Transplant outcomes and economic costs associated with patient noncompliance to immunosuppression.

We describe factors associated with immunosuppression compliance after kidney transplantation and examine relationships between compliance with allograft outcomes and costs. Medicare claims for immunosuppression in 15 525 renal transplant recipients with at least 1 year of graft function were used to calculate compliance as medication possession ratio. Compliance was categorized by quartiles as poor, fair, good and excellent. We modeled adjusted associations of clinical factors with the likelihood of persistent compliance by multiple logistic regressions (aOR), and estimated associations of compliance with subsequent graft and patient survival with Cox proportional hazards (aHR). Adolescent recipients aged 19-24 years were more likely to be persistently noncompliant compared to patients aged 24-44 years (aOR 1.49 [1.06-2.10]). Poor (aHR 1.80 [1.52-2.13]) and fair (aHR 1.63[1.37-1.93]) compliant recipients were associated with increased risks of allograft loss compared to the excellent compliant recipients. Persistent low compliance was associated with a $12 840 increase in individual 3-year medical costs. Immunosuppression medication possession ratios indicative of less than the highest quartile of compliance predicted increased risk of graft loss and elevated costs. These findings suggest that interventions to improve medication compliance among kidney transplant recipients should emphasize the benefits of maximal compliance, rather than discourage low compliance.

Predictive ability of pretransplant comorbidities to predict long-term graft loss and death.

Whether to include additional comorbidities beyond diabetes in future kidney allocation schemes is controversial. We investigated the predictive ability of multiple pretransplant comorbidities for graft and patient survival. We included first-kidney transplant deceased donor recipients if Medicare was the primary payer for at least one year pretransplant. We extracted pretransplant comorbidities from Medicare claims with the Clinical Classifications Software (CCS), Charlson and Elixhauser comorbidities and used Cox regressions for graft loss, death with function (DWF) and death. Four models were compared: (1) Organ Procurement Transplant Network (OPTN) recipient and donor factors, (2) OPTN + CCS, (3) OPTN + Charlson and (4) OPTN + Elixhauser. Patients were censored at 9 years or loss to follow-up. Predictive performance was evaluated with the c-statistic. We examined 25 270 transplants between 1995 and 2002. For graft loss, the predictive value of all models was statistically and practically similar (Model 1: 0.61 [0.60 0.62], Model 2: 0.63 [0.62 0.64], Models 3 and 4: 0.62 [0.61 0.63]). For DWF and death, performance improved to 0.70 and was slightly better with the CCS. Pretransplant comorbidities derived from administrative claims did not identify factors not collected on OPTN that had a significant impact on graft outcome predictions. This has important implications for the revisions to the kidney allocation scheme.

Association of lower costs of pulsatile machine perfusion in renal transplantation from expanded criteria donors.

Pulsatile machine perfusion (PMP) has been shown to reduce delayed graft function (DGF) in expanded criteria donor (ECD) kidneys. Here, we investigate whether there is a cost benefit associated with PMP utilization in ECD kidney transplants. We analyzed United States Renal Data System (USRDS) data describing Medicare-insured ECD kidney transplant recipients in 1995-2004 (N = 5840). We examined total Medicare payments for transplant hospitalization and annually for 3 years posttransplant according to PMP utilization. After adjusting for other recipient, donor and transplant factors, PMP utilization was associated with a $2130 reduction (p = 0.007) in hospitalization costs. PMP utilization was also associated with lower DGF risk (p < 0.0001). PMP utilization did not predict differences in rejection, graft survival, patient survival, or costs at 1, 2 and 3 years posttransplant. PMP utilization is correlated with lower costs for the transplant hospitalization, which is likely due to the associated reduction in DGF among recipients of PMP kidneys. However, there is no difference in long-term Medicare costs for ECD recipients by PMP utilization. A prospective trial is necessary as it will help determine if the associations seen here are due to PMP utilization and not differences in the population studied.

A retrospective analysis of immunosuppression compliance, dose reduction and discontinuation in kidney transplant recipients.

We describe factors associated with poor compliance and dose reductions and examine the relative impact of compliance, dose reduction and discontinuation on graft outcome. Medicare claims for MMF in 7062 deceased donor renal recipients with at least 1 year of graft function were used to calculate compliance and dose reductions. Compliance was modeled using medication possession ratio to define quartiles for poor, low, medium and high compliance. The relative impact of compliance, dose reduction and discontinuation on graft outcome was assessed with Cox proportional hazards. Pediatric (Age 0-18, Odds ratio = 1.71, 95% CI 1.11-2.63, p = 0.014) and adolescent recipients (19-24, 1.57, 1.23-2.00, p < 0.001) were more likely poorly compliant compared to adults age 25-44. Poor compliance was also associated with physical limitations, hypertension, delayed graft function, rejection, infection and GI conditions. Poor (1.43, 1.11-1.84, p = 0.005) and low (1.46, 1.13-1.88, p = 0.004) compliance was associated with an increased hazard of graft loss as was >50% dose reduction (1.69, 1.15-2.50, p = 0.008) and discontinuation (8.34, 6.85-10.2, p < 0.001). Medication possession ratios lower than the 3-year mean were associated with an increased risk of graft loss. These results may indicate that interventions to improve compliance among kidney transplant recipients should strive for high rather than discourage low compliance.

Patient satisfaction measurement strategies: a comparison of phone and mail methods.

BACKGROUND: In 1998 the BJC Health System (St Louis) made the decision to migrate its patient satisfaction measurement system from a mail-out/mail-back method to a phone interview method. Out of concern that results obtained by phone would not be comparable with the 4 years of mail-based data, a controlled study was undertaken to directly compare mail and phone responses and to evaluate response rates, patient sample demographics, and patient satisfaction ratings. METHODS: Mail and phone responses obtained from parallel random samples selected from inpatient, outpatient test/treatment, outpatient surgery, and emergency service patient populations were compared. Patients were randomly selected to receive a standardized satisfaction survey by either phone or mail 10 to 14 days postdischarge. RESULTS: Significantly higher response rates were obtained by telephone then via the mail-based method for all four samples. After adjusting for demographic differences, numerous significant differences in mean scores as well as percentages of excellent and fair or poor responses were observed, and more positive ratings were obtained by phone. DISCUSSION: Crude comparisons of satisfaction scores between organizations using phone and mail-based responses may lead to erroneous conclusions about consumer-perceived quality. Organizations that use mixed-mode surveys should conduct careful side-by-side studies of the methods used on the survey of interest and then establish a correction formula to adjust the results for the measurement biases.

Using root cause analysis to address patient satisfaction and other improvement opportunities.

BACKGROUND: Despite the considerable attention that health care organizations are devoting to the measurement of patient satisfaction, there is often confusion about how to systematically use these data to improve an organization's performance. A model to use in applying traditional quality improvement methods and tools to patient satisfaction problems includes five primary steps: (1) identifying opportunities, (2) prioritizing opportunities, (3) conducting root cause analysis, (4) designing and testing potential solutions, and (5) implementing the proposed solution. PATIENT SATISFACTION SURVEYS: A satisfaction survey serves best as a high-level screening device, not as a tool to provide highly detailed information about the root causes of patient dissatisfaction. The primary purpose of the survey in the model is to identify improvement opportunities and areas of significant improvement or deterioration. Secondary tools such as brief patient interviews or focus groups may better serve to probe intensively into the problem areas identified by the survey. These tools allow for a direct dialog with the patient to uncover root causes of dissatisfaction and establish potential solutions. DISCUSSION: Although the primary focus of this model has been patient satisfaction issues, the basic steps could easily be applied to virtually any improvement opportunity. Improvement teams should commit to a schedule of 90-minute weekly meetings for 7 weeks. The model, a simple translation of traditional improvement methods and tools to address the unique issues facing patient satisfaction improvement teams, can save improvement teams considerable time, resources, and frustration as they design and launch initiatives to improve patient satisfaction.

Understanding patient willingness to recommend and return: a strategy for prioritizing improvement opportunities.

BACKGROUND: Beginning in April 1995, an ongoing, comprehensive measurement system has been developed and refined at BJC Health System, a regional integrated delivery and financing system serving the St Louis metropolitan area, mid-Missouri, and Southern Illinois, to assess patient satisfaction with inpatient treatment, outpatient treatment, outpatient surgery, and emergency care. This system has provided the mechanism for identifying opportunities, setting priorities, and monitoring the impact of improvement initiatives. METHODS: Satisfaction with key components of the care process among 23,361 patients (7,083 inpatients, 8,885 patients undergoing outpatient tests/procedures, 5,356 patients undergoing outpatient surgery, and 2,037 patients receiving emergency care) at 15 BJC Health System facilities was assessed through weekly surveys administered in April 1995 through December 1996. RESULTS: Structural equation models were developed to identify the key predictors of patient advocation-willingness to return for or recommend care. Across all venues of care the compassion provided to patients had the strongest relationship to patient advocation. Within each venue of care, however, a slightly different set of secondary factors emerged. The resulting models provided important information to help prioritize competing improvement opportunities in BJC Health System. In one hospital, a general medicine unit working for several years with little success to improve its patient satisfaction decided to focus on two primary factors predicting patient advocation: nursing care delivery and compassionate care. Root cause analysis was used to determine why two items-staff willingness to help with questions/concerns and clear explanation about tests and procedures-were rated low. On the basis of feedback from phone interviews with discharged patients, the care delivery process was changed to encourage patients to ask questions. Across the next two quarters, this unit experienced significant improvements in both targeted items. DISCUSSION: The significance of compassionate care and care delivery again speaks not only to the importance of the technical quality of clinical care but also to the customer-focused way in which this care was provided. After the primary predictors of patient advocation were identified, management was able to strategically focus improvement initiatives to maximize their impact. Across the organization, improvement teams scanned their data to find key factors where performance was lacking. Once these key opportunities were identified, the teams developed potential solutions and launched initiatives to improve their performance. SUMMARY AND CONCLUSIONS: Results suggest that some core issues are of extreme importance to patients regardless of whether they are receiving care in an inpatient, outpatient, or emergency setting. The compassion with which care is provided appears to be the most important factor in influencing patient intentions to recommend/return, regardless of the setting in which care is provided.

The stability of family decisions to consent or refuse organ donation: would you do it again?

OBJECTIVE: Past organ donation research has studied attitudes toward donation, predictors of signing donor cards, and distinguishing characteristics of donors vs. nondonors. The current study is the first to examine predictors of family members' satisfaction with the decision to consent or refuse donation of a dying loved one's organs or tissue. METHOD: This study surveyed 225 family members who had been approached to donate the organs or tissue of a dying loved one. Participants were surveyed about demographic characteristics, medical/hospital factors, previous knowledge of transplantation, the request process, religion, and characteristics of the deceased and of the recipient. Discriminant analyses were conducted to characterise four specific groups: a) donors who would donate again; b) donors who would not donate again; c) nondonors who would now donate; and d) nondonors who still would not donate. RESULTS: Three significant discriminant functions emerged discriminating donors from nondonors, those who were satisfied with their decision from those who were not, and people who would now donate from those who would not. Donation was predicated by formal education, being married, volunteerism, signing donor cards, and having personal conversations about donation. Subsequent satisfaction was predicted by comfort and confidence during the decision-making process, familiarity with medical center, and understanding of brain death. A willingness to now donate was predicted by personal discussions about donation. CONCLUSIONS: People should be encouraged not only to sign donor cards, but to have discussions with family about wishes. Individuals should be encouraged to seek the help of family and friends during the decision, and be aware of the need of social support from family and friends during and after the decision.

Research on social support in adolescents with IDDM: a critical review.

This article provides a review of the findings of 32 scientific studies that examined the relationship between social support and adherence/metabolic control in adolescents with insulin-dependent diabetes mellitus. Social support included qualitative family support characteristics, communication patterns, sibling and peer relationships, and regimen-specific support behaviors. The literature was examined in the context of adolescent development. Although the results of these studies were somewhat inconsistent, some general patterns emerged that are described and discussed in detail. Methodological limitations and suggestions for future research are provided.

Accuracy and reliability of temperature measurement in the emergency department by instrument and site in children.

PURPOSE: 1. To determine the accuracy, precision, specificity, sensitivity, positive prediction, and negative prediction of TempaDOT, FirstTEMP, and Genius as compared to the glass mercury thermometer; 2. To determine the influence of age, behavior, febrile status, tympanic membrane bulge, presence of ear wax, and site on temperature readings; and 3. To determine the ability of each instrument to detect a shift in temperature after Tylenol. METHOD: A quasi-experimental, multiple-correlational design was used to study 960 temperature measurements obtained on 89 febrile and 83 afebrile children in an emergency unit. FINDINGS: TempaDOT was found to be the most accurate and most precise instrument for children ages 5 years and under with and without fevers. FirstTEMP was found to be most sensitive for temperatures above 37.5 degrees C and best in detecting shifts after Tylenol was given. Age, behavior, febrile status or tympanic membrane bulge did not significantly affect accuracy. The most accurate sites in order of accuracy were: oral axillary, aural, rectal. The order of precision of sites was: oral, aural, rectal, and axillary. Behavior did not significantly affect the precision. CONCLUSION: TempaDOT was found to be the most clinically useful temperature measurement instrument. FirstTEMP may be used as a screening tool to determine if antipyretic medication is working to decrease fevers. TempaDOT is recommended for use in emergency units to validate the presence or absence of fevers in children especially when the FirstTEMP reading is near 37.0-38.8 degrees C.

The relationship among six psychosocial domains, age, health care adherence, and metabolic control in adolescents with IDDM.

This pilot study examined the relationship among six psychosocial factors, age, health care compliance, and metabolic control in adolescents with IDDM. Four objectives were identified: 1) to determine whether specific compliance areas predict metabolic control; 2) to determine whether specific psychosocial factors predict metabolic control; 3) to determine whether compliance and psychosocial issues change with age; and 4) to determine whether the parent or the youth is the more accurate predictor of metabolic control. Twenty-one adolescents age 13 through 18 years participated in this study. Dietary compliance was found to be the best predictor of metabolic control. Parents more accurately predicted metabolic control for youths younger than 16 years old, while the reverse was true for older youths. A negative relationship was identified among strong self-concept, high knowledge of IDDM, parental support, and poor metabolic control. Several possible explanations are discussed, including power struggles, coping difficulties, and fear of peer reactions.

Linkage analysis of a complex disease: application to familial Alzheimer's disease.

Evidence for linkage of the Alzheimer's gene to markers on chromosomes 19 and 21 was assessed using single-locus and two-locus models of inheritance. Families were divided into groups determined by their average age at onset. The youngest group produced higher lod scores for markers on chromosome 21 while an older group showed evidence for linkage to markers on chromosome 19. Two-locus models of disease were used to analyze the youngest group for linkage to pairs of markers on chromosome 21 and an older group with markers on chromosome 19.