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Annette Eidam,1 Anja Roth,1 Eduard Frick,2 Michael Metzner,2 Anette Lampert,2,3 Hanna M Seidling,2,3 Walter E Haefeli,2,3 Jürgen M Bauer1,4 1Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany; 2Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg, Germany; 3Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany; 4Network Aging Research (NAR), Heidelberg University, Heidelberg, GermanyCorrespondence: Annette Eidam, Center for Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany, Tel +49 6221-319-1795, Fax +49 6221-319-1505, Email Annette.Eidam@agaplesion.dePurpose: Medical decision-making in older adults with multiple chronic conditions and polypharmacy should include the individual patient’s treatment preferences. We developed and pilot-tested an electronic instrument (PolyPref) to elicit patient preferences in geriatric polypharmacy.Patients and Methods: PolyPref follows a two-stage direct approach to preference assessment. Stage 1 generates an individual preselection of relevant health outcomes and medication regimen characteristics, followed by stage 2, in which their importance is assessed using the Q-sort methodology. The feasibility of the instrument was tested in adults aged ≥ 70 years with ≥ 2 chronic conditions and regular intake of ≥ 5 medicines. After the assessment with PolyPref, the patients rated the tool with regard to its comprehensibility and usability and assessed the accuracy of the personal result. Evaluators rated the patients’ understanding of the task.Results: Eighteen short-term health outcomes, 3 long-term health outcomes, and 8 medication regimen characteristics were included in the instrument. The final population for the pilot study comprised 15 inpatients at a clinic for geriatric rehabilitation with a mean age of 80.6 (± 6.0) years, a median score of 28 (range 25– 30) points on the Mini-Mental State Examination, and a mean of 11.6 (± 3.6) regularly taken medicines. Feedback by the patients and the evaluators revealed ratings in favor of understanding and comprehensibility of 86.7% to 100%. The majority of the patients stated that their final result summarized the most important aspects of their pharmacotherapy (93.3%) and that its ranking order reflected their personal opinion (100%). Preference assessment took an average of 35 (± 8.5) min, with the instrument being handled by the evaluator in 14 of the 15 participants.Conclusion: Preference assessment with PolyPref was feasible in older adults with multiple chronic conditions and polypharmacy, offering a new strategy for the standardized evaluation of patient priorities in geriatric pharmacotherapy.Keywords: geriatric pharmacotherapy, medication priorities, multimorbidity, multiple chronic conditions, patient-centered, preference assessment

Viktoria S Wurmbach,1,2 Steffen J Schmidt,3 Anette Lampert,1,2 Simone Bernard,3 Christine K Faller,1,2 Petra A Thürmann,3,4 Walter E Haefeli,1,2 Hanna M Seidling1,2 On behalf of HIOPP-6 Consortium1Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; 2Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Heidelberg, Germany; 3Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany; 4Philipp Klee-Institute for Clinical Pharmacology, HELIOS University Clinic Wuppertal, Wuppertal, GermanyCorrespondence: Hanna M SeidlingHeidelberg University Hospital, Department of Clinical Pharmacology and Pharmacoepidemiology, Im Neuenheimer Feld 410, Heidelberg, 69120, GermanyTel +49 6221/56-38736Email hanna.seidling@med.uni-heidelberg.dePurpose: The development and testing of key questions suitable to identify patients’ difficulties with medication administration.Materials and Methods: We used a consecutive five-step process to draft key questions regarding 43 aspects of medication administration that can be difficult for patients who manage a complex drug treatment: Step 1) Identification of potentially error-prone characteristics of drug treatment (such as certain dosage forms) and initial draft of key questions. Step 2) Assessment of how comprehensible the questions are for patients. Step 3) Pre-testing of exemplary key questions with patients and monitoring of patient’s actual medication administration behavior. Step 4) Evaluation by general practitioners of how well the questions may be integrated into actual patient visits. Step 5) Final approval of the questions in an expert panel. Thereafter, we pilot-tested exemplary questions with 36 patients (43 tests). In the course of this pilot-testing, the patients’ answers to the key questions were tested against both their actual behavior during medication administration and against their answers to more general questions regarding potential difficulties with medication administration.Results: More than half of the key questions (N = 24/43) were revised at least once during the development process. During the pilot-testing, 55.8% of the pilot-tests (N = 24/43) revealed medication administration difficulties. It was observed that the key questions identified significantly more difficulties (N = 17) than the general questions (N = 8; P = 0.021, positive predictive value = 94.4% vs 88.9%). In one case, both a key question and a general question identified difficulties, which, however, was not confirmed during the drug administration demonstration, indicating a false positive rate of 5.3% in both cases.Conclusion: We developed key questions aimed at detecting administration errors with a high specificity and a significantly higher sensitivity than general questions, suggesting that the resource-intensive demonstration of medication administration can be reserved for the detection of rarer and uncommon administration errors.Keywords: medication adherence, medication errors, quality of health care, patient preference

Annette Eidam, 1 Anja Roth, 1 André Lacroix, 1 Sabine Goisser, 1, 2 Hanna M Seidling, 3, 4 Walter E Haefeli, 3, 4 Jürgen M Bauer 1, 2 1Center of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg 69126, Germany; 2Network Aging Research (NAR), Heidelberg University, Heidelberg 69115, Germany; 3Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University, Heidelberg 69120, Germany; 4Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg 69120, GermanyCorrespondence: Annette EidamCenter of Geriatric Medicine, Heidelberg University, AGAPLESION Bethanien Hospital Heidelberg, Rohrbacher Straße 149, Heidelberg 69126, GermanyTel +49 6221-319-1795Fax +49 6221-319-1505Email Annette.Eidam@bethanien-heidelberg.dePurpose: The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy.Material and Methods: Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy.Results: Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were “medication willingness” (description of a specific medication with inquiry of the participant’s willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, “MediMol” questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy.Conclusion: Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.Keywords: polypharmacy, outcome priorities, multimorbidity, older adults, multiple chronic conditions, patient-centered

Marcel KP Kusch,1,2 Walter E Haefeli,1,2 Hanna M Seidling1,2 1Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, 69120 Heidelberg, Baden-Wurttemberg, Germany; 2Cooperation Unit Clinical Pharmacy, University of Heidelberg, 69120 Heidelberg, Baden-Wurttemberg, Germany Purpose: The aim of this study was to 1) describe drug information desired by patients and 2) analyze how such information could be customized to be presented to patients according to their individual information needs.Materials and methods: We performed a scoping literature search and identified relevant drug information topics by assessing and clustering 1) studies analyzing patients’ enquiries to drug information hotlines and services, and 2) qualitative studies evaluating patient drug information needs. For the two most frequently mentioned topics, we further analyzed which components (ie, information domains) the topics contained and examined patients’ and health care professionals’ (HCPs) views on these components.Results: Of 27 identified drug information topics in the literature search, patients most frequently requested information on adverse drug reactions (ADRs) and drug–drug interactions (DDIs). Hypothetically, those topics are composed of seven distinct information domains each (eg, ADR and DDI classification by frequency, severity, or onset; information on management strategies, monitoring, and prevention strategies). Patients’ and HCPs’ appraisal concerning the information content of these domains varies greatly and is even lacking sometimes.Conclusion: Patients particularly request information on ADRs and DDIs. Approaches to customize such information are sparse. The identified information domains of each topic could be used to structure corresponding drug information and to thus facilitate customization to individual information needs. Keywords: medication information, information needs, customization, adverse drug reactions, side effects, drug–drug interactions

Gerda Längst,1 Hanna Marita Seidling,2,3 Marion Stützle,2,3 Dominik Ose,1 Ines Baudendistel,1 Joachim Szecsenyi,1 Michel Wensing,1,4 Cornelia Mahler1 1Department of General Practice and Health Services Research, University Hospital of Heidelberg, Heidelberg, Germany; 2Cooperation Unit Clinical Pharmacy, University of Heidelberg, Heidelberg, Germany; 3Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany; 4Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, the Netherlands Purpose: This qualitative study in patients with type 2 diabetes and health care professionals (HCPs) aimed to investigate which factors they perceive to enhance or impede medication information provision in primary care. Similarities and differences in perspectives were explored.Methods: Eight semistructured focus groups were conducted, four with type 2 diabetes patients (n=25) and four with both general practitioners (n=13) and health care assistants (n=10). Sessions were audio and video recorded, transcribed verbatim, and subjected to computer-aided qualitative content analysis.Results: Diabetes patients and HCPs broadly highlighted similar factors as enablers for satisfactory medication information delivery. Perceptions substantially differed regarding impeding factors. Both patients and HCPs perceived it to be essential to deliver tailored information, to have a trustful and continuous patient–provider relationship, to regularly reconcile medications, and to provide tools for medication management. However, substantial differences in perceptions related to impeding factors included the causes of inadequate information, the detail required for risk-related information, and barriers to medication reconciliation. Medication self-management was a prevalent topic among patients, whereas HCPs’ focus was on fulfilling therapy and medication management responsibilities.Conclusion: The findings suggest a noteworthy gap in perceptions between information provision and patients’ needs regarding medication-related communication. Medication safety and adherence may be improved if HCPs collaborate more closely with diabetes patients in managing their medication, in particular by incorporating the patients’ perspective. Health care systems need to be structured in a way that supports this process. Keywords: medication information, patient–provider communication, type 2 diabetes, focus groups, primary care

Diana Witticke,1,2 Hanna Marita Seidling,1,2 Hans-Dieter Klimm,3 Walter Emil Haefeli1,21Department of Clinical Pharmacology and Pharmacoepidemiology, 2Cooperation Unit Clinical Pharmacy, 3Department of General Practice and Health Service Research, University of Heidelberg, Heidelberg, GermanyBackground: The aim of this pilot study was to evaluate patients' self-reported attitudes towards medication-related factors known to impair adherence and to assess their prevalence in ambulatory care as an essential prerequisite to improve patient adherence.Methods: We conducted a face-to-face interview with 110 primary care patients maintained on at least one drug. For each drug, the patient was asked to specify medication-related factors of interest, ie, dosage form, dosage interval, required relationship with food intake, and the planned time of day for intake, and to rate the individual relevance of each prevalent parameter on a three-point Likert scale (discriminating between prefer, neutral, and dislike).Results: Tablets with a once-daily dosage frequency were the most preferred dosage form, with a high prevalence in the ambulatory setting. Drug intake in the morning and evening were most preferred, and drug intake at noon was least preferred, but also had a low prevalence in contrast with drug intake independent of meals that was most preferred. Interestingly, only one quarter (26.4%) of all the patients were able to indicate clear preferences or dislikes.Conclusion: When patients are asked to specify their preferences for relevant medication regimen characteristics, they clearly indicated regimens that have been associated with better adherence in earlier studies. Therefore, our results suggest that adaptation of drug regimens to individual preferences might be a promising strategy to improve adherence. Because the German health care system may differ from other systems in relevant aspects, our findings should be confirmed by evaluation of patient preferences in other health care systems. Once generalizability of the study results is shown, these findings could be a promising basis upon which to promote patient adherence right from the beginning of drug therapy.Keywords: patient perception, medication regimen complexity, adherence