Françoise G. Pradel

Reasons for discharges against medical advice: a qualitative study

Background There is limited information in the literature about reasons for discharges against medical advice (DAMA) as supplied by patients and providers. Information about the reasons for DAMA is necessary for identifying workable strategies to reduce the likelihood and health consequences of DAMA. The objective of this study is to identify the reasons for DAMA based on patient and multicategory provider focus-group interviews (FGIs). Methods Patients who discharged against medical advice between 2006 and 2008 from a large, academic medical centre along with hospital providers reporting contact with patients who left against medical advice were recruited. Three patient-only groups, one physician-only group and one nurse/social worker group were held. Focus-group interviews were transcribed, and a thematic analysis was performed to identify themes within and across groups. Participants discussed the reasons for patient DAMA and identified potential solutions. Results Eighteen patients, five physicians, six nurses and four social workers participated in the FGIs. Seven themes emerged across the separate patient, doctor, nurse/social worker FGIs of reasons why patients leave against medical advice: (1) drug addiction, (2) pain management, (3) external obligations, (4) wait time, (5) doctors bedside manner, (6) teaching hospital setting and (7) communication. Solutions to tackle DAMA identified by participants revolved mainly around enhanced communication and provider education. Conclusions In a large, academic medical centre, the authors find some differences and many similarities across patients and providers in identifying the causes of and solutions to DAMA, many of which relate to communication.

Outcomes of irinotecan-based chemotherapy regimens in elderly medicare patients with metastatic colorectal cancer

BACKGROUND Several population-based studies have confirmed the benefits of adjuvant chemotherapy with 5-fluorouracil/leucovorin for treatment of colorectal cancer. Few population-based studies have evaluated other chemotherapies that are now available for colorectal cancer management. OBJECTIVE This study primarily sought to evaluate the survival benefit of first-line irinotecan use in a group of Medicare patients with stage IV (metastatic) colorectal cancer. METHODS Data on chemotherapy users with a diagnosis of colorectal cancer reported between 1998 and 2002 were obtained from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Irinotecan, marketed in 1997, was one of the newer chemotherapy agents in the available data. Chemotherapy episodes, defined as periods of continuous chemotherapy treatment with no gaps >90 days between successive claims, were identified. The first chemotherapy episode after diagnosis was used to identify lines of treatment: patients may have initiated irinotecan therapy within 2 months (first-line), used irinotecan later in the first episode (second-line), or not used irinotecan at all. Descriptive statistics were generated and a multivariable Cox proportional hazards model was used to determine the survival benefit of irinotecan. Secondary analyses explored the survival benefit in specific patient subgroups. The impact of irinotecan use on health care utilization also was assessed. RESULTS Of 3327 chemotherapy users (mean/median age, 75 years), 842 (25.3%) initiated chemotherapy using irinotecan. No overall survival benefit for irinotecan was observed in the primary analysis comparing irinotecan initiators with all other chemotherapy users (including those who used irinotecan subsequently). Covariates that were negatively associated with survival included older age, presence of >1 comorbidity, a high tumor grade, lymph node involvement, and a primary tumor site in the colon. Surgery was positively associated with a lower hazard of death. In subgroup analyses that excluded subsequent irinotecan users, a survival benefit for irinotecan was observed but diminished over time. Irinotecan users had higher rates of hospitalizations possibly due to chemotherapy-related adverse effects. This retrospective claims study had limitations such as a lack of information on patient performance status, dosing, and the types of regimens used; hence, certain assumptions had to be made and selection bias may have been involved. CONCLUSIONS The definitive survival advantage of irinotecan observed in clinical trials was not reproducible in this population of elderly Medicare patients. The results emphasize the need for expansion of trials to include a more diverse patient group as well as continued evaluation of more recent chemotherapies in real-world settings.

A review of how the quality of HIV clinical services has been evaluated or improved

To examine approaches being used to evaluate and improve quality of HIV clinical services we searched the MEDLINE, Cochrane Library collection, EMBASE, Global Health, and Web of Science databases for articles and abstracts focused on evaluating or improving quality of HIV clinical services. We extracted country income level, targeted clinical services, and quality evaluation approaches, data sources, and criteria. Fifty journal articles and 46 meeting abstracts were included. Of the 96 studies reviewed, 65% were programme evaluations, 71% focused on low- and middle-income countries, and 65% focused on antiretroviral therapy services. With regard to quality, 45% used a quality improvement model or programme, 13% set a quality threshold, and 51% examined patient records to evaluate quality. No studies provided a definition for quality HIV care. Quality assurance and improvement of HIV clinical services is increasingly important. This review highlights gaps in knowledge for future research, and may also help countries and programmes develop their HIV care quality improvement frameworks.

Perceptions of patient provider agreements

Use of patient provider agreements (PPAs) is increasing, yet there is limited evidence on the effectiveness of PPAs to prevent prescription opioid misuse and diversion, and few guidelines for providers. We conducted eight focus groups to understand patient and prescriber perceptions of PPAs.

Assessing Physician and Patient Perceptions of Generic Drugs via Facebook: A Feasibility Study:

Background: Social media offer a novel avenue to engage with and recruit research participants. Facebook in particular is a promising option given its popularity and widespread use. Objective: To explore the feasibility of using Facebook to recruit physicians and patients to participate in a survey to assess their perceptions about generic venlafaxine extended release (ER) tablet indicated for depression. Methods: Web-based surveys were developed to gauge physicians’ prescribing experiences with and patients’ perceptions of generic venlafaxine ER tablet. The surveys included questions specific to venlafaxine ER tablets, such as perceived safety and efficacy of the drug and overall comfort level with either prescribing or taking the drug. Survey links were then posted and advertised on Facebook to recruit physicians and patients. Results: Advertisement for physicians reached 1898 Facebook users and advertisement for patients reached 1144 users during a 10-day advertising period. However, only 14 and 35 users clicked on the survey for physicians and patients, respectively. No physician completed the physician survey while 3 patients completed the patient survey. Conclusions: The findings of this study suggest that Facebook may not be an effective method to recruit physicians. Facebook holds promise to recruit patients, but additional recruitment efforts, such as incentives, are needed.

Benefits Improvement and Protection Act's impact on transplantation rates among elderly MEDICARE beneficiaries with end-stage renal disease.

Background The Benefits Improvement and Protection Act (BIPA) expanded Medicare coverage for posttransplantation immunosuppresants for elderly patients and others eligible for Medicare beyond their end-stage renal disease (ESRD) status yet retained the 3-year limit for patients eligible solely because of ESRD status. Our objective was to determine BIPA’s impact on renal transplantation among elderly patients (age ≥65 years) affected by BIPA. Methods Medicare claims and the U.S. Renal Data System Standard Analysis Files were used to analyze the likelihood of transplantation among elderly patients, all of whom were affected by BIPA, versus the nonelderly, many of whom were unaffected by BIPA. A difference-in-differences approach and generalized logistic regressions were used to estimate BIPA’s impact. Results Analysis of data for 632,904 ESRD Medicare beneficiaries who met inclusion/exclusion criteria suggests that BIPA made elderly patients more likely (relative likelihood, 1.36; 95% confidence interval, 1.32–1.41) to have a transplant. The likelihood for nonelderly patients decreased following BIPA (relative likelihood, 0.93; 95% confidence interval, 0.92–0.94). Conclusion Transplantation rates increased among those elderly patients, all of whom were affected by BIPA by extending immunosuppressant coverage under BIPA. These results suggest that removing financial barriers to posttransplantation care may positively impact transplantation rates yet raise questions regarding whether the law shifted transplants from younger to older patients.