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Patient work self-managing medicines: a skilled job at the sharp end of care
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  1. Beth Fylan1,2,
  2. Justine Tomlinson1
  1. 1School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
  2. 2NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Institute for Health Research, Bradford, UK
  1. Correspondence to Professor Beth Fylan; B.Fylan{at}bradford.ac.uk

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Maintaining the safety and continuity of medicines at care transitions is a long-standing healthcare challenge and a global priority.1 Medication errors at hospital discharge are common and harmful: a systematic review reported a median rate of medication error and unintentional medication discrepancies of approximately 50% of adult and elderly patients, and adverse drug events affected a fifth of all discharged adult and older patients.2 Older people are particularly at risk, and more susceptible to the impact of errors, yet approximately a third to two-thirds of medication-related harm experienced by older people after discharge is considered preventable.3 Problems can often arise from care fragmentation when two or more healthcare organisations operating distinct work systems are involved in the care transition.4 Between those systems the tasks, tools and technologies are misaligned, and the resulting processes cause error and confuse patients.5

In this month’s edition, Xiao et al draw on work system design to explore medicines management at the hospital to home transition for older patients.6 In the research, patient work is viewed as part of a work system, which aligns with a body of academic work using work systems models to research patients’ roles and responsibilities.7 8 The authors developed capacity, task and practice indicators to predict safety and patient experience outcomes postdischarge, administering structured interviews, conducting observations and assessing medicines discrepancies in patients’ homes within a week of discharge. They found three indicators (number of medicines, number of regimen changes and low self-efficacy) increased the likelihood that the patient felt overwhelmed by their medication regimens, assessed using a binary response to the question: ‘Were you overwhelmed in the first few days after coming home with the new medication regimen?’ Several indicators (low transportation independence, not having a home caregiver, low medicines administration skills, and being prescribed more than 10 discharge medicines) increased the risk of medicines discrepancies following discharge.

In our view, the complexity and burden of patient work managing their medicines regimens after hospital discharge arises from several sources:

(1) Upon leaving hospital, managing medicines primarily falls under the responsibility of patients; the ‘sharp end’ of care is in the patient’s own home where they take sole (or shared with informal carers) responsibility, including ordering and obtaining supplies, checking they are correct, sorting and storage, taking their medicines, monitoring for problems and deterioration, and seeking help with medicines from their care team.9 It is a patient-led function with interdependencies with other functions led by healthcare providers, such as prescribing, dispensing and review, and the handover of that function to patients in preparation for their discharge is minimal.10

(2) Patients may experience numerous postdischarge medicines problems,11 yet healthcare organisations may only become aware of errors if they lead to increased health service utilisation, such as a hospital re-admission. Worryingly, patients also experience gaps in care, which may not necessarily result in error, but cause significant confusion, anxiety and stress,12 and necessitate hard work to resolve.13 These issues should be captured and fed back to the system, so that organisations can learn and adapt to better support the patient experience.

(3) Problems arising from the varying quality and timeliness of communication between different healthcare providers, between healthcare professionals and patients can be compounded because the patient may still be unwell (or recovering) and treatment may be ongoing.14 Furthermore, due to the way hospital work systems operate, older patients can become de-skilled during an admission, and therefore have lower capacity for resuming responsibility for their medicines management at the point of discharge.15 Healthcare teams tend to focus on and prioritise the presenting complaint, with limited capacity and scope to truly understand the patient’s medicines management capabilities or what the potential impacts of making changes to medicines regimens means in the context of their homework system.

(4) Medicines can be complicated to manage, and the more comorbidities the patient has, the more complex and burdensome their medicines regimens and may be,16 and the more problems they may experience.11

Solutions are available while being resource intensive. Tomlinson et al, using systematic review and meta-analysis, identified that interventions providing support for up to 90 days after discharge were more likely to support medicines safety.17 Medicines self-management activities, telephone follow-up and medicines reconciliation were associated with reduced re-admission rates. The focus on patients’ medicines self-management activities is key: recent research has identified the burdensome patient work of managing medicines—‘a skilled job I didn’t apply for’—especially for those on multiple medicines, taken at different times of the day, with different formulations and changing doses.9 A renewed focus on the wider job of medicines taking represents progress from the narrow emphasis on patients’ responsibility as adherence to regimens (taking ‘as prescribed’) or self-administration accuracy,18 19 both of which overlook the complexity of the job, especially for those on polypharmacy. In Xiao et al’s research,6 just over two-fifths of patients reported low self-efficacy in managing their medicines.

In table 1 we have used a work system lens to further outline some considerations on the role of patients in managing polypharmacy and posed questions about how well the system functions and what further research could explore.

Table 1

Considerations and questions about medicines management systems

Finally, for healthcare to be sustainable, particularly in settings where resources are stretched, there is a drive to situate acute or postsurgical care in the patient’s own home where appropriate, and for patients to take more responsibility for tools, tasks and technologies, for example, home monitoring of vital signs and app usage on postsurgical virtual wards.20 Managing medicines is one of healthcare users’ main responsibilities and an example of the increasingly complicated and burdensome tasks patients manage at home with limited input from healthcare professionals. Developing a more detailed view of this—as Xiao et al have begun to do—6 and the other work systems patients interact with on their care journeys will afford full recognition of the burden of care they experience and can inform policy if more care activities are to shift into people’s homes.

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References

Footnotes

  • X @bethfylan, @just_greenwood

  • Contributors Both authors were involved in the conceptualisation. BF wrote the original draft and JT was involved in reviewing and editing. BF is responsible for the overall content as guarantor.

  • Funding This work was supported by the National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration. The views expressed are those of the authors, and not necessarily those of the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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