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Patient socioeconomic data is not usually included in medical records nor easily accessible to clinicians, yet socioeconomic disadvantage can be an important guide to disease management. This study evaluated the neighborhood-level Area Deprivation Index (ADI), a measure of neighborhood socioeconomic disadvantage, as a factor in diabetes mellitus prevalence. Electronic health records at an academic hospital system identified 4,770 Medicare beneficiaries. Logistic regression of diabetes diagnosis (ICD9=250.x) against ADI quintile, age, gender, and race/ethnicity found all these patient characteristics to be significantly associated. Diabetes prevalence was lowest in the least disadvantaged quintile of neighborhoods after adjusting for age, gender, and race/ethnicity. The positive non-linear association of diabetes prevalence with ADI demonstrates the power of this index to practically quantify socioeconomic disadvantage. The ADI may be suitable for clinical decision support, and for informing the policy changes which are needed to reduce socioeconomic disparities in diabetes prevalence and other health outcomes.

OBJECTIVE To better characterize medication-related problems among inner-city patients after hospital discharge and to suggest potential interventions. PATIENTS AND METHODS Between August 9, 2005, and April 3, 2006, we interviewed 84 patients hospitalized with acute coronary syndromes at Grady Memorial Hospital in downtown Atlanta, GA, and contacted them by telephone about 2 weeks later. English-speaking patients who managed their own medications were studied. Patients reported their adherence with filling prescriptions and taking medications after discharge, as well as barriers to and potential enablers of proper medication use. RESULTS Most of the 84 respondents were African American (74 [88%]), male (49 [58%]), and middle-aged (mean age, 54.5 years). Only 40% of patients filled their prescriptions on the day of discharge, 20% filled them 1 or 2 days later, and 18% waited 3 to 9 days; 22% had not filled their prescriptions by the time of the follow-up telephone call (median, 12 days; interquartile range, 8-18 days). Transportation, cost, and wait times at the pharmacy were cited as the main barriers. Many patients reported it was somewhat or very difficult to understand why they were prescribed medications (21%), how to take them (11%), or how to reconcile them with the medications they had been taking before hospitalization (16%). About half the patients (40 [48%]) reported some degree of nonadherence after discharge. Patients noted that several forms of assistance could improve medication use after discharge, including lower medication costs (75%), a follow-up telephone call (68%), transportation to the pharmacy (65%), pharmacist counseling before discharge (64%), and a pillbox (56%). CONCLUSION Patients often delay filling prescriptions and have difficulty understanding medication regimens after hospital discharge. Interventions that reduce medication costs, facilitate transportation, improve medication counseling, and supply such organizing aids as pillboxes might be beneficial.

Objective: Patients with low health literacy have difficulty understanding prescription drug labels and other medication instructions. This article describes the development, implementation, and preliminary evaluationof an illustrated medication schedule (a‘‘pill card’’) that depicts a patient’s daily medication regimen using pill images and icons. Methods: Participants in a randomized controlled trial whowere assigned to receive the pill card intervention described their use of thecard and its perceived effectiveness. Responses were analyzed by level of patient literacy and other characteristics. Results: Among the 209 respondents, 173 (83%) reported using the pill card when they initially received it, though use declined to 60% approximately 3 months later. Patients with inadequate or marginal literacy skills, less than high school education, or cognitive impairment were most likely to refer to the card on a regular basis initially and at 3 months (p < 0.05). Most pill card users (92%) rated the tool as very easy to understand, and 94% found it helpful for remembering important medication information, such as the name, purpose, or time of administration. Conclusion: Nearly all patients considered an illustrated medication schedule to be a useful and easily understood tool to assist with medication management. Patients with limited literacy skills, educational attainment, or cognitive function referred to the aid with greater frequency. Practice implications: Picture-based instructions promote better understanding of prescription medications, particularly among patients with limited literacy skills or cognitive impairment, and should be used more widely in practice. # 2007 Elsevier Ireland Ltd. All rights reserved.

To the Editor:—We greatly appreciate the letter from Prakash and colleagues, which brings to light recent reports on the use of personal digital assistants (PDAs) in medical education published since the completion of the literature search for our systematic review.1 These reports confirm that PDAs remain useful to trainees in a variety of ways—e.g., in logging work hours2 and examination skills,3 and in learning about disease processes.4 Most of the reports cited by Prakash and colleagues were observational studies, while only 1 was a controlled trial. This underscores the continued lack of, and need for, more rigorously designed investigations. The controlled trial, by Grad et al.,5 warrants comment. It found no effect on knowledge test scores after first-year family medicine residents used a PDA-assisted evidence-based medicine (EBM) course. These findings differ from results of a randomized control trial by Leung et al.,6 which demonstrated that third-year medical students using PDAs with clinical decision support software increased their learning and application of EBM. Several factors may have led to these conflicting results, including differences in the study design and populations. In addition, more technical problems with the handheld device occurred in Grad's5 study, where 65% of the residents in the intervention group had technical problems with their handheld device on an average of 28.5 days over the 208 investigational days. The recent reports highlighted by Prakash are noteworthy. However, more rigorous controlled studies are still needed to examine how handheld devices impact medical learning and patient outcomes.

Patients' ability to manage medications is critical to chronic disease control. Also known as medication management capacity (MMC), it includes the ability to correctly identify medications and describe how they should be taken.To evaluate the effects of low literacy, medication regimen complexity, and sociodemographic characteristics on MMC.Cross-sectional analysis of enrollment data from participants in a randomized trial.Patients with coronary heart disease in an inner-city clinic.Medication management capacity was measured with the Drug Regimen Unassisted Grading Scale (DRUGS), which scores subjects' ability to identify, open, describe the dose, and describe the timing of their medications. DRUGS overall and component scores were compared by literacy, Mini Mental State Exam score, regimen complexity (number of prescription medications), and sociodemographic characteristics.Most of the 152 participants were elderly (mean age 65.4 years), women (54.6%), and African American (94.1%). Approximately half (50.7%) had inadequate literacy skills, and 28.9% had marginal skills. In univariate analysis, MMC was significantly associated with literacy (P.001), and this effect was driven by the ability to identify medications. In multivariable models, patients with inadequate literacy skills had 10 to 18 times the odds of being unable to identify all of their medications, compared with those with adequate literacy skills (P.05).Adults with inadequate literacy skills have less ability to identify their medications. Techniques are needed to better educate low-literacy patients about their medications, as a potential strategy to enhance adherence.

Over the past decade, handheld computers (or personal digital assistants [PDAs]) have become a popular tool among medical trainees and physicians. Few comprehensive reviews of PDA use in medicine have been published.We systematically reviewed the literature to (1) describe medical trainees' use of PDAs for education or patient care, (2) catalog popular software applications, and (3) evaluate the impact of PDA use on patient care.MEDLINE (1993 to 2004), medical education-related conference proceedings, and hand search of article bibliographies.We identified articles and abstracts that described the use of PDAs in medical education by trainees or educators. Reports presenting a qualitative or quantitative evaluation were included.Sixty-seven studies met inclusion criteria. Approximately 60% to 70% of medical students and residents use PDAs for educational purposes or patient care. Satisfaction was generally high and correlated with the level of handheld computer experience. Most of the studies included described PDA use for patient tracking and documentation. By contrast, trainees rated medical textbooks, medication references, and medical calculators as the most useful applications. Only 1 randomized trial with educational outcomes was found, demonstrating improved learning and application of evidence-based medicine with use of PDA-based decision support software. No articles reported the impact of PDA use on patient outcomes.Most medical trainees find handhelds useful in their medical education and patient care. Further studies are needed to evaluate how PDAs impact learning and clinical outcomes.