drug information for patients—an update of long-term results: type of enquiries and patient...

pharmacoepidemiology and drug safety 2009; 18: 111–119ww.interscience.wiley.com) DOI: 10.1002/pds.1682
Published online 19 December 2008 in Wiley InterScience (w
ORIGINAL REPORT

Drug information for patients—an update of long-term results:type of enquiries and patient characteristicsy

Martin Huber MPharm1,2*, Gerd A. Kullak-Ublick MD2 and Wilhelm Kirch MD1

1Institute of Clinical Pharmacology, Faculty of Medicine, Technische Universitat Dresden, Germany2Division of Clinical Pharmacology and Toxicology, Department of Internal Medicine, University Hospital Zurich, Switzerland

SUMMARY

Purpose To analyse the type of enquiries to a drug information service in Germany, available exclusively for patients.Methods Sociodemographic characteristics of the patients who used the service, number and kind of drugs taken, existing diseases, reasonsfor enquiry as well as type of answers provided were recorded. For the present evaluation we analysed all enquiries to the service from August2001 to January 2007.Results A total of 5587 enquiries were received. 5013 enquiries from 4091 patients were available for further analysis in detail. The patientgroup using the service most frequently were women between 61 and 70 years (23.3%). 1457 enquiries (29.1%) were made by patients whohad contacted the information service once or several times before. The group of drugs most often asked about were cardiovascular drugs(33.4%), followed by drugs for the nervous system (16.2%) and for the alimentary tract and metabolism (12.4%). On average, each patient hadquestions about 2.6 (median 1; 1–22) drugs simultaneously. Common reasons for contacting the service were adverse drug reactions (22.1%),the need for general information about the drug (19.9%), information about therapy (12.4%) and drug interactions (10.2%).Conclusions A lot of patients need additional information about their medication, especially concerning drug groups that are frequentlyprescribed. The presented drug information service can be one helpful tool to counteract these information deficits and to increase patients’knowledge about their drugs. Copyright # 2008 John Wiley & Sons, Ltd.

key words— drug information service; patients; age distribution; type of enquiry

Received 5 October 2007; Revised 29 September 2008; Accepted 20 October 2008

INTRODUCTION

Safety is an essential principle of patient care;therefore, the Fifty-fifth World Health Assemblyunderlined the importance of promoting science-basedsystems to improve patient safety and the quality ofhealth care, including the safe use of medicinalproducts.1 Medication errors and adverse drug reac-tions not only have an impact on human health but arealso a significant financial burden on the health caresystem.2,3 The high costs due to these events show thenecessity of prevention, e.g. through educationalprogrammes, to save money and to improve the qualityof care.2,3 Dietary supplements, which are frequently

* Correspondence to: M. Huber, Division of Clinical Pharmacology andToxicology, Department of Internal Medicine, University Hospital Zurich,Ramistrasse 100, 8091 Zurich, Switzerland. E-mail: [email protected] conflict of interest was declared.

Copyright # 2008 John Wiley & Sons, Ltd.

regarded as harmless and safe by the patients, can beassociated with adverse events, too.4,5

Deficiencies in system design, organisation andoperation are primarily seen as the reasons leading toadverse events, and the individual physician may onlycontribute to a lesser extent.6 As the average length ofconsultation in a German general practitioner’s officeis less than 8 minutes, the limited time with the doctorcould be one aspect inherent to the health caresystem.7,8 Misinterpretation of the advice given by thephysician or pharmacist, or insufficient provision ofrequired information about the medication, may resultin decreased compliance of the patient.9 However,patient education and counselling are of primeimportance to improve compliance, as a well-informedpatient is the key to ensure taking the drugsprescribed.10 In particular those patients with multipledrugs have the need for adequate information, as theyare more likely to be noncompliant.11

112 m. huber ET AL.

As one resource, patients try to inform themselvesabout their medication and diseases using the inter-net,12 but the quality of websites about drugs andhealth-related topics varies widely,13 and not authenti-ficated information might be associated with somedangers.14 The patient package insert of a drug couldbe another—and reliable—source of information.Literature data, however, suggest that patients do notunderstand its meaning, and that personal recommen-dations of a physician or pharmacist are more helpfuland better accepted.15 This is in accordance withidentified preferences of patients for a patient-centredconsultation including communication.16

Drug information services managed by health careprofessionals can be a helpful tool to answermedication-related questions and to provide generalinformation about drugs.17 Such centres addressingphysicians and pharmacists have existed in Germanyfor a long time, and their usefulness has beendemonstrated.18,19 In 2001, a drug information servicewas established in Dresden, Germany, availableexclusively for patients.20,21 For the present paper,we evaluated all enquiries to this service within 6 years.The objectives were to analyse the type of enquiries aswell as answers provided by the drug informationservice. Finally, the kind of information need on thepatient side should be identified.

METHODS

The drug information service for patients (DISP)—located at the Institute of Clinical Pharmacology,Faculty of Medicine of the Technische UniversitatDresden, Germany, and financed by the German HeadAssociations of Health Insurance Funds according tox65b of Social Code Book V—has been operatingsince 2001. The service was initially organised forpatients in the area of Saxony, and was repeatedlyadvertised in media (print, radio and television). Since2005, enquiries from all over Germany have beenaccepted. The DISP was free of charge for theenquiring person to prevent disadvantages towardspersons with lower income, and independent as regardscontent. The consultation of the patients was managedby pharmacists and clinical pharmacologists. TheInstitute of Clinical Pharmacology has already hadexperience with a drug information service for office-based physicians in Saxony, existing since 1995.22–24

Operation of the DISP

The DISP was available by telephone during officehours from Monday to Friday. The initial phone call


was answered by skilled staff members of the institute.Outside of office hours, patients had the possibility toleave a message on an answering machine, send an E-mail or a regular mail. All enquiries were documentedusing a standardised drug consultation form that hadbeen specially created for the DISP. Sociodemographiccharacteristics (age, gender, geographical region etc.)were recorded, also complete medication as well asexisting diseases of the patients, and in addition whichof these drugs and diseases had caused the enquiry.Classification of drugs was made according to theAnatomical Therapeutic Chemical (ATC) classifi-cation system (WHO Collaborating Centre for DrugStatistics Methodology, Oslo, Norway). The patient-reported diseases were categorised using the Inter-national Statistical Classification of Diseases andRelated Health Problems 10th Revision (ICD-10,World Health Organization, Geneva, Switzerland).Furthermore, the reasons for an enquiry were recorded.These were classified into appropriate categories, e.g.adverse drug reactions, drug interactions, informationabout therapy, application or dosage of the drug).

The enquiry was transmitted to an adviser (pharma-cist or clinical pharmacologist) and answered after aninvestigation period. The summary of medicinalproduct characteristics of the respective drug, theinternational drug databases DRUGDEX1 and DRUG-REAX1 System (Thomson Healthcare, GreenwoodVillage, CO, USA) as well as current guidelines ofGerman and international medical associations werecommonly used as sources of information. For complexproblems experts from the University Hospital Dresdenwere consulted. Answers were primarily given bytelephone, because only a personal conversationenables to directly respond to the needs andexpectations of the enquiring person. The patientswere informed that the advice provided by the DISPcan only be general information about drugs and is nota treatment recommendation. In addition, patients wereregularly encouraged to consult their attendingphysician. The types of answer provided by the DISPwere documented on the drug consultation form. Thetime to answer an enquiry (investigation and counsel-ling the patient) was recorded, too.

Analyses

All enquiries including answers were stored in arelational database using Microsoft Access 2003(Microsoft Corporation, Redmond, WA, USA). Forthe present evaluation the data of each enquiry to theDISP between August 2001 and January 2007 wereanalysed. Due to study design approval by an

Pharmacoepidemiology and Drug Safety, 2009; 18: 111–119DOI: 10.1002/pds

drug information for patients 113

institutional or national ethics committee was notrequired according to German law.

Statistical comparison of categorical variables wasperformed using chi-square test. Continuous variableswere compared with t-test and Mann–Whitney U-test.For all tests a two-sided p value below 0.05 wasconsidered significant. All statistical analyses wereperformed using SPSS 15.0.1 (SPSS Inc., Chicago, IL,USA).

RESULTS

Patient characteristics

During the analysed period (August 2001–January2007), a total of 5587 enquiries were registered.Figure 1 shows the monthly number of all enquiries,which varied widely over time; on average, therewere 85 enquiries per month. Restricting analysis tothose enquiries for which age and gender of the patientwere known, 5013 enquiries from 4091 individualswere available for further evaluation. 35.5% (n¼ 1451)of the patients were male, 64.5% (n¼ 2640) female,the mean age was 61.5 (SD 14.9) years (men: 62.5 (SD15.0), women: 60.9 (SD 14.8); p¼ 0.002). Themajority of patients were older than 60 (n¼ 2621,64.1%). The largest group were women between 61and 70 years (n¼ 955, 23.3% of patients). A higherproportion of female individuals could be found in eachage group. Two thirds of the patients originated from

Figure 1. Number of all enquiries to the drug information services for patients


Saxony, the geographical area around Dresden (men:66.9%, n¼ 970; women: 69.9%, n¼ 1845). In 85.2%(n¼ 4272) of the enquiries, patients contacted theDISP by themselves, whereas 14.8% (n¼ 741) of theenquiries were managed via a third person (e.g. spouse,child of the patient).

In 4914 enquiries, drugs were indicated by thepatients. On average, men took significantly moredrugs than women (5.5 (SD 3.6) vs. 4.9 (SD 3.3);p< 0.001), patients older than 60 years significantlymore than patients less than or equal to 60 years of age(5.8 (SD 3.5) vs. 3.9 (SD 2.9); p< 0.001). Existingdiseases of the patients were reported in 4849enquiries. No significant difference concerning meannumber of diseases was found between male andfemale (3.0 (SD 1.9) vs. 2.9 (SD 1.7); p¼ 0.388).However, the age had an impact (>60 years: 3.2 (SD1.8) vs. �60 years: 2.4 (SD 1.5); p< 0.001). 535patients contacted the DISP more than once, causing1457 (29.1%) enquiries (Table 1). There was nosignificant difference in gender distribution betweensingle and repeat enquiries (p¼ 0.674).

Content of enquiries

Table 2 gives an overview of the drug and diseasegroups that caused an enquiry. 4914 of the 5013enquiries analysed were drug-related. Cardiovasculardrugs (ATC group C) clearly dominated with 33.4%(n¼ 4269), followed by drugs for the nervous system

per month in the period from August 2001 to January 2007


Table 1. Differences in patient characteristics between single and repeat enquiries

Single enquiries Repeat enquiries p value

n % n %

Total� 3556 100.0 1457 100.0Gender 0.674

Male 1267 35.6 510 35.0Female 2289 64.4 947 65.0

Age, years <0.001�40 378 10.6 117 8.041–60 923 26.0 336 23.1>60 2255 63.4 1004 68.9

Number of drugs taken <0.001�4 1912 53.8 692 47.5>4 1644 46.2 765 52.5

Number of patient-reported diseases 0.0020–1 919 25.8 347 23.82–3 1616 45.4 617 42.3>3 1021 28.7 493 33.8

*Percentages may not add exactly to 100.0 due to rounding error.

114 m. huber ET AL.

(ATC group N) with 16.2% (n¼ 2066). Substancesenquired about without ATC code included dietarysupplements, homoeopathics and medical devices, andwere ranked fourth (7.5%, n¼ 954). It is noteworthythat only a total of 7.8% (n¼ 1000) of all drugs askedabout were bought by the patients without prescription,including 710 dietary supplements—which wereranked sixth with 5.6% if regarded as separatecategory.

On average, 2.6 (median 1; 1–22) drugs were askedabout per enquiry, significantly more drugs by malethan by female patients (2.9 (median 1; 1–21) vs. 2.4(median 1; 1–22); p< 0.001). The mean number ofmedicines enquired about increased with the age of thepatient. Drugs for the cardiovascular system were morefrequently stated as the reason for the enquiry by menas well as by patients older than 60 years (39.3% and37.2%, respectively), than by women (29.5%) orpatients less than/equal to 60 years (�40: 12.7%, 41–60: 26.5%). However, drugs for the nervous systemwere more often asked about by younger individuals(�40 years: 25.4%, 41–60 years: 20.0%, >60 years:14.2%). The number of drugs taken by the patient hadan impact, too, in particular on the frequency ofenquiries about cardiovascular drugs (�4 drugs taken:26.8%, >4 drugs taken: 36.0%).

In 3339 enquiries, diseases were stated by thepatients as responsible for the question to the DISP(Table 2). Diseases of the circulatory system (19.5%,n¼ 702) most frequently caused an enquiry.

Common reasons leading patients to contact theDISP were, as presented in Table 3, adverse drugreactions (22.1%, n¼ 2177), the need for general


information about the drug (19.9%, n¼ 1964),information about therapy (12.4%, n¼ 1221) and druginteractions (10.2%, n¼ 1002). On average, there were2.0 reasons for an enquiry from a patient. As additionalcause, lack of available time of the attending physicianwas stated in 238 enquiries. Furthermore, each drugasked about was linked with the reasons for thequestion. Drugs for the blood and blood forming organsas well as for the cardiovascular system were morelikely to be associated with enquiries about adversedrug reactions (25.4% and 25.9%, respectively) anddrug interactions (19.8% and 18.0%, respectively). The99 enquiries in which no drug was mentioned by thepatients were mainly related to questions abouttreatment options in general.

Type of information provided by the DISP

Table 4 shows the types of answer which were given bythe DISP during consultations. As the answersprovided were dealing with the individual problemsof the patients in a more detailed way, the totallednumber was higher than the number of reasons leadingto an enquiry. General information about the drug wasmost frequently given as answer (24.4%, n¼ 3000).Advice concerning adverse drug reactions was in thesecond place, accounting for 14.8% (n¼ 1827). In1453 consultations patients were encouraged to visit aphysician for discussing their drug-related problem.The average time to answer an enquiry (investigationand counselling the patient) was 26.7 (SD 17.5)minutes (data were not available for 187 enquiries).


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Copyright # 2008 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2009; 18: 111–DOI: 10.1002/


119pds

Tab

le3

.R

easo

ns

that

led

pat

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dru

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Copyright # 2008 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2009; 18: 111–119DOI: 10.1002/pds

116 m. huber ET AL.

Table 4. Types of answer provided by the drug information service. Morethan one category per enquiry was possible

n %

General information about drug 3000 24.4Adverse drug reactions 1827 14.8Information about therapy 1702 13.8Drug interactions 825 6.7General need for information 614 5.0Costs/refund/prescription requirement 530 4.3Change of medication 508 4.1Mechanism of drug action 492 4.0Indication of drug 477 3.9General rules of conduct concerning drug 390 3.2Information about self-medication 378 3.1Dietary supplements 291 2.4Dosage correction 268 2.2Application of drug 238 1.9Drug-related legislation 190 1.5Contraindication 156 1.3Pharmacokinetics 88 0.7Alternative medicine 82 0.7Pregnancy/breastfeeding 60 0.5Generics 28 0.2Availability of drug 27 0.2Eating habit 26 0.2Medical devices 20 0.2Other topics not categorised elsewhere 102 0.8Total� 12319 100.0

*Percentages do not add exactly to 100.0 due to rounding error.

Table 5. The 12 most frequently prescribed drug groups in Germany (atthe expense of the Statutory Health Insurance),33 compared with thepercentages of the respective drug groups asked about by the patients, inthe year 2006 (classified according to ATC system)

ATC group SHI DISP

% %

C09 Agents acting on the renin–angiotensin system 7.0 9.1J01 Antibacterials for systemic use 6.5 1.2M01 Antiinflammatory and antirheumatic products 6.0 2.5C07 Beta blocking agents 5.7 7.4N02 Analgesics 5.6 4.2A10 Drugs used in diabetes 4.7 4.3N05 Psycholeptics 4.5 3.8R03 Drugs for obstructive airways diseases 4.3 3.6A02 Drugs for acid related disorders 3.7 3.6C03 Diuretics 3.5 5.3N06 Psychoanaleptics 3.2 4.9H03 Thyroid therapy 3.2 2.5

ATC, Anatomical Therapeutic Chemical; SHI, Statutory Health Insurance;DISP, drug information service for patients.


DISCUSSION

In the analysed period, the DISP was frequentlycontacted by patients, indicating an existing need foradditional information about their medication. Therewas a wide fluctuation in the monthly number ofenquiries to the service over time. Advertising in printmedia as well as via radio or television highlyincreased the number of questions.

The majority of enquiring patients were older than60 years. As the number of drugs prescribed increaseswith age,25,26 and polypharmacy is associated with ahigher risk for several health problems (e.g. adversedrug reactions),27 a greater need for medication-relatedinformation among the elderly may have been theunderlying reason. In addition, more women than menused the DISP, possibly due to their higher proportionin the older population.28 As this, however, does notexplain the imbalance between male and female amongyounger patients, another factor could have been thatwomen are more likely to use external help than men.29

Reports on drug information services in other countriesshowed a gender distribution comparable to ourfindings.30–32 As expected, patients contacting theservice more than once were older, had to take moredrugs or were suffering from more diseases, whichincreased the number of medication-related questions.


On average, men asked about significantly more drugsper enquiry than women, correlating with a largernumber of drugs taken. Their higher mean age mayhave been responsible, because older age is generallyassociated with an increased medication use.25,26 Inaddition, the number of drugs prescribed to older menslightly exceeds that prescribed to older women.26

The distribution of the drug groups enquired aboutwas paralleled by national prescription figures, for theyear 2006 see Table 5, with few exceptions (e.g.antibacterials for systemic use/ATC group J01).33

Drugs for the cardiovascular system were mostcommonly prescribed in the analysed period,33,34

and they were most often stated by the patients asreason for an enquiry—more frequently by older aswell as male individuals, which is in accordance withfindings from the literature, too.25 Moreover, as mentaldisorders are highly prevalent in the German popu-lation,35 a lot of questions were about drugs for thenervous system. In general, the medication asked aboutcorrelated with the patient-reported diseases. However,as diseases of the circulatory system are usually treatedwith a combination of multiple agents, the proportionof cardiovascular drugs was substantially higher. Thefact that the majority of questions were related tofrequently prescribed drugs, and not only to those withspecial pharmacological characteristics, may argue fora general information need. Furthermore, the numberof dietary supplements enquired about—taken by thepatients without consultation of a doctor—wasnotable. Limited product information might lead tomisconceptions about the effects of these substances.36

Therefore, drug information centres can be useful as avaluable source of information.37


118 m. huber ET AL.

Adverse drug reactions are common reasons forcontacting a drug information service,31,32,38 whichwas also observed in our evaluation of the DISP, andare of particular relevance for patient safety. Adversedrug reactions are responsible for an increasing numberof hospital admissions in recent years.39 Certain drugs,e.g. for the blood and blood forming organs or for thecardiovascular system, are more likely to be associatedwith serious adverse events.40 As a considerablenumber of adverse drug reactions leading to hospital-isation is regarded as avoidable—especially in olderindividuals—appropriate prevention is needed.40 Suf-ficient information of the patient could be oneimportant measure.

In addition, patients who experienced adverse drugreactions are more likely to be noncompliant.41 On theother hand, adequate consultation on the prescribeddrugs and the concept of therapy leads to increasedcompliance.41 For this purpose, distance medicinetechnology (e.g. telephone counselling as provided bythe DISP) can be one useful instrument which hasshown benefits for the patients.42 Consultations byphone are highly accepted due to convenience,43 andmay reduce the use of medical care—implicatingpotential cost saving effects.44

The intention of the DISP was not to substitute theface-to-face consultation with the treating physician,who knows most of the patient and his medical history,and who should be the primary responsible forproviding comprehensive information about the useof medication. However, the service was suppor-tive whenever there were any further questions on thepatients’ side. As mostly self-motivated individualsare addressed by a telephone-based drug informationservice, further research is needed to determine how toreach other patient groups.31

The advice provided by the DISP could only be givenwithin the context of patients’ self-reported infor-mation about their drugs and diseases. This is a

KEY POINTS

� A lot of patients need additional information abouttheir medication.

� The DISP can be a useful instrument to counteractdeficits in drug-related knowledge.

� Enquiries were mainly related to frequently prescribedmedication, such as drugs for the cardiovascularsystem, for the nervous system or for the alimentarytract and metabolism.

� Adverse drug reactions were the most common reasonfor contacting the service.


limitation of an independent and telephone-based druginformation service, as it was not possible to verifypatients’ statements with medical records kept byattending physicians. However, there is evidence fromthe literature that self-reports by patients are reliablewhen compared to objectively obtained data.45

CONCLUSION

The findings that emerge from our experience with theDISP demonstrate an existing need on the patient sidefor additional counselling about the medication. Inparticular frequently prescribed drugs were enquiredabout, which may indicate an information need notonly for drugs with special pharmacological charac-teristics. Medical advice given by telephone may serveas an additional source of drug-related information forpatients. Therefore, the DISP can be one helpful tool tocounteract information deficits and to increasepatients’ knowledge about their medication.

ACKNOWLEDGEMENTS

The drug information service for patients was financedby the German Head Associations of Health InsuranceFunds according to x65b of Social Code Book V. Therewas no involvement of the study sponsor in studydesign, in the collection, analysis and interpretationof data, in the writing of the report and in the decisionto submit the report for publication.

The authors are grateful to all former and presentstaff members of the Institute of Clinical Pharmacology,Faculty of Medicine of the Technische Universitat Dres-den, Germany, involved in the drug information service.

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