Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome.

BACKGROUND: Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI<40events/h. METHODS: Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss' Kappa statistics (Kappa). RESULTS: A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa=0.83, 95% CI, 0.75-0.90, p<0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa=0.46, 95% CI, 0.42-0.51, p<0.001). Nevertheless, it was especially low when considering AHI<15events/h. CONCLUSIONS: This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols.

Using Collaborative Drug Therapy Agreements to Train Student Pharmacists to Provide Clinical Patient Care Services.

Objective. To assess the impact of a new course designed to train student pharmacists to provide clinical patient care services delivered through collaborative drug practice agreements. Design. An intensive two-credit, one-week course with a combined self-study and interactive pedagogical approach was developed. Content from the online Washington State Pharmacy Association Clinical Community Pharmacist training program was integrated with a live, eight-hour seminar. Assessment. Student-pharmacist learning, effectiveness of content presented, and perceived value of the material were evaluated. Scores on quizzes, a knowledge assessment, a patient-case examination, pre- and post-seminar surveys, and voluntary student certification rate were collected and analyzed. Of 132 student pharmacists enrolled in the course, 121 students met competency on their first attempt at completing the knowledge assessment and 126 students met competency on their first attempt at completing the practical examination. A pre- and post-training survey found that student pharmacists were significantly more comfortable performing and recommending implementation of services after completing the course. Conclusions. Training student pharmacists who are competent and comfortable providing clinical patient care services can improve access to care and reduce the impact of the impending physician shortage.

Adesão ao tratamento com anti-retrovirais entre pacientes com AIDS / Compliance with antiretroviral treatment among patients with AIDS: a descriptive study

Objective: To assess compliance with antiretroviral therapy (ARVT) among HIV/aids patients and to propose strategies that would facilitate it. Methods: A study of the descriptive and exploratory type was conducted at a specialized outpatient clinic in Fortaleza-CE between May and June 2004, with Thirty-eight patients with aids taking ARVT of a structured interview. Compliance was calculated on the basis of the sum of the total quantities of ARVT pills taken during the three days preceding the interview. A patient who used at least 95% of the amount of ARVT prescribed was considered to be compliant. Results: There was a predominance of males aged 30 years or more, with elementary schooling, married, Catholic, unemployed and with a family income of up to one minimum wage. The rate of compliance was 71%. Correlation of the different variables showed that non-compliance was related to male sex, age range between 20 and 29 years, low educational level, being single, being unemployed, and having low financial resources. Conclusions: Among the different socioeconomic variables, age showed statistical significance, i.e., the older individuals tended to show more compliance. It is assumed that the intervention of health professionals directly aimed at improving the use of specific medications may act as a facilitating factor in the process and maintenance of the expected pattern of compliance. In this respect, we suggest that adequate organization of the service and of a multi-professional team, the creation of ties and the formation of adhesion groups, in addition to individual care, may respond to the expectations and the doubts due to the continuous use of ARVT.

O uso da terapia anti-retroviral combinada colabora para a regressão de manifestações clínicas da infecção pelo HIV e para a melhoria na qualidade de vida dos pacientes, no entanto, apesar da adesão à terapêutica constituir importante ação para a resolutividade do tratamento, permanece como sério problema, tendo em vista as inúmeras dificuldades para alcançar a adesão. Objetivo: Avaliar a adesão dos portadores de HIV/aids em face do uso de terapia anti-retroviral (TARV) e propor estratégias que facilitem a adesão. Métodos: Desenvolveu-se estudo do tipo descritivo e exploratório em ambulatório especializado em Fortaleza-CE entre maio e junho de 2004, com 38 pacientes com aids em uso da TARV, por meio de entrevista semi-estruturada. A adesão foi baseada na soma das quantidades totais de comprimidos da TARV tomados nos três dias que antecederam a entrevista. Como aderente considerou-se o paciente que utilizou pelo menos 95% da quantidade de TARV prescrita. Resultados: Houve predomínio do sexo masculino, com trinta anos ou mais, com ensino fundamental, casados, católicos, desempregados e renda familiar de até um salário mínimo. A taxa de adesão foi de 71%. Ao correlacionar as diferentes variáveis, a não-adesão esteve relacionada ao sexo masculino, faixa etária entre 20 e 29 anos, pouca escolaridade, solteiros, desempregados e entre aqueles com escassos recursos financeiros. Conclusão: Nas diferentes variáveis socioeconômicas obteve-se significância estatística para a idade: os mais velhos tendem a maior adesão. Supõe-se que a atuação de profissional de saúde diretamente voltada a melhorar o uso de medicamentos específicos poderá agir como um facilitador no processo e manutenção de um padrão esperado de adesão...