Does providing prescription information or services improve medication adherence among patients discharged from the emergency department? A randomized controlled trial.

STUDY OBJECTIVE: We determine whether prescription information or services improve the medication adherence of emergency department (ED) patients. METHODS: Adult patients treated at one of 3 EDs between November 2010 and September 2011 and prescribed an antibiotic, central nervous system, gastrointestinal, cardiac, or respiratory drug at discharge were eligible. Subjects were randomly assigned to usual care or one of 3 prescription information or services intervention groups: (1) practical services to reduce barriers to prescription filling (practical prescription information or services); (2) consumer drug information from MedlinePlus (MedlinePlus prescription information or services); or (3) both services and information (combination prescription information or services). Self-reported medication adherence, measured by primary adherence (prescription filling) and persistence (receiving medicine as prescribed) rates, was determined during a telephone interview 1 week postdischarge. RESULTS: Of the 3,940 subjects enrolled and randomly allocated to treatment, 86% (N=3,386) completed the follow-up interview. Overall, primary adherence was 88% and persistence was 48%. Across the sites, primary adherence and persistence did not differ significantly between usual care and the prescription information or services groups. However, at site C, subjects who received the practical prescription information or services (odds ratio [OR]=2.4; 95% confidence interval [CI] 1.4 to 4.3) or combination prescription information or services (OR=1.8; 95% CI 1.1 to 3.1) were more likely to fill their prescription compared with usual care. Among subjects prescribed a drug that treats an underlying condition, subjects who received the practical prescription information or services were more likely to fill their prescription (OR=1.8; 95% CI 1.0 to 3.1) compared with subjects who received usual care. CONCLUSION: Prescription filling and receiving medications as prescribed was not meaningfully improved by offering patients patient-centered prescription information and services.

Hybrid effectiveness-implementation study of two novel spectrally engineered lighting interventions for shiftworkers on a high-security watchfloor.

Shiftwork leads to myriad negative health and safety outcomes. Lighting countermeasures can benefit shiftworkers via physiological effects of light (e.g. alerting, circadian adjustment), and short-wavelength light is the most potent for eliciting those responses; however, limited work indicates it may not be required for alerting. We developed similar-appearing light boxes (correlated color temperature: 3000-3375 K; photopic illuminance: 260-296 lux), enriched (SW+, melanopic EDI: 294 lux) or attenuated (SW-, melanopic EDI: 103 lux) in short-wavelength energy, and implemented them on a high-security watchfloor. Efficacy and feasibility of these two novel lighting interventions were assessed in personnel working 12-hour night shifts (n = 47) in this within-participants, crossover study. For each intervention condition, light boxes were arranged across the front of the watchfloor and illuminated the entire shift; blue-blocking glasses were worn post-shift and before sleep; and sleep masks were used while sleeping. Comparisons between baseline and intervention conditions included alertness, sleep, mood, quality of life (QOL), and implementation measures. On-shift alertness (Karolinska Sleepiness Scale) increased in SW- compared to baseline, while changes in SW+ were more limited. Under SW+, both mood and sleep improved. Psychomotor vigilance task performance did not vary by condition; however, perceived performance and QOL were higher, and reported caffeine consumption and sleep onset latency were lower, under SW-. For both interventions, satisfaction and comfort were high, and fewer symptoms and negative feelings were reported. The addition of spectrally engineered lights to this unique work environment improved sleep, alertness, and mood without compromising visual comfort and satisfaction. This paper is part of the Sleep and Circadian Rhythms: Management of Fatigue in Occupational Settings Collection.

Performance of seven consumer sleep-tracking devices compared with polysomnography.

STUDY OBJECTIVES: Consumer sleep-tracking devices are widely used and becoming more technologically advanced, creating strong interest from researchers and clinicians for their possible use as alternatives to standard actigraphy. We, therefore, tested the performance of many of the latest consumer sleep-tracking devices, alongside actigraphy, versus the gold-standard sleep assessment technique, polysomnography (PSG). METHODS: In total, 34 healthy young adults (22 women; 28.1 ± 3.9 years, mean ± SD) were tested on three consecutive nights (including a disrupted sleep condition) in a sleep laboratory with PSG, along with actigraphy (Philips Respironics Actiwatch 2) and a subset of consumer sleep-tracking devices. Altogether, four wearable (Fatigue Science Readiband, Fitbit Alta HR, Garmin Fenix 5S, Garmin Vivosmart 3) and three nonwearable (EarlySense Live, ResMed S+, SleepScore Max) devices were tested. Sleep/wake summary and epoch-by-epoch agreement measures were compared with PSG. RESULTS: Most devices (Fatigue Science Readiband, Fitbit Alta HR, EarlySense Live, ResMed S+, SleepScore Max) performed as well as or better than actigraphy on sleep/wake performance measures, while the Garmin devices performed worse. Overall, epoch-by-epoch sensitivity was high (all ≥0.93), specificity was low-to-medium (0.18-0.54), sleep stage comparisons were mixed, and devices tended to perform worse on nights with poorer/disrupted sleep. CONCLUSIONS: Consumer sleep-tracking devices exhibited high performance in detecting sleep, and most performed equivalent to (or better than) actigraphy in detecting wake. Device sleep stage assessments were inconsistent. Findings indicate that many newer sleep-tracking devices demonstrate promising performance for tracking sleep and wake. Devices should be tested in different populations and settings to further examine their wider validity and utility.

Performance of a Portable Sleep Monitoring Device in Individuals with High Versus Low Sleep Efficiency.

STUDY OBJECTIVES: Portable and automated sleep monitoring technology is becoming widely available to consumers, and one wireless system (WS) has recently surfaced as a research tool for sleep and sleep staging assessment outside the hospital/laboratory; however, previous research findings indicate low sensitivity for wakefulness detection. Because difficulty discriminating between wake and sleep is likely to affect staging performance, we sought to further evaluate the WS by comparing it to the gold-standard polysomnography (PSG) and actigraphy (ACT) for overall sleep/wakefulness detection and sleep staging, within high and low sleep efficiency sleepers. METHODS: Twenty-nine healthy adults (eight females) underwent concurrent WS, PSG, and ACT assessment in an overnight laboratory study. Epoch-by-epoch agreement was determined by comparing sleep/wakefulness decisions between the WS to both PSG and ACT, and for detection of light, deep, and rapid eye movement (REM) sleep stages between the WS and PSG. RESULTS: Sensitivity for wakefulness was low (40%), and an overestimation of total sleep time and underestimation of wake after sleep onset was observed. Prevalence and bias adjusted kappa statistic indicated moderate-to-high agreement between the WS and PSG for sleep staging. However, upon further inspection, WS performance varied by sleep efficiency, with the best performance during high sleep efficiency. CONCLUSIONS: The benefit of the WS as a sleep monitoring device over ACT is the ability to assess sleep stages, and our findings suggest this benefit is only realized within high sleep efficiency. Care should be taken to collect data under conditions where this is expected.

Effects of caffeine on the human circadian clock in vivo and in vitro.

Caffeine's wakefulness-promoting and sleep-disrupting effects are well established, yet whether caffeine affects human circadian timing is unknown. We show that evening caffeine consumption delays the human circadian melatonin rhythm in vivo and that chronic application of caffeine lengthens the circadian period of molecular oscillations in vitro, primarily with an adenosine receptor/cyclic adenosine monophosphate (AMP)-dependent mechanism. In a double-blind, placebo-controlled, ~49-day long, within-subject study, we found that consumption of a caffeine dose equivalent to that in a double espresso 3 hours before habitual bedtime induced a ~40-min phase delay of the circadian melatonin rhythm in humans. This magnitude of delay was nearly half of the magnitude of the phase-delaying response induced by exposure to 3 hours of evening bright light (~3000 lux, ~7 W/m(2)) that began at habitual bedtime. Furthermore, using human osteosarcoma U2OS cells expressing clock gene luciferase reporters, we found a dose-dependent lengthening of the circadian period by caffeine. By pharmacological dissection and small interfering RNA knockdown, we established that perturbation of adenosine receptor signaling, but not ryanodine receptor or phosphodiesterase activity, was sufficient to account for caffeine's effects on cellular timekeeping. We also used a cyclic AMP biosensor to show that caffeine increased cyclic AMP levels, indicating that caffeine influenced a core component of the cellular circadian clock. Together, our findings demonstrate that caffeine influences human circadian timing, showing one way that the world's most widely consumed psychoactive drug affects human physiology.

Combination of light and melatonin time cues for phase advancing the human circadian clock.

STUDY OBJECTIVES: Photic and non-photic stimuli have been shown to shift the phase of the human circadian clock. We examined how photic and non-photic time cues may be combined by the human circadian system by assessing the phase advancing effects of one evening dose of exogenous melatonin, alone and in combination with one session of morning bright light exposure. DESIGN: Randomized placebo-controlled double-blind circadian protocol. The effects of four conditions, dim light (∼1.9 lux, ∼0.6 Watts/m(2))-placebo, dim light-melatonin (5 mg), bright light (∼3000 lux, ∼7 Watts/m(2))-placebo, and bright light-melatonin on circadian phase was assessed by the change in the salivary dim light melatonin onset (DLMO) prior to and following treatment under constant routine conditions. Melatonin or placebo was administered 5.75 h prior to habitual bedtime and 3 h of bright light exposure started 1 h prior to habitual wake time. SETTING: Sleep and chronobiology laboratory environment free of time cues. PARTICIPANTS: Thirty-six healthy participants (18 females) aged 22 ± 4 y (mean ± SD). RESULTS: Morning bright light combined with early evening exogenous melatonin induced a greater phase advance of the DLMO than either treatment alone. Bright light alone and melatonin alone induced similar phase advances. CONCLUSION: Information from light and melatonin appear to be combined by the human circadian clock. The ability to combine circadian time cues has important implications for understanding fundamental physiological principles of the human circadian timing system. Knowledge of such principles is important for designing effective countermeasures for phase-shifting the human circadian clock to adapt to jet lag, shift work, and for designing effective treatments for circadian sleep-wakefulness disorders.

Comparing National Institutes of Health funding of emergency medicine to four medical specialties.

OBJECTIVES: The purpose of this study was to compare National Institutes of Health (NIH) funding received in 2008 by emergency medicine (EM) to the specialties of internal medicine, pediatrics, anesthesiology, and family medicine. The hypothesis was that EM would receive fewer NIH awards and less funding dollars per active physician and per medical school faculty member compared to the other four specialties. METHODS: Research Portfolio Online Reporting Tools (RePORT) were used to identify NIH-funded grants to 125 of the 133 U.S. allopathic medical schools for fiscal year 2008 (the most recent year with all grant funding information). Eight medical schools were excluded because six were not open in 2008, one did not have a website, and one did not have funding data available by medical specialty. From RePORT, all grants awarded to EM, internal medicine, family medicine, anesthesiology, and pediatric departments of each medical school were identified for fiscal year 2008. The authors extracted the project number, project title, dollars awarded, and name of the principal investigator for each grant. Funds awarded to faculty in divisions of EM were accounted for by identifying the department of the EM division and searching for all grants awarded to EM faculty within those departments using the name of the principal investigator. The total number of active physicians per medical specialty was acquired from the Association of American Medical Colleges' 2008 Physician Specialty report. The total number of faculty per medical specialty was collected by two research assistants who independently counted the faculty listed on each medical school website. The authors compared the total number of NIH awards and total funding per 1,000 active physicians and per 1,000 faculty members by medical specialty. RESULTS: Of the 125 medical schools included in the study, 84 had departments of EM (67%). In 2008, NIH awarded over 9,000 grants and approximately $4 billion to the five medical specialties of interest. Less than 1% of the grants and funds were awarded to EM. EM had the second-lowest number of awards and funding per active physician, and the lowest number of awards and funding per faculty member. A higher percentage of grants awarded to EM were career development awards (26%, vs. a range of 11% to 19% for the other specialties) and cooperative agreements (26%, vs. 2% to 10%). In 2008, EM was the only specialty of the five not to have a fellowship or T32 training grant. EM had the lowest proportion of research project awards (42%, vs. 58% to 73%). CONCLUSIONS: Compared to internal medicine, pediatrics, anesthesiology, and family medicine, EM received the least amount of NIH support per active faculty member and ranked next to last for NIH support by active physician. Given the many benefits of research both for the specialty and for society, EM needs to continue to develop and support an adequate cohort of independent investigators.

A randomized controlled trial of the effect of service delivery information on patient satisfaction in an emergency department fast track.

OBJECTIVES: The objective was to determine the effect on patient satisfaction of providing patients with predicted service completion times. METHODS: A randomized controlled trial was conducted in an urban, community teaching hospital. Emergency department (ED) patients triaged to fast track on weekdays between October 26, 2009, and December 30, 2009, from 9 am to 5 pm were eligible. Patients were randomized to: 1) usual care (n = 342), 2) provided ED process information (n = 336), or 3) provided ED process information plus predicted service delivery times (n = 333). Patients in group 3 were given an "average" and "upper range" estimate of their waiting room times and treatment times. The average and upper range predictions were calculated from quantile regression models that estimated the 50th and 90th percentiles of the waiting room time and treatment time distributions for fast track patients at the study site based on 2.5 years of historical data. Trained research assistants administered the interventions after triage. Patients completed a brief survey at discharge that measured their satisfaction with overall care, the quality of the information they received, and the timeliness of care. Satisfaction ratings of very good versus good, fair, poor, and very poor were modeled using logistic regression as a function of study group; actual service delivery times; and other patient, clinical, and temporal covariates. The study also modeled satisfaction ratings of fair, poor, and very poor compared to good and very good ratings as a function of the same covariates. RESULTS: Survey completion rates and patient, clinical, and temporal characteristics were similar by study group. Median waiting room time was 70 minutes (interquartile range [IQR] = 40 to 114 minutes), and median treatment time was 52 minutes (IQR = 31 to 81 minutes). Neither intervention affected any of the satisfaction outcomes. Satisfaction was significantly associated with actual waiting room time, individual providers, and patient age. Every 10-minute increase in waiting room time corresponded with an 8% decrease (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.89 to 0.95) in the odds of reporting very good satisfaction with overall care. The odds of reporting very good satisfaction with care were lower for several triage nurses and fast track nurses, compared to the triage nurse and fast track nurse who treated the most study patients. Each 10-minute increase in waiting room time was also associated with a 10% increase in the odds of reporting very poor, poor, or fair satisfaction with overall care (OR = 1.10; 95% CI = 1.06 to 1.14). The odds of reporting very poor, poor, or fair satisfaction with overall care also varied significantly among the triage nurses, fast track doctors, and fast track nurses. The odds of reporting very poor, poor, or fair satisfaction with overall care were significantly lower among patients aged 35 years and older compared to patients aged 18 to 34 years. CONCLUSIONS: Satisfaction with overall care was influenced by waiting room time and the clinicians who treated them and not by service completion time estimates provided at triage.