Evidence from 2 alcohol-reduction interventions was limited. Behavioural support and/or nicotine replacement therapy are effective and cost-effective for smoking cessation: pooled OR was 2.56 (95% CI 1.45 to 4.53) for active intervention vs usual care. Pharmacy-based interventions produced similar weight loss compared with active interventions in other primary care settings; however, weight loss was not sustained longer term in a range of primary care and commercial settings compared with control. Pharmacy-based weight management interventions have similar provider costs to those delivered in other primary care settings, which are greater than those delivered by commercial organisations. Very few studies explored if and how sociodemographic or socioeconomic variables moderated intervention effects. Insufficient information was available to examine relationships between effectiveness and behaviour change strategies, implementation factors, or organisation and delivery of interventions. CONCLUSIONS: Community pharmacy-delivered interventions are effective for smoking cessation, and demonstrate that the pharmacy is a feasible option for weight management interventions. Given the potential reach, effectiveness and associated costs of these interventions, commissioners should consider using community pharmacies to help deliver public health services.

Community pharmacy interventions for public health priorities: protocol for a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions.

BACKGROUND: Community pharmacists can deliver health care advice at an opportunistic level, related to prescription or non-prescription medicines and as part of focused services designed to reduce specific risks to health. Obesity, smoking and excessive alcohol intake are three of the most significant modifiable risk factors for morbidity and mortality in the UK, and interventions led by community pharmacists, aimed at these three risk factors, have been identified by the government as public health priorities. In 2008, the Department of Health for England stated that 'a sound evidence base that demonstrates how pharmacy delivers effective, high quality and value for money services is needed'; this systematic review aims to respond to this requirement. METHODS/DESIGN: We will search the databases MEDLINE, Embase, CINAHL, PsycINFO, Social Sciences Citation Index, ASSIA, IBSS, Sociological Abstracts, Scopus and NHS Economic Evaluation Database for studies that have evaluated interventions based on community pharmacies that aim to target weight management, smoking cessation and alcohol misuse. We will include all randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series (ITS) and repeated measures studies. Data from included studies will be extracted by two independent reviewers and will include study details methods, results, intervention implementation/costs and methodological quality. Meta-analysis will be conducted if appropriate; if not, the synthesis will be restricted to a narrative overview of individual studies looking at the same question. DISCUSSION: The review aims to summarise the evidence base on the effectiveness of community pharmacy interventions on health and health behaviours in relation to weight management, smoking cessation and alcohol misuse. It will also explore if, and how, socio-economic status, gender, ethnicity and age moderate the effect of the interventions and will describe how the interventions included in the review have been organised, implemented and delivered, since context is an important factor governing the success of public health interventions. The findings from this review will have an impact on the commissioning of public health services aiming to promote healthy weight, smoking cessation and prevent excessive alcohol consumption. SYSTEMATIC REVIEW REGISTRATION: The review has been registered with PROSPERO (registration no. CRD42013005943). Available at: http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42013005943.

Integrating science and practice in pharmacy curricula.

An integrated curriculum is one where the summation of different academic disciplines forms a coherent whole and, importantly, where the relationships between the different disciplines have been carefully and strategically considered when forming the composite. Within pharmacy curriculum integration is important in order to produce graduates who have the capacity to apply their knowledge to a range of complex problems where available information is often incomplete. This paper discusses the development of an integrated curriculum in which students are presented with an organized, logical sequence of material, but still challenged to make their own integrations and develop as integrative thinkers. An evidence-based model upon which an interdisciplinary undergraduate pharmacy curriculum can be built is presented.

Patients using antifungals following laryngectomy: a qualitative study of community pharmacists in the North of England.

OBJECTIVE: To explore community pharmacists' understanding and opinions in relation to the prevention of fungal colonisation of voice prostheses amongst laryngectomy patients. METHOD: Semi-structured interviews were conducted on a purposive sample of 12 community pharmacists from the North of England. Interviews were undertaken until data saturation was reached and responses were transcribed verbatim and analysed using a thematic approach. KEY FINDINGS: Six themes emerged from the data analysis. These were: terminology confusion about laryngectomy, stoma and voice prostheses; smoking as a risk factor for the development of laryngeal cancer; using nystatin to prevent biofilm formation; counselling information related to nystatin; prescription intervention and additional education in relation to laryngectomy. The theme of counselling information related to nystatin use and additional education was a key finding: our data show that when dispensing nystatin to patients with a voice prosthesis, community pharmacists would either give no advice related to medication use or would give incorrect advice that may lead to premature prosthesis failure amongst this patient group. CONCLUSION: This study highlights that community pharmacists lack understanding in relation to laryngectomy and are unaware of the off-label doses and administration methods of the drugs (specifically nystatin) used to prevent fungal colonisation on voice prostheses. Additional information sources in the form of an educational leaflet, possibly obtained through the local department of speech and language therapy, would be perceived as a valuable resource to support community pharmacists who are required to manage these patients in the community.