Keywords

Pharmacists; WINPEPI software; Patients' Demographics; Antidepressants

Introduction

Patient-centered care has become an important indicator for excellence in healthcare.1 The involvement of the patient as an equal partner in the care process significantly contributes to high-quality health care outcomes and ultimately leads to improvements in efficacy of medication management, adherence, and safety [1,2]. Multiple studies have also concluded that provision of patient centred- care approach can also reduce healthcare costs [2-5].

Patient-centered care requires a respectful interaction with consumers, offering them the opportunity to express themselves, providing them with relevant information about their treatment options, considering their concerns, alleviating their fears and provide information and reassurance during their health care journey. It not only engages the patient but also the family, friends and careers and encourages them to take an active role in the decision-making process that enable the development of a treatment care plan that suits the patient’s needs. Thus, it is able to improve the patient’s satisfaction and overall care experience [1-6].

A high degree of patients’ satisfaction has been associated with high quality of care, health care providers and organizations have sought ways to measure patient satisfaction in order to gain an insight into the consumer-perceived quality of an institution’s performance. Patient satisfaction surveys are a suitable tool and provide a good opportunity to identify potential gaps in the provider health care to address ways to improve their services to improve patients ’ satisfaction and experience [7,8].

Another approach cited in the literature is asking patients to report on their experience during their hospital stay. While satisfaction questionnaires describe the patient ’ s individual feelings about their care, the experience surveys objectively reflect the perceived quality of care they received. By specifically addressing patient-centered care domains and gauging whether appropriate processes were followed, this type of questionnaire is able to deliver results that can be interpreted in terms of potential enhancements and follow up actions for healthcare settings. They are also a useful tool for monitoring the performance of various hospital departments and could identify directions in which delivery of healthcare could be improved [7].

Multiple patients’ surveys are available to measure patients’ satisfaction and experience. The Picker Institute introduced inpatient surveys based on eight principles of patient-centered care, which are used in Europe, the US, Canada and Australia. A shorter version of this survey, consisting of 15 questions relating to patient experience, is an integral part of the standard questionnaires of the National Health Service (NHS) National Survey Programmed in England. In the US, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is widely used to measure patients’ experiences. This instrument is also based on the Picker principles and assesses the overall rating of health care services as well as the likelihood of patients recommending the services to others [7-10].

The Australian Commission on Safety and Quality in Healthcare has developed a framework for monitoring quality use of medicines across multiple domains. The commission has published several guidelines and standards to ensure safe and effective delivery of healthcare services across the hospitals by assisting hospitals to identify their gaps against an expected practice standards and address them accordingly [1]. More recently, the commission has updated their guidelines to focus on collaborating with consumers in every step during their hospital admission. The new revised standard recognizes the importance of involving patients and their careers in every aspect in their care during their hospital admission. It focuses on strategies that can assist healthcare providers improving communication with patients to encourage them to take part in their health. More importantly, the new standard supports a patient centred care approach and focuses on patients satisfaction and experience in the health settings [1].

Information on patients’ satisfaction and experience in health settings is paramount to policy makers to ensure they are fulfilling their obligations towards their patients and providing a high level of healthcare. In Australia, patient satisfactions and experiences with their health providers is an important key performance indicator for multiple healthcare outcomes [1].

Although, there is a plethora of published data on patient’s level of satisfaction and experience with the level of care they receive in any given health care settings, there is limited information published on reasons for patients reporting lack of satisfaction with their experiences in healthcare [6-8].

Pharmacists play a vital role in providing information to patients on their medications as well as optimizing their medical treatment as part of the multidisciplinary treating team in various health care settings [11]. A recent study investigating the impact of pharmacist using shared decision making on adherence and measurable depressed patient outcomes found that Pharmacist involvement in shared decision making improved adherence, treatment satisfaction and patients’ belief in antidepressants compared to usual care. This study was based in an outpatient clinic where patients were followed up for six months [12].

To date, there are few studies available that have assessed pharmacists’ role in provision of shared decision-making and its effect on improving patients experience with their hospital stay [12-15].This study will therefore explore pharmacists’ impact in the provision of shared decision making on patients ’ satisfaction.

Aim of the Study

The primary aim of this study is to assess whether the provision of a patient centered care approach through shared decision-making improves inpatients overall satisfaction with their care. The secondary aim evaluates the pharmacist impact on the patients overall satisfaction.

Methods

This prospective study was conducted over two stages. The first stage involved a prospective cross sectional quality baseline audit of patients satisfaction conducted at an Australian hospital over four months, from September 2017 to December 2017 using the usual care process. The data obtained from the baseline study informed the intervention method. The intervention included the development of a suite of patients’ leaflets on various treatment options to improve patients ’ health literacy on their treatment options and to empower them to take active part in shared decision making on their medical management. The second stage involved evaluating pharmacist role in the provision of shared decision-making on patients experience in this tertiary setting. The second stage was conducted from May 2018 to Sept 2018. Shared decision making principles was implemented by provision of a suite of leaflets on treatment options of various disease states to patients as well staff education about delivering patient centered care approach by involving patients in every aspects of their management during patients hospitals stay. Both stages of the study were conducted in a 454 bed hospital that is a major health provider of Victoria’s Morning ton Peninsula and provides a range of health services including specialty wards consisting of: stroke ward, gastroenterology, orthopedics, cardiology, intensive care, geriatrics, mental health, maternity, rehabilitation, general surgery and medical wards. Patients were invited to participate in the study.

A total of five satisfaction and experience questions were devised from the Picker questionnaires that specifically targeted patients ’ medication management were used to measure patients’ satisfaction and experience. They measured five core dimensions: awareness of any medications changes, education about their medications, purpose, administration, side effects and their involvement or their family/careers in their treatment. Answers to questions in both surveys were based on a likertscale for ease of analysis. Overall positive satisfaction and experience were determined if the patients scored positively in five out of the six questionnaires in both stages of the studies. The same set of questions was used in both stages of the study.

A total of 100 Patients in each arm were invited to participate in the study and were randomly selected by a random number generator from all hospital wards and all specialties. From this population, it was calculated that a sample size of 90 patients would be needed in each arm, with a confidence index of 95%, using the WINPEPI software [13]. Patients were eligible to participate in this audit if they were 18 years of age or older and admitted to the hospital for more than 24 hours. Exclusion criteria included patients who were not able to communicate due to language barrier, severe illness, cognitive impairment and those who have a length of stay of less than 24 hours. Data collected from patients ’ medical history included patients ’ demographics, comorbidities, length of stay, documentation of medication changes in the history, and pharmacist input and/or counseling. Pharmacist input was determined if there was a documented medication history or medication chart verification or documentation of discharge counseling on the discharge script or on the electronic system or in the medical history.

Statistical Analysis

Descriptive statistics were used to summaries patients' demographics, satisfaction and experience questionnaires results. Chi squared was used to examine the relationship between two categorical variables. A significance level of P <0.05 was considered statistically significant for all tests. The two sets of questionnaire were broken down by overall satisfaction and experience for the purpose of facilitating further analysis. Multiple logistic regression analysis was used to examine the relationship between the independent variables such as gender, age, marital status, education level, smoking status, Charlson comorbidity index, length of stay, admission ward, pharmacist input and medication changes and the dependent variables, which were satisfaction. The results are presented in adjusted odds ratios (OR) with 95% confidence intervals (95% CI).

Results

Demographics differences between the two cohorts

63.1 ± 13.4, p=0.032). More tertiary educated patients and non-smokers were pertained to the control group than the intervention group (31% vs. 19%, p=0.050 and 42% vs. 25%, p=0.011) respectively. On the other hand, more patients in the intervention group were admitted to medical wards during their hospital admission than those who were included in the stage 1 group; (59.6% vs. 44.44%, p=0.033). Refer to Table 1.

Table 1: Patient characteristics.

Patients’ experience

Ninety nine patients were included in both stages of the patient satisfaction and experience survey. The survey consisted of questions assessing objectively patients’ experience to obtain an insight into the hospital’s actual performance and activities regarding their medication management during their hospital stay. All patients included in stage 1 of the study received the usual care. No information leaflets were provided during their stay; however, members of the treating team were providing patients with verbal information pertaining to their medical management. Conversely, patients included in stage 2 of the study were provided with written information specifically tailored to on their disease states related to their hospital admission by the unit pharmacist. The leaflets provided background information on their medical condition and outlined the various treatment options available to treat their condition. Patients in this group were encouraged to interact with the medical team during the daily ward round and to actively take part of their medical management.

Table 2 outlines patients ’ answers to the type of survey questions in both groups. A statistically significant higher proportion of patients in stage 2 of the study reported increase satisfaction about the explanations they received relating to the purpose of their medications, side effects as well as instructions they received about their medications and care explained to them than those who were recruited in stage 1, p<0.005. Additionally, more patients reported that they had a pharmacist input by way of counseling or provision of additional information during their hospital stay in stage 2 than those who were recruited in stage 1 (85.9% vs. 63.6%, p=0.003). Overall patients satisfaction was also higher in stage 2 compared to those who were included in stage 1 (79.8% vs. 52.5%, p=0.0003) as shown in Table 2.

Table 2: Total responses for questions [1-5].

Factors that influence patients ’ satisfaction and experiences

Univarate analysis of data has shown a statistically significant relationship between patients ’ overall satisfaction and pharmacist input during their hospital stay, in both study groups, p<0.05. Additionally, data outlined in Table 3 also shows an association between patients overall satisfaction in group 1 and their Charlson comorbidity index as well as those who are over 70 years of age, p=0.002 and p<0.01 respectively. Moreover, association between patients ’ marital status and overall satisfaction was statistically significant in those who were recruited to stage 2.

Table 3: Univarate analysis of the association between patient overall positive experience and other variables.

Data presented in Table 4.Outlines data for regression analysis of predictors of patients overall satisfaction with their hospital stay. Patients who have had a pharmacist input during their hospital stay were more likely to report a positive experience as shown in both study groups (study group 1, OR=5.821, 95% CI (1.757-19.290); study 2, OR=2.734; 95% CI(0.802-9.316) P=0.108), although the results were statistically significant for those included in stage 1 only. Additionally, patients with Charlson comorbidity index less than 3 were less likely to show a positive response with their overall experience at their inpatient admission, OR=0.655; 95%CI (0.452-0.948), P=0.025.

Table 4: Regression analysis of predictors of overall positive patients’ experience.

Discussion

This study has shown that the involvement of a pharmacist in shared decision making had a positive experience on patients’ satisfaction in a large metropolitan hospital. In this study, we have chosen to use a suite of patient information leaflets designed with consumer involvement to deliver evidence based health information that is specific and relevant to every patient disease state. The main purpose of this information leaflets were to improve patients’ health literacy to enable them to take part of their medical management during their hospital admission. Shared decision-making combines patients’ values, goals and preferences with the best available treatment evidence in order to reach the most appropriate healthcare decision for that individual [15-18]. Delivery of a patient centered care via shared decision making incorporates provision of evidence based information through various methods of decision support systems [19,20]. Similar to published evidence, our study has shown that provision of patient specific decision aids such as information leaflets tailored to their disease states statistically improves patients overall satisfaction with their care (79.8% vs. 52.5%, P=0.0003),[17,20]. Moreover, pharmacists input in patients care via various decision support systems (either through delivery of verbal or written information) results in patients reporting positive overall experience as shown by Univarate and regression analysis in Tables 3 and 4. Strong evidence is available regarding the association of pharmacists’ role in the multidisciplinary team and patients positive health outcomes [21-23].

The Society of Hospital Pharmacy in Australia provides guidelines for clinical pharmacists to priorities their clinical workload. Patients with high acuity, or those with multiple comorbidities or on more than 5 or more medications require a priority review by pharmacists to ensure their medications are charted correctly and to avoid any medications misadventures. 23 Additionally, data presented in Table 4 outlines patients included in study group 1 who had with less medical comorbidities were less likely to provide an overall positive experience with their hospital stay (Charlson Comorbidity Index<3: OR=0.655 95%CI (0.452-0.948), P=0.025. This data is also backed up the fact patients who were included in study group 1 were reviewed by ward pharmacist less frequently than those patients who were recruited to study group 2 (28% vs. 66%, P=0.0001).

Our study had several limitations. The impact of overall patients’ satisfactions was not assessed on patients’ compliance with their medical treatment, hospital readmissions or mortality.

Conclusion

This study has highlighted that pharmacists input as well as provision of shared decision making materials promotes the delivery of a patient centred care approach resulting in patients overall satisfaction.

Ethics Approval

Ethics approval was obtained from the hospital Research and Ethics Committee to conduct the survey questionnaires.

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