Table 1 Final set of complexity factors and the allocated key questions and optimisation measures

  Metered dose inhaler

yes

Pharmacy Product Number

Many patients find it difficult to pull the trigger of their inhaler and to inhale at the same time.

Are you having any trouble using your inhaler?

For how many seconds after inhalation do you hold your breath?

Recommendation of action

Training material

  Elpenhaler

Do you always manage to insert and remove the blister strip without any problems?

For how many seconds after inhalation do you hold your breath?

Training material

  Nebulisers

Many patients find it difficult to measure the exact number of drops.

Do you have any problems measuring the dose for your nebuliser?

Training material

  Capsule-based inhalers

For how many seconds after inhalation do you hold your breath?

Do the capsules contain powder residues after inhalation

Training material

  Other inhalers

For how many seconds after inhalation do you hold your breath?

Training material

 Injection devices (non-prefilled)

yes

Pharmacy Product Number

How frequently do you change the injection site?

Algorithm

 Injection devices (prefilled)

yes

Pharmacy Product Number

How frequently do you change the injection site?

Training material

 Transdermal patches

yes

Pharmacy Product Number

Do you sometimes have to change your patch more often than prescribed, e.g. because it does not last or the effect wears off too quickly?

Training material

 Nasal preparations (prescription-only)

yes

Pharmacy Product Number

Many patients have the feeling that they have to use more spray/drops than prescribed in order to achieve a sufficient effect.

Does this reflect your experience?

Training material

 Solid dosage forms for oropharyngeal use

yes

Pharmacy Product Number

This drug should not be swallowed but should be applied to the oral cavity.

Have you ever swallowed this drug by mistake?

Recommendation of action

 Liquid dosage forms for oropharyngeal use

yes

Pharmacy Product Number

This drug is not to be swallowed. It should be applied to the oral cavity.

Have you ever swallowed this drug by mistake?

Recommendation of action

  Drops

yes

Pharmacy Product Number

Do you always succeed in inserting a drop into the conjunctival sac at the first attempt?

Do you always keep both eyes closed after the drop?

Training material

  Ointment/ creme/ gel

Do you always succeed in inserting the correct amount of this medication into the conjunctival sac at the first attempt?

Training material

 Rectal preparations

yes

Pharmacy Product Number

Many patients have problems with the use of this drug.

Does this equally apply to you?

Training material

 Dermatological preparations (prescription-only)

yes

Pharmacy Product Number

Many patients find it difficult to choose the right amount of cream or ointment.

Do you equally have problems using your cream or ointment?

Recommendation of action

  With measuring device

yes

Pharmacy Product Number

Many patients describe the measurement of a liquid drug as difficult.

Do you have any difficulties with the measurement - for example when using the enclosed dosage device?

Recommendation of action

Training material

  Dry syrup

Many patients report problems with the preparation of their liquids, e.g. because a strong foam develops.

Do you have any difficulties with the preparation?

Training material

  Drops

Counting drops is difficult for many patients.Do you have any difficulties concerning this?

Training material

 Otological preparations

yes

Pharmacy Product Number

Patients often find it often difficult to use ear drops - for example using the dropper with a tilted head.

Does the application also cause problems for you?

Training material

 Vaginal preparations

yes

Pharmacy Product Number

Many patients are insecure about the vaginal application of drugs.

Does this also apply to you?

Training material

 Once weekly administration

Yes

Free text (definition of keywords)

This drug should be used once a week.

Is it difficult for you to use this drug always at the same day of the week?

Recommendation of action

 Tablet splitting

Yes

Dosage scheme

Do you find it difficult to split your tablets consistently into pieces that have the same size?

Algorithm

Training material

 Total number of drugs

Yes

Lines in medication schedule

When taking a multitude of drugs simultaneously, many patients feel overburdened.

Do you have difficulties keeping track of your drugs?

Algorithm

Recommendation of action

 Administration more than two times daily

yes

Dosage scheme

Is it a problem for you to take your medication several times a day in everyday life?

Recommendation of action

 Administration at lunch time

Yes

Dosage scheme

According to your medication schedule, you should use this drug at noon. Many patients find it difficult to actually do this in everyday life.

Have you found it difficult to take your drugs at noon?

Recommendation of action

 Administration every two days or less frequently

Yes

Free text (definition of keywords)

Is it difficult for you to remember taking this drug because it is not used every day?

Recommendation of action

 Fixed dosing interval

Yes

Free text (definition of keywords)

Are you able to keep the exact intervals between the administrations of this drug in everyday life?

Recommendation of action

 Use of multiple doses concurrently

Yes

Dosage scheme

This drug should be used more than once at the same point in time.

Do you find it difficult to use this drug repeatedly each single time?

Algorithm

 Different doses of the same active ingredient at different times of day

Yes

Dosage scheme

You use different doses of this drug during one day.

Do you sometimes accidentally mix up these doses?

Recommendation of action

 Variable dosing

Yes

Dosage scheme

No exact dose is indicated for this drug.

Does this make you insecure about how to take this drug?

Recommendation of action

 Occasional, episodic drug treatment

Yes

Free text (definition of keywords)

This drug is used for a limited time only.

Are you able to integrate this drug into your daily routine?

Training material

 Only one drug at one specific point in time

Yes

Dosage scheme

Your medication schedule specifies that you use this drug at a separate time.

Do you ever forget to take this drug?

Recommendation of action

 Pro re nata (as needed) medication

Yes

Free text (definition of keywords)

In your medication schedule, it is specified that you may use this medication if necessary.

Do you know the medical condition that is treated with this drug?

Do you know what dose you can use?

Recommendation of action

 The same active ingredient in different preparations

Yes

Pharmacy Product Number

These two drugs contain the same active ingredient.

Is there a risk of you confounding these drugs?

Recommendation of action

 Meal-dependent administration

Yes

Free text (definition of keywords)

Do you find it difficult to coordinate the daily use of your medication with your meals?

Recommendation of action

 Crushing tablets

Yes

Free text (definition of keywords)

This drug is to be crushed.

Do you have any difficulties crushing this drug in such a way that it is it easier to take?

Algorithm

 Disintegrating tablets, capsules and powders

Yes

Free text (definition of keywords)

This drug should be dissolved before use.

Is your drug always completely dissolved?

Recommendation of action

 Administration at fixed times of the day

Yes

Free text (definition of keywords)

Your medication schedule specifies that this drug should be used at a certain time of the day.

Are you able to integrate this into your daily routine?

Recommendation of action

 Intake with advised liquid (or food)

Yes

Free text (definition of keywords)

Do you find it difficult in everyday life to remember taking this medication only with the special liquid or food?

Recommendation of action

 Opening capsules

Yes

Free text (definition of keywords)

These capsules are to be opened before use.

Do you have any difficulties opening the capsules?

Training material

 Increasing doses

Yes

Free text (definition of keywords)

Can you tell me in your own words how you should increase the dose?

Recommendation of action

Training material

 Decreasing doses

Yes

Free text (definition of keywords)

Can you tell me in your own words how you should reduce the dose?

Recommendation of action

Training material

 Cognitive impairment ^a

No

–

Do you find it difficult to remember names, times, or dosages?

Recommendation of action

 Physical impairment ^a

No

–

Many patients do not manage to use their drugs without experiencing some problems. For example, they may lack strength or may no longer be able to read instructions.

Do you also have physical restrictions when it comes to the use of your drugs?

Recommendation of action

 Low health literacy

No

 Lack of knowledge regarding disease/drug treatment

No

 No support in drug handling

No

 Busy lifestyle

No

 Poor numeracy skills

No

 Swallowing difficulties

No

–

Do you have problems swallowing your drugs?

Algorithm

Recommendation of action

Training material

 Use of alternative medicines

No

 Alcohol or illicit drug use

No

 Similar drug names ^a

No

–

Do you have problems distinguishing your drugs because they look similar or their names sound alike?

Recommendation of action

 Similar drug appearance ^a

No

–

Recommendation of action

 Patient-unfriendly nature of solid oral dosage forms

No

 Patient-unfriendly nature of liquid oral dosage forms

Yes

Pharmacy Product Number

Have you ever not taken your drug because the smell, taste, or consistency disturbed you?

Recommendation of action

 Intricate packaging ^a

No

–

Many patients find it difficult to remove their drugs from the packaging.

Do you have any difficulties with the packaging of one of your drugs?

Recommendation of action

 Lack of training in dosage form use

Yes

Pharmacy Product Number

Have you been advised on how to use this drug? Do you think that an explanation of how to use your drug would make it easier for you to perform your therapy?

Training material

 Frequently changing prescriptions ^a

No

–

Have your drugs changed recently, for example because a drug is from another brand or because a new drug has been prescribed?

Do you find these changes difficult?

Recommendation of action

 Changes in existing medication regimen ^a

No

–

 New prescription ^a

No

–

 Frequent generic substitution ^a

No

–

 Changes in tablet color or shape ^a

No

–

 Hospital discharge ^a

No

–

 Lack of comprehensibility and transparency of the instructions for drug treatment

No

 Complex measurements (self-performed)

Yes

Pharmacy Product Number & Free text (definition of keywords)

Do you feel safe adjusting your dose after measuring blood glucose/ blood coagulation?

Recommendation of action

 No use of medication schedule ^a

No

–

Do you use your medication schedule in everyday life, e.g. when you administer or prepare your drugs?

Recommendation of action

 Diverse storage conditions ^a

No

–

Do you store all of your drugs in one place? Has it ever happened that you forget to take drugs that you do not keep with others?

Recommendation of action