Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation.

BACKGROUND: Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant. METHODS: A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant. RESULTS: After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74). CONCLUSIONS: The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.

Medical compliance and its predictors in the first year after heart transplantation.

BACKGROUND: Although poor medical compliance is a major risk factor for morbidity and mortality after heart transplantation, no prospective data are available on rates of noncompliance with each component of the posttransplantation regimen. Little is known about the impact of health history, sociodemographic, or perioperative psychosocial variables on long-term compliance. METHODS: Compliance in eight domains was examined in a cohort of 101 heart recipients followed through the first year after transplantation. Patients received detailed interviews at 2, 7, and 12 months after transplantation. Additional corroborative information was obtained from family member interviews and nurse evaluations. Potential predictors of noncompliance were obtained from medical record reviews and from initial patient interviews. Predictors pertained to cardiac-related history, psychiatric history, sociodemographic variables, and perioperative psychosocial status (psychologic adaptation, social supports, coping strategies). RESULTS: Although degree of noncompliance varied across timepoints, rates of persistent noncompliance during the year were as follows: 37% (exercise); 34% (monitoring blood pressure); 20% (medications); 19% (smoking); 18% (diet); 15% (having blood work completed); 9% (clinic attendance); and 6% (heavy drinking). Compliance in most areas worsened significantly (p < 0.05) over time. Background health-related and sociodemographic characteristics showed no significant influence on any area of posttransplantation compliance. Perioperative psychosocial characteristics were strong and significant predictors of noncompliance. CONCLUSIONS: Pretransplantation screening for background and demographic variables may have limited utility for compliance outcomes. Strategies to improve compliance should focus on psychosocial risk factors pertaining to early psychologic reactions to transplantation, the quality of family relationships, and patients' styles of coping. These risk factors are each potentially modifiable through appropriate educational and supportive interventions.

Patients who refuse treatment in medical hospitals.

Treatment refusal in medical hospitals, despite the interest it has aroused among lawyers and ethicists, has been largely ignored by the medical profession. This study of the phenomenon in a number of medical and surgical settings has disclosed that refusal is a common occurrence. In this study, refusals were often precipitated by problems within the physician-patient relationship, although several interactive factors were usually involved. Physicians' responses to refusal tended to be undifferentiated with regard to the precipitants, depending more heavily on the medical urgency of the situation. Costs of refusal were measurable in terms of delay and increased expense when treatment was ultimately accepted and, less commonly, in terms of physical harm to the patient. These findings illustrate important strains in the modern physician-patient relationship and suggest that closer attention to factors underlying refusal may increase the rate of successful resolution.

KIE: The results of a study of treatment refusal in various medical and surgical settings within several Pittsburgh community and university hospitals are presented and analyzed. Refusal was found to be a common occurrence, usually involving multiple causative factors and precipitated by problems within the physician patient relationship. Physicians' responses to refusal were determined by their perception of the urgency of situations rather than by their communicating with patients. Most patients ultimately accepted treatment although the problems causing initial refusal were not always resolved.