Automatic medication refills to improve glycaemic control among patients with diabetes and low medication adherence.

BACKGROUND: Medication adherence impacts health outcomes. Healthcare organisations implementing system-level interventions have potential for greater spread and sustainability than individual-level interventions. Within the integrated US Veterans Health Administration, a multidisciplinary team developed and evaluated a pilot quality improvement programme to assess the feasibility of automatic mailed prescription refills for patients with diabetes and low medication adherence (assessed by medication possession ratio <80%). METHODS: Patients were randomised to usual care with self-initiated refills versus automatic mailed refills for 6 months. Process outcomes included glycaemic control measures (HgbA1C), medication possession ratios for both automatic and self-initiated (reference) refills of medications, patient satisfaction and workforce effort (pharmacist time). RESULTS: Overall, 199 patients were randomised to automatic refills (n=99; 40 of whom participated) versus usual care (n=100). In multivariable analysis adjusting for baseline differences, after 6 months there was no difference in the proportion of patients with follow-up HgbA1C <8% (60.8% automatic refills vs 60.5% usual care, p=0.96). In the automatic refill group, the medication possession ratio for reference medicines was significantly higher than usual care (63.9% vs 54.5%, 95% CI (for difference) 3.1% to 15.9%, p<0.01). CONCLUSIONS: Implications and lessons from this pilot programme include potential beneficial indirect effects from automatic medication refills on patient self-initiated refills of other medications; the importance of tailoring solutions to patient subgroups and specific adherence barriers; and recognition that the rapid deployment, iteration and evaluation of the project was facilitated by a multidisciplinary team embedded within an organisational learning health system.

Simple signature/countersignature shared-accountability quality improvement initiative to improve reliability of blood sample collection: an essential clinical task.

BACKGROUND: Timely lab results are important to clinical decision-making and hospital flow. However, at our institution, unreliable blood sample collection for patients with central venous access jeopardised this outcome and created staff dissatisfaction. METHODS: A multidisciplinary team of nurses including a specialist clinical nurse leader (CNL), the hospital intravenous team and quality improvement (QI) consultants aimed to achieve >80% blood sample collection reliability among patients with central venous access by employing a simple signature/countersignature form coupled with audit-feedback and behavioural economics strategies. The form was piloted on one 25-bed unit. Data were collected for 60 weeks and interpreted per standard run chart rules. RESULTS: Blood sample collection reliability exceeded the 80% goal by week 22. The practice was sustained on the pilot unit and spread successfully to other wards despite significant operational threats including the COVID-19 pandemic. CONCLUSIONS: At our institution, a simple signature/countersignature form supplemented by audit-feedback and behavioural economics strategies led to sustained practice change among staff. The pairing of CNL to QI consultant enhanced change potency and durability.