Background: The research team aimed to assess the relationship between performance in a competency-based curriculum (CBC) evaluation, and the Orthopaedic In-Training Examination (OITE) in the Postgraduate Year 1 (PGY1) cohort of 2016-2017. Methods: After development of the ‘Basic Trauma’ (BHT) and ‘Basic Arthroplasty’ (BA) CBC modules, assessment consisted of multiple-choice questions (MCQ), objective structured clinical evaluation (OSCE), structured oral panels, and the OITE were conducted annually. We collated MCQ and OSCE evaluations for BHT and BA, as well as the OITE result for the same cohort from PGY1 and the end of PGY2. We evaluated the OITE score difference for correlation with the scores attained for the two CBC modules. Results: Among all participants (n=9), there was a significant improvement in mean OITE scores from PGY1 to PGY2 (43.78% (±4.09) to 56.67% (±4.24); t-test p= 0.00). There was no significant correlation between OITE improvement, and scores attained in the BHT and BA modules, nor between BHT and BA results and the ‘Hip and Knee’ and ‘Trauma’ domains of the OITE exam. Conclusions: Improvement in OITE performance is not dependent on evaluated CBC modules. Further research to determine what factors play a role in trainee improvement in objective performance is required.

Context Gastro-oesophageal reflux disease (GORD) is common in western countries. Up to 40% experience symptoms at least once a month and 10% of adults use proton pump inhibitor (PPI) medication for GORD. The REFLUX study addresses a question fundamental to the management of this problem: what is the best treatment strategy? The current study reports 5-year outcomes of a multicentre randomised clinical trial of surgery versus medical management in the UK.

Background Medication organisation devices (MODs) provide compartments for a patient’s medication to be organised into the days of the week and the recommended times the medication should be taken. Aim To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs. Design The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated. Setting Potential participants were identified by medical practices. Participants Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable. Interventions One of three MODs widely used in routine clinical practice supplied either weekly or monthly. Objectives To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation. Methods The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery. Results Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50–60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [ n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly. Conclusions MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients. Future work A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required. Study registration Current Controlled Trials ISRCTN 30626972 and UKCRN 12739. Funding This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment ; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

Background An estimated 50% of patients do not take their medicines as prescribed, which is decision intentional for an estimated 30% of these patients(1). Reasons for this intentional non-adherence are numerous and include a desire to reduce inconvenient effects, to avoid adverse effects, or a fear of medication dependence. For the remaining 70% of non-adherent patients, their behaviour is dominated by unintentional factors such as confusion and memory failure.(1) Medication Organisation Devices (MODs) are an integral part of standard care to support patients suspected of being unintentionally non-adherent. Accurate data for the prevalence of their use are unavailable, however, conservative estimates indicate that in 2001 at least 100,000 people were using MODs in the UK; with an aging population, this number will have substantially increased over the past 13 years.(2) MODs are usually a box or blister pack divided into days of the week with several compartments per day to allow for different dose timings. However, there is no definitive evidence for the effect(s) of MODs on adherence. The UK National Institute for Health Research Health Technology Assessment programme therefore funded a pilot randomised controlled study. Objectives Provide an indication of the effect(s) of MODs and generate data to inform a full trial of their effectiveness and cost effectiveness. Methods Patients were randomised to receive their usual prescribed medication either in standard packaging or a MOD. Patients were eligible if community dwelling, aged 75 years or more, self-medicating at least three different solid orally administered medicines and identified as non-adherent through a pill count three weeks after provision of a new medication supply. This was likely unintentional non-adherence based on self-report questionnaire data. Post-randomisation, adherence for two months was measured by pill count. Findings Post ethical approval from NHS East of England, 29 community dwelling patients were recruited. Three participants subsequently withdrew and one was excluded due to level of visual impairment being unsafe for standard care medication packaging. Of the remaining 25 participants, 12 received standard medication packaging and 13 received their medication in a MOD. Five (38%) participants receiving a MOD experienced an adverse event (AE) or serious adverse event (SAE). No AEs or SAEs were reported for the control group. The table below summarises the (S)AEs recorded. The median (IQR) increase in adherence was 11% (0, 45) for MOD participants experiencing an (S)AE compared with 5% (0, 17) for standard packaging participants. An adherence increase exceeding 40% was measured for 35% (95% CI 21%) of the medicines prescribed for participants experiencing an AE compared with 13% (95% CI 10%) for those with no reported AE. Discussion The small sample size precludes determination of any definitive causal link between MODs and AEs. The relationship is, however, plausible; all of the participants described in the table were prescribed at least one medicine which may contribute to a fall and the increase in adherence for MOD participants was greater than for the control. The use of MODs appears to have resulted in a greater proportion of the prescribed medicine being administered and thereby increasing risk of iatrogenic events.(5) The findings of this study are in agreement with previous studies designed to promote adherence which have reported increased mortality and healthcare costs for participants receiving the intervention.(6, 7) It is intuitive that increasing adherence to a medication may result in a dose related AE. It may therefore be prudent to review the prescribed dose of any medication with a high risk of dose related AEs (e.g. antihypertensives, hypoglycaemics, anticoagulants, and anticonvulsants) before introduction of an adherence intervention, and to monitor after its introduction to ensure treatment is optimised.

AIMS Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence. METHODS This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: 'patient, admission and discharge', 'medicine' and 'therapy change' information. RESULTS Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines. CONCLUSIONS Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface.

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