Interventions for Improvement

No validated questionnaires asking the patient direct questions about the indication for each medication were found. For each drug we therefore let the patient specify against which disease or symptom each medicine was taken. Discrepancies in the patient drug use and knowledge of each medication is revealed, comparing drug use stated by the patient by the medical charts, and by other available sources. 

There are some external evidences from systematic research in the field. As for other Evidence based medicines principles, these evidences have to be used together with the knowledge of the individual patient characteristics. As described previously the physicians have difficulties in appraising the compliance behaviour of their patients. Therefore it is important to identify possible non-compliance based also on knowledge, attitudes and motivational aspects as described above. 

There are some systematic reviews in the field as presented below and a guidance (Nice Guidance 2008) is available as of January 2009. 

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It should be stated that medication errors can be made by health care professionals, but also by the patient, or a combination of both as highlighted in Table 7.1. Different aspects of these errors, consequences and interventions for improvement are presented in this book... 

Interventions for improved compliance interventions can have a much larger impact on the population s health than any specific medical intervention... 

Shi, L., and Zhang, J., Recent evidence of the effectiveness of educational interventions for improving complementary feeding practices in developing countries, / Trop Pediatr Apr 57(2) 91-98, 2011. 

Behavior-based safety trainers and consultants teach the ABC model (or three-term contingency) as a fi amework to understand and anatyze behavior or to develop interventions for improving behavior. As given in Principle 3, the A stands for activators or antecedent events that precede behavior B, and C refers to the consequences following behavior and produced by it. Activators direct behavior consequences motivate behavior. 

Continuous feedback from others was invaluable as a mohvator and necessary mechanism for continuous improvement. As soon as a chapter appeared close to my internal standard, I distributed copies to about ten colleagues and friends who had expressed interest in reading early drafts and offering feedback. The feedback I received from these earlier versions was valuable in refining this text and in motivating my progress. Feedback is obviously a powerful consequence intervention for improving behavior. In the next chapter, I shall discuss ways to maximize the beneficial impact of feedback. 

Figures 28 and 29 are also very useful in identifying as weak the locations of cross section change from double box section to I section (sections 3 -3 and 4 -4 in Fig. 23). An extension of the box section or a more gradual transition to the 1 section would thus be an appropriate intervention for improving the collapse behavior of the arch and enhancing its ultimate strength.

Phosphodiesterase Inhibitors. Because of the complexity of the biochemical processes involved in cardiac muscle contraction, investigators have looked at these pathways for other means of dmg intervention for CHF. One of the areas of investigation involves increased cycHc adenosine monophosphate [60-92-4] (cAMP) through inhibition of phosphodiesterase [9025-82-5] (PDE). This class of compounds includes amrinone, considered beneficial for CHF because of positive inotropic and vasodilator activity. The mechanism of inotropic action involves the inhibition of PDE, which in turn inhibits the intracellular hydrolysis of cAMP (130). In cascade fashion, cAMP-catalyzed phosphorylation of sarcolemmal calcium-channels follows, activating the calcium pump (131). A series of synthetic moieties including the bipyridines, amrinone and milrinone, piroximone and enoximone, [77671-31-9], C22H22N2O2S, all of which have been shown to improve cardiac contractiUty in short-term studies, were developed (132,133). These dmgs... 

California Acute Stroke Pilot Registry (CASPR) Investigators. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology. 2005 64 654-659. 

The mean dietary intake of soy isoflavones in Asian populations consuming soy-based diets ranges from 20-40 mg isoflavones/day, with upper percentile consumer intakes of 70 mg/day (corresponding to around 1 mg/kg body weight). In the six month intervention studies in Western postmenopausal women, the effective dose for improved BMD was around 80-90 mg/day, while in the one year, randomized, double-blind, placebo controlled clinical trial, the effective dose was 54 mg/day. Overall, the dietary recommendation is to consume 50 mg isoflavones/day in combination with standard nutritional requirements for calcium and vitamin D. 

Interventions for managing PMS and PMDD focus on alleviation of the presenting symptoms and subsequent improvement in quality of life. See Table 46-2 for a listing of the various agents used in the management of this disorder, their recommended dosing, and common side effects. 

Therapeutic interventions for SCD should be targeted at preventing and/or minimizing the symptoms related to the disease and its complications. The goals of treatment are to reduce or eliminate the patient s symptoms decrease the frequency of sickle crises, including vaso-occlusive pain crises prevent the development of complications and maintain or improve the quality of life through decreased hospitalizations and decreased morbidity. Specific therapeutic options may... 

UVB light (290 to 320 nm) therapy is an important phototherapeutic intervention for psoriasis. The most effective wavelength is 310 to 315 nm, which led to development of a UVB narrowband light source, in which 83% of the UVB emission is at 310 to 313 nm. Topical and systemic psoriatic therapies are used adj unctively to hasten and improve the response to UVB phototherapy. Emollients enhance efficacy of UVB and can be applied just before treatments. Combining short-contact anthralin, calcipotriene, or topical retinoids to UVB may also improve results. However, topical application should be done after or at least 2 hours before UVB therapy because phototherapy can inactivate the topical product. UVB phototherapy may also be more effective when added to systemic treatments such as methotrexate and oral retinoids. 

The Institute for Healthcare Improvement (IHI) (IHI 2008) launched a national American campaign for improvement and five years after the IOM report Leape and Berwick summarise what has happened, analysed the reasons why improvement has not been greater, and made recommendations for what needs to be accomplished to realise the IOM s vision (Leape and Berwick 2005). After that IHI has launched a new campaign (5 Million lives) and added intervention targets as presented in Box 7.2(IHI 2008). The specific drug-related problems and interventions are market in bold and will be highlighted below. 

Elliott RA and Stewart DC (2008) A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging 25 307-324 Epstein RM, Alper BS, Quill TE (2004) Communicating evidence for participatory decision making. JAMA 291 2359-2366... 

Further evidence was presented at the second international conferences for improving the use of medicines held in Chiang Mai, Thailand in 2004 respectively (URL http //www.icium.org). On the basis of this evidence the second conference issued a major recommendation for countries to have national programmes to promote rational use of medicines. The conference further recommended that such programmes should be based on coordinated implementation of sustainable multi-faceted interventions, scaled up to the national level and with inbuilt systems for monitoring medicines use in order to evaluate progress. 

Antimicrobial agents are frequently used before the pathogen responsible for a particular illness or the susceptibility to a particular antimicrobial agent is known. This use of antimicrobial agents is called empiric (or presumptive) therapy and is based on experience with a particular clinical entity. The usual justification for empiric therapy is the hope that early intervention will improve the outcome in the best cases, this has been established by placebo-controlled, double-blind prospective clinical trials. For example, treatment of febrile episodes in neutropenic cancer patients with empiric antimicrobial therapy has been demonstrated to have impressive morbidity and mortality benefits even though the specific bacterial agent responsible for fever is determined for only a minority of such episodes. 

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