Pharmacy Department, Brigham and Women's Hospital, Boston, MA, USA.
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, BC-3, Boston, MA, 02120, USA.
BMC Health Serv Res. 2022 Oct 30;22(1):1304. doi: 10.1186/s12913-022-08702-y.
Adverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention.
Eligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research.
Barriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them.
In this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions.
Clinicaltrials.gov NCT03475030.
在医疗护理交接过程中，不良药物事件很常见。作为旨在减少药物差异并提高出院后用药依从性的智能药盒研究的一部分，这是一项电子药盒的整群随机对照试验，我们探讨了成功实施和评估该干预措施的障碍。
符合条件的患者为因计划出院后服用五种或更多慢性药物而被收入一家大型教学医院内科的患者。干预措施包括在出院前为患者提供带有预先填充每周药板的电子药盒。药盒的特点包括服药提醒、检测每个药孔的取药情况、如果患者未服药则通过电话、电子邮件或短信向患者或护理人员发出警报、以及提供供医务人员查阅的用药依从报告。连续三天错过 20%以上的剂量则会触发药剂师的联系。为了确定实施和评估干预措施的障碍，我们回顾了患者出院调查，包括满意度的定量数据和关于其经历的自由文本回复；技术问题日志；以及团队会议记录。主题是通过研究作者的共识得出的，并使用实施研究的综合框架进行组织。
实施障碍包括干预措施的特点，如药盒被认为便携性差，药剂师输入药物信息所需的时间；外部政策，如提前配药缺乏保险覆盖和重新包装药物的监管禁令；实施环境问题，如医院出院仓促与部署干预措施所需时间之间的不兼容；以及患者问题，如否认以前存在用药依从性问题。我们发现了一些进行研究的障碍，包括患者拒绝入组研究以及医院试图通过将干预措施纳入常规护理来简化后勤工作的尝试有限。为解决其中的许多挑战，实施了或计划实施了一些解决方案。尽管存在这些挑战，许多使用药盒的患者对该服务感到满意，并认为该干预措施对他们很有效。
在这项评估中，确定了实施和进行干预有效性研究的几个障碍。我们的研究结果为其他希望实施和评估旨在改善医疗护理交接期间用药安全性的与医疗信息技术相关的干预措施提供了经验教训。
Clinicaltrials.gov NCT03475030。
