Filling a pillbox from a medication prescription displayed

Filling a pillbox from a medication prescription displayed on a tablet Impact of presentation formats in young and older adults Vandenbergh*, Élodie ; Hainselin*, Mathieu ; Quaglino*, Véronique ; Mouras*, Harold & Heurley*, Laurent * CRP-CPO EA 7273 Université de Picardie Jules Verne - 80025 Amiens CEDEX 1 elodie. vandenbergh@gmail. com laurent. heurley@u-picardie. fr

Page 2 The CONSIGNELA Project Context: the present study is part of the CONSIGNELA Project CONSIGNELA = CONSIGNes Électroniques Adaptées (Adapted electronic instructions) Goal: to improve drug prescription comprehension and execution in elderly and parkinsonian patients Partners: Funding: Regional Council Hauts-de-France and the European Regional Development Fund (FEDER)

Medication non-adherence Page 3 Medication non-adherence (non-compliance) – Non-adherence = deviations from prescription – Very frequent: 50% non-adherent patients – Consequences: reduced quality of life, rehospitalisations, … death. – Multifactorial and complex phenomenon Baudrant-Boga, Lehmann, & Allenet (2012) Older patients: Three important factors (Heinrich & Karner, 2011; Morrow et al. , 2004) – Regimen complexity – Age-related decrease of perceptual, motor and cognitive capacities – Inadequate patient-provider communication

Regimen complexity Multiple chronic illnesses & polypharmacy: - Multiple chronic illnesses (Bainbridge & Ruskin, 2009) - “many drugs” or “too many drugs” (Hughes et al. , 2016; Tandy & Bamford, 2010) - Self-medication (Bainbridge & Ruskin, 2009) Complex and changing administration schedules: - Multiple doses at different moments of the day (Bainbridge & Ruskin, 2009) - Multiple changes in the patient’s therapy (Malek & Grosset, 2015) Page 4

Age-related decrease of cognitive capacities Page 5 Decrease of: - Executive functions: planning, inhibition, … (Collette & Salmon, 2014) - Memory: working memory, prospective memory (Guillaume et al. , 2009; Insel et al. , 2013) - Comprehension (Lauverjat, et al. , 2005) - Cognitive performances under time pressure (Logie et al. , 2015)

Inadequate patient-provider communication Different sources and standard (inadequate) documents: Oral instructions: - Doctor’s instructions - Pharmacist’s instructions - Other sources (e. g. , internet, etc. ) Visual instructions: - Doctor’s prescription Medication leaflet and package Annotations written by the pharmacist Other sources (e. g. , internet, etc. ) Mc. Carthy et al. (2012); Serper et al. (2013); Tarn et al. (2008) Wolf et al. (2007, 2009) Page 6

Inadequate patient-provider communication Written or printed « ordonnance » « prescription » Patient information leaflet Package insert Page 7 Package information Annotations written by the pharmacist Source: http: //www. popcenter. org/proble ms/prescription_fraud/print/ Source: https: //www. shop-pharmacie. fr/p/ibufetumibuprofene-gel-5 -60 -g-10002093. html è Too many sources

Inadequate patient-provider communication « Ordonnance » Page 8 « Prescription » Source : http: //medicalschoolhq. net/prescription-writing-101/ è Inadequate presentation Source : www. droitpharma. fr/8/ordo_reg. htm

How to improve patient-provider communication? How to make prescriptions more understandable? … by adopting a multidisciplinary patient-centered approach: • Medical • Technological • Cognitive Morrow et al. (2004); Morrow (2015) Page 9

Medical patient-centered approach Page 10 Simplifications and visual aids: – Lexical simplification – Visual aids: tables, illustrations (pictograms or photographs), medication schedules Chuang, Lin, Wang, & Cham (2010) Morrow, Leirer, Andrassy, Hier, & Menard (1998)

Page 11 Medical patient-centered approach Table format is often used as an aid to communicate « prescriptions » Hawkins & Firek (2014) Cordasco et al. (2009)

Medical patient-centered approach Table format: Medtable. TM Morrow et al. (2008) Page 12

Page 13 Medical patient-centered approach Table format advantages: - Integrated presentation of information - Spatialisation of information - More concrete than verbal instructions better comprehension - Isomorph to pillbox filling task - Adapted to patients with low health literacy / low level of education

Technological patient-centered approach Electronic collaborative tools: Electronic Medical Record (EMR) – integrated tool and Medtable™ Morrow (2015); Morrow et al. (2012) Page 14

Technological patient-centered approach Touchscreens and tablets: Piper & Hollan (2013) Page 15

Cognitive patient-centered approach Page 16 Cognitive psychology and cognitive neuropsychology: - Concepts: procedural documents, mental model (situational models) - Models: procedural document processing - Methods: experimental paradigms

Cognitive patient-centered approach / concepts Page 17 Procedural documents - Procedural documents = documents designed to communicate procedures - Procedures = actions to execute to reach a goal One must distinguish: PRESCRIPTION and « Prescription » : - PRESCRIPTION = procedure that patients should execute « prescriptions » & « ordonnances » « table medication schedules » = procedural documents Visual aids - A « prescription » is a specific reification of a PRESCRIPTION

Cognitive patient-centered approach / concepts PRESCRIBER PRESCRIPTION (procedure): How to take drugs PROCEDURAL DOCUMENT(S) Instructions given in a particular format Page 18 PATIENT Actions è What is the most adequate presentation format and why?

Cognitive patient-centered approach / concepts Page 19 To execute instructions from a procedural document: A complex task Multiple cognitive processes involved : - Understanding = mental model (Ganier 2004) / situation model (Morrow, 2015) “For medication instructions, the situation model represents how to take the medication, including how much to take, when to take it, and what warnings to keep in mind” (Morrow et al. , 1998) - Remembering (episodic and semantic memory) - Planning (prospective memory) - Deciding and monitoring - Acting (procedural memory; motor planning, control and execution)

Cognitive patient-centered approach / models Presentation format mental model construction - Illustrations: - Animations: + - - Table format: A model of procedural document processing Source : Ganier (2004) + + ? Page 20

The study Page 21 Objectives: - To analyze the impact of two presentation formats (table vs. sheet) on prescription comprehension and execution in older and young adults - To control possible biases with an experimental procedure General procedure: - Procedure adapted from a previous study (Heurley, Vandenbergh, Quaglino, 2013) - Participants were given a tablet and had to: • Study at their own rhythm two fictive prescriptions displayed either in a table or in a sheet format (non tabular format) • Fill a pillbox from memory immediately and after a 30 minute delay.

Page 22 Method Prescriptions: - Each prescription = 4 medications / 6 days - One medication per page; - Two formats: table vs. sheet Table format Sheet format

Page 23 Materials Medication type: – 2 regular intake medications – 2 irregular intake medications Regular intake Irregular intake

Page 24 Method Procedure: Prescription studying Delay: 30 min Immediate Pillbox filling Cognitive tests Delayed Pillbox filling

Page 25 Participants: 32 young adults / 32 older adults Table 1. Sample characteristics Age (years) Education (years) MMS NS = non significant Young Older Différence (n = 32) 23. 21 (n = 32) 74. 75 p <. 05 (18 -33) (65 -88) 14. 3 14. 2 (12 -19) (10 -22) 29. 1 28. 6 (27 -30) NS NS

Variables and design Independent variables: – Age (A: young vs. older) – Format (F: tabular vs. sheet) – Medication Type (T: regular intake vs. irredular intake) – Pillbox filling delay (D: immediate vs. 30 min. ) Design: S 32 < A 2 > * F 2 * T 2 * D 2 Page 26

Hypotheses Main hypotheses: – Hyp 1: Format – Hyp 2: Age – Hyp 3: Age x Format interaction Secondary hypotheses*: – Hyp 4: Type – Hyp 5: Age x Type – Hyp 6: Delay – Hyp 7: Age x Delay *As these hypotheses are beyond the scope of the present communication they won’t be detailed later Page 27

Results Analyses: – Level of significance: 0. 05 – Non-parametric statistics: • Repeated measures: Wilkoxon rank test for related samples • Group analyses: Mann-Whitney U test for independent samples Dependent variables: medians and IQRs – Median studying time (sec. ) – Median pillbox filling score (%) Page 28

Page 29 Results / Hypothesis 1: Format * * NS p >. 05 * * * p <. 05 p <. 01

Page 30 Results / Hypothesis 1: Format * *

Page 31 Results / Hypothesis 2: Age NS

Page 32 Results / Hypothesis 2: Age * *

Page 33 Results / Hypothesis 3: Age x Format * *

Page 34 Results / Hypothesis 3: Age x Format * * *

Discussion Hypothesis 1 / Format: – Adequate format better comprehension – Adequate format better execution Hypothesis 2 / Age: - No age effect during the prescription studying phase - Age effect on execution Hypothesis 3 / Age x Format: - Format effect for both ages Limits of the study Page 35

Discussion A multidimensional approach is useful … – Patient-centered approach – Cognitive models from cognitive psychology – Medical expertise / experience – Interactive electronic devices … to improve patient-provider communication Page 36

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