Should we pay the patient? Review of financial incentives to enhance patient compliance

OBJECTIVE: To determine whether financial incentives increase patients' compliance with healthcare treatments. DATA SOURCES: Systematic literature review of computer databases--Medline, Embase, PsychLit, EconLit, and the Cochrane Database of Clinical Trials. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. STUDY SELECTION: Only randomised trials with quantitative data concerning the effect, of financial incentives (cash, vouchers, lottery tickets, or gifts) on compliance with medication, medical advice, or medical appointments were included in the review. Eleven papers were identified as meeting the selection criteria. DATA EXTRACTION: Data on study populations, interventions, and outcomes were extracted and analysed using odds ratios and the number of patients needed to be treated to improve compliance by one patient. RESULTS: 10 of the 11 studies showed improvements in patient compliance with the use of financial incentives. CONCLUSIONS: Financial incentives can improve patient compliance.     

Burnout: current knowledge and relevance to old age psychiatry

OBJECTIVES: To review the literature on burnout and consider its relevance to old age psychiatry and the role of the consultant. DATA SOURCES: Medline and PsychLit computerized databases. DATA SYNTHESIS: Burnout is a syndrome of emotional exhaustion, depersonalization and decreased sense of personal accomplishment which is recognized in people working in the human service professions and can have adverse effects on the workforce. There is little evidence of unique stressors related to care of elderly mentally ill people. Burnout is likely to be modified by workplace interventions. Relevant areas for intervention are political and social, organizational and management, training and personal issues. Support to consultants and their continuing professional development need to be radically reviewed.     

Techniques to improve physicians' use of diagnostic tests: a new conceptual framework

OBJECTIVES: To review the published literature on interventions aimed at improving physicians' testing practices and propose methodologic standards for these studies and to review selected studies using the PRECEDE framework, a behavioral model that helps categorize interventions based on which behavioral factors are being affected. DATA SOURCES: MEDLINE, EMBASE, and HEALTHStar databases were searched for the years 1966 to January 1, 1998, for English-language articles pertaining to diagnostic testing behavior; bibliographies were scanned to identify articles of potential interest; and researchers in health services, health behavior, and behavior modification were contacted for proprietary and other unpublished articles. STUDY SELECTION: A total of 102 articles were identified that described the results of interventions aimed at changing physicians' testing practices. We included the 49 studies that compared diagnostic testing practices in intervention and control groups. DATA EXTRACTION: Two investigators independently reviewed each article in a blinded fashion using a standard data collection form to obtain a methodologic score and to abstract the key elements of each intervention. DATA SYNTHESIS: On a 38-point methodologic criteria scale, the mean +/- SD score was 13+/-4.4. The desired behavior change was reported in the intervention group in 37 (76%) of 49 studies. Twenty-four (86%) of 28 interventions targeted at many behavioral factors were successful, while 13 (62%) of 21 studies aimed at a single behavioral factor were successful (P=.12). CONCLUSIONS: A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results.     

Does oral zinc aid the healing of chronic leg ulcers? A systematic literature review

OBJECTIVE: To determine whether oral zinc sulfate is an effective treatment for promoting healing of venous or arterial leg ulcers. DATA SOURCES: The search strategy of the Cochrane Wounds Group was used. This includes searches of electronic databases, conference proceedings, relevant bibliographies, and hand searching of journals. STUDY SELECTION: Studies were included if they were randomized controlled trials of oral zinc sulfate in the treatment of chronic venous or arterial ulcers with objective measures of healing. Six of the 10 studies initially identified were included in the review. DATA EXTRACTION: The trial method, participants, interventions, outcomes, baseline comparability, adequate reporting of withdrawals, and blinding of assessment were extracted by 2 reviewers independently. DATA SYNTHESIS: No trial showed a statistically significant benefit of zinc sulfate for healing leg ulcers. There is limited evidence to suggest that zinc might increase healing in individuals with a low serum zinc level, but more evidence is needed. CONCLUSIONS: There is no evidence of benefit from the general use of zinc sulfate in patients with chronic leg ulcers. There is a need for further research to see if oral zinc sulfate is beneficial in the treatment of patients with leg ulcers who have a low serum zinc level. If it is demonstrated to be beneficial, further trials are required to establish dose and duration of treatment.     

Crystalloids vs. colloids in fluid resuscitation: a systematic review

OBJECTIVE: To systematically review the effects of isotonic crystalloids compared with colloids in fluid resuscitation. DATA SOURCES: Computerized bibliographic search of published research and citation review of relevant articles. STUDY SELECTION: All randomized clinical trials of adult patients requiring fluid resuscitation comparing isotonic crystalloids vs. colloids were included. Pulmonary edema, mortality, and length of stay were evaluated. Independent review of 105 articles identified 17 relevant primary studies of 814 patients. Weighted c about article inclusion was high (0.76). DATA EXTRACTION: Data on population, interventions, outcomes, and methodologic quality of the studies were obtained by duplicate independent review with differences resolved by consensus. Weighted ic on the validity assessment was moderate (0.54). DATA SYNTHESIS: No difference was observed overall between crystalloid and colloid resuscitation with respect to mortality and pulmonary edema; however, the power of the aggregated data was insufficient to detect small but potentially clinically important differences. Subgroup analysis suggested a statistically significant difference in mortality in trauma in favor of crystalloid resuscitation (relative risk 0.39, 95% confidence intervals: 0.17 to 0.89). Several methodologic issues are noteworthy regarding the primary studies, including lack of blinding (except in three studies). The type, dose, and duration of fluid administration and outcomes measured were different across these trials. CONCLUSIONS: Overall, there is no apparent difference in pulmonary edema, mortality, or length of stay between isotonic crystalloid and colloid resuscitation. Crystalloid resuscitation is associated with a lower mortality in trauma patients. Methodologic limitations preclude any evidence-based clinical recommendations. Larger well-designed randomized trials are needed to achieve sufficient power to detect potentially small differences in treatment effects if they truly exist.     

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review

CONTEXT: Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes. OBJECTIVE: To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. DATA SOURCES: We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted. STUDY SELECTION: Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. DATA EXTRACTION: The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings. DATA SYNTHESIS: A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect. CONCLUSIONS: Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.     

Educating young people about drugs: a systematic review

AIMS: To assess the effectiveness of interventions directed at the prevention or reduction of use of illicit substances by young people or those directed at reducing harm caused by continuing use. DESIGN: A systematic review was conducted. Reports were identified through electronic and hand searching and contact with known workers in the area. Studies were included if they reported evaluations of interventions targeting illicit drug use and provided sufficient detail of the intervention and design of the evaluation to allow judgements to be made of their methodological soundness. Meta-analyses were conducted combining the data of the methodologically sound studies. PARTICIPANTS AND SETTINGS TARGETED BY INTERVENTIONS: Evaluations of interventions were included if their targeted audience included young people aged between 8 and 25 years. Identified evaluations were delivered in a range of settings including: schools and colleges; community settings; the family; medical/therapeutic settings; mass media. MEASUREMENTS: Data extracted from each report included details of design, content and theoretical orientation of intervention, setting of the intervention, target audience, methods, population size, subject refusal rates, rates of attrition, outcome measures, length of follow-up and findings, including statistical power. FINDINGS: The majority of studies identified were evaluations of interventions introduced in schools and targeting alcohol, tobacco and marijuana simultaneously. These studies were methodologically stronger than interventions targeting other drugs and implemented outside schools. Meta-analyses showed that the impact of evaluated interventions was small with dissipation of programme gains over time. Interventions targeting hard to reach groups have not been evaluated adequately. CONCLUSIONS: Effort needs to be directed towards the development of improved evaluative solutions to the problems posed by these groups. There is still insufficient evidence to assess the effectiveness of the range of approaches to drugs education; more methodologically sound evaluations are required. There is also a need to target interventions to reflect the specific needs and experiences of recipients.     

Introducing Critical Appraisal to studies of animal models investigating novel therapies in sepsis

OBJECTIVES: To discuss theoretical and practical aspects relating to the design of animal studies investigating the efficacy of novel therapeutic agents for the treatment of sepsis, and to make explicit the process whereby these studies can be evaluated for the purpose of designing clinical trials in humans. DATA SOURCES: Relevant articles from the pertinent literature were reviewed. STUDY SELECTION: Studies relevant to an evidence-based assessment of clinical studies on therapeutic efficacy, and studies relevant to the design of animal models of sepsis were selected. DATA EXTRACTION: Concepts relevant to an evidence-based assessment of the animal literature were extracted. DATA SYNTHESIS: Articles were reviewed and an evidence-based framework for the assessment of animal studies was developed. In this process, we discuss the steps that are necessary to assess the internal validity of an individual study and review topics relevant to the application of animal data to the design of clinical trials. CONCLUSIONS: The success of clinical trials of sepsis therapies is predicated on the generation and interpretation of sound preclinical data. In this review, we have attempted to outline an evidence-based approach to the assessment of preclinical animal studies evaluating novel therapeutic interventions in sepsis.     

Understanding prognosis to improve rehabilitation: the example of lateral elbow pain

OBJECTIVE: A systematic overview of evidence aimed at determining the clinical course of lateral elbow pain and prognostic factors that affect elbow pain duration and outcomes. DATA SOURCES: Online bibliographic database searches from 1983 to 1994; information requests from selected authors and bibliography screenings. STUDY SELECTION: One author reviewed 424 articles; 40 met the following eligibility criteria: any study with primary data on soft tissue injuries specific to the elbow which referred to prognosis or reported use of any outcome measure. DATA ABSTRACTION: Strength of evidence grade based on clinical epidemiological validity assessment. Criteria included in the validity assessment included case definition, patient selection, follow-up, outcome, prognostic factors, and analysis. All eligible studies were independently assessed by two investigators. DATA SYNTHESIS: Four studies (10%) were judged to provide moderate strength of evidence; no studies were graded as providing strong evidence on prognosis. All four moderate-quality studies were clinical trials of short duration. One study indicated that site of lesion and prior occurrence may be predictive of poorer outcome in patients with lateral epicondylitis. CONCLUSION: The majority of studies on lateral elbow pain were limited by methodological weaknesses in selection and definition of the study population, length of follow-up, and analysis of prognostic factors. Estimates of duration were only available from weaker studies with longer follow-up times; significant subject heterogeneity in the weaker studies prevented a determination of usual clinical course. More methodologically rigorous research on prognosis could assist clinicians in patient care and evaluation of interventions.     

Analysis of obstetric complications reported to the National Patient Insurance Association in Finland from 1987 to 1995

OBJECTIVE: To review comparative studies evaluating oral propafenone for restoring sinus rhythm in recent onset atrial fibrillation. DATA SOURCES: A MEDLINE search of the English-language literature (1966 to 1996) along with any referenced articles not identified by MEDLINE. STUDY SELECTION: Because intravenous propafenone is not marketed in Canada, only studies evaluating oral propafenone were included. Studies were selected if they compared oral propafenone with placebo or other antiarrhythmic agents for converting recent onset atrial fibrillation to normal sinus rhythm. DATA SYNTHESIS: Propafenone is often used as a first-line agent for pharmacological cardioversion of atrial fibrillation. In earlier studies, the efficacy of propafenone in restoring sinus rhythm was reported to be low with conversion rates of 6% to 62%. Many of these studies were noncomparative and often included patients with refractory, chronic atrial fibrillation or employed suboptimal doses of propafenone. More recently propafenone has been evaluated in the treatment of recent onset atrial fibrillation by using a single 600 mg oral loading dose. Success rates of 76% at 8 h and 83% at 12 h following the loading dose are reported. The incidence of atrial flutter during active treatment was similar to that with placebo, with the majority exhibiting 2:1 or greater atrioventricular conduction ratios and heart rates 150 beats/min or less. CONCLUSIONS: A single 600 mg oral dose of propafenone is highly effective at restoring sinus rhythm in patients with acute onset atrial fibrillation with few adverse effects. The small studies reviewed cannot lead to definitive conclusions about the safety of propafenone without prior administration of agents for rate control.     

Hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone associated with the use of selective serotonin reuptake inhibitors: a review of spontaneous reports

OBJECTIVE: To review reported cases of hyponatremia and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) associated with the use of selective serotonin reuptake inhibitors (SSRIs). DATA SOURCES: A search of MEDLINE for reports of hyponatremia and SIADH associated with the use of fluoxetine, fluvoxamine, paroxetine or sertraline published between January 1980 and May 1995. Unpublished reports of cases were requested from the pharmaceutical industry, the Ontario Medical Association, the Health Protection Branch of Health Canada, the US Food and Drug Administration and the World Health Organization. DATA SELECTION AND EXTRACTION: Spontaneous reports from postmarketing surveillance. DATA SYNTHESIS: A total of 736 cases of hyponatremia [corrected] and SIADH associated with SSRI use were reported. Fluoxetine was involved in 554 (75.3%) of the cases, paroxetine in 91 (12.4%), sertraline in 86 (11.7%) and fluvoxamine in 11 (1.5%). Reports of 30 cases were published. The remaining 706 cases were reported to monitoring bodies and the pharmaceutical industry. According to information in the published reports, the median time to onset of hyponatremia was 13 days (range 3 to 120 days). Most (83%) of the published cases involved patients 65 years of age or more, as compared with 74% of the unpublished cases. CONCLUSION: Elderly people may be at increased risk for hyponatremia associated with SSRI use. Physicians caring for elderly patients should be aware of this potentially serious but reversible adverse effect. Further research is required to determine the incidence of this adverse effect, the relative risk of hyponatremia and SIADH in different age groups and the risk associated with different SSRI drugs.     

Treatment integrity in psychotherapy research: Analysis of the studies and examination of the associated factors.

Treatment integrity refers to the degree to which an intervention is delivered as intended. Two studies evaluated the adequacy of treatment integrity procedures (including establishing, assessing, evaluating, and reporting integrity; therapist treatment adherence; and therapist competence) implemented in psychotherapy research, as well as predictors of their implementation. Randomized controlled trials of psychosocial interventions published in 6 influential psychological and psychiatric journals were reviewed and coded for treatment integrity implementation. Results indicate that investigations that systematically addressed treatment integrity procedures are virtually absent in the literature. Treatment integrity was adequately addressed for only 3.50% of the evaluated psychosocial interventions. Journal of publication and treatment approach predicted integrity implementation. Skill-building treatments (e.g., cognitive-behavioral) as compared with non-skill-building interventions (e.g., psychodynamic, nondirective counseling) were implemented with higher attention to integrity procedures. Guidelines for implementation of treatment integrity procedures need to be reevaluated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Infection and atherosclerosis--focus on cytomegalovirus and Chlamydia pneumoniae

BACKGROUND AND OBJECTIVE: Numerous studies have reported an association of coronary atherosclerosis and restenosis with certain bacterial and viral infections. This article reviews the pathophysiology of atherosclerosis, the role of infectious agents (i.e, cytomegalovirus and Chlamydia pneumoniae) in atherogenesis, and studies supporting the potential beneficial effects of antibiotics or antiviral agents in the management of atherosclerotic disease. DATA SOURCES: English-language clinical studies, abstracts, and review articles pertaining to infectious agents and coronary atherosclerosis. STUDY SELECTION AND DATA EXTRACTION: Relevant seroepidemiologic and pathologic studies and animal models evaluating the role of cytomegalovirus or C. pneumoniae in coronary atherosclerosis. DATA SYNTHESIS: Studies evaluating the possible role of cytomegalovirus and C. pneumoniae in the pathogenesis of atherosclerosis, as well as studies examining the use of antimicrobial and antiviral agents for reduction of cardiovascular events, are reviewed and critiqued. CONCLUSIONS: Current data do not allow us to determine whether infection is a cause or a cofactor of atherosclerosis. These uncertainties can be resolved by larger scale seroepidemiologic, pathologic, and interventional studies. Such efforts will contribute to identifying populations that are appropriate for particular surveillance or specific interventions, such as antibiotics or antiviral therapy.     

Establishing pharmaceutical care services in an HIV clinic

OBJECTIVE: To present a brief overview of human immunodeficiency virus (HIV) infection and to describe the implementation of pharmaceutical care services for adult patients with HIV infection. SETTING: University hospital clinic. PRACTICE DESCRIPTION: A pharmacist joined a multidisciplinary team serving HIV-infected patients in January 1994. PRACTICE INNOVATION: Current pharmacy services include taking medication histories, educating patients, counseling patients on compliance, monitoring response to therapy, identifying drug-related problems, documenting all interventions, and making therapeutic decisions and formulary choices. The pharmacist also participates in research. INTERVENTIONS: The pharmacist sees patients immediately after their physician appointments. Patients with one or more of the following characteristics are targeted to receive pharmaceutical care: multiple drugs, history of noncompliance, initiation of new drug therapy, recently discharged from hospital or emergency department, identification of potential adverse effects, identification of potential drug-drug interactions, and presence of drug toxicities. CONCLUSION: Pharmacists are uniquely qualified to provide a wide range of pharmaceutical care services to HIV-positive patients. Pharmacy interventions should lead to improved outcomes and decreased costs for a chronic and very expensive disease.     

Laminin-like proteins are differentially regulated during cerebellar development and stimulate granule cell neurite outgrowth in vitro

OBJECTIVE: To review data supporting the hypothesis that syndrome X plays a major role in the pathogenesis of coronary artery disease (CAD), and the effects of lifestyle factors and pharmacologic interventions on insulin, other metabolic parameters, and outcomes. DATA SOURCES: MEDLINE (January 1966-August 1997) and Current Contents database searches identified applicable English-language experimental trials, epidemiologic studies, reviews, and editorials. STUDY SELECTION AND DATA EXTRACTION: Studies that were included addressed the role of insulin resistance and hyperinsulinemia in the pathogenesis of CAD or the effects of lifestyle factors and pharmacologic interventions on metabolic parameters and outcomes. DATA SYNTHESIS: The main characteristics of syndrome X are hyperinsulinemia and insulin resistance. These result in secondary syndrome X features, including hyperglycemia, increased very-low-density lipoprotein concentrations, decreased high-density lipoprotein cholesterol, and hypertension. Insulin resistance is worsened by obesity, and insulin has been shown to contribute to the development of hypertension. Other studies demonstrate that smoking adversely affects glucose and insulin concentrations. Animal studies have linked hyperinsulinemia and atherogenesis. These animal data have been confirmed by several large prospective and population studies that have identified associations between hyperinsulinemia and CAD. CONCLUSIONS: Strong evidence links insulin resistance and hyperinsulinemia to CAD. Lifestyle modifications play an important role in decreasing cardiovascular risk, and clinicians should strongly encourage such changes. Clinicians must also carefully consider the effects of antihypertensive, antihyperglycemic, and antidyslipidemic agents on patients' metabolic profiles when choosing appropriate therapeutic regimens. However, outcome data on many potentially beneficial agents, including calcium antagonists, alpha 1-adrenergic antagonists, angiotensin-converting enzyme inhibitors, metformin, acarbose, and troglitazone, are not yet available.     

DNA reactions, mutagenic action and stealth properties of polycyclic aromatic hydrocarbon carcinogens (review)

OBJECTIVE: To present a critical review and meta-analysis of studies evaluating the long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease (COPD). DATA SOURCES: A database of articles published over the last 45 years, compiled by using medical subject heading key words pulmonary, obstructive, rehabilitation, and exercise. Articles not written in English, Dutch, or German and abstracts were excluded. STUDY SELECTION: Selected studies (1) evaluated the effects of pulmonary rehabilitation, (2) included patients with asthma or COPD older than 18 years, (3) evaluated outcome measures of exercise capacity or health related quality of life (HRQL), and (4) included a control condition lacking exercise training. DATA EXTRACTION: Independent extraction by two reviewers. DATA SYNTHESIS: For each outcome, summary effects were computed by pooling standardized mean differences as well as raw mean differences. Significant improvements were found for all outcomes (p < .001). Sensitivity analyses for methodological quality of the selected studies did not change summary effect sizes. Effect sizes were significantly heterogeneous for the outcome endurance time (p < .0001). Pooling raw mean differences revealed overall effects in 6-minute walking distance (49+/-26 m) and all 4 dimensions of the chronic respiratory questionnaire (range, 0.5+/-0.3 to 0.8+/-0.3 points), indicating substantial improvements in these outcomes. Significant summary effect sizes were found up to 9 months after finishing rehabilitation for maximal exercise capacity (p < .003) and 6-minute walking distance (p < .005). CONCLUSIONS: Patients with asthma and COPD benefit from pulmonary rehabilitation.     

Therapy of shock with naloxone: a meta-analysis

OBJECTIVES: To evaluate the effectiveness of naloxone in human shock; and to estimate the methodologic quality of the clinical trials. DATA SOURCES: Computerized bibliographic search on MEDLINE covering the period from January 1979 to July 1996, review of references of all papers found on the subject, and contact with primary investigators of eligible studies. STUDY SELECTION: To be included in this study, a paper should be a randomized, clinical trial published in a peer-reviewed journal evaluating naloxone in human shock, regardless of the patient's age (adult, child, neonate). Three independent readers reviewed 61 human publications and selected five clinical trials. Overall agreement on study selection was perfect (concordance: 100%). We excluded a posteriori two studies whose authors were unable to provide us with the raw data to complete contingency tables. This meta-analysis deals with three studies including 61 patients with septic shock. DATA EXTRACTION: Three independent reviewers extracted data on study design, intervention, outcome, and methodologic quality. The intraclass correlation coefficient was 0.7. The quality score of each study was 48, 60, and 61, on a scale of 104. DATA SYNTHESIS: Naloxone therapy was associated with statistically significant hemodynamic improvement (typical odds ratio: 0.241; 95% confidence interval: 0.08 to 0.68). The overall effect size was 0.89. However, a publication bias was possible. The case fatality rate was not decreased by naloxone (typical odds ratio: 0.60; 95% confidence interval: 0.21 to 1.67); a chi-square analysis detected significant heterogeneity for the latter outcome (p < .05). CONCLUSIONS: Naloxone improves blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined and additional randomized clinical trials are needed to assess its usefulness.