Partial Compliance Research Articles

Effect of partial compliance on the prevention of recurrent preterm birth in women receiving weekly 17 alpha-hydroxyprogesterone caproate injections

Purpose: To analyze the effect of partial compliance on preterm birth (PTB) prevention among women with previous PTB and receiving 17 alpha-hydroxyprogesterone caproate (17-OHPC).Study Design: This is a secondary analysis of a multicenter trial for the prevention of recurrent PTB. Women with prior PTB were randomly assigned between 15 0/7 and 20 3/7 weeks to weekly injections of either 17-OHPC or placebo. Full 100% compliance (group 1) was compared to 40-80% (group 2). Recurrent PTB rates and odds ratios were calculated. Student's t, Chi-square, Wilcoxon Rank-Sum, multivariate logistic regression and Breslow-Day tests were used.Results: Group 1 included 370 women versus 35 in group 2. In each group, the PTB rate was significantly reduced in pregnancies receiving 17-OHPC compared to placebo. The adjusted odds ratio for PTB rate in group 1 was 0.48 (95% CI 0.31–0.75) versus 0.18 (95% CI 0.04–0.92) in group 2. Comparing the homogeneity of both odds ratios, the rates of recurrent PTB prevention in both groups were not statistically different (Breslow–Day test; p= .15).Conclusion: A compliance rate of 40–80% did not significantly reduce 17-OHPC’s efficacy. If confirmed, our findings could lead to a dramatic decrease in costs related to prevention of recurrent PTB.

Behavioral factors for predicting severity of enuresis and treatment responses in different compliance groups receiving behavioral therapy.

Objective:To investigate behavioral factors for predicting severity of nocturnal enuresis and compare response rates in different compliance groups of behavioral interventions.Methods:Three hundred eleven children diagnosed with nocturnal enuresis were enrolled. This study was conducted at Beijing Children’s Hospital affiliated to the Capital Medical University from September 2016 to December 2016. Correlation of severity of enuresis and behavioral factors was investigated. All patients were treated with desmopressin based on behavioral interventions. After twomonth treatment, the patients were grouped according to the compliance of behavioral therapy. Then response rates in different compliance groups were compared.Results:Multivariate analysis revealed stool frequency, drinking water before going to bed, awaking the child to toilet at night, and appetite were independent risk factors affecting the severity of enuresis. The complete response rate of enuresis and partial response ratein fullcompliance group are higher than thoseof partial compliance and non-compliance group(21.9% vs 11.3%, 78.1% vs 59.8%; 21.9% vs 0%, 78.1% vs 49.1%; P<0.01). The complete response rate and partial response rate of partial compliance group are higher than those of the non-compliance group (P<0.01).Conclusions:Stool frequency, drinking water before going to bed, awaking the child to toilet at night, and appetite are independent predictive factors affecting the severity of enuresis. Good compliance of behavioral interventions may have a crucial role for better therapeutic outcomes.

Implementation of a Centralized Telehealth-based Antimicrobial Stewardship Program (ASP) for 16 Small Community Hospitals (SCHs)

BackgroundInnovative strategies are needed for ASP implementation in SCHs (<200 beds). Most SCHs lack ASPs that meet Joint Commission (JC) requirements and CDC core elements. Telehealth can help extend infectious diseases expertise and stewardship resources to such facilities.MethodsThe Infectious Diseases Telehealth (IDt) program provides consultation and ASP support to 16 Intermountain SCHs (18-150 beds). Key stakeholders were identified at each site to establish formal ASPs. An IDt physician and pharmacist attended local meetings as ASP members to provide guidance. Centrally tracked antibiotic usage and resistance data were reviewed with each program to identify opportunities for improvement. Daily stewardship responsibilities were shared: front-line pharmacists were trained to review charts for appropriateness using automated electronic alerts, while the IDt pharmacist reviewed high priority alerts (e.g., positive blood cultures). Recommendations were made to local staff, or to the IDt physician in cases needing telehealth consultation.ResultsASPs were formed at 15/16 hospitals (1/16 had an existing ASP). Members included: local physician (15/16), local pharmacist (15/16), infection preventionist (16/16), quality representative (15/16), nursing (5/16), and administration (5/16). Collaborative data review led to 16 planned projects to improve antimicrobial prescribing. Eleven targeted specific drugs [carbapenems (n = 6), piperacillin-tazobactam (n = 1), fluoroquinolones (n = 2), vancomycin (n = 2)], and five aimed to improve processes [allergy assessment (n = 2), order sets (n = 2), and implementation of rapid diagnostics (n = 1)]. Five of 16 ASPs documented full compliance with JC and CDC requirements, and 11/16 documented partial compliance (none were compliant prior to IDt implementation). Front-line pharmacists reviewed 3,593 stewardship alerts during the first 7 months, leading to 826 interventions across 16 facilities. The IDt pharmacist reviewed 1,198 alerts leading to 318 interventions.ConclusionWe established or augmented ASPs in 16 Intermountain SCHs through local empowerment, central data sharing, and IDt mentorship. Future goals include documenting improvement in antibiotic use and patient outcomes.Disclosures All authors: No reported disclosures.

The Impact of Traineeships on the Employment of the Mentally Ill: The Role of Partial Compliance

Lavoro&Psiche is a RCT aimed at increasing employment among severely mentally ill patients, by offering them a structured job-search experience. The key feature of the treatment was the presence of a entirely dedicated to support the job search of a small number (12-13) of mentally ill patients. What most often the job coach did was finding the patient a traineeship. If one were to consider only the effect of making the support of the coach available – the so-called Intention-To-Treat effect – it would be a disappointing statistically non significant 5 percentage point difference in the employment of treatment and control members, in the full post-treatment year. However, the impact of making something available is rarely the primary interest of policy-makers, who would rather know the effect of receiving it. The main difficulty in obtaining unbiased estimates of the latter is that 'who receives what' is no longer solely determined by randomization, but also by post-randomization events and decisions. During the implementation period of Lavoro&Psiche of 2011-12, an unprecedented wave of traineeship opportunities hit those enrolled in the demonstration, both in the experimental and in the control group. The main finding is that, for the subset of the experimental group that was induced by the offer to be involved in a traineeship the chances of having a job in the post-treatment year more than double from the 17% of those who did not do any traineeship to the 34% of those who did, well above the Intention-To-Treat impact estimates.

Effects of teach-back method on the compliance of functional exercises in postoperative patients with breast cancer

Objective To explore the effects of teach-back method on the compliance of functional exercises in postoperative patients with breast cancer. Methods Totally 105 postoperative patients with breast cancer admitted in our hospital from March to September 2015 were selected as the control group, and 114 patients from October 2015 to March 2016 were selected as the intervention group. Patients in the intervention group received the functional exercises based on teach-back method, while patients in the control group received routine health education method. The mastery skill score and compliance of functional exercise one day before discharge in two groups were compared. Results The mastery skill score of functional exercise one day before discharge was (63.73±5.51) in the intervention group, which was significantly higher than (56.45±4.88) in the control group (P<0.05); the constituent ratio of fully compliance, partial compliance and noncompliance status in the intervention group one day before discharge were 64.91%, 25.44%, 9.65%, and they were obviously superior to the control group (47.62%, 36.19%, 16.19%) (P<0.05). Conclusions Teach back method can effectively improve the skill and compliance of functional exercise in postoperative patients with breast cancer. Key words: Breast cancer; Teach-back method; Functional exercise; Compliance

Ratner, Steven R. The Thin Justice of International Law: A Moral Reckoning of the Law of Nations.New York: Oxford University Press, 2015. Pp. 496. $85.00 (cloth).

Ratner, Steven R. <i>The Thin Justice of International Law: A Moral Reckoning of the Law of Nations</i>.New York: Oxford University Press, 2015. Pp. 496. $85.00 (cloth).

Kaizen practice in healthcare: a qualitative analysis of hospital employees' suggestions for improvement

ObjectivesKaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this...

Disability and Philosophy: Applying Ethics in Circumstances of Injustice

Despite antidiscrimination laws, disability discrimination remains ongoing. A recent field experiment in the USA indicates that employers are significantly more reluctant to interview qualified applicants with disabilities, whether physical or mental. This reluctance is especially noticeable among smaller employers and for more experienced job applicants. Such barriers impede people with disabilities from work, economic self-sufficiency, employer provided health insurance, and more generally full participation in the societies in which they live. These impediments, in short, are a serious problem of justice and yet another indication that we live in an imperfect world in which non-ideal and partial compliance theorising about justice is imperative.

Textile wastewater reuse after additional treatment by Fenton’s reagent

This study verifies textile wastewater reuse treated by the conventional activated sludge process and subjected to further treatment by advanced oxidation processes. Three alternative processes are discussed: Fenton, photo-Fenton, and UV/H2O2. Evaluation of treatments effects was based on factorial experiment design in which the response variables were the maximum removal of COD and the minimum concentration of residual H2O2 in treated wastewater. Results indicated Fenton's reagent, COD/[H2O2]/[Fe2+] mass ratio of 1:2:2, as the best alternative. The selected technique was applied to real wastewater collected from a conventional treatment plant of a textile mill. The quality of the wastewater before and after the additional treatment was monitored in terms of 16 physicochemical parameters defined as suitable for the characterization of waters subjected to industrial textile use. The degradation of the wastewater was also evaluated by determining the distribution of its molecular weight along with the organic matter fractionation by ultrafiltration, measured in terms of COD. Finally, a sample of the wastewater after additional treatment was tested for reuse at pilot scale in order to evaluate the impact on the quality of dyed fabrics. Results show partial compliance of treated wastewater with the physicochemical quality guidelines for reuse. Removal and conversion of high and medium molecular weight substances into low molecular weight substances was observed, as well as the degradation of most of the organic matter originally present in the wastewater. Reuse tests indicated positive results, confirming the applicability of wastewater reuse after the suggested additional treatment. Graphical abstract Textile wastewater samples after additional treatment by Fenton's reagent, photo-Fenton and H2O2/UV tested in different conditions.

Disclosure indexes and compliance with mandatory disclosure—The case of intangible assets in the Italian market

Disclosure of financial statements is an important topic both for investors and for preparers as disclosure allows investors to understand the application of the accounting principles used by companies. This research examines the 2010 financial statements under IFRS of 189 Italian listed groups and their compliance with mandatory disclosure on intangible assets and presents an in depth empirical analysis of the Italian market—that belongs to the Continental European accounting cluster. Different variables were tested to analyze the compliance with the mandatory disclosure such as size variables, performance variables, financial interest variables and market variables. Many studies on mandatory disclosure are based on one disclosure index method and results are affected by the different approaches used: Cooke's dichotomous approach, Partial Compliance method, weighted and unweighted. In this paper, the decision was taken to run all the previous methods: results show that the only significant variable for all Dscore indexes is the weight of interests on revenues and this result is a distinctive feature of the Italian market where the role of the banking systems is more important than in other countries.

Multidisciplinary optimization of oral chemotherapy delivery at the UW Carbone Cancer Center.

58 Background: Use of oral chemotherapy is expanding and offers advantages but introduces unique safety challenges. ASCO and ONS addressed these issues with inclusion of oral chemotherapy in published chemotherapy administration safety standards. Methods: The updated ASCO/ONS standards offered a framework for the University of Wisconsin Carbone Cancer Center to evaluate and improve our practice with the goal of full compliance with these standards. Gap analysis revealed noncompliance with five and partial compliance with eleven standards. We divided areas for improvement into three foci: patient education, workflow, and information technology. Multidisciplinary groups addressed each area generating twenty-five recommendations. Important changes included: defining chemotherapy, standardization of patient and caregiver education, mandated use of standardized electronic order sets incorporating safety checks, and standardizing dose modification documentation. The revised electronic process allows for prospective order review of all oral chemotherapy by pharmacists and supports automated processes for assessing adherence and toxicities utilizing a library of scripted drug specific materials. Results: Prior to implementation of new processes we estimated that only 39% of our oral chemotherapy was delivered with potential demonstrable compliance with ASCO/ONS standards. Audit of oral chemotherapy orders from February to July 2015 now shows compliance with use of electronic chemotherapy plans in 244/251 (97.5%) of cases. Prospective pharmacist order review resulted in one or more interventions in 24% of these cases.Identification of patients to receive adherence and toxicity monitoring calls is 100%. Conclusions: Closure of significant gaps between institutional practice and published standards was accomplished for our oral chemotherapy practice. Key elements of success included: multidisciplinary approach, defining chemotherapy, leveraging our electronic health record with mandated use of standardized order sets, and standardization of clinical and educational processes. We are disseminating this approach across our regional network and we believe our tools are broadly applicable.

Clinical pharmacist assisted thromboprophylactic optimization in general surgical patients

Practice of prophylaxis against venous thromboembolism (VTE) following surgical procedures has been in the scenario for about half a century. Despite the surging evidence regarding the clinical and economic efficacy, the practice remains underutilized. The study was aimed at optimizing the prophylactic practices for prevention of VTE in the general surgical patients in a tertiary care hospital using a pharmacist assisted multi-strategy intervention. The prospective quasi-experimental study was conducted in general surgical department of a tertiary care hospital in Kerala. The initial audit phase was targeted at assessing the prevailing prophylactic practices and its adequacy in relation to American College of Chest Physicians (ACCP) guidelines. This was followed by an educational phase where physicians were provided the feedback and institutional protocol. The third phase involved intervention through patient risk stratification and prophylactic recommendation by pharmacist concomitantly with reaudit. The overall non-compliance to the therapy decreased from 52% in the control phase to 20% in the intervention phase with P = 0.0009. The partial compliance to therapy reduced from 40% in the control phase to 32% in the intervention phase with P = 0.4047. Total compliance to therapy increased from 8% in the control to 48% in the intervention stage and the difference was found to be significant with P < 0.0001. The study was effective in increasing the overall compliance to the ACCP 9th guidelines by 40% and the average duration by 1.61 days. Clinical pharmacist assisted multi-strategy interventions were effective in enhancing the appropriateness of the prophylaxis as per the ACCP recommendations. Les recommandations concernant la prévention du thrombo-embolisme veineux (VTE) postopératoire datent d’un demi-siècle. Malgré l’évidence de l’efficacité clinique et économique, les recommandations restent encore parfois peu ou mal utilisées. L’étude a visé à optimiser les pratiques de prévention du VTE chez les patients hospitalisés en chirurgie générale dans un hôpital de soin possédant des pharmaciens cliniciens. L’étude quasi expérimentale éventuelle a été conduite dans le département de chirurgie générale d’un hôpital du Kerala. La phase initiale a été un audit des pratiques prophylactiques existantes et leur adéquation avec les directives cliniques de l’American College of Chest Physicians (ACCP). Ceci a été suivi par une phase éducative où les pharmaciens cliniciens ont présenté le résultat d’audit aux médecins avec un protocole institutionnel. La troisième phase a impliqué une intervention des pharmaciens selon le profil de risque du patient avec un rappel de la recommandation prophylactique et dans la foulée un nouvel audit. Le non-respect global à la thérapie a diminué de 52 % dans la phase de contrôle à 20 % dans la phase d’intervention (p = 0,0009). La conformité partielle aux directives cliniques a été réduite de 40 % pour la phase de contrôle jusqu’à 32 % pour la phase d’intervention (p = 0,4047). La conformité totale aux directives cliniques s’est accrue significativement de 8 % pour le contrôle jusqu’à 48 % pour l’étape d’intervention (p < 0,0001). La stratégie utilisée s’est avérée efficace pour améliorer la conformité globale aux 9es directives ACCP (+ 40 %) et la durée moyenne à 1,61 jours. Les interventions du pharmacien clinicien se sont avérées efficaces pour assurer le respect des directives cliniques de l’ACCP.

Does Weighting Really Matter? The 'Blind Spot' of Corporate Governance Ratings

This methodological paper highlights the differences and the resulting implications from the application of the three most commonly applied weighting index methods to measuring corporate governance quality at an aggregate level: the Dichotomous; the partial compliance (PC) unweighted; and the Experts’ methods. In particular, first, we demonstrate how each method is applied and provide the details needed for readers to replicate each method. Second, we employ these methods on a sample of companies and compare the corresponding scores by testing their differences statistically. Third, as an indicative example of the potential implications arising from the use of these measures, we test whether the relation between market value and corporate governance levels differs, depending on the method applied. We find that the three methods produce significantly different overall and relative (i.e., ranking order) scores and, consequently, the relation between market value and corporate governance levels differs, depending on the method applied. Thus, we contribute to the corporate governance literature by showing that weighting in corporate governance indices matters and we recommend simultaneous application of at least two methods (i.e., the PC unweighted and the Experts’ methods) for deriving robust findings.

JUSTICE AND RECIPROCITY: THE CASE FOR NONIDEAL THEORY

Abstract:This essay discusses and criticizes the claim that normative political theory can be (justifiably and fruitfully) divided into two parts—a part having to do with ideal theory which assumes full compliance and abstracts away from issues having to do with implementation and, contrasting with this, a nonideal part having to do with implementation and with rules and institutions appropriate for conditions of partial compliance. On this conception of ideal theory, empirical facts about human behavior and motivation, connected to issues surrounding compliance and implementation, are irrelevant to ideal theory, although such facts can be relevant to the nonideal part of normative theory. I argue against this conception, holding instead that such empirical facts are relevant to most or all of normative political theory, including “fundamental” normative principles.

533: The effect of partial compliance on the prevention of recurrent preterm birth in women receiving weekly 17 alpha-hydroxyprogesterone caproate injections

To analyze the effect of partial compliance on the prevention of preterm birth (PTB; defined as less than 37 weeks of gestation) among women with previous preterm births and receiving 17 alpha-hydroxyprogesterone caproate (17-P). This is a secondary analysis of a multicenter trial for the prevention of recurrent PTB. Women with a history of PTB were enrolled between 16 and 20 weeks and randomly assigned to weekly injections of either 17-P or placebo. Noncompliance was defined by a gap of at least 10 days between any two injections. Women with 100% compliance rate were compared to those with a compliance rate between 40-80%. Cases with missing data were excluded. The rate of recurrent PTB was the primary outcome. Relative risks were calculated and adjusted to race and the number of previous PTBs. Student's t, Chi-square and mantel-haenszel tests were used as appropriate. A total of 409 women were studied: 370 were 100% compliant, whereas 35 had a compliance rate of 40-80%. The average compliance rate (%) in the group with partial compliance was 62 ± 13. The average gestational age at delivery in the full compliance group was 36w0d ± 4.7 weeks; whereas women with partial compliance delivered in average at 34w1d ± 5.7 weeks. In each group, the PTB rate was significantly reduced in pregnancies receiving 17-P compared to placebo [table]. Women on 17-P whether they were 100% or partially (40-80%) compliant had statistically similar PTB rates [table]. Comparing the homogeneity of both relative risks, the rate of recurrent PTB prevention in both groups was not statistically different (p= 0.1). A 17-P injection compliance rate of 40-80% did not reduce the efficacy of 17-P for the prevention of recurrent preterm birth. This may be explained by the recently reported long half-life of 17-P of 16 days. A randomized trial might help in determining the frequency of injections and the interval between injections of 17-P to prevent recurrent preterm birth. If confirmed, our findings could lead to a dramatic decrease in costs related to prevention of recurrent preterm.

Disability and philosophy: applying ethics in circumstances of injustice

Despite antidiscrimination laws, disability discrimination remains ongoing. A recent field experiment in the USA indicates that employers are significantly more reluctant to interview qualified applicants with disabilities, whether physical or...

Hydroxyurea Shows Clinical Benefit without Alteration of Fetal Hemoglobin, MCV, or Hemoglobin in Unselected Adult and Pediatric Patients with Sickle Cell Anemia

IntroductionSickle cell anemia is the most common single gene defect in the United States, affecting approximately 100,000 individuals (Hassel Am J Prev Med 2010). It is characterized by chronic hemolysis, unpredictable vaso-occlusive episodes (VOEs), and chronic organ damage leading to early death in patients affected by the disorder. Hydroxyurea, a small molecule chemotherapeutic agent, has been used to treat patients with severe sickle cell disease since 1984 (Brawley Ann Intern Med 2008). Two randomized controlled trials, the Multicenter Study of Hydroxyurea (Charache N Engl J Med 1995) in adults and the Baby HUG trial (Wang Lancet 2011) in children, showed that hydroxyurea reduced the number of VOEs and hospital admissions, while simultaneously increasing hemoglobin and fetal hemoglobin in patients with sickle cell anemia. The goal of this study was to determine the clinical effectiveness of hydroxyurea in reducing the number VOEs and hospitalizations in unselected patients with sickle cell anemia.MethodsThe CASIRE group is an international multi-institutional collaborative group evaluating the clinical severity of patients with sickle cell anemia through a validated questionnaire, chart review and laboratory studies. Patients were enrolled on the CASIRE study after informed consent and assent was obtained from either the parent or patient when appropriate. The study was approved at each participating institution's IRB. A questionnaire was answered by the parents and/or patient, and baseline and current laboratory studies were collected. Patients were stratified into those who were not on hydroxyurea, and those who were currently on hydroxyurea. Number of VOEs, admissions, baseline and current fetal hemoglobin, and change in hemoglobin and MCV were compared.ResultsThere were 349 patients in this study (134 on hydroxyurea). Baseline laboratory data are reported in table 1. Hemoglobin level and MCV were not statistically different in patients prior to and after taking hydroxyurea (table 2). Fetal hemoglobin in adults increased 2.7 times baseline, whereas in children it was unchanged. All patients on hydroxyurea had a reduction of VOEs, ED visits and admissions compared to prior to hydroxyurea (see table 3).Table 1Baseline laboratory dataBaseline dataPatients on HydroxyureaPatients not on HydroxyureaPediatricAdultPediatricAdultN785614075Age1026.98.628.3Hemoglobin (g/dL)8.79.79.399.4MCV (fL)9191.57986Fetal Hemoglobin (%)15.112.49.65Table 2Clinical data for patients on HUPatients on HydroxyureaPediatric (78)Adult (56)Dose of HU (mg/kg)23.820.5# doses missed/wk11.55Fetal Hemoglobin on HU (%)14.513.8D MCV from baseline (fL)+5.4+0.1D Hgb from baseline (g/dL)+0.23+0.4Table 3Number of pain episodes in patients on HU.Prior to HUIn last year on HU2 tailed paired t testPediatric patients (N = 78)# pain episodes/year2512.90.62# requiring ED/year2.6610.93# requiring admission/year4.281.790.017Adult patients (N = 56)# pain episodes/year36.728.60.021# requiring ED/year5.72.40# requiring admission/year6.63.150.117ConclusionThe Multicenter Study of Hydroxyurea and the BABY HUG study showed that hydroxyurea is efficacious for patients with sickle cell anemia. No previous study has evaluated the effectiveness of hydroxyurea in clinical practice. Our study suggests that, although baseline and current laboratory values are similar in patients prior to versus after taking hydroxyurea, there was a clear reduction in the number of VOEs and admissions, similar to the Baby HUG and MSH studies. These results suggest that the reduction of VOEs could be the product of a generalized decrease in overall inflammation and hemolysis or increased nitric oxide production rather than an increase in fetal hemoglobin by itself. Reasons for the similarity in laboratory values could include the length of time patients have been on hydroxyurea or that hydroxyurea was not escalated to maximum tolerated dose. Another reason may be the degree of compliance of patients in a clinical setting. We noted that 1/3 of our pediatric and ½ of our adult patients missed at least 1 dose of hydroxyurea per week suggesting that even partial compliance with hydroxyurea may prove beneficial clinically. This study demonstrates that hydroxyurea is effective in reducing the number of VOEs and admissions for unselected patients with sickle cell anemia. DisclosuresNo relevant conflicts of interest to declare.

Partial minimum wage compliance

In many developing countries, a significant portion of the wage distribution is found below the legal minimum wage. In order to fully understand the nature of this non-compliance, we need to compare the counterfactual wage distribution without the minimum wage law to the current wage distribution. Such a comparison could reveal partial compliance, where employers raise wages some of the way to the minimum wage, to balance out the benefits of non-compliance with the costs and penalties to the extent that they depend on the gap between the legal minimum wage and the wage actually paid. This paper presents a simple model of such partial compliance and uses its predictions to structure an empirical investigation of the impact of introducing a minimum wage law for agricultural workers in South Africa. We find that partial compliance is indeed taking place and further, the lowest wages are being raised disproportionately, consistent with the predictions of the model. JEL codes: J23, J25, J31, J32, J38, J43

Business Process Regulatory Compliance is Hard

Verifying whether a business process is compliant with a regulatory framework is a difficult task. In the present paper we prove the hardness of the business process regulatory compliance problem by taking into account a sub-problem of the general problem. This limited problem allows to verify only the compliance of structured processes with respect to a regulatory framework composed of a set of conditional obligations including a deadline. Experimental evidence from existing studies shows that compliance is a difficult task. In this paper, despite considering a sub-problem of the general problem, we provide some theoretical evidence of the difficulty of the task. In particular we show that the source of the complexity lies in the core language of verifying conditional obligations with a deadline. We prove that for this simplified case verifying partial compliance belongs to the class of NP -complete problems, and verifying full compliance belongs to the class of co NP -complete problems. Thus by proving the difficulty of a simplified compliance problem we prove that the general problem of verifying business process regulatory compliance is hard.

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). A multifaceted intervention improved compliance with a pediatric AP guideline.