Patient Self-Administration of Medicine Essay

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Patient Self-Administration of Medicine Essay

Although patient empowerment is valuable, it is essential that hospitals exercise control over the medications patients take. It is impossible to design an effective plan of care otherwise. However, many patients wish to self-administer medications within the hospital setting. For many patients, self-administration is a reasonable goal at home: it is particularly necessary for chronic conditions like diabetes, where patients must learn to self-administer their medications to remain independent over the course of their lives. There also appears to be a desire amongst patients to take control over their own medications even in a hospital context. In a qualitative study of self-medication: “seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Patient Self-Administration of Medicine Essay.

Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses’ heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting” (Beanland, Riley, & Baker 2004). This discrepancy in attitude (a desire amongst nurses for control and amongst patients for the ability to not lose direction over their care, even when in an institutional context) makes self-administration an important topic for study. These two competing desires must be balanced with compassion and efficacy…..

Self-administration of medicines is believed to increase patients’ understanding about their medication and to promote their independence and autonomy in the hospital setting. The effect of inpatient self-administration of medication (SAM) schemes on patients, staff and institutions is currently unclear.

Objective

To systematically review the literature relating to the effect of SAM schemes on the following outcomes: patient knowledge, patient compliance/medication errors, success in self-administration, patient satisfaction, staff satisfaction, staff workload, and costs.

Design

Keyword and text word searches of online databases were performed between January and March 2013. Included articles described and evaluated inpatient SAM schemes. Case studies and anecdotal studies were excluded.

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Results

43 papers were included for final analysis. Due to the heterogeneity of results and unclear findings it was not possible to perform a quantitative synthesis of results. Participation in SAM schemes often led to increased knowledge about drugs and drug regimens, but not side effects. However, the effect of SAM schemes on patient compliance/medication errors was inconclusive. Patients and staff were highly satisfied with their involvement in SAM schemes.

Conclusions

SAM schemes appear to provide some benefits (e.g. increased patient knowledge), but their effect on other outcomes (e.g. compliance) is unclear. Patient Self-Administration of Medicine Essay. Few studies of high methodological quality using validated outcome measures exist. Inconsistencies in both measuring and reporting outcomes across studies make it challenging to compare results and draw substantive conclusions about the effectiveness of SAM schemes.

The Royal Pharmaceutical Society (RPS) describes patient self-administration of medication (SAM) as a ‘transfer of responsibility’ which should be dependent on a patient’s ability to manage the tasks involved, as well as giving their consent to do so [1]. The concept of inpatient SAM has been around for more than 60 years [2] and self-administration is encouraged in many hospitals worldwide [3]–[6]. The National Prescribing Centre (NPC) in the UK describes the aims of SAM as establishing ‘a standardised approach for determining the ability of patients to take their own medication correctly and safely, increase the patient’s knowledge and understanding of their medication, and promote and maintain patient independence and autonomy’ [7].

Hospital SAM schemes often incorporate several stages of increasing patient independence and decreasing nurse involvement as patients become more competent [7]. Within different SAM schemes this transition to independence often includes different numbers of stages and variations in the roles of patients and nurses within each stage. For example, nurses may initially administer medications to patients. Following this, patients may request medications from the nurse and self-administer their medications under observation. Patient Self-Administration of Medicine Essay. Eventually, patients may become completely responsible for administering their medication regimen, with nurses or pharmacists intermittently checking that patients are administering their medications correctly using, for example, random pill counts or covert observations.

For many patients, it is important to be able to self-administer their medications successfully as they will often be expected to do so once they are discharged from hospital. In line with this, the UK’s National Institute for Health and Care Excellence (NICE) states that prescribers should, ‘when possible, support patients to take responsibility for their medicines and self-manage their conditions’ [8]. However, the NPC emphasises that allowing patients to self-administer, ‘…must balance the benefits to patients against the risks introduced’ [7].

It has been proposed that patients, staff and healthcare systems will benefit from the implementation of a SAM scheme [9], [10]; however the evidence is not clear cut. Two previously published English language literature reviews on the effectiveness of SAM schemes [11], [12] both concluded that there is a dearth of well-designed studies, with a lack of validated measures and inadequate reporting strategies. Therefore, it is difficult to fully understand whether SAM schemes are beneficial to patients and/or institutions that implement them. No active systematic reviews were found following a thorough search of databases. Therefore, in order to assess the effectiveness of SAM schemes for improving patient, staff and system outcomes and to reassess the evidence from previous publications, we performed a systematic review of the literature to evaluate the effectiveness of implementing SAM schemes in hospitals. Patient Self-Administration of Medicine Essay.

Study objective

We reviewed the literature in order to answer the following questions about hospital inpatient self-administration:

What types of SAM scheme interventions have been implemented by healthcare professionals among hospital inpatients?
What effects have these interventions had on outcomes related to patients, staff and institutions?

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Methods

We undertook a systematic search of the literature and a narrative synthesis. Full details of the study protocol can be accessed via PROSPERO [reference CRD42013003498] [13].

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs), non-RCTs, cohort studies, observational studies, cross-sectional studies, before-and-after studies, and case series. Case studies and anecdotal studies were excluded, as were those which did not evaluate the scheme or provided insufficient information about the evaluation.

Types of participants

We included studies that reported evaluations of SAM schemes implemented in a hospital inpatient setting. We excluded texts for the following reasons: where patients were assisted by relatives or carers, as this may negate the experience of self-administering; where drugs were administered as needed by patients (PRN), as these did not follow a pre-specified regimen; studies which described outpatient or community-based interventions; or where patients would use their own (prescribed or otherwise) drugs that were not dispensed by the hospital. Patient Self-Administration of Medicine Essay. The reasons for excluding the latter group were that patients’ own drugs are generally considered to reduce medication waste and aid the reconciliation process on admission, and is not necessarily an indicator of self-administration. In addition, we felt the use of the patient’s own drugs for self-administration may be more likely to have been initiated by the patient, as opposed to a structured scheme implemented by the healthcare team, as our objective states.

Types of outcome measures

We included studies that provided information on at least one of the following primary outcome measures: patient knowledge and patient compliance or error. We also investigated a number of secondary outcome measures: patient success in self-administering; patient satisfaction; staff satisfaction; staff workload; and costs.

Search strategy

We performed a comprehensive search (see Table S1) based on a combination of text words and controlled vocabulary search terms using the following databases: EMBASE via OVID; MEDLINE via OVID; Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus via OVID; PsycINFO via OVID; Health Management Information Consortium (HMIC) via OVID; National Electronic Library for Medicines (NELM; previously PharmLine); Conference Proceedings Citation Index – Science (CPCI-S) and Conference Proceedings Citation Index – Social Science and Humanities (CPCI- SSH) via Web of Knowledge; Zetoc; Clinical Trials Register; World Health Organization’s Clinical Trials Registry Platform; National Institute for Health Research Health Technology Assessments (NIHR HTA). Prior to our main search we checked the following databases for recent or ongoing similar reviews: PROPSPERO, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews (CDSR), Campbell Collaboration & Evidence for Policy and Practice Information’s Database of Promoting Health Effectiveness Reviews (EPPI: DoPHER). Some of the databases (CINAHL, CPCI-S, CPCI-SSH, HMIC, and Zetoc) contained grey literature, which we chose to include in our review if it met the inclusion and exclusion criteria. Key search terms included: self-administration; hospital; compliance; error; patient satisfaction; knowledge; self-efficacy; drug; and medication (see Table S1 for full search strategy). The searches were performed between January and March 2013, with searches including studies from between 1950–1993 (each database offered a different search data range) to March 2013. In addition, we identified additional relevant articles cited in the selected texts. Searches were not limited by language or publication status. Patient Self-Administration of Medicine Essay.

Data collection and analysis

Selection of studies

Titles and abstracts of papers identified in the search were reviewed independently by two of four review authors (SR, HB, GB or JC), and articles that appeared to fulfil the inclusion criteria were retrieved. The degree of agreement for each pair of reviewers was calculated using Kappa coefficients. Where there were discrepancies, a decision to include or exclude the study was reached by consensus between the two reviewers, or if necessary a third reviewer was also involved. From the full text of these papers, three review authors (SR, HB, GB) independently established whether studies met the inclusion criteria.

Included texts were assessed for quality of reporting using a modified version of the quality assessment checklist for health care interventions developed by Downs and Black [14]. In the original checklist, the final question (number 27) regarding statistical power is awarded between 0 and 5 points. We found, like other studies [15]–[17] the scoring criteria to be unclear and so limited our score to either 0 (study includes no discussion of statistical power) or 1 (study includes discussion of statistical power). This scoring method was also used by Deshpande et al [14]. The maximum possible score on the checklist was 28 points, with a higher score indicating a higher quality study.

Studies were assessed independently by two of three reviewers (SR, HB or GB) and the third reviewer acted as adjudicator where consensus could not be reached.

Data extraction and analysis

For each text, two of the three aforementioned reviewers independently undertook data extraction using a piloted data extraction form. Information was collated on rationale, aims and design of intervention, population, country, study design, baselines and comparators, outcomes and reported barriers. Due to the anticipated heterogeneity of study designs and reported outcomes a narrative synthesis is presented. Patient Self-Administration of Medicine Essay.

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Results

The searches identified 1321 articles, and from these 160 studies were independently selected by two reviewers based on titles and abstracts (see Figure 1). One hundred and seventeen studies were excluded. The most common reasons for excluding studies were that they did not carry out an intervention (n = 31), were anecdotal or descriptive only (n = 21), or took place in an outpatient setting (n = 16). We were unable to obtain three articles through online, local or national resources. Regarding the inclusion or exclusion of articles through to the full text screening, inter-rater reliability for the four pairs of reviewers (SR and HB; SR and GB; SR and JC; HB and GB) ranged between 0.45 (95% confidence interval 0.30 to 0.60) to 0.83 (95% confidence interval 0.72 to 0.94). These scores represent fair to excellent agreement between reviewers [18]. A total of 43 studies were included in this review.

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Figure 1

PRISMA flow diagram of study selection.

Study design

The characteristics of the 43 included studies are shown in Table S2. All of the studies included in this review originated in English-speaking countries and were published in the English language. Countries included the United Kingdom (n = 18), the United States (n = 15), Canada (n = 5), Australia (n = 3), New Zealand (n = 1) and Ireland (n = 1).Patient Self-Administration of Medicine Essay. A variety of study designs were used: case series (n = 11); before-and-after (n = 8); non-randomised controlled trial (n = 8); randomised Controlled trials (RCT; n = 6); cross-sectional (n = 5), prospective cohort (n = 4) and cohort (n = 1). In terms of the quality of study design and reporting and as can be seen in Table S2, 20 studies [9], [10], [19]–[36] scored ≧15 out of 28 on the modified version of the Downs and Black quality assessment scale [14]. We have emphasised our discussion around studies which achieved the highest quality scores. In general, higher quality assessment scores were found for RCTs (median: 16.5, range: 14–20) than for other studies (median: 12, range: 4–20).

Structure of the SAM schemes

The rationale behind implementing a SAM scheme in each study was either explicitly stated or it was possible to infer the rationale from the article. The most common reasons for implementing SAM schemes were to improve patient compliance (n = 28), to improve patient knowledge (n = 18), to increase patient independence (n = 14) and to reduce medication errors (n = 4); most studies provided multiple reasons.

Of the 43 interventions, 10 SAM schemes had a single-staged approach to patient self-administration [21], [22], [25], [31], [36]–[41], two had two stages [24], [42], 12 had three stages [9], [10], [20], [26], [27], [30], [32], [34], [43]–[46], four had four stages[19], [47]–[49], two had five stages [28], [33], one had six stages [35], one had seven stages [50] and one paper described an intervention comprising of nine stages of increasing patient independence [51]. For the remaining ten studies, it was not clear how many stages were used [23], [29], [52]–[59]. Most studies (n = 40) had an educational element to their SAM scheme. For the remaining three studies, there was not enough information to determine whether an educational element existed [23], [52], [57]. In the majority of papers (n = 20) the educator was a pharmacist [20]–[22], [27]–[30], [32], [34]–[36], [38]–[40], [44], [46], [48], [50], [54], [56], [58], in seven a nurse [9], [19], [25], [41], [47], [51], [59] and in six both a nurse and pharmacist [10], [26], [42], [43], [49], [55]. Two studies relied solely on education through written material [33], [53], in two studies it was not possible to determine who delivered the educational element [24], [37], in one study education was provided by a physician [31], and in one study education was provided by a psychologist [45]. Patient Self-Administration of Medicine Essay.

The types of drugs self-administered varied between studies, often reflecting different study populations. Most studies did not specify which drugs were self-administered (n = 23) or simply allowed all drugs to be self-administered (n = 3). Commonly described self-administered drugs included psychotropic medicines [38], [45], [50], insulin [23], [34] and regular oral medication [34], [56]. Drugs commonly excluded from SAM schemes were parenteral medication [10], [20], [28], [29], [31], [39], [49], drugs of dependence [10], [19], [20], [36], [51], insulin [10], [29], [31], as required (PRN) drugs [19], [36], [49], antibiotics [36], [49], and controlled substances [49], [58]. Drugs included in some interventions (e.g. insulin) were excluded in other interventions.

Evaluation of SAM schemes

Outcome measures were assessed at a variety of time points across the 43 studies, from admission to a maximum of 24 months after patients started the SAM scheme [45]. In those studies in which patients were followed up after discharge, the median follow-up period was 40 days post-discharge (range: 0–730 days), though not all follow-up periods were explicitly specified. Multiple outcomes were measured in 26 of the 42 studies. The most common outcome measures used for evaluating SAM schemes were ‘patient knowledge’ and ‘patient satisfaction’, with 19 studies investigating each of these. Other common outcomes included compliance (n = 16) and patient success in self-administering (n = 12). Below is a summary of the findings regarding each outcome and more detailed results can be found in Table S3.

Patient knowledge

Nineteen studies assessed patients’ knowledge of their own medicines [9], [19], [20], [24], [27], [28], [32]–[35], [37], [38], [40], [41], [43], [44], [49], [53], [59]. Knowledge topics assessed included drug name, purpose, appearance, dosage, frequency (or time of administration), and side-effects. Variation was found in the way that knowledge about medicines was both measured and reported. Patient Self-Administration of Medicine Essay.Eight of the 19 studies reported some significant improvement in knowledge which could be attributed to participation in SAM schemes [20], [24], [26], [27], [33], [35], [44], [53]. Two studies found that self-administering their own medicines was associated with a decrease in patients’ medicines knowledge in one [28] or two [19] knowledge areas. Knowledge of side-effects was the topic that patients knew least about both before and after intervention (n = 11; n = 10 studies, respectively).

Of the five RCTs that measured patient knowledge, four found a greater increase in knowledge in SAM participants compared with control participants [27], [33], [34], [41]. However when different subsections of knowledge were individually analysed both Proos and colleagues [33] (quality score of 17) and Tan [34] (quality score of 16) found that there were no group differences regarding knowledge of medication dosage. One RCT [32] found no group differences in the degree to which knowledge increased. Two non-RCTs achieved quality assessment scores which were comparable to the RCT scores for study quality. Jensen [24] (quality score of 20) found significantly higher knowledge scores for self-administering patients compared with controls both in hospital and at discharge, while Trapp and colleagues [28] (quality score of 19) found a significant difference between groups at discharge but no significant differences at 6-weeks follow-up; however no post-hoc tests were completed and so it was not possible to understand the nature of this difference.

Patient compliance/error

Twenty four studies measured patient compliance/error [10], [20]–[33], [39]–[41], [47], [49], [52], [54], [58], [59]. The terminology used (e.g. medication error vs. compliance) varied between studies however the outcome measures were often identical; therefore all of these studies are discussed together.Common methods for measuring this outcome included pill counts (or a comparable alternative) conducted by staff (n = 13) [20], [22], [23], [27]–[30], [32], [33], [39], [41], [47], [54] and patient self-reported compliance (n = 10) [10], [21], [24], [26], [31], [40], [41], [49], [52], [59]. One study measured patient compliance/error through patient urine samples [25] and one study measured compliance/error through disguised observation [58]. Of the studies, nine reported greater compliance or fewer errors in SAM groups compared with control groups [20], [21], [23], [24], [27], [30], [32], [33], [52]; in five studies this difference was statistically significant [20], [23], [27], [30], [32]. Patient Self-Administration of Medicine Essay. Two of these five studies gained the equal highest quality assessment score for those studies measuring patient compliance. Three studies found lower compliance or greater error in SAM scheme participants compared with controls [25], [40], [58] and another study found no differences in a SAM group compared with controls [41]. Wandless and Davie [29] found that patients who received standard verbal instructions (i.e. the purpose of the trial was explained and the name, purpose, dose, and time of administration of each drug were described to the patient) and a calendar aid as part of the SAM scheme made significantly more medication errors than those patients who received only standard verbal instructions (p<0.0005) and a medication card (p<0.005). A third group receiving verbal instructions only made significantly more errors than both of the other groups (p<0.005 and p<0.01, respectively). A further two studies found no medication errors attributable to the SAM scheme over the course of their respective study periods [10], [49].

Four studies compared the change in compliance over time in patients who were self-administering [22], [26], [30], [32]. Lam and colleagues [26], whose study received a quality score of 17, found a significant reduction in non-compliant behaviours (e.g. varying the recommended medication management) and a non-significant increase in compliant behaviours (e.g. having strict routines for regular medication use). Seven studies were descriptive and reported percentage compliance to medication regimens ranging from 40% to 100% [28], [47], [54], [59] or error rates of between 2.5% and 7.5% in self-administering patients [31], [39], [58]. Of these, Trapp and colleagues’ study [28], which reported 100% compliance, received the highest quality assessment score of 19. Patient Self-Administration of Medicine Essay.

Patient satisfaction

Nineteen studies investigated patient satisfaction with SAM programmes [10], [20], [23]–[25], [27], [31], [32], [34], [37], [39], [42], [43], [49], [51]–[53], [57], [59]. Patient satisfaction was measured either via a questionnaire (n = 16) or an interview (n3). However, questionnaire design was not consistent across studies. The majority of studies reported positive responses from patients regarding the SAM schemes. In several studies participants reported overall satisfaction levels of 90% to 100% [10], [24], [25], [42], [59] or recommended that the SAM scheme be continued following its evaluation [31]. Furthermore, in a study of diabetic patients whose medications were nurse-administered 71% would prefer to have self-administered their insulin [23]. The reasons patients would prefer to self-administer included increased independence [51], [59], control [23], [27], confidence [24], [27], [43] and knowledge [24], [27], [43], [51]. However not all responses were positive. In one study [34] 19% of the 14 participants were dissatisfied with the programme (measured on a 5-point Likert scale). In two studies, [52], [57] patients involved in SAM schemes reported greater satisfaction with discharge than control groups, but were not more satisfied with the medication information they received. Of the three RCTs [27], [32], [34] and highest quality non-RCT [24], there were mixed findings regarding patient satisfaction with SAM schemes.

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Patient success/programme completion

Success within the SAM scheme was measured in 12 studies [10], [26], [32], [36], [37], [42], [45], [46], [48], [50], [55], [56]. In eleven studies (all excluding DeProspero & Wiffle [45]), the number or percentage of participants successfully participating in and/or completing the SAM scheme was recorded. This value ranged from 26% [56] to 86% [55], although what constituted success/failure differed between studies. In three studies, it was found that the percentage of participants successfully self-administering decreased after discharge [32], [37], [55]. Patients sometimes required additional intervention, such as simplified drug regimens or memory aids, to ensure their success (e.g. Fuller [37]). DeProspero and Wiffle [45] found that those patients who were successful had a shorter length of stay and fewer readmissions, compared with unsuccessful patients. Factors affecting patients’ failure to complete SAM schemes included memory impairment, additional medical problems, and insufficient time spent in hospital [48], as well as increasing age and lower scores on the mini mental state examination (MMSE) [36].Patient Self-Administration of Medicine Essay. The highest quality studies [26], [32] offered contradictory findings; Lam and colleagues [26] (a before-and after study) found that competency to self-administer increased significantly from admission to discharge in those patients involved in a SAM scheme, while Pereles and colleagues [32] found that participation was not a significant predictor of successful self-administration following discharge.

Staff satisfaction

Seven studies investigated staff satisfaction with SAM schemes [10], [19], [24], [31], [42], [49], [52]. Of these, six studies used questionnaires to measure staff satisfaction [10], [19], [24], [42], [49], [52] but none used identical questions or scales. The method used to obtain results could not be determined in the final study [31]. In general, staff satisfaction regarding SAM schemes was high. For example, Desborough and Wiffle [52] found that 91% of staff would prefer to use SAM schemes. Other staff–reported benefits of self-administration included increased structured teaching and participation by patients alongside increased follow-up by members of the multidisciplinary team [49]. Some staff reported an increased workload following the implementation of the SAM scheme [10], but these same staff also highlighted benefits of increasing nurses’ medicines knowledge and satisfaction with collaboration between nurses, pharmacists, patients, and their carers. Jensen and colleagues [24] reported that nearly a quarter (23%) of nurses believed medication errors had increased due to the SAM scheme. Furthermore, staff believed the programmes to be time consuming and increase work stress, although these disadvantages were eliminated once the patient was following their protocol reliably [24]. Nonetheless, 75% of staff in Jensen’s non-RCT [24] (which gained the highest quality assessment score of the studies measuring staff satisfaction) agreed the programme was beneficial, although only 34% would choose to use SAM schemes rather than nurse administration of medications. Patient Self-Administration of Medicine Essay.