A major theme in the literature was patients’ accounts of receiving information about their medicines, their perceptions of medicines information they received, and their role in managing that information. A total of 15 studies employed a range of qualitative and quantitative methods to either measure or explore their experiences. They are presented in Table 2 on page 56.
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Measures of receiving medicines information
The evidence about the recall of receiving discharge medicines information is conflicting. Measures were conducted in four studies;136–139 one reported 40%
of patients (n=341) recalled counselling for new medicines and 64% recalled counselling for existing medicines.137 Over two fifths of patients (42%) wanted more comprehensive counselling, although their reasons were not explored.
Patients reported preferring medicines counselling from doctors (85%). Another paper one year later from the same research group (possibly using the same data) also reported that 40% of patients recalled counselling.138 Other Swiss patients recalled receiving information for 15% of long-term medicines and 19%
of new medicines.136 These patients (n=362) were significantly less likely to report receiving information in hospital if they reported having help with their medicines at home (CI 0.19-0.98; p=0.05); and significantly more likely to do so if the medicine had been introduced when the patient was in hospital (CI 1.2-2.0; p=0.001).
A further study of USA patients (n=104) found they were mostly (89%) in strong agreement that instructions were communicated in language they understood, 80% were in strong agreement that instructions were communicated clearly, however many fewer (40%) were in strong agreement that the information they received at discharge had been easy to understand, although the measure used was unvalidated so it is not completely reliable.139 Inadequate written
information was identified in a Danish study (n=200), in which 66 patients who used prescription medicines had no medicines list in their discharge letter.140 A USA study of those taking insulin (n=47) found the majority 81% received written instructions and all patients that were new to insulin received written information.141
Qualitative studies of receiving discharge medicines information A set of nine studies explored views of medicine information and education qualitatively. One study explored Dutch patients’ perceived medicines
information needs at discharge using a qualitative approach.142 Semi-structured interviews with cardiology, pulmonary and internal medicine patients (n=31) identified four aspects of information considered important by patients: basic drug information (name, purpose, use); side effects; alternatives that could be used; and what to do if problems occur. Patients preferred verbal and written
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information in combination. Unfortunately, the study does not attempt to draw comparisons between those who it described as receiving enhanced care and those who did not. In a Swedish study of patients following a heart attack, information was described as confusing and conflicting, for example information was difficult to understand because of the terminology used or the stressful environment it was given in, and GPs, nurses and hospital staff offered the patient differing accounts of their need for medicines.143 Views about discharge medicines information were examined in depth in a UK study by Knight and colleagues.144 Discharged elderly patients and carers (n=19) took part through responding to an advert and were given the option of completing an interview or keeping a medicines diary in addition to an interview. Their views of medicines information provision were found to be mixed, although most perceived the information they received to be inadequate, especially the level of explanation they received about changes to their medicines and new medicines. Patients and carers reported assuming that staff had no time to give them information.
Written information was lacking for the majority and difficult to understand for those who had received a list of medicines. In another USA, information was judged lacking because it was thought not to be personalised to the patient.145 In a study of 40 older patients in New Zealand many could not recall receiving information in hospital about medicines changes and were reluctant to ask questions of hospital staff.146 Lack of recall was more pronounced in those who had discontinued an antiplatelet medicine, rather than in continuers of 22 stent patients and patients described an lack of opportunity to ask questions about their medicines in hospital and a rushed discharge and receipt of conflicting information;147,148 some did not recall receiving information and those who continued taking clopidogrel found other sources of information. An earlier study found that patients who had received information in hospital did not recall
receiving medicines information 1-2 weeks after leaving hospital.145 This
qualitative study (an ethnography) explored ‘medicines education’ at discharge, combining observation with telephone and face-to-face interviews in a sample of older US patients (n=114) with heart disease. The authors reported that patients received ‘unstructured education’ during their hospital stay and
structured education at discharge. Education was offered in varying depths and was not tailored to the patient. Those patients using anti-coagulants, those with
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new medicines and those who asked more questions received more
information. Patients experienced education about their medicines from both doctors and nurses, yet patients perceived the doctor to be responsible for giving them information, although nurses were seen as effective and acceptable in doing so. Patients reported preferring information before the day of their discharge to allow them time to understand it, and again at discharge so the information they received was relative in time to their departure from hospital.
Education about medicines was valued when it was personalised and given verbally and in writing and, once back at home, patients were found to lack recall of their medicines education. This study might usefully have drawn a distinction between encounters that merely provided patients with information and those that used other methods to develop their medicines use capabilities.
Qualitative studies in part described patients’ roles in using medicines
information. Martens described how patients “need to be aware that a goal of the hospital stay is to learn how to safely and correctly manage their
medications”;145(p347) thereby highlighting the role of self-management which is also mentioned in a study of patients taking warfarin who reported wanting enough information to enable confident self-management of their medicines after their discharge.149 Other elderly patients wanted deeper involvement in decisions about medicines and once they were discharged, and therefore not immediately able to access healthcare professionals, they reported difficulty interpreting the information they received;144 difficulty getting further medicines information;150 or needing help creating a personal schedule to self-manage their medicines.145 Heart attack patients used alternative sources of information, such as the internet;143 and clopidogrel discontinuers struggled to relay
medicines information to the primary care team after their discharge or interpreted information incorrectly.147
Summary
In summary there is a small evidence base and a lack of consistent evidence to show that comprehensive, clear and structured medicines information is
received by patients at discharge. International policy considers providing information to be only one means of educating patients about their
medicines,151 and it is also understood that when attempting to influence health behaviours, providing information is only one of the range of methods
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available.152 There is also little evidence that patients are positioned in any other role than of passive recipients of information. There is some evidence that patients receive information that they subsequently struggle to recall and that patients fail to receive a usable list of their medicines. Studies that measure patient satisfaction with their medicines are of limited value; rather research should focus on how patients use their medicines and what types of patient education are appropriate to support the effective use of medicines. Two studies attempted to associate recall of receiving information to outcomes or contextual factors, for example discontinuation of medicines, or support with medicines. Interestingly those patients with support in the home in one study had lower recall of receiving information, which may be either explained by the patient’s lack of ability to either recall or a lack of need to recall because they have help, although neither of these factors were explored. Conducting memory tests of what patients are told in hospital lacks value as an approach to
understanding how patients might use information as part of a process of building their abilities to safely manage their medicine once they are home.