Relevant factors in treatment adherence: A case study / Factores importantes en la adhesión al tratamiento: un estudio de casos

In this paper, a case study is presented. The client had been in therapy before, and had abandoned all previous treatments before any significant improvement had taken place. In the treatment reported here, she committed to the therapy and made progress. Possible reasons for this change in adherence are discussed

En este estudio se presenta un caso. La cliente había estado ya en terapia, abandonando todos los tratamientos previos antes de que su problema hubiera mejorado significativamente. En el tratamiento resenado aquí finalmente se comprometió con la terapia y mejoró. Se discuten posibles explicaciones para este cambio en la adhesión terapéutica

Larva migrans múltiple en el pie de un viajero / Multiple larva migrans on the foot of a traveller

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Adherencia terapéutica en la enfermedad crónica: estado de la situación y perspectiva de futuro / Treatment compliance in chronic illness: current situation and future perspectives

Las enfermedades crónicas de larga duración poseen una elevada mortalidad y afectan por igual a ambos sexos. La falta de adherencia a las recomendaciones terapéuticas continúa siendo un obstáculo para mejorar la salud y la calidad de vida de los pacientes, además de conllevar un elevado coste sociosanitario. En este trabajo se desarrolla el concepto «adherencia terapéutica» que engloba tratamientos farmacológicos (cumplimiento terapéutico) y no farmacológicos (grado de coincidencia entre las recomendaciones ofrecidas, como pueden ser cambios en los hábitos de vida y su implantación por el paciente). También se analiza el impacto clínico y sociosanitario de la «adherencia terapéutica», así como las causas de la falta de adherencia y métodos y estrategias para mejorarla. Concluimos que la adherencia terapéutica debe ser un objetivo esencial del sistema sanitario, englobando todos los agentes implicados en la salud del paciente (AU)

Long-term chronic diseases have a high mortality rate around the world, affecting both genders equally. Despite improvements in the diagnosis and treatment of various health problems, lack of treatment compliance remains an obstacle to improving health and patient quality of life, and it carries a high associated socio-healthcare cost. The objectives of this study were to develop the concept of «therapeutic adherence», which includes both pharmacological compliance as well as non-pharmacological (level of agreement and patient involvement, lifestyle changes, etc.) treatments. The study also aimed to establish the clinical and socio-health impact of non-compliance, the reasons for non-compliance, and methods and strategies to improve compliance. The results of this study support therapeutic adherence as an essential goal of the healthcare system that encompasses all stakeholders involved in patient health (AU)

Sociodemographic and psychiatric predictors of attrition in a prospective psychiatric epidemiological study among the general population. Result of the Netherlands Mental Health Survey and Incidence Study-2.

BACKGROUND: In prospective psychiatric epidemiological studies, attrition at follow-up can be selective, and can bias the research findings. Therefore, knowledge of predictors of attrition and of its different types (noncontact, refusal, inability to participate) is of importance. METHODS: By means of (multinomial) logistic regression analyses, predictors of attrition were studied in the first 3-year follow-up of the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2), a prospective psychiatric epidemiological study among 6646 subjects of the general population aged 18-64 years. Baseline sociodemographic characteristics, physical health, mental disorders and their clinical characteristics, and experience with the previous interview were studied as predictors of attrition and of its different types. RESULTS: The attrition rate at follow-up was 20.2%. Refusal (14.2%) was more common than noncontact (4.6%) and inability to participate (1.4%). Compared to respondents, nonrespondents were more often younger, lower educated, unemployed and born outside the Netherlands. A less positive experience with the baseline interview and shorter interview duration also predicted attrition. Any 12-month mental disorder, the categories and separate mental disorders, and their clinical characteristics, were not significantly associated with attrition, after controlling for sociodemographics. Sociodemographic predictors and experience with the baseline interview differed between the three types of attrition, but these types were also hardly or not associated with previous mental disorders. CONCLUSIONS: The authors conclude that bias due to selective attrition was limited to sociodemographics and experience with the baseline interview. Mental health status at baseline was not of influence, possibly due to the large time investment to persuade respondents to re-participate and to find them in case of noncontact or removal to an unknown address. During follow-up waves of future prospective studies it is important to implement an intensive recruitment period with special efforts among young adults and the lower educated.

Premature termination in couple therapy with veterans: definitions and prediction of long-term outcomes.

Premature termination (PT) has been identified as widespread in individual, family, and couple therapy. Unfortunately, research on PT utilizes numerous definitions of PT without providing guidance on which definition may be most clinically useful. The current study investigated seven definitions of PT (three based on therapist ratings and four based on quantitative measures) utilizing a sample of 177 couples seeking treatment at two Department of Veterans Affairs medical centers. Results indicated that PT occurred in 50-80% of couples; however, agreement between the definitions of PT was generally only in the slight to fair range, making it difficult to determine whether a particular couple was ready to terminate treatment. Additionally, many commonly used definitions of PT were unrelated to level or maintenance of relationship functioning following treatment. In contrast, two definitions of PT (ending treatment in the distressed range and therapist-rated likelihood of future unhappiness) significantly predicted larger decreases in relationship satisfaction during the 18 months following therapy, as well as lower levels of satisfaction and relationship stability 18 months after termination. Additionally, long-term relationship functioning was especially poor when both these definitions of PT were met, suggesting that both qualitative and quantitative definitions should inform decisions about termination in couple therapy.

An alternative way to classify missing data mechanism in clinical trials--a dialogue on missing data.

Statisticians in pharmaceutical field are constantly challenged by missing data caused by patient dropout in clinical trials. What the targeted population parameter for statistical inference should be when missing data are present has been a much-debated point. Many missing data methods aim at the so-called hypothetical parameter, i.e., treatment effect of a drug assuming no patients dropout from a clinical trial for the drug. Other methods intend to combine all dropout information into the treatment effect estimate. We believe that patient dropouts should not be treated equally when determining the population parameter of treatment effect. The objective of clinical trials, after all, is to evaluate a drug's effect on patients. Dropouts due to drug-related reasons such as drug-induced adverse experience are part of the drug's attributes, while dropout due to non-drug-related reasons, such as protocol deviation, are not inherent characteristics of the drug. Hence we propose to classify the patient dropouts into two classes: intrinsic (drug-related) and extrinsic (non-drug-related) dropouts. The former should be taken into account when defining the population parameter of the treatment effect, while the latter should not be. This classification will help determine a target population parameter that depicts a fair picture of a drug's effect, while the common classification of missing data as missing completely random (MCAR), missing at random (MAR), and missing not at random (MNAR) will help define appropriate statistical approach to analysis when missing data exist. Other related issues, such as statistical inference under this classification and implementing the classification in real clinical trials, are also touched upon here.

Qualitative study of reasons for discontinuation of injectable contraceptives among users and salient reference groups in Kenya.

Discontinuation of contraception is a major problem in Kenya. Even though they want to space or limit their births, over a quarter of contraceptive injectable users discontinue use of the method within 12 months of beginning use. Fourteen focus group discussions were conducted in Nyando District, Kenya among current contraceptive injectable users and their salient reference groups (e.g. husbands, mothers-in-law, community leaders, service providers) to understand why women discontinue using contraceptives (with a focus on injectables). Thematic analysis was performed using NVivo 8 software. Discontinuation of contraceptives in Nyando District occurs for logistical, social and medical reasons. Common reasons for discontinuation include side effects, husbands' opposition, provider and/or clinic restrictions, misconceptions about injectables, stock outs, and lack of cash to pay for family planning services. This research expands the literature by examining social influences on discontinuation by incorporating the perspectives of salient reference groups. The results suggest points of intervention for increasing continuation in this community and similar resource-poor settings.

Issues of loss to follow-up in a population study of traumatic brain injury (TBI) followed to 3 years post-trauma.

PRIMARY OBJECTIVE: To examine loss to follow-up (LTFU) using a population with traumatic brain injury (TBI) to include a range of severity and to follow participants to 3 years post-injury. Also investigated were cause of TBI and employment status. RESEARCH DESIGN: The research included 947 adults from a TBI population study. Data were obtained on severity, cause of TBI and employment status and participants were followed up at 1, 3, 6, 12, 24 and 36 months after injury. Chi-squared analyses were used to examine rates of loss to follow-up. MAIN OUTCOME AND RESULTS: Overall LTFU increased from 22% at 1 month post-injury to 81% at 3-year follow-up. Most participants (52%) were employed at the time of their TBI, with 39% of TBIs being motor vehicle related. Lower LTFU at 2 and 3 years post-TBI was significantly associated with severe TBI. Within the mTBI sub-group significantly higher LTFU at 1 and 6 months after injury and at 2 and 3 years post-injury was associated with TBI from assault. Those sustaining mTBI from a fall or sport-related injury showed significantly lower LTFU at the 6-month, 12-month and 2-year follow-up points. The highest LTFU was noted for unemployed participants, with retired participants showing the lowest rate.

Adherencia al tratamiento en personas mayores / Adherence to the treatment in the old people

La falta de adherencia al tratamiento supone uno de los grandes problemas de la salud pública actual, teniendo gran trascendencia en las personas de avanzada edad, tanto por el creciente envejecimiento de las poblaciones de los países desarrollados, como por tratarse del grupo etario que presenta con mayor frecuencia enfermedades crónicas. El objetivo del trabajo fue valorar el grado de adherencia al tratamiento farmacológico de los pacientes mayores de 75 años en una zona básica de salud rural de Atención Primaria. Para ello se realizó un estudio descriptivo observacional durante los meses de agosto a octubre de 2008; como instrumento de medida se utilizó el cuestionario de Morisky Green para valorar el grado de cumplimiento terapéutico. Se estudió un total de 89 pacientes (tasa de respuesta del 100%). El 55,1% no tenía adherencia con el tratamiento farmacológico prescrito, mientras que el 44,9% sí. Existe un mayor grado de cumplimiento del tratamiento entre las mujeres. La causa principal de no adhesión al régimen terapéutico fue el olvido a la hora de tomar la medicación (64,8%). De este estudio se deduce que el grado de falta de adherencia a la prescripción indicada es alto en nuestra zona básica de salud, por lo que hay que desarrollar actividades en la práctica clínica diaria para generar estrategias de mejora en el cumplimiento de la terapia(AU)

Introducction: The lack of adherence to the treatment is one of the big problems of the actual public health. It has great importance in advanced in years people, due to the increasing ageing of the population in developed countries and because of they are the population group that more often presents chronic diseases. The aim of the proyect was to evaluate the grade of adherence to the pharmacological treatment of patiens aged 75 in a basic area of primary atention rural health. Material and methods: An observational descriptive study was made from August to October 2008. Morisky Green´s questionarire is employed as a measure instrument to evaluate the grade of therapeutic fulfilment. Results: 89 patiens were studied (response rate of 100%). 55,1% of the patients didn´t have got adherence with the prescribed phamacological tretment, but 44,9% of the patients have got it. There is a bigger grade of fulfilment in women. The main cause of no adherence to the therapeutic system was the absentmindedness of taking the medical treatment (64,8%). Conclusion: It is obtained from this study that the lack of adherence to the highlighted treatment is high in our basic area of health, so we have to develop activities in every day clinic practice to generate estrategies to improve the therapy fulfilment(AU)

An empirical approach to defining loss to follow-up among patients enrolled in antiretroviral treatment programs.

In many programs providing antiretroviral therapy (ART), clinicians report substantial patient attrition; however, there are no consensus criteria for defining patient loss to follow-up (LTFU). Data on a multisite human immunodeficiency virus (HIV) treatment cohort in Lusaka, Zambia, were used to determine an empirical "days-late" definition of LTFU among patients on ART. Cohort members were classified as either "in care" or LTFU as of December 31, 2007, according to a range of days-late intervals. The authors then looked forward in the database to determine which patients actually returned to care at any point over the following year. The interval that best minimized LTFU misclassification was described as "best-performing." Overall, 33,704 HIV-infected adults on ART were included. Nearly one-third (n = 10,196) were at least 1 day late for an appointment. The best-performing LTFU definition was 56 days after a missed visit, which had a sensitivity of 84.1% (95% confidence interval (CI): 83.2, 85.0), specificity of 97.5% (95% CI: 97.3, 97.7), and misclassification of 5.1% (95% CI: 4.8, 5.3). The 60-day threshold performed similarly well, with only a marginal difference (<0.1%) in misclassification. This analysis suggests that > or =60 days since the last appointment is a reasonable definition of LTFU. Standardization to empirically derived definitions of LTFU will permit more reliable comparisons within and across programs.

Abandono del tratamiento en adictos a la cocaína / Treatment dropout in cocaine addicts

La alta tasa de abandonos de los programas de tratamiento es uno de los problemas más graves en el ámbito de las drogodependencias. La identificación temprana de predictores de riesgo de abandono puede proporcionar información útil sobre las necesidades específicas de tratamiento de este tipo de pacientes. El objetivo de este estudio fue identificar predictores de la finalización prematura de un programa de tratamiento ambulatorio para adictos a la cocaína. El estudio se realizó en varias unidades asistenciales públicas de una ciudad española. Los participantes fueron 91 adictos a la cocaína admitidos para ser tratados de su adicción, evaluados mediante entrevista y varias medidas de autoinforme. Para identificar las variables predictivas se utilizó un análisis factorial, un análisis cluster y un análisis CHAID. Las variables que obtuvieron capacidad predictiva fueron las puntuaciones en el MAST, y las puntuaciones compuestas de alcohol y drogas del Europ ASI. Estas tres variables quedaron agrupadas en un mismo factoral que se denominó gravedad adictiva. El análisis predictivo mostró que este factor tenía una cierta capacidad de predicción del abandono, pero que no era totalmente determinante. Los resultados apuntan hacia la conveniencia de detectar en la admisión a los pacientes que pudieran requerir una mayor preparación motivacional, mayor control e intensidad en el tratamiento, o la prestación de intervenciones coadyuvantes (AU)

The high rate of dropout from treatment programs is one of the most serious problems in the field of drug dependence. Early identification of predictors of dropout risk can provide useful information on the specific treatment needs of these types of patient. The aim of this study was to identify predictors of premature cessation of an outpatient treatment program for cocaine addicts. The study was carried out at public healthcare units in a Spanish city. Participants were 91 cocaine addicts admitted for treatment for their addiction, assessed by means of interview and various self-report measures. For identifying predictive variables the researchers used a factor analysis, a cluster analysis and a CHAID analysis. The variables that obtained predictive capacity were the MAST scores and the combined alcohol and drugs scores on the Europ ASI. These three variables were grouped in a single factor which was called addictive severity. The predictive analysis showed that this factor had some degree of capacity for the prediction of dropout, but that it was not completely determinant. The results suggest the advantageousness of detecting at the admission stage those patients who might require more attention to their motivational aspects, greater treatment control and intensity, or the provision of complementary interventions (AU)

What's in a name? Classifying 'the dropout' from treatment for anorexia nervosa.

Treatment drop-out rates for anorexia nervosa (AN) are notoriously high, and have remained so over the course of time, and across different treatment settings and modalities. The outcome for such patients is frequently poor. Despite the prevalence of this problem, there is little quality evidence as to why this is the case, and what the predictors of drop-out are. Methodological uniformity has been called for in order to develop a cohesive literature in this field, and this paper argues that we must also reflect upon how our labelling of 'the dropout' has shaped what we have examined to date, and how that has in turn led to a weak evidence base. A new, less pejorative term for those who do not complete treatment is needed to reflect the direction research in this area needs to take.

Patient factors associated with attrition from a self-management education programme.

OBJECTIVE: To examine utilization patterns of diabetes self-management training (DSME) and identify patient factors associated with attrition from these services at an ambulatory diabetes education centre (DEC). METHODS: A retrospective medical chart review of first time visits (536) to the centre between 1 August 2000 and 31 July 2001 was conducted for patients with type 2 diabetes. Descriptive analyses were conducted to examine utilization patterns over a 1-year period. Multivariable logistic regression was used to identify patient factors associated with attrition from DSME and non-use of group education among new patients. RESULTS: Almost 50% of new patients withdrew prematurely from recommended DSME services over the 1-year period, and only 24.8% attended group education. Patient variables such as being older than 65 years of age, primarily speaking English, or working full or part-time were associated with attrition from DSME and non-use of group education when compared with middle aged, non-English-speaking, and non-working patients. CONCLUSIONS: High DSME attrition rates indicate that retention needs to become a focus of programme policy, planning and evaluation to improve programme effectiveness. DSME tailored to the cultural and linguistic characteristics of the community, and convenient and accessible to working and older patients will potentially increase retention in and accessibility to these services.

No show: incidence of nonattendance at a dermatology practice in a single universal payer model.

BACKGROUND: Nonattendance at scheduled appointments is a major problem. Previous studies have shown rates between 17 and 31%. Most US studies found the type of payer to be the greatest determinant of attendance rates. OBJECTIVES: This study examines the no-show rate in a private dermatology practice under a single universal payer model, including the effects of old versus new patient, gender, day of the week, month, and weather. RESULTS: The overall rate of nonattendance was lower than in all previous studies (7.79%), with the only statistically significant variable being established versus new patients. LIMITATIONS: Certain demographic data investigated in previous studies (eg, age, socioeconomic status) were not assessable. Data are from a single office. CONCLUSION: The no-show rate in a single universal payer, private practice model is low, especially for established patients.

Are non-responders in a quitline evaluation more likely to be smokers?

BACKGROUND: In evaluation of smoking cessation programs including surveys and clinical trials the tradition has been to treat non-responders as smokers. The aim of this paper is to assess smoking behaviour of non-responders in an evaluation of the Swedish national tobacco cessation quitline a nation-wide, free of charge service. METHODS: A telephone interview survey with a sample of people not participating in the original follow-up. The study population comprised callers to the Swedish quitline who had consented to participate in a 12 month follow-up but had failed to respond. A sample of 84 (18% of all non-responders) was included. The main outcome measures were self-reported smoking behaviour at the time of the interview and at the time of the routine follow-up. Also, reasons for not responding to the original follow-up questionnaire were assessed. For statistical comparison between groups we used Fischer's exact test, odds ratios (OR) and 95% confidence intervals (CI) on proportions and OR. RESULTS: Thirty-nine percent reported to have been smoke-free at the time they received the original questionnaire compared with 31% of responders in the original study population. The two most common reasons stated for not having returned the original questionnaire was claiming that they had returned it (35%) and that they had not received the questionnaire (20%). Non-responders were somewhat younger and were to a higher degree smoke-free when they first called the quitline. CONCLUSION: Treating non-responders as smokers in smoking cessation research may underestimate the true effect of cessation treatment.

Predicting premature termination from counseling using the Butcher Treatment Planning Inventory.

This investigation examined the extent to which premature termination from counseling could be predicted from selected scales on the Butcher Treatment Planning Inventory (BTPI). Ninety-five new clients at a university counseling center agreed to participate in the study and completed the BTPI as part of the intake evaluation. Premature termination occurred when a participant missed a scheduled appointment and unilaterally dropped out of counseling. Higher scores on Closed-Mindedness, Problems in Relationship Formation, Somatization of Conflict, Self-Oriented/Narcissism, Perceived Lack of Environmental Support, and the Treatment Difficulty Composite were associated with premature termination. The General Pathology Composite, a general index of symptomatic distress, also enhanced the prediction of premature termination by suppressing irrelevant variance in other BTPI scales. The results provide support for the validity of the BTPI in identifying clients at risk for premature termination from counseling.

Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario.

OBJECTIVE: The authors interviewed individuals treated for self-described mental health problems in the preceding year to examine patterns and predictors associated with dropping out of treatment. METHOD: Subjects were drawn from respondents to community epidemiological surveys carried out in representative samples of the United States and Ontario populations. Dropouts were those who had left mental health treatment during the prior year for reasons other than symptom improvement. The surveys also assessed potential dropout correlates: sociodemographic characteristics, attitudes about mental health care, disorder type, provider type, and treatment received. RESULTS: The proportion of dropouts did not significantly differ between the United States (19.2%) and Ontario (16.9%), nor did the effects of the predictors differ significantly between the two samples. Sociodemographic characteristics associated with treatment dropout included low income, young age, and, in the United States, lacking insurance coverage for mental health treatment. Patient attitudes associated with dropout included viewing mental health treatment as relatively ineffective and embarrassment about seeing a mental health provider. Respondents who received both medication and talk therapy were less likely to drop out than those who received single-modality treatments. CONCLUSIONS: Mental health treatment dropout is a serious problem, especially among patients who have low income, are young, lack insurance, are offered only single-modality treatments, and have negative attitudes about mental health care. Cost-effective interventions targeting these groups are needed to increase the proportion of patients who complete an adequate course of treatment.

Patient, hospital, and general practitioner characteristics associated with non-attendance: a cohort study.

Studies examining characteristics of non-attendance at hospital outpatients have given inconsistent results. We examined a cohort of 1972 referrals from 26 general practitioners, with complete follow-up. Five factors were found to be significantly associated with non-attendance: male sex, younger age, longer interval between referral and appointment, higher Jarman score and patients of a high-referring general practitioner. Targeting of strategies to reduce non-attendance is possible using these results.

Characteristics of people lost to attrition in psychiatric follow-up studies.

In a large (N = 1,744) study of previously hospitalized psychiatric patients, multiple follow-up attempts were made to contact the ex-patients over a 1-year period after their discharges. When contacted they were asked to provide information about their posthospital adjustment; 59.5% of the sample was reached at least once and usable data obtained either in a telephone interview or from a mailed survey form. The contacted and noncontacted people represented very different subpopulations, both demographically and in terms of typical psychiatric descriptors. Those who were of lower socioeconomic status, male, unmarried, racial minorities, and those with records of substance abuse or assaultiveness, and who were generally more severely impaired during the baseline hospitalization were underrepresented in the contacted group. Possible reasons for these sample biases, the implications for hospitals conducting outcome assessments (i.e., for research and program evaluation purposes), and strategies for dealing with this kind of methodological problem are discussed.