Measurement of continuous ambulatory peritoneal dialysis prescription adherence using a novel approach.
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OBJECTIVE: The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription. DESIGN: A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time. SETTING: Patients were recruited from an outpatient dialysis center. PARTICIPANTS: A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston-Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate. MEASURES: Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened. RESULTS: One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent (p = 0.015). CONCLUSIONS: This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach. (+info)
Natural history of amblyopia untreated owing to lack of compliance.
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AIMS: A prospective study of the efficacy of amblyopia treatment in preschool children has recently been called for, requiring an untreated control group. The present study assessed data from patients with amblyopia untreated owing to lack of compliance, or with amblyopia risk factors, to determine outcome. METHODS: Longitudinal data were obtained from 18 4-6 year old patients who had initially been screened for amblyopia, strabismus, and/or bilateral refractive error, failed to comply with prescribed treatment, and in whom amblyopia was detected at a rescreening approximately a year later. The data from three previous studies comparing outcome of patients compliant and non-compliant with amblyopia treatment were also reanalysed. RESULTS: One child of the 18, who wore glasses sporadically, showed some improvement in visual acuity in the amblyopic eye. Otherwise, no child showed an improvement, and seven of the 17 (41%) for whom visual acuities were available at both screenings showed a deterioration of visual acuity in the amblyopic eye, including three who apparently developed amblyopia for the first time. A child with an ametropic risk factor for amblyopia whose visual acuity was not obtained at the first screening and who was largely non-compliant presented with amblyopia at the second screening. The reanalysed data from the three previous studies demonstrated a significantly poorer visual acuity outcome in the amblyopic eye in the non-compliant patient groups than in the compliant groups in each study. CONCLUSION: Preschool children with amblyopia or its risk factors are at risk of having the current amblyopia deteriorate, or of developing amblyopia, if not treated. These results raise questions about the ethical acceptability of a prospective study of amblyopia treatment at these ages. (+info)
Suicide within 12 months of contact with mental health services: national clinical survey.
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OBJECTIVE: To describe the clinical circumstances in which psychiatric patients commit suicide. DESIGN: National clinical survey. SETTING: England and Wales. SUBJECTS: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death. MAIN OUTCOME MEASURES: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending. RESULTS: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases. CONCLUSIONS: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk. (+info)
Is default from colposcopy a problem, and if so what can we do? A systematic review of the literature.
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It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature to assess the extent of default from colposcopy and to identify interventions, suitable for implementation within primary care, to reduce the proportion of women defaulting. Searches were performed on MEDLINE, PsychLIT, Bids and Cancerlit from 1986 to September 1997 using the terms colposcopy or cervical/Pap smear in association with default, non-attendance, adherence, patient compliance, treatment refusal, patient dropouts, attendance, barriers or intervention. The inclusion criteria for primary papers were that they contained data that enables the calculation of default rates for colposcopy or the results of interventions aimed at improving the default rates. Thirteen publications describing default rates and four describing interventions were included as primary papers. Combining the data from these studies suggests default rates of 3%, 11%, and 12% for assessment/treatment visits, first review, and second review respectively. The intervention studies suggested a need to tailor the intervention to the population and the type of information to suit the individual. Varying definitions make comparison of default rates difficult, and the use of a crude non-attendance rate may result in an overestimate of default rates. The vast majority of women invited to colposcopy eventually attend. It is questionable if there is a need for interventions to increase compliance. Where necessary, greater cooperation across the primary/secondary care interface and use of the extended primary care team may be a more cost-effective means of increasing compliance. (+info)
The value of provocation methods in patients suspected of having non-epileptic seizures.
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Non-epileptic seizures (NES) are reported in 18-23% of patients referred to comprehensive epilepsy centres. Non-epileptic seizures may also be present in 5-20% of the patients who are diagnosed as having refractory seizures. Because of their prevalence, financial and psychosocial outcomes cannot be ignored and accurate diagnosis is of the utmost importance. Various methods of seizure induction have been developed with the aim of differentiating epileptic from non-epileptic seizures. However, recording the attacks by video-EEG monitoring is the gold standard. In our outpatient EEG laboratory we try to induce seizures with verbal suggestion or IV saline infusion in patients who are referred by a clinician with the diagnosis of probable non-epileptic seizures. In this study we investigated the results of 72 patients who were referred between January 1992-June 1996. Non-epileptic seizures were observed in 52 (72.2%) patients. Thirteen of these patients still had risk factors for epilepsy. We could not decide whether all of their previous attacks were non-epileptic because 10-30% of the patients with NES also have epileptic seizures. For a more accurate diagnosis it was decided that these 13 patients, together with the 20 patients who did not have seizures with induction, needed video-EEG monitoring. Thirty-nine patients who had NES and no risk factors for epilepsy were thought to have pure non-epileptic seizures. We claim that not all patients suspected of having NES need long-term video-EEG monitoring and almost half (54.2%) of the cases can be eliminated by seizure induction with some provocative techniques. (+info)
Respiratory rehabilitation in chronic obstructive pulmonary disease: predictors of nonadherence.
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Rehabilitation is now an integral part of chronic obstructive pulmonary disease (COPD) management. The objective of the study was to determine predictors of nonadherence to a COPD rehabilitation programme. Patients attending a COPD clinic were invited to participate in a 4 week, hospital-based, outpatient, COPD rehabilitation programme conducted predominantly by respiratory physiotherapists. All potential participants undertook an interviewer administered questionnaire addressing social, economic, psychological and healthcare factors, and underwent baseline physiological measures. Subsequently they were classified as: 1) "adherent" group who completed the total programme (n=55) or 2) "nonadherent" group who refused or began but did not complete the programme (n=36). The nonadherent group compared to the adherent group were more likely to be divorced (22 versus 2%, p<0.005), live alone (39 versus 14%, p<0.02), and to live in rented accommodation (31 versus 6%, p<0.005). There were no differences between the two groups in terms of baseline physiological parameters (forced expiratory volume in one second, forced vital capacity, 6-min walk distance, oxygen saturation, perceived dyspnoea), quality of life domains (Chronic Respiratory Disease Questionnaire), or indices of COPD-related morbidity. The nonadherent group were more likely to be current smokers (28 versus 8%, p<0.02) and less likely to use inhaled corticosteroids (16 versus 42%, p<0.005). The nonadherent group was not significantly likely to be depressed, anxious, prone to hyperventilation or to have had previous emotional counselling and was more likely to be dissatisfied with disease-specific social support (51 versus 2%, p<0.001). In conclusion, a substantial proportion of eligible subjects who did not participate in a chronic obstructive pulmonary disease rehabilitation programme were not more physiologically impaired, but were more likely to be: socially isolated, lack chronic obstructive pulmonary disease-related social support, still be smoking and be less compliant with other healthcare activities. Identification of one or more of these factors reliably allows prediction for nonadherence to a rehabilitation programme. (+info)
Reducing non-attendance at outpatient clinics.
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Outpatient non-attendance is a common source of inefficiency in a health service, wasting time and resources and potentially lengthening waiting lists. A prospective audit of plastic surgery outpatient clinics was conducted during the six months from January to June 1997, to determine the clinical and demographic profile of non-attenders. Of 6095 appointments 16% were not kept. Using the demographic information, we changed our follow-up guidelines to reflect risk factors for multiple non-attendances, and a self-referral clinic was introduced to replace routine follow-up for high risk non-attenders. After these changes, a second audit in the same six months of 1998 revealed a non-attendance rate of 11%--i.e. 30% lower than before. Many follow-up appointments are sent inappropriately to patients who do not want further attention. This study, indicating how risk factor analysis can identify a group of patients who are unlikely to attend again after one missed appointment, may be a useful model for the reduction of outpatient non-attendance in other specialties. (+info)
Issues of consent in colonoscopy: if a patient says 'stop' should we continue?
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Colonoscopy is generally performed under intravenous sedation, which may alter a patient's responses and perception. What should be done if, during the procedure, a patient withdraws the consent previously given? The views of gastroenterologists and patients were ascertained by mailing questionnaires to 100 members of the British Society of Gastroenterology and to 100 patients who had undergone colonoscopy with intravenous sedation. Only 1 of 59 eligible consultants who replied said they would stop the procedure after a single request, but a further 51 would stop if repeatedly asked to do so. Of the remaining 7 who would complete the procedure, 1 nevertheless believed that a sedated patient is capable of making a rational decision. Of the 51 patients who returned a usable questionnaire, 25 thought that the procedure should be stopped immediately following a request, while 26 felt that the doctor should continue. The divergent and sometimes inconsistent views found in this study highlighted the need for further clarification of the issue of informed consent for procedures conducted with the patient under sedation. (+info)