Willingness to pay to assess patient preferences for therapy in a Canadian setting.

BACKGROUND: Adult outpatient parenteral antibiotic therapy (OPAT) programs have been reported in the literature for over 20 years, however there are no published reports quantifying preference for treatment location of patients referred to an OPAT program. The purpose of this study was to elicit treatment location preferences and willingness to pay (WTP) from patients referred to an OPAT program. METHODS: A multidisciplinary, single centre, prospective study at a 1000-bed Canadian adult tertiary care teaching hospital. This study involved a WTP questionnaire that was administered over a 9-month study period. Eligible and consenting patients referred to the OPAT program were asked to state their preference for treatment location and WTP for a hypothetical treatment scenario involving intravenous antibiotic therapy. Multiple linear regression analysis was performed to determine predictors of WTP. RESULTS: Of 131 eligible patients, 91 completed the WTP questionnaire. The majority of participants were males, married, in their sixth decade of life and had a secondary school education or greater. The majority of participants were retired or they were employed with annual household incomes less than 60,000 dollars. Osteomyelitis was the most common type of infection for which parenteral therapy was required. Of those 87 patients who indicated a preference, 77 (89%) patients preferred treatment at home, 10 (11%) patients preferred treatment in hospital. Seventy-one (82%) of these patients provided interpretable WTP responses. Of these 71 patients, 64 preferred treatment at home with a median WTP of 490 dollars CDN (mean 949 dollars, range 20 to 6250 dollars) and 7 preferred treatment in the hospital with a median WTP of 500 dollars CDN (mean 1123 dollars, range 10 to 3000 dollars). Tests for differences in means and medians revealed no differences between WTP values between the treatment locations. The total WTP for the seven patients who preferred hospital treatment was 7,859 dollars versus 60,712 dollars for the 64 patients who preferred home treatment. Income and treatment location preference were independent predictors of WTP. CONCLUSION: This study reveals that treatment at home is preferred by adult inpatients receiving intravenous antibiotic therapy that are referred to our OPAT program. Income and treatment location appear to be independently associated with their willingness to pay.

An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients.

BACKGROUND: Hospitalization can significantly disrupt sleeping patterns. In consideration of the previous reports of insomnia and apparent widespread use of benzodiazepines and other hypnotics in hospitalized patients, we conducted a study to assess quality of sleep and hypnotic drug use in our acute care adult patient population. The primary objectives of this study were to assess sleep disturbance and its determinants including the use of drugs with sedating properties. METHODS: This single-centre prospective study involved an assessment of sleep quality for consenting patients admitted to the general medicine and family practice units of an acute care Canadian hospital. A validated Verran and Snyder-Halpern (VSH) Sleep Scale measuring sleep disturbance, sleep effectiveness, and sleep supplementation was completed daily by patients and scores were compared to population statistics. Patients were also asked to identify factors influencing sleep while in hospital, and sedating drug use prior to and during hospitalization was also assessed. RESULTS: During the 70-day study period, 100 patients completed at least one sleep questionnaire. There was a relatively even distribution of males versus females, most patients were in their 8th decade of life, retired, and suffered from multiple chronic diseases. The median self-reported pre-admission sleep duration for participants was 8 hours and our review of PharmaNet profiles revealed that 35 (35%) patients had received a dispensed prescription for a hypnotic or antidepressant drug in the 3-month period prior to admission. Benzodiazepines were the most common sedating drugs prescribed. Over 300 sleep disturbance, effective and supplementation scores were completed. Sleep disturbance scores across all study days ranged 16-681, sleep effectiveness scores ranged 54-402, while sleep supplementation scores ranged between 0-358. Patients tended to have worse sleep scores as compared to healthy non-hospitalized US adults in all three scales. When compared to US non-hospitalized adults with insomnia, our patients demonstrated sleep disturbance and supplementation scores that were similar on Day 1, but lower (i.e. improved) on Day 3, while sleep effectiveness were higher (i.e. better) on both days. There was an association between sleep disturbance scores and the number of chronic diseases, the presence of pain, the use of bedtime tricyclic antidepressants, and the number of chronic diseases without pain. There was also an association between sleep effectiveness scores and the length of hospitalization, the in hospital use of bedtime sedatives and the presence of pain. Finally, an association was identified between sleep supplementation scores and the in hospital use of bedtime sedatives (tricyclic antidepressants and loxapine), and age. Twenty-nine (29%) patients received a prescription for a hypnotic drug while in hospital, with no evidence of pre-admission hypnotic use. The majority of these patients were prescribed zopiclone, lorazepam or another benzodiazepine. CONCLUSIONS: The results of this study reveal that quality of sleep is a problem that affects hospitalized adult medical service patients and a relatively high percentage of these patients are being prescribed a hypnotic prior to and during hospitalization.

Quality-of-life assessment in an outpatient parenteral antibiotic program.

OBJECTIVE: To measure changes and to identify predictors of change of health-related quality of life (HRQoL) for enrollees into an outpatient parenteral antibiotic therapy (OPAT) program. METHODS: A multidisciplinary, single-center, prospective investigation was conducted at a 1000-bed Canadian adult tertiary-care teaching hospital. Over a 15-month study period, consenting patients who were enrolled in the OPAT program completed paired Short Form-36 (SF-36) questionnaires within 48 hours prior to discharge from the hospital and again 26-30 days after discharge. Sociodemographic data and clinical variables were also collected for the purpose of determining potential predictors of change in quality of life. RESULTS: During the study period, 134 patients were enrolled in the OPAT program and 82 completed the paired SF-36 questionnaires. Study participants experienced a significant improvement in 3 SF-36 domains (physical functioning, bodily pain, role emotional) and the mental component summary scale (MCS) scores when they were transferred from the hospital to home setting. The SF-36 scores for all domains and summary scales were lower than the Canadian population average (all p < 0.001). Multiple linear-regression analysis revealed that infectious disease diagnosis and baseline physical component summary scale (PCS) scores were predictors of the change in the PCS score when patients transferred from the hospital to the home setting. Length of hospital stay and baseline MCS scores were predictors of the change in MCS scores when patients transferred from the hospital to the home setting. CONCLUSIONS: This study reveals that some domains in HRQoL appear to improve 4 weeks after discharge for adults enrolled in an OPAT program and that there are different predictors for changes in physical and mental health.

Influence of standardized orders on postoperative nausea and vomiting after gynecologic surgery.

OBJECTIVE: The risk of postoperative nausea and vomiting (PONV) after gynecologic surgery remains high, despite effective prophylactic medications. Thus, the objectives of this study were to determine whether standardized orders for the prophylaxis and treatment of PONV in gynecologic surgery patients (1) reduce PONV occurrence, (2) reduce total costs, and (3) influence the choice of medications used for PONV prophylaxis and treatment. METHODS: A retrospective design was employed in which a random sample of 200 patients was selected from each of the two 6-month phases before (pre) and after (post) the implementation of standardized orders for PONV prophylaxis and treatment. The primary outcome was the occurrence of any PONV episode. Logistic regression was used to adjust for potential confounding factors. All costs were in 1999 Canadian dollars (Canadian dollar = US$0.673 in 1999). RESULTS: Characteristics were similar except for surgical and anesthesia length between phases. The proportion of patients who received PONV prophylaxis increased from 31% (pre) to 47% (post; p = 0.002). There was a reduction in the risk of a PONV event in the post-phase (odds ratio [OR] 0.67, 95% CI 0.67 to 0.97; p = 0.04). The risk of PONV was significantly reduced with the administration of prophylactic medications (OR 0.46, 95% CI 0.46 to 0.67; p = 0.001). There was a reduction in the mean number of PONV episodes in the post-phase (1.47 events) versus the pre-phase (1.81 events; p = 0.02). A reduction in mean PONV management costs was observed in the post-phase ($8.31, SD +/- 8.50) compared with the pre-phase ($10.23, SD +/- 8.25; p = 0.02). For mean prophylactic costs, these were significantly higher in the postimplementation phase compared with the preimplementation phase ($1.64, SD +/- 3.36 vs. $0.91, SD +/- 2.43; p = 0.013). For mean total PONV costs (prophylaxis plus management costs), there was a nonsignificant reduction in the postimplementation phase compared with the preimplementation phase ($9.95, SD +/- 9.20 vs. $11.15, SD +/- 8.51, respectively; p = 0.18). Univariate sensitivity analyses revealed that the economic results were sensitive to several parameters. CONCLUSIONS: The implementation of preprinted order forms for PONV prophylaxis and treatment appears to be an effective and economically attractive strategy.

Patterns of use and patients' attitudes toward complementary medications: a survey of adult general medicine patients at a major Canadian teaching hospital.

OBJECTIVE: To characterize the preadmission and hospital utilization of, and patients' attitudes toward, complementary medications. PATIENTS AND METHODS: Patient survey data were collected at an acute care hospital over a four-month period for 85 patients who had been admitted to the general medicine wards. Patient information about complementary medicine use and opinions were obtained through patient interviews. Patient demographic information including age, sex, ethnic background, level of education and annual household income were gathered. Patients were eligible to participate in the survey if they were on a general medicine ward on any given interview day. Patients were excluded if they were absent from their room, were sleeping, spoke no English and had no translator present, were occupied by other health care staff or friends and family on days of interviewing, or did not consent. Logistical regression was used to identify predictive factors for complementary medicine use. RESULTS: Eighty-five of 105 patients (81%) consented to complete the survey. The mean patient age was 55 years (range 19 to 91), and 45 respondents (53%) were male. About one-third of patients surveyed reported having previously visited a practitioner of natural medicine. Thirty-three patients (39%) interviewed indicated that they had used complementary medications at some time in their lives. One in six respondents (17%) reported using a complementary medicine immediately before admission to the hospital, although only two patients (3%) reported using a complementary medicine while in hospital. The most commonly reported products of use were echinacea, garlic pills and ginseng. Five patients (15%) indicated that their pharmacists were aware of their complementary medicine use, while 17 patients (52%) stated that their family doctors were aware. The majority of patients indicated they were satisfied with the information provided to them from various sources. Other data collected revealed that almost one-half would choose to take a complementary medicine for the ailment that brought them into the hospital. Univariate analysis indicated that age was a significant negative predictor for complementary medication use. CONCLUSIONS: The use of complementary medications on general medicine wards appears to be low; however, preadmission use of complementary medications appears common. The present study results suggest that use of complementary medications may go unreported; therefore, all health care providers should be aware of and knowledgeable about the potential self-administration of complementary medications by their patients.