Communication, compliance, and concordance between physicians and patients with prescribed medications

Improving patient satisfaction with the transfer of care. A randomized controlled trial

OBJECTIVE

To determine whether educational sessions with medical residents, with or without letters to their patients, improve patient satisfaction with transfer of their care from a departing to a new resident in an internal medicine clinic.

DESIGN

Observational study in Year 1 to establish a historical control, with a randomized intervention in Year 2.

SETTING

An internal medicine clinic in a teaching hospital.

PATIENTS/PARTICIPANTS

Patients of departing residents completed questionnaires in the waiting room at their first visit with a new resident, with mail-administered questionnaires for patients not presenting to the clinic within 3 months after transfer of their care. In Year 1, 376 patients completed questionnaires without intervention. The following spring, we conducted interactive seminars with 12 senior residents to improve their transfer of care skills (first intervention). Half of their patients were then randomized to receive a letter from the new doctor informing them of the change (second intervention). We assessed the efficacy of the interventions by administering questionnaires to 437 patients in the months following the interventions.

MEASUREMENTS AND MAIN RESULTS

Multivariate analysis of Year 1 results identified doctors personally informing patients prior to leaving as the single strongest predictor of patient satisfaction (partial R2=.41). In Year 2, our first intervention increased the percentage of patients informed by their doctors from 71% in 1991 to 79% in 1992 (P <.001). Mean satisfaction dramatically improved, with the fraction of fully satisfied patients increasing from 47% at baseline, to 61% with the first intervention alone, and 72% with both interventions (P <.0001).

CONCLUSIONS

Simple methods such as resident education and direct mailings to patients significantly ease the difficult process of transferring patients from one physician to another. This has implications not only for residency programs, but for managed care networks competing to attract and retain patients.

Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: the Ontario Walk-In Clinic Study

BACKGROUND

Although walk-in clinics are an increasingly common feature of Ontario's health care system, the quality of care they provide is the subject of continuing debate. In this study we examined differences in patient satisfaction and quality of care for common acute conditions in walk-in clinics, family practices and emergency departments.

METHODS

For this prospective cohort study, we recruited 12 walk-in clinics, 16 family practices and 13 emergency departments from 11 geographic areas in greater Toronto, Hamilton-Burlington and London, Ont. An expert review panel selected and established quality-of-care criteria for 8 common acute conditions. Patients who sought initial care for 1 of the 8 conditions were recruited by an on-site data collector. We used a questionnaire to assess the satisfaction of 433 patients with patient-centred communication, the physician's attitude and any delay in the waiting room during the study visit. Abstractors reviewed 600 charts for the study patients to assess whether the quality-of-care criteria had been met. A quality score for each case was computed as the percentage of applicable criteria that were met. Mean quality scores for the 3 settings were computed, with adjustment for potentially confounding variables (sex, age, city and diagnosis).

RESULTS

After adjustment for 12 patient characteristics, walk-in clinic patients were significantly more satisfied than emergency department patients on all 3 satisfaction scales. Family practice patients were more satisfied than walk-in clinic patients on all 3 satisfaction scales, but the difference was statistically significant only for satisfaction with waiting time. Adjusted mean quality-of-care scores were 73.1% for emergency departments, 69.9% for walk-in clinics and 64.1% for family practices. The scores for walk-in clinics and emergency departments were significantly higher than that for family practices.

INTERPRETATION

Satisfaction with waiting time was highest among family practice patients. Both family practices and walk-in clinics were perceived more positively than emergency departments on all 3 dimensions of satisfaction. Overall quality-of-care scores were higher in walk-in clinics and emergency departments than in family practices.

Relationship between quality of diabetes care and patient satisfaction

OBJECTIVE

Patient satisfaction is regarded as a component of the quality of medical care. We examined the association between quality of care and patient satisfaction.

DESIGN

Cross-sectional study.

SETTING

Population-based random sample in North Carolina, United States, 1997.

PARTICIPANTS

591 African-Americans aged > or = 18 years with self-reported diabetes were interviewed for providers' delivery of 10 preventive measures and patients' performance of four preventive measures for diabetes care.

MAIN OUTCOME MEASURES

Satisfaction with health care providers with respect to 11 items, on a 4-point scale (excellent, good, fair, and poor). Average satisfaction scores were compared according to levels of quality of care.

RESULTS

Patient satisfaction was positively associated with income, employment, diabetes education, ease of getting care during the last year, having health care coverage and having one physician for diabetes care (P < 0.05 for each). Adjusted for age, sex, education, employment, and income, 8 of 10 preventive care practices by providers during the previous year--monitoring of concentrations of glycosylated hemoglobin (HbA1c) and cholesterol; performing eye, foot, and gum examinations; and physician counseling on self-monitoring of blood glucose concentrations, exercise, and weight reduction--were associated with higher satisfaction scores (P < 0.05). Patients' performance of three of four preventive practices--taking medications for diabetes as prescribed, performing daily self-examination of the feet, and going for an eye examination with dilation of the pupils--were also associated with higher satisfaction scores (P < 0.05).

CONCLUSION

Quality of diabetes care was positively associated with patient satisfaction with provider of care. Prospective studies are needed to confirm this association and its direction.

Understanding variation in chronic disease outcomes

We propose an explanation for variation in disease outcomes based on patient adaptation to the conditions of chronic disease. We develop a model of patient adaptation using the example of Type 2 diabetes mellitus and assumptions about the process entailed in transforming self-care behaviors of compliance with treatment, compliance with glucose monitoring, and patient's knowledge seeking behavior into health outcomes of glycemic control and patient satisfaction. Using data from 609 adults with diagnosed Type 2 diabetes we develop an efficiency (fitness) frontier in order to identify best practice (maximally adapted) patients and forms (archetypes) of patient inefficiency. Outcomes of frontier patients are partitioned by categories of returns to scale. Outcomes for off-frontier patients are associated with disease severity and patient archetype. The model implicates strategies for improved health outcomes based on fitness and self-care behaviors.

Communication issues in migraine diagnosis

OBJECTIVES

To examine the importance of good communication when informing the patient of the diagnosis of migraine; to review the essentials of successful communication between physician and patient on the aspect of diagnosis; to survey learning resources for physicians on communicating information to patients.

METHODS

This paper is based on observations made by the author of the successful interactions of numerous international "headache experts" with their patients, on a review of the medical education literature pertaining to the teaching of communication skills, and on 30 years of not always successful communication with patients.

RESULTS

Communicating the diagnosis of migraine is an opportunity to educate and reassure the patient, to lay the foundation for rational treatment and to help establish the successful doctor-patient relationship which is essential for effective management. No matter how accurate the diagnosis, failure to communicate it effectively to the patient (and often to significant others) may impair interactions with the patient and compromise therapy. Effective communication of a diagnosis requires clarity, relevance to the patient, a positive attitude, and reinforcement through repetition, questioning and dialogue. In terms of using the diagnosis to lay a foundation for therapy, it is useful to explain the symptoms as transient physical dysfunction of normal tissues, to indicate that there are multiple mechanisms underlying the dysfunction of which only some may presently be susceptible to treatment and to stress the relevance of emotions as factors which may powerfully affect, for better or worse, the underlying disturbed physiology of migraine. Into this model can be "plugged" all the relevant therapies for migraine. This is the ideal, but every day experience in the headache consultant's office suggest that in both primary care and specialist practice, it is infrequently attained. There are scant resources other than example for physicians to learn communication of headache diagnosis specifically but there are numerous print and web resources available to physicians wh wish to learn and/or teach the generic principles of effective communication, and these principles require little or no modification to be applied to the headache patient and the headache doctor.

Social support, medication compliance and HIV/AIDS

Social work practitioners and researchers have greatly understudied the idea of how social support correlates with combination therapy medication compliance, in people living with HIV disease. Meanwhile, such data could help health social workers better assist HIV-infected people who want to cope well, live long, and avoid drug resistance. Therefore, this article presents findings from a three-stage empirical secondary data analysis that examined seven specific types of social support, psychological history and stage of illness variables, and sociodemographics and their connection to medication compliance ratings. A sub-sample of 179 HIV-infected clinical trial study participants enrolled in a federally funded combination therapy treatment study and a nested compliance study were analyzed. Analysis of 14 bivariate hypotheses and 20 predictor variables at the multivariate level revealed that having emotional support and being employed seemed to be predictive of being a "Good Complier." Also, having higher levels of HIV symptoms appeared to be associated with being a "Poor Complier."

Drug users and HIV-combination therapy (HAART): factors which impede or facilitate adherence

The current highly active antiretroviral therapy (HAART), i.e., triple combination treatment including a protease inhibitor, allows for long-term suppression of HIV-replication. The intake guidelines, however, are very strict and, like many other HIV positive patients, drug users have problems in achieving good therapy compliance. As a result, the effectiveness of the medication therapy is seriously jeopardized. This qualitative study, involving in-depth interviews with 27 "hard drug" users in Amsterdam, seeks to provide better insights into the extent of adherence to HAART. In addition, factors that impede or facilitate adherence have been listed in order to develop and improve strategies. The study shows that almost half of the "hard drug" users interviewed do not adhere to the therapy. A large number of determinants for adherence were identified at the level of medication, the individual, and the environment. Many of these determinants can be influenced, which means that they can provide clues for the effective implementation of measures that may enhance effectiveness of treatment.

Perceptual gaps in understanding patient expectations for health care service quality

This article assesses how well physicians, health administrators, patient-contact employees, and especially medical and nursing students understand patient expectations for service quality as measured by the SERVQUAL scale. Using a cross-sectional research design and discriminant analysis, it was found that health administrators were most likely to accurately estimate the service expectations of patients, while medical and nursing students were most likely to underestimate them.

Factors associated with medication self-administration in children with asthma

This study investigated factors associated with early self-administration of inhaled asthma medications by minority children. Specifically, the study evaluated: (1) the reasons parents allow early administration of inhaled medications, (2) childhood activities associated with early medication administration, (3) parent's perception of the child's ability to use a metered-dose inhaler (MDI), (4) the child's actual ability to use an MDI, and (5) concordance/discordance between physician-parent reports and parent-child reports of asthma medications. Study results indicated that 93% of the children were taking inhaled asthma medications without adult supervision. Early self-administration of asthma medications was related to the parent's employment status and the performance of other childhood behaviors such as completion of homework independently and crossing the street alone. Only 7% of the children had effective MDI skills, but 60% of the parents rated their child's MDI skills as excellent. Twenty percent, 67%, and 50%, respectively, of the parents' reports of beta-agonists, daily inhaled steroids, and cromolyn were discordant with the physician's actual prescriptions. Sixty-two percent, 57%, and 79%, respectively, of the children's reports for inhaled beta-agonists, daily inhaled steroids, and cromolyn were discordant with their parents' reports. Implications for anticipatory guidance, future educational strategies, and supervision of MDI technique are provided.

Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS

The purpose of this descriptive, correlational study was to examine the relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. The convenience sample of 707 non-hospitalized persons receiving health care for HIV/AIDS was recruited from seven U.S. sites. All measures were self-report. Perception of engagement with health care provider was measured by the newly developed Engagement with Health Care Provider scale. Adherence to therapeutic regimen included adherence to medications, provider advice, and appointments. Health status was measured by the Medical Outcomes Study Short Form 36 (MOS SF-36), Living with HIV scale, CD4 count, and length of time known to be HIV-positive. There were no significant relationships between engagement with health care provider and age, gender, ethnicity, and type of health care provider. Subscales of the MOS SF-36 and Living with HIV explained a significant, but modest amount of the variance in engagement. Clients who were more engaged with their health care provider reported greater adherence to medication regimen and provider advice. Clients who missed at least one appointment in the last month or who reported current or past injection drug use were significantly less engaged.

Challenges of and strategies for changing prescribing practices of health care providers

Problems related to inappropriate prescribing practices of physicians in general are well recognized. Dietary fluoride supplements have been implicated as one of the contributing factors in an increase in dental fluorosis. Inappropriate prescribing practices of providers have been cited as a major factor in this implication. Numerous studies of physicians and dentists have documented a lack of knowledge and inappropriate prescribing practices regarding fluoride supplements. The purpose of this paper is to identify barriers to changing fluoride-prescribing practices of health care providers and to suggest strategies for implementing change. To increase optimal and appropriate use of fluoride supplements, educational interventions are necessary for all user groups--detail men and women, physicians, dentists, pharmacists, nurse practitioners, dental hygienists, and the public. In addition, environmental supports for the educational activities in the form of policy, regulation, standards of care, and guidelines are recommended for consideration.

Pharmaceutical care for patients with chronic conditions

OBJECTIVE

To assess factors associated with participation in pharmaceutical care and the benefits of participation--in terms of amount of information about medications, administration of medications, and awareness of side effects.

DESIGN

Quasi-experimental design, with a control group. Medication Survey, administered 6 months after pharmaceutical care intervention to participants, refusers, and controls. Logistic regression analyses.

SETTING

Three staff clinic pharmacies and three contract clinic pharmacies affiliated with a health maintenance organization (HMO).

PATIENTS AND OTHER PARTICIPANTS

Patients with chronic health conditions (asthma, chronic obstructive pulmonary disease, or heart disease) enrolled at six intervention sites, identified through the HMO's electronic pharmacy database. Control sample with the same chronic health conditions, without access to pharmaceutical care (n = 210 participants, 162 refusers, and 368 controls; overall adjusted response rate = 72%).

INTERVENTION

Pharmaceutical care, in the form of a comprehensive drug therapy management program.

MAIN OUTCOME MEASURES

Predictors of participation, amount of information about medications, use of reminder methods, and awareness of side effects.

RESULTS

The following variables were significantly associated with the probability of participating in pharmaceutical care (P < .05): number of medications, employment, income, health status, education, and living situation. Participants were more likely than controls to say they received "a lot of information" from their pharmacist about all aspects of medications (odds ratio [OR], 1.75 to 2.68). Participants were more likely to report leaving their medication container in a visible place and using two or more reminder methods (OR, 1.87 to 1.48). There were no significant differences in the probability of missing doses. Participants were more likely to report experiencing "symptoms or problems" associated with prescription medications (OR, 1.81).

CONCLUSION

Pharmaceutical care appears to increase the information given to patients about medications, promote more effective self-administration of medications by encouraging patients to use systematic reminders, and increase awareness of medication side effects.

The Client Adherence Profiling-Intervention Tailoring (CAP-IT) intervention for enhancing adherence to HIV/AIDS medications: a pilot study

This article describes the Client Adherence Profiling-Intervention Tailoring (CAP-IT) intervention designed to enhance adherence to HIV/AIDS medications and reports the results of a pilot study aimed at assessing the feasibility of CAP-IT. Initially, CAP-IT was designed to be implemented by nurse case managers during regularly scheduled home visits; it is currently under revision for use in an outpatient, ambulatory care setting. CAP-IT is an innovative, structured nursing assessment and care-planning activity that allows a standardized assessment of client needs and tailored highly active antiretroviral therapy adherence intervention strategies. CAP-IT is significantly different from the current standard nursing case management practice. Pilot study results in a sample of 10 home care patients suggests that clients have knowledge and skill deficits related to adherence and in the management of the side effects of medications. In addition, the pilot study supported the acceptability of the protocol to clients and the feasibility of integrating CAP-IT into nurse case manager practice. The pilot study results also provided evidence for the efficacy of CAP-IT. The next steps include testing CAP-IT in a randomized clinical trial to determine its effectiveness.

Medication education of acutely hospitalized older patients

OBJECTIVES

To determine the amount of time spent providing medication education to older patients, the impact of medication education on patients' knowledge and satisfaction, and barriers to providing medication education.

DESIGN

Telephone survey of patients within 48 hours of hospital discharge and direct survey of physicians and pharmacists.

SETTING

Internal medicine ward in a tertiary care teaching hospital.

PARTICIPANTS

Patients 65 years of age and over regularly taking at least one medication.

MEASUREMENTS

Patient demographics, medication use, time spent receiving or providing medication education, and satisfaction scores.

MAIN RESULTS

Forty-seven respondents with a mean age of 77.1 years reported that physicians spent a mean of 10.5 minutes (range, 0-60 minutes) and pharmacists spent a mean of 5.3 minutes (range, 0-40 minutes) providing medication education. Fifty-one percent reported receiving no education from either physician or pharmacist, and only 30% reported receiving written medication instructions. Respondents were generally quite satisfied with their education. Physicians identified one or more barriers to providing education 51% of the time and pharmacists 80%. Lack of time was the most common barrier (18%) identified by physicians, but pharmacists cited lack of notification of discharge plans (41%) and lack of time (39%) as the main barriers. Respondents made many medication errors and knew little about their medications.

CONCLUSIONS

Although older hospitalized patients received little medication education or written information and made many medication errors with and without medication education, approximately one half of physicians perceived no barriers to providing education.

Prescription noncompliance: contribution to emergency department visits and cost

We randomly surveyed 100 patients in the acute care section of a large urban university hospital Emergency Department (ED) on 6 days with regard to the existence of and reasons for prescription noncompliance. Noncompliance was considered a major factor contributing to the ED visit if: (1) no medications had been taken for at least 48 h before the ED visit; (2) the medications, when previously taken, had routinely controlled the condition for which the patient was presenting to the ED; and (3) no other significant cause or illness was believed to have precipitated the ED visit. ED, admissions, and yearly medication costs were calculated for all patients. Noncompliance was found to be a contributing factor in the cases of 22 patients (22%). The most common medications involved were phenytoin and albuterol. Cost was the most common reason for noncompliance (11 [50%]). The average ED charge per noncompliant patient discharged was $576.61. Six noncompliant patients were admitted at an average cost of $4,834.62. The average cost of a year's medication was $520.72. Noncompliance with drug prescriptions is a significant contributor to ED visits and health care costs.

The necessary role of the autopsy in cardiovascular epidemiology

The autopsy rate in the United States today is remarkably low, with proportionally fewer autopsies for natural causes of death. Consequently, most cardiovascular epidemiology studies do not use autopsy data and rely on death certificates, medical records, questionnaires, and family interviews as sources of mortality information. These practices introduce a high degree of variability and uncertainty regarding cause of death. This review illustrates the necessity for increased use of autopsies in cardiovascular epidemiology by critically evaluating other measures of cardiovascular disease (CVD) incidence. We evaluated the literature regarding CVD as cause of death and conducted discussions with cardiologists, pathologists, and epidemiologists. No attempt was made for meta-analysis. This review shows the limited reliability of death certificates, medical records, and interviews as sources of mortality statistics. In addition, the autopsy's role in clearly indicating the presence of CVD is illustrated. The autopsy used in conjunction with medical records is the only reliable means for establishing cause of death from CVD. There is an urgent need to reassess the current dependence of statistical mortality data on death certificates and other inadequate sources of CVD incidence. Death certificates, in general, are inadequately monitored for quality control and appropriate administrative oversight. With an increase in the number of hospitals performing no autopsies to investigate cause of death, a uniform national autopsy database is needed.

Predictors of medication adherence in the elderly

As average life expectancy increases, so do the incidence of chronic diseases and the number of persons receiving long-term drug therapy. Thus elderly patients' noncompliance with medication regimens has the potential for sweeping medical and economic consequences and is likely to become increasingly important in the design of disease-management programs for this population. The author conducted a MEDLINE search of the English-language literature for the years 1962 to 1997 to identify articles concerning predictors of medication compliance in the elderly. A descriptive analysis of this literature indicated that there remains some uncertainty about the reasons for noncompliant medication-taking in the elderly. Clear associations have been established between elderly patients' medication adherence and race, drug and dosage form, number of medications, cost of medications, insurance coverage, and physician-patient communication. However, the findings are inconsistent with regard to the effects of patients' age, sex, socioeconomic status, living arrangement, comorbidities, number of physician visits, and knowledge, attitudes, and beliefs about health. Until the results of further comprehensive studies are available, the current knowledge should be considered when designing and implementing disease-management programs for the elderly.

Metabolic control, quality of life, and negative life events: a longitudinal study of well-controlled and poorly regulated patients with type 1 diabetes after changeover to insulin pen treatment

In a previous study of a group of 74 patients with Type I diabetes, quality of life was found to be consistently enhanced a year after transition to multiple injection therapy with the insulin pen, whereas metabolic control (HbA1C) only improved moderately. The aim of the present investigation was to examine quality of life, recent life events, and metabolic control longitudinally in this original study group over a 5-year period beginning 1 year after transition to the insulin pen. Multiple analysis of variance with a repeated-measures design was used to analyze the data longitudinally and compare metabolic control in subgroups of well-controlled and poorly regulated patients during the study period. For the group as a whole, quality of life was found to change only moderately, whereas metabolic control deteriorated significantly across time following transition to the insulin pen. The two subgroups exhibited distinct differences, however, in quality of life, recent life events, and metabolic control patterns. These findings are discussed in terms of the clinical suitability of a multiple injection regimen.

[Physician-patient interactions: a comparison of analysis systems]

OBJECTIVE

The medical interview has important diagnostic and therapeutic functions and requires the integration of doctor-centred and patient-centred interviewing techniques to collect accurate and complete biopsychosocial data from the patient. Analysis of the interaction between patient and doctors which occur during the medical interview allow to evaluate physicians' interview techniques and to eventually improve them.

OBJECTIVE

1. To review different Interaction Analysis Systems (IAS) used to describe doctor-patient communication in terms of clinical relevance, observational strategy, reliability and behavioural and verbal contents. 2. To critically evaluate these IASs on the basis of their relevant research outcomes.

METHOD

Previous reviews on interaction and keywords for Medline research (HealthGate) listed above were utilised to collect the relevant literature.

RESULTS

Seventeen classification systems were identified and ten were discussed in a chronological order. Starting from a general sociological or psycholinguistic approach, the IASs over the years have became more specific and detailed, focusing more on the medical interview and on specific topics, such as cancer or hospital medical consultations.

CONCLUSIONS

When studying interactions in general practice medicine, it is important to define the significant units of interaction which allow to identify a "patient-centred approach", since this is relevant not only for obtaining reliable and complete medical and social data, but also for the recognition of patients with emotional disorders and their correct diagnosis. Listening to the patient and facilitating the expression of emotions is an important aspect of patient education too, as patients learn that talking about psychological problems to their physician is appropriate and may be therapeutic.

Reactance theory and patient noncompliance

With surprising frequency, and to the considerable dismay of health care professionals, patients both subtly and overtly refuse to cooperate with medical treatment. Despite considerable empirical and theoretical attention, and an abundance of interventions designed to combat it, noncompliance continues. Its persistence is accompanied by considerable costs borne by patients and society alike. The theory of psychological reactance sheds new light on the phenomenon. Reactance theory proposes that a perceived threat to an individual' freedom generates a motivational state aimed at recapturing the affected freedom and preventing the loss of others. In a medical context, patients' perceptions of threats to their freedom or control may induce noncompliance. This theory permits integration of many of the seemingly disparate and/or contradictory findings, and may afford professionals new opportunities for improving patient compliance.

Patient comprehension of doctor-patient communication on discharge from the emergency department

An exit interview was conducted during March, 1994 on 314 patients treated and released from the Emergency Department at Kern Medical Center in Bakersfield, California. The questionnaire was designed to assess understanding of diagnosis, prescribed medications, additional instructions, and plans for follow-up care. The patients' own perceptions of the adequacy of communication and whom they considered the most important source of information were also determined. Overall, patients correctly identified 59% of their instructions. The performance of the English speaking and the Spanish speaking patients was compared. Spanish speaking patients scored significantly lower on all questions. The physician was identified by most patients (63.8%) as the source of the most information.

Clwydian Community Care Trust: district nursing patients' questionnaire

The aim of this project was to develop a reliable and valid consumer satisfaction questionnaire for users of the District Nursing Service in Clywd. During the qualitative phase 18 quality themes were identified. These were used to construct a draft questionnaire. Respondents were to rate their experience of the service (experience scale) as well as the importance to them of each service feature listed (importance scale). Following pilot testing and item analysis the importance scale was dropped. Factor analysis of the resulting 11-item questionnaire yielded four factors, similar to those identified in other studies. Makes some suggestions to improve the reliability and practical utility of the questionnaire, and describes its use in Clwyd.

Patient characteristics associated with failure of tuberculosis prevention

OBJECTIVES

The cost-effectiveness of tuberculin screening may be substantially reduced by non-compliance of patients and physicians. We have examined the association of these problems with the socio-demographic characteristics of tuberculin reactors.

METHODS

Community-based tuberculin screening was conducted among students in grades 6 and 10, and in post-secondary health training, as well as young adult workers. A follow-up survey was conducted to determine if tuberculin reactors referred for further evaluation actually reported, if they were prescribed therapy when indicated, and if they took therapy when it was prescribed. Association of reactors' socio-demographic characteristics with these outcomes was analyzed.

RESULTS

Canadian-born subjects were less likely to report if they were: older (adjusted and standardized odds ratio: 0.7, 95% confidence interval: [0.5, 0.9]), resident in more affluent neighbourhoods (0.7 [0.6, 0.99]), and from single parent households (0.1 [0, 0.9]). Even when indicated, physicians were less likely to prescribe treatment for Canadian-born subjects who reported bacille Calmette-Guérin vaccination, but had not actually received this (0.3 [0.1, 0.7]), or who were from single-parent households (0.1 [0, 0.9]). Physicians were less likely to prescribe treatment for foreign-born who gave a history of BCG vaccination (0.1 [0.1, 0.3]), and were more likely to prescribe treatment for reactors from countries such as Haiti or Vietnam. The only factor significantly associated with compliance was that older Canadian-born subjects were less compliant (0.6 [0.4, 0.97]).

CONCLUSIONS

Failure to report for further medical evaluation and physician non-compliance were associated with a number of socio-demographic characteristics, and substantially reduced the benefit of a tuberculosis screening program.

An analysis of drug information desired by the patient. (Are patients being told everything they wish to know under OBRA '90?)

The need for patient package inserts (PPI) has been a controversial issue for many years. In August 1995, the FDA proposed 'MedGuide', a mandatory PPI programme. Recent efforts to educate patients about drug therapy include the OBRA '90 (Omnibus Budget Reconciliation Act of 1990) requirement for pharmacists to offer counselling to all patients receiving prescription drugs. In order to assess if patient information needs are being met, an 18-item survey was distributed to 873 patients at eight randomly selected New Jersey pharmacies until 100 patients had anonymously responded. Seventy-five per cent or more of respondents indicated that they received the following information from a health professional: medication name, reason prescribed, how often to take and duration of therapy. Less than 50% of respondents received information concerning: storage conditions, over-the-counter (OTC) or prescription only (Rx) interactions, what happens to the body if a dose is missed and how to avoid side-effects. Using a five item scale, every item was rated as important by at least 60% of respondents. Although information was reaching the majority of patients who responded, there were still some gaps between that which they considered to be important and information actually received. Some additional intervention might be beneficial to help to bridge these informational gaps.

Non-compliance in elderly people: evaluation of risk factors by longitudinal data analysis

Studies on risk factors for drug non-compliance have not taken into account the possibility of correlated outcomes. We therefore conducted a study into risk factors for non-compliance by using analysis techniques that adjust for these correlations (longitudinal data analysis). Data were obtained from interviews and pharmacy records in a cross-sectional survey in Amsterdam. The subjects were 157 elderly people aged 70 years or older. Of these subjects, 37 were residents of a home for the elderly, 40 were community-dwelling elderly who needed to be visited regularly by a district nurse, and 80 were community-dwelling elderly who did not need to be visited by a district nurse. Most drugs (78%) were used according to the directions; the remainder (22%) were not used as intended. Odds ratios (95% confidence intervals) for non-compliance for moderate and poor/wrong knowledge of the purpose of a drug as compared with good/correct knowledge were 2.8 (1.2-6.7) and 4.2 (1.5-12), respectively. Drug regimens of two times daily and more than two times daily were associated with odds ratios for non-compliance of 4.5 (1.6-12) and 4.2 (1.7-11), respectively, compared to a regimen of once daily. Compliance increased if a drug was prescribed by a specialist instead of a general practitioner odds ratio 0.1 (0.04-0.4)]. There was no significant relation between compliance and the number of drugs prescribed to a patient, sex, age, living situation, patient group, or perceived effect. This study, which was based on longitudinal data analysis, demonstrates that in elderly people non-compliance with drug therapy is related to the knowledge of purpose of a drug, the complexity of a drug regimen, and the type of prescriber. The positive association between compliance and the number of drugs prescribed found in former studies was not confirmed.

Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment

PURPOSE

The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence.

PATIENTS AND METHODS

One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients.

RESULTS

Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7).

CONCLUSIONS

These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Compliance with treatment in adult patients with cystic fibrosis

BACKGROUND

Patients with chronic disease comply with about 50% of their treatment. The complex and time consuming daily drug regimens needed in the care of adult patients with cystic fibrosis encourage non-compliance with prescribed treatments. Understanding the reasons for, and the extent of, non-compliance is essential for a realistic appraisal of the patient's condition and sensible planning of future treatment programmes.

METHODS

Patients were invited to complete a questionnaire which asked about their compliance with daily treatment. The data were used to calculate a compliance score, the percentage of prescribed treatment taken, and to examine patient attitudes to each individual prescription. An assessment score derived from consultant, cystic fibrosis research fellow, specialist nurse, and physiotherapist ratings of patient compliance was compared with the compliance score. Both scores were correlated with patient characteristics and disease severity, and the compliance score was also correlated with the patient's knowledge of cystic fibrosis.

RESULTS

More than half the patients claimed to take more than 80% of their treatments. Compliance with individual treatments varied according to their perceived unpleasantness and degree of infringement on daily activities. The most common reason given for omitting treatment was forgetfulness. Professional carers were poor judges of patient compliance. There was no correlation between compliance and patients' sociodemographic characteristics or their knowledge about cystic fibrosis.

CONCLUSIONS

Non-compliance is universal and should be recognised as normal behaviour. There are no reliable criteria for predicting any patient's level of compliance. Treatment protocols should be planned around individual patient's requirements, modifying treatment ideals where necessary according to the exigency and pattern of that patient's lifestyle.

Self-management of chronic illness: implications for nursing

Health problems and disease have changed during the last century with an increase in the numbers of people with chronic illness. Literature reveals the role of patients changing from passive to active participation in care management. A study of factors influencing self-management using both quantitative and qualitative methods was carried out. Selected results, with the major focus on the qualitative data, are presented to support discussion of a number of issues related to self-management of diabetes. However, many of the implications of the results also apply to those with chronic illness.

Living with a chronic illness: Chinese-Canadian and Euro-Canadian women with diabetes--exploring factors that influence management

The study reported on here was designed to address how Euro-Canadian and Chinese-Canadian women living with diabetes experience and manage their illness in their day to day lives, and the factors that influence daily management (diet, exercise, medication and blood testing). It was hypothesized that women's patterns of diabetes management would be associated with (a) ethnicity and/or (b) fluency in English. It was also hypothesized that the extent to which women with diabetes (whether Chinese- or Euro-Canadian, fluent or not fluent in English) would carry out daily management in accordance with western health care practices would be associated with: (i) the extent to which desired professional care is experienced; (ii) the women's awareness of facts as endorsed by health professionals (biomedical knowledge); and (iii) her satisfaction with the support received from family and friends. A total of 196 women were interviewed to explore these hypotheses. While we do not yet know the magnitude or relative importance of each of the independent variables, the findings from this study suggest that the management of diabetes is a complex construct, comprised of several components, each being influenced by a number of factors. How a woman managed her illness was not reducible to her ethnicity. Instead, the contextual features of her life, coupled with her ability to access resources seemed to organize the ways in which she managed her illness. Diabetes management therefore becomes a multifaceted phenomenon, which has to be understood within the mediating circumstances of a woman's life.

Adherence to recommended medical regimens in childhood and adolescence

OBJECTIVE

Factors that appear to influence treatment adherence among adults have been the focus of considerable research in recent years. However, less research has focused on children's treatment adherence. This paper reviews current knowledge about factors that appear to influence adherence among children and adolescents.

METHODOLOGY

Factors associated with adherence to medical regimens reviewed here include: (i) the psychosocial characteristics of children and their parents; (ii) the nature of the treatment regimen; and (iii) the relationship between health practitioners, parents and paediatric patients.

CONCLUSIONS

Issues for future research include: (i) the adherence of both children and their parents to children's treatment, and the allocation of responsibility for treatment adherence; (ii) the wide range of behaviours involved in regimen adherence should be acknowledge; patients' adherence to one aspect of their regimen should not be considered indicative of their overall adherence; and (iii) longitudinal studies are required to examine the causal relations between patient adherence and its antecedents.

When the physician leaves the patient: predictors of satisfaction with the transfer of care in a primary care clinic

OBJECTIVE

To identify independent predictors of patients' satisfaction with transfer of their care from a departing to a new resident physician.

DESIGN

A self-administered questionnaire completed by consecutive patients following up after transfer of their care, and by a randomly selected 50% of patients not returning within three months after transfer.

SETTING

An internal medicine clinic in a teaching hospital.

PATIENTS

Questionnaires were completed by 376 patients: 237 returning to clinic and 139 (91%) of 152 randomly selected patients who had not returned. Mean age of the patients was 65 years, 52% were men, and they had come to the clinic for a median of four years.

RESULTS

57% of the patients were satisfied with the transfer process, 25% were neutral, and 18% expressed frank dissatisfaction. Of nine variables significantly associated with satisfaction by univariate analysis, stepwise multiple regression identified five independent predictors. Personal notification of the patient by the departing physician was the most powerful determinant, explaining 41% of the variability in satisfaction. Other predictors were whether patients believed their physicians had done everything possible to facilitate transfer, whether the departing physician had provided opportunity for discussion of the transfer, whether this discussion was considered sufficient, and patients' impressions of the institution.

CONCLUSIONS

Most of the predictors identified can be influenced by physician behavior, suggesting that physicians should personally notify patients of their departure and provide an opportunity for discussion. This could significantly improve patient satisfaction with the transfer process and, as previous studies suggest, translate into greater compliance with medications and follow-up.

Taking antihypertensive medication--controlling or co-operating with patients?

Low compliance with antihypertensive drug regimens has been a well documented reason for inadequate control of hypertension. We assessed recent literature regarding compliance from different disciplines to clarify the nature of reported problems on low compliance to prescribed antihypertensive medication. Much research focuses on primary factors for compliance, methods to monitor and measure individual rates and patterns of compliance. From a behavioural oriented point of view, the focus is on understanding why patients act as they do. This review indicates that there is an almost complete lack of knowledge about how the decision making in the clinical practice is organized when prescribing antihypertensive medication and/or when following up treatment from patients already taking such drugs. Since the concrete communication and collaboration between patient and physician in the clinical setting are of prime significance for patient adherence to drug regimens, it is important to shed light on what happens in this critical situation.

Patient decision making. The missing ingredient in compliance research

Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one third and one half of patients fail to comply with medical advice and prescriptions. Critically absent from this research record has been the patient's role in medical decision making. For patients, particularly those with chronic illnesses, compliance is not an issue: they make their own reasoned decisions about treatments based on their own beliefs, personal circumstances, and the information available to them. The traditional concept of compliance is thus outmoded in modern health care systems, where chronic illness and questioning patients predominate.

Non-compliance--or how many aunts has Matilda?

The compliance of patients with medication prescribed for them is a challenge. It seems that one-third of patients comply adequately, one-third more-or-less, and one-third are non-compliant, so that compliance rates hover around 50%. This can be improved upon, but not by treating failure to comply as a deplorably aberrant behaviour. First we need to know more about compliance and non-compliance, and that means standardising methods of study and measuring, by questioning the patient, counting tablets, or looking at drug metabolites or markers in faeces, blood or urine. Doctors' prejudices and patients' perceptions alike have to be taken into account since strategies for improvement must include both educating the prescriber and counselling the patient.

Failure to have prescriptions filled among Black elderly

Despite extensive research on drug consumption and compliance with drug regimens within the geriatric population, little attention has been given to the failure to have prescriptions filled among elderly in general and Black elderly in particular. The prevalence and correlates of patients' failure to have prescriptions filled were investigated for a sample of 571 Black elderly. In terms of prevalence, 12.8% of this sample asserted that they had received a prescription from a physician and not had it filled during the 6 months period prior to interview. Multivariate logistic regression was employed to detect the significant predictors of this type of noncompliance. According to our data, failure to have prescriptions filled was significantly greater among Black elderly with higher levels of anxiety, those with lower levels of internal health locus of control, those who did not have prescription medication coverage through Medicaid, those who were currently using prescription medications, those who consumed greater numbers of over-the-counter medications, and those who reported more financial problems. Implications of these findings are discussed.