Jill Cockburn

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patients daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.

Psychological Consequences of Screening Mammography

Objective- To examine the psychological consequences at a number of stages in the screening process for women attending a screening mammography programme. Setting- A pilot mammographic screening programme in Melbourne, Australia. Method — The psychological consequences questionnaire (PCQ; a reliable and valid measure of the psychological consequences of screening mammography) was used to measure the emotional, social, and physical functioning of women in a mammographic screening programme and a control community sample. A screening group (in whom no abnormality was detected at initial screen; n=142) had four measurements: at screening clinic; before results were received; one week after all-clear results were received; and eight months after initial visit. The recall group (who were recalled for further investigation which showed the detected abnormality to be benign; n = 58) had measurements at the same points as the screening group and an additional measurement while waiting at the recall assessment clinic. A randomly selected community control group (n = 52) had measurements one week, two weeks, three weeks; and eight months after consenting to participate. Results - Emotional, social, and physical functioning of women in the screening group did not change over time and at no point differed significantly from that of community controls. The profiles of emotional and physical dysfunction of women in the recall group differed significantly from those of the screening and control groups. The level of emotional and physical dysfunction in the recall group was highest while waiting at recall assessment clinic, and scores were still significantly higher than scores obtained at comparable times from screening and control groups one week after obtaining notification that there was no sign of cancer (emotional P< 0·001; physical P < 0·05). This difference had disappeared eight months after the screening visit, when the level of emotional and physical functioning was similar to that of the screening and control groups. Social dysfunction scores did not change significantly over time and were similar for all three groups. Conclusions - Given that up to 10% of women are recalled for further investigations on first round screening, significant numbers of women may have psychological consequences. This speaks for the necessity for accurate reading of mammograms to minimise the false positive recall rate, and for counselling services to be available at recall assessment centres.

Promoting urinary continence in women after delivery: randomised controlled trial

Abstract Objectives: To test the effectiveness of a physiotherapist delivered intervention designed to prevent urinary incontinence among women three months after giving birth. Design: Prospective randomised controlled trial with women randomised to receive the intervention (which entailed training in pelvic floor exercises and incorporated strategies to improve adherence) or usual postpartum care. Setting: Postpartum wards of three tertiary teaching hospitals in the Hunter region, New South Wales, Australia. Participants: Women who had forceps or ventouse deliveries or whose babies had a high birth weight (4000 g), or both—676 (348 in the intervention group and 328 in the usual care group) provided endpoint data at three months. Main outcome measures: Urinary incontinence at three months measured as a dichotomous variable. The severity of incontinence was also measured. Self report of the frequency of performance of pelvic floor exercises was recorded. Results: At three months after delivery, the prevalence of incontinence in the intervention group was 31.0% (108 women) and in the usual care group 38.4% (125 women); difference 7.4% (95% confidence interval 0.2% to 14.6%, P=0.044). At follow up significantly fewer women with incontinence were classified as severe in the intervention group (10.1%) v (17.0%), difference 7.0%, 1.6% to 11.8%). The proportions of women reporting doing pelvic floor exercises at adequate levels was 84% (80% to 88%) for the intervention group and 58% (52% to 63%) for the usual care group (P=0.001). Conclusions: The intervention promoting urinary continence reduced the prevalence of urinary incontinence after giving birth, particularly its severity, and promoted the performance of pelvic floor exercises at adequate levels; both continence and adherence to the programme were measured at three months after delivery in women who had forceps or ventouse deliveries or babies weighing 4000 g or more. What is already known on this topic Intensive pelvic floor exercise programmes can reduce urinary incontinence in selected groups of female patients The effectiveness of interventions promoting continence in reducing urinary incontinence in the female population overall has not been investigated Pelvic floor exercises are widely held to be an important component of continence promotion programmes What this study adds Continence promotion programmes delivered to a selected population are able to prevent urinary incontinence in that population Few studies have examined the efficacy of compliance aiding strategies in helping women adhere to prescribed pelvic floor exercise programmes

Development and validation of the PCQ: A questionnaire to measure the psychological consequences of screening mammography

We have developed a reliable and valid questionnaire to measure the psychological consequences of screening mammography. The questionnaire measures the effect of screening on an individuals functioning on emotional, social, and physical life domains. Content validity was ensured by extensive review of the relevant literature, discussion with professionals and interviews with attenders at a pilot Breast X-ray Screening Program in Melbourne, Australia. Discriminant validity was assessed by having expert judges sort items into dimensions which they appeared to be measuring. Acceptable levels of concordance (above 80%) with a priori classifications were found. Concurrent validity was demonstrated by comparison of subscale scores of 53 attenders at the Breast X-ray Program with an independent interview assessment of dysfunction on each of the emotional, social and physical dimensions. There was over 79% agreement between interview scores and questionnaire scores for each dimension. Construct validity was confirmed by showing that subscale scores varied in predicted ways. For women who were recalled for further investigation, scores on each subscale measuring negative consequences, were higher at the recall clinic than at screening clinic (emotional: t = -7.28; df = 70; P less than 0.001; physical: t = -2.53; df = 70; P = 0.014; social: t = -2.49; df = 70; P = 0.015). The internal consistency of all subscales was found to be acceptable. This questionnaire is potentially useful for assessing the psychological consequences of the screening process and should have wide application.

Knowledge and perceptions about breast cancer incidence, fatality and risk among Australian women.

Objective: Breast cancer is the most common fatal cancer among Australian women. This study aimed to provide an accurate national picture of womens understanding of breast cancer incidence, fatality and risk.

Integrated, collaborative palliative care in heart failure: the St. George Heart Failure Service experience 1999-2002.

Background:Chronic heart failure (HF) is the only heart condition increasing in prevalence and is primarily a condition of aging. This condition has outcomes worse than many cancers; however, patients are often denied the benefits of palliative care with its important emphasis on symptom management, spirituality, and emotional health and focus on family issues. Aim:To describe the development of a model of an integrated, consultative, palliative care approach within a comprehensive HF community-focussed disease management program. Method:A collaborative model was developed following a systematic needs assessment and documentation of local resources. Principles underpinning this model were based upon fostering of communication, consultancy, and skill development. Within this model a health care system, based upon universal coverage, supported co-management of patients and their families. The place of death, level of social support available at home, and degree of palliative care involvement was documented in 121 consecutive deaths from 1999–2002. Findings:Following a period of skill sharing and program development, only 8.3% of HF patients in the collaborative program required specialized palliative care intervention for complex symptom management, carer support, and issues related to spirituality. Twenty percent of this cohort died in nursing homes underscoring the importance of supporting our nursing colleagues in this setting. Conclusions:In spite of well-documented difficulties in determining prognosis, it is the St George experience that key principles of a palliative care strategy can be implemented in a HF disease management program with support and consultancy from expert palliative care services.

The Adequacy of Measurement of Short and Long-Term Consequences of False-Positive Screening Mammography

Objectives: The aim of this study is to review quantitative studies on womens experiences of consequences of false-positive screening mammography to assess the adequacy of the most frequently used instruments for measuring short-term and long-term psychological consequences. Methods: Relevant papers reporting quantitative studies on consequences of false-positive screening mammography were identified using MEDLlNE, CINAHL, EMBASE and PsycInfo databases. Articles citing development and psychometric properties of the most frequently used measures were also retrieved. Finally, the review focused on studies that had used at least one of the most frequently used measures. Results: Twenty-three relevant studies were identified. The most commonly used measures were the General Health Questionnaire (GHQ), the Hospital Anxiety and Depression Scale (HADS), the Psychological Consequences Questionnaire (PCQ) and the State-Trait Anxiety Inventory (STAI). One or more of these was used in 17 of the 23 studies. Conclusions: The GHQ, the HADS and the STAI have problems with language, content relevance, and content coverage in studies of false-positive screening mammography. These instruments should not be used to measure psychological consequences of any kind of cancer screening. The PCQ is an adequate questionnaire for measuring short-term consequences, and the PCQ is preferable to other measures because of its higher sensitivity. However, there is little evidence that the PCQ is able to adequately detect all long-term consequences of screening mammography. Given the inadequacy of the measurement instruments used, any current conclusions about the long-term consequences of false-positive results of screening mammography must remain tentative.

Perceptions and Experiences of Heart Disease: A Literature Review and Identification of a Research Agenda in Older Women

Background:: Following diagnosis of heart disease women have poorer health related outcomes compared with men. Nursing science lacks well-evaluated interventions to address the specific rehabilitative needs of older women with heart disease. AIMS:: This paper seeks to inform the development of nursing intervention studies by a review of published studies on the experiences and rehabilitative needs of older women with heart disease. Methods:: The CINAHL, MEDLINE, FAMILY and PsychINFO databases were searched, identifying literature published from 1982 and written in English. Keywords used were women, old∗ (old, older) women, elderly women and: heart disease, heart failure, cardiac and rehabilitation. Hand searching of nursing and medical textbooks also occurred. These searches resulted in over 120 articles that met the criteria of describing experiences, perceptions, psychological responses and support rehabilitative needs of older women. Results:: Older women present with symptoms that are different from those derived from a male-dominated research agenda and further there is a paucity of data related to evaluation of interventions tailored to the needs of women. Key themes emerging from the literature review include not only that older women compared with men have a poorer prognosis and experience greater disability moreover they: (1) are at a higher risk of psychosocial distress; (2) have a greater need for instrumental support and social support; (3) have an altered perception of risk; and (4) demonstrate the need for specific rehabilitation programs, tailored to their needs. Conclusion:: Future research should develop and evaluate intervention studies that better meet the unique needs of older women with heart disease. Particular emphasis needs to be on psychosocial aspects, given evidence that identify these are major concerns for women.

Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?

Background Heart failure is a common and costly condition, particularly in the elderly. A range of models of interventions have shown the capacity to decrease hospitalizations and improve health-related outcomes. Potentially, cardiac rehabilitation models can also improve outcomes. Aim To assess the impact of a nurse-coordinated multidisciplinary, cardiac rehabilitation program to decrease hospitalizations, increase functional capacity, and meet the needs of patients with heart failure. Method In a randomized control trial, a total of 105 patients were recruited to the study. Patients in the intervention group received an individualized, multidisciplinary 12-week cardiac rehabilitation program, including an individualized exercise component tailored to functional ability and social circumstances. The control group received an information session provided by the cardiac rehabilitation coordinator and then follow-up care by either their cardiologist or general practitioner. This trial was stopped prematurely after the release of state-based guidelines and funding for heart failure programs. Results During the study period, patients in the intervention group were less likely to have been admitted to hospital for any cause (44 vs. 69%, P = 0.01) or after a major acute coronary event (24 vs. 55%, P = 0.001). Participants in the intervention group were more likely to be alive at 12 months, (93 vs. 79%; P = 0.03) (odds ratio =3.85; 95% confidence interval = 1.0314.42; P = 0.0042). Quality of life scores improved at 3 months compared with baseline (intervention t = 4.37, P [ 0.0001; control t= 3.52, P [0.01). Improvement was also seen in 6-min walk times at 3 months compared with baseline in the intervention group (t = 3.40; P = 0.01). Conclusion This study shows that a multidisciplinary heart failure cardiac rehabilitation program, including an individualized exercise component, coordinated by a specialist heart failure nurse can substantially reduce both all-cause and cardiovascular readmission rates, improve functional status at 3 months and exercise tolerance.

Accuracy of Telephone Self-Report of Drug Use in Older People and Agreement with Pharmaceutical Claims Data

ObjectiveTo determine the agreement between two measures of medication use, namely telephone interview self-report and pharmaceutical claims data, in an elderly population.MethodsAn agreement study of 566 community-dwelling, general practice patients aged ≥65 years was conducted to compare self-reported use of medicines with pharmaceutical claims data for different retrieval periods. Classes of drugs commonly used in the elderly were selected for comparison.Results1094 people were eligible for the main study. Of these, 697 people completed a follow-up survey and 625 of these patients consented to the release of pharmaceutical claims data. A further 59 participants were excluded from the analysis because they had a home visit instead of a telephone interview. The proportion of observed agreement between the telephone self-report and the various retrieval periods was consistently high. Kappa coefficients showed good to very good agreement (≥0.75) with retrieval periods of 30, 60 and 90 days for benzodiazepines, low-risk NSAIDs, thiazide diuretics and most other drugs. The specificity of self-reported medication use compared with claims data was consistently high across all drug classes, suggesting that people usually did not mention drugs that were not included in the claims data. Sensitivity values varied according to drug class and retrieval period, and were lower for NSAIDs than for benzodiazepines and thiazide diuretics. Decline in sensitivity with increased retrieval periods was most marked for benzodiazepines, NSAIDs and low-risk NSAIDs, which are often used on an as-needed basis. Positive predictive values increased with longer retrieval periodsConclusionHigh agreement and accuracy were demonstrated for self-reported use of medicines when patients were interviewed over the telephone compared with pharmaceutical claims data. The telephone inventory method can be used in future studies for accurately measuring drug use in older people when claims data are not available.