Partial Compliance Research Articles

PMO-184 Colonoscopic tattooing of colorectal neoplasia: a change in practice

IntroductionQuality Assurance Guidelines for colonoscopy in the Bowel Cancer Screening Programme recommend tattooing of all lesions that may require later surgical or endoscopic localisation, using local protocols as guidance.1 The...

Variations in surgical outcomes associated with hospital compliance with safety practices

The Leapfrog Group aims to improve patient safety by promoting hospital compliance with National Quality Forum (NQF) safe practices. It is unknown, however, whether implementation of these safety practices improve outcomes after high-risk operations. We conducted a cross-sectional analysis of 658 nationwide hospitals that responded to the 2005 Leapfrog Group Hospital Quality & Safety survey. A total of 79,462 patients were identified from Medicare claims data who underwent a pancreatectomy, hepatectomy, esophagectomy, open aortic aneurysm repair, colectomy, or gastrectomy procedure from 2004 through 2006. Random effects logistic regression models were used to estimate the association between hospital compliance with NQF safe practices and risk-adjusted odds of complications, rate of failure to rescue, and mortality after adjusting for patient- and hospital-level confounders. Of the 658 hospitals that responded to surveys, 41% had fully implemented NQF safe practices and 59% reported partial compliance with these standards. Compared with hospitals with partial NQF compliance, we found evidence that hospitals with full compliance had an increased likelihood of diagnosing a complication after any of the 6 high-risk operations (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.25), but had a decreased likelihood of failure to rescue (OR, 0.82; 95% CI, 0.71-0.96), and a decreased odds of mortality (OR, 0.80; 95% CI, 0.71-0.91). Despite having a greater rate of postoperative complications, hospitals fully complying with safe practices were associated with less failure to rescue and decreased mortality after high-risk operations. These results highlight the importance of having hospital systems in place to promote safety and manage postoperative complications.

P-1192 - Results of effectiveness of long term using of neurocognitive trainings and atypical antipsychotics

Neurocognitive deficits in schizophrenia patients is a major health and social problem of modern psychiatry nowadays. Many patients with schizophrenia are of working age and there is a high enough percentage of their disability. Objective To study the influence of neurocognitive training on higher cortical functions in schizophrenia patients and to evaluate their effectiveness in the treatment of schizophrenia. Material and methods All patients received adequate pharmacotherapy with atypical neuroleptics. Patients of the main group (102 patients) additionally participated in the training of cognitive deficits. Patients in the comparison group (48 patients) received only pharmacotherapy. Study design:The assessment of long term data means prospective follow-up study after 1-year trainings. Neurocognitive training is a psycho correctional training which aim is to improve the disabled cognitive functions such as memory, attention and executive functions. All patients took part in the prospective follow-up study. There was a good compliance as well as in group with trainings and in group without them. During the prospective follow-up study we observed data on compliance and number of re-hospitalizations. The analysis of follow-up study showed that, 1) Number of patients with drug compliance is higher in group with neurocognitive trainings 2) Number of patients with partial drug compliance is higher in comparison group 3) Number of patients who stopped taking medication was the same in both groups Conclusion The neurocognitive training showed itself as an effective method of correcting neurocognitive deficits. Inclusion trainings in the rehabilitation program helps to reduce the term of the patients stay in hospital.

A Bayesian Semiparametric Approach to Intermediate Variables in Causal Inference

In causal inference studies, treatment comparisons often need to be adjusted for confounded post-treatment variables. Principal stratification (PS) is a framework to deal with such variables within the potential outcome approach to causal inference. Continuous intermediate variables introduce inferential challenges to PS analysis. Existing methods either dichotomize the intermediate variable, or assume a fully parametric model for the joint distribution of the potential intermediate variables. However, the former is subject to information loss and arbitrary choice of the cutoff point and the latter is often inadequate to represent complex distributional and clustering features. We propose a Bayesian semiparametric approach that consists of a flexible parametric model for the potential outcomes and a Bayesian nonparametric model for the potential intermediate outcomes using a Dirichlet process mixture (DPM) model. The DPM approach provides flexibility in modeling the possibly complex joint distribution of the potential intermediate outcomes and offers better interpretability of results through its clustering feature. Gibbs sampling based posterior inference is developed. We illustrate the method by two applications: one concerning partial compliance in a randomized clinical trial, and one concerning the causal mechanism between physical activity, body mass index, and cardiovascular disease in the observational Swedish National March Cohort study.

Estimation of cost-effectiveness in randomised controlled trials when not all participants allocated to active intervention receive it

effect of non-compliance on estimates of cost-effectiveness considered. Of the remaining studies, one conducted an intention-to-treat analysis for the clinical outcome but appeared to omit non-compliers from the estimates of cost; one study calculated intention-to-treat estimates of effect on the clinical and the cost outcomes and an unbiased estimate of the clinical effect in compliers; and one study included non-compliers in their allocated groups for the main analysis but conducted a sensitivity analysis of cost-effectiveness with these people excluded. The fourth was a cluster-randomised trial, which presented costs and clinical effects per catchment area and costs per individual receiving the intervention. Conclusions Preliminary findings suggest that the majority of studies take an intention-to-treat approach to comparing costs between randomly allocated treatments. However, it is unclear whether the costs of allocated or of received treatment are contributing to these estimates. A minority of studies are conducting secondary per protocol analyses, with no study attempting an unbiased estimate of cost-effectiveness in compliers. How the costs of partial compliance, which may be associated with treatment success, can be incorporated into these estimates without causing bias is unclear.

Adequacy of Vaccine Documentation Against Encapsulated Bacteria in a Population of Children with Sickle Cell Disease

Abstract 4853Immunization status is often used as an indicator of improved quality of health care and access in pediatric populations. The increased life expectancy in the general pediatric population has largely been attributed to the prevention of infectious disease through immunizations, and this fact is even truer for individuals with sickle cell disease. Adherence to recommended vaccination schedules against encapsulated bacteria in patients with sickle-cell anemia has not been well studied in any population. In order to determine documented compliance rates based on the current recommendations of the Department of Health and Human Services Center for Disease Control Immunization Schedules, a retrospective chart review was performed on 117 patients diagnosed with sickle cell anemia (HbSS) followed at the Penn State Hershey Children’s Hospital Regional Pediatric Sickle Cell Center, through the year 2009. Since the vaccinations were given by each patient’s primary provider(s), we attempted to obtain documentation of immunizations given by these providers, particularly against encapsulated bacteria. For 35 of the 117 patients, we were unable to obtain any forwarded documentation of any vaccinations. The vaccination schedules of the remaining 82 patients were audited for coverage against encapsulated bacteria. Only 16 of the 82 patients (19.5%) with forwarded documents demonstrated complete documented compliance, defined as having complete coverage against H. influenzae, N. meningitides, and S. pneumococcus. Of the remaining forwarded charts, 63 patients (76.8%) demonstrated some form of partial documented compliance, but four patients (4.9%) did not have documentation of vaccinations against any encapsulated bacteria despite documentation of receiving other vaccinations. Full documented compliance as indicated by forwarded records was most noted in children between the ages of 0–11.9 years (14/16 of patients with complete compliance). The proportion of adolescents without any forwarded documentation was larger than the younger age group; however, this difference did not reach statistical significance (p=0.36). Of the 82 patients whose primary care physicians forwarded documents, significantly more (14 of 34) adolescents (≥12 years of age) than children aged 0–11.9 years (8 of 48) were missing documentation of more than half of their vaccines (p=.014). These results indicate deficient documentation of vaccination coverage against encapsulated organisms, particularly in the adolescent population. To determine the clinical implications of these results, further studies detailing the demographics, socioeconomic status and correlations of such characteristics to morbidity and mortality should be completed. Disclosures:No relevant conflicts of interest to declare.

Stepping in for the Polluters? Climate Justice under Partial Compliance

Abstract Not all countries do their fair share in the effort of preventing dangerous climate change. This presents those who are willing to do their part with the question whether they should ‘take up the slack’ and try to compensate for the non-compliers’ failure to reduce emissions. There is a pro tanto reason for doing so given the human rights violations associated with dangerous climate change. The article focuses on fending off two objections against a duty to take up the slack: that it is unfair and ineffective. We grant that it is unfair if some have to step in for others but argue that this does not amount to a decisive objection under conditions of partial compliance. With regard to the charge of emission reductions being ineffective, we argue that the empirical case for this claim is missing and that even if it were not, there still remains the option of taking up the slack in other forms.

Comment on Sabine Hohl and Dominic Roser. Stepping in for the Polluters? Climate Justice under Partial Compliance

Comment on Sabine Hohl and Dominic Roser. Stepping in for the Polluters? Climate Justice under Partial Compliance

P.3.c.062 Factors associated with medication adherence in outpatients with schizophrenia on oral antipsychotics only

Clozapine is the most effective treatment for refractory schizophrenia, yet it remains underused in clinical practice. The current study examined the awareness, familiarity and attitude of a nationwide sample of Israeli psychiatrists regarding the use of clozapine.Data were collected using questionnaires, completed by 295 psychiatrists. Participants were asked to score questions regarding clozapine procedures; familiarity with guidelines, drug properties, prescription and attitude towards specialized clozapine resources.About half (53.3%) of the psychiatrists reported initiating treatment with clozapine according to the guidelines, whereas 33% reported that they administered clozapine only after three or more unsuccessful antipsychotic treatments. Surprisingly, availability of specialized resources for clozapine treatment (such as clozapine clinics) was associated with delayed initiation of clozapine treatment, and a lower rate of clozapine administration. Barriers to clozapine use included concerns about patient adherence, side effects and partial compliance with the required blood monitoring.Delaying or avoiding clozapine treatment to potentially eligible patients, despite familiarity with the drug efficacy and treatment guidelines, is a major mental health concern. However, executive allocation of resources to support the use of clozapine may be ineffective in promoting clozapine use.

Modeling Partial Compliance Through Copulas in a Principal Stratification Framework

Within the principal stratification framework for causal inference, modeling partial compliance is challenging because the continuous nature of the principal strata raises subtle specification issues. In this context, we propose an approach based on the assumption that the joint distribution of the degree of compliance to the treatment and the degree of compliance to the control follows a Plackett copula, so that their association is modeled in a flexible way through a single parameter. Moreover, given the two compliances, the distribution of the outcomes is parameterized in a flexible way through a regression model which may include interaction and quadratic terms and may also be heteroscedastic. In order to estimate the parameters of the resulting model, and then the causal effect of the treatment, we adopt a maximum likelihood approach via the EM algorithm. In applying this approach, the marginal distributions of the two compliances are estimated by their empirical distribution functions, so that no constraints are posed on these distributions. Since the two compliances cannot be jointly observed, there is not direct empirical support for the association parameter. We describe a strategy for studying this parameter by a profile likelihood method and discuss an analysis of the sensitivity of the causal inference results to its value. We apply the proposed approach to data from a study about a drug for lowering cholesterol levels previously analyzed by Efron and Feldman and by Jin and Rubin. Estimated causal effects are in line with those of previous analyses, but the pattern of association between the compliances is qualitatively different, apparently due to the flexibility of the copula and to allowing regression equations in the proposed method to include interactions and heteroscedasticity.

Assessment of Compliance Performance of Environmental Regulations of Industries in Tuzla (Istanbul, Turkey)

Although environmental management in Turkey is evolving, its performance needs to be assessed in terms of the extent to which polluters and dischargers are complying with their legal obligations. In spite of this necessity, however, not a single study evaluating the effectiveness of command-and-control strategy of environmental management has been conducted. It is for this reason that it was decided to conduct an analysis of the impact of environmental legislation on a major industrial area in Turkey. Accordingly, Turkish environmental legislation was analyzed and all relevant obligations and responsibilities of industry are identified. Based upon this appraisal, a questionnaire was prepared and used to conduct interviews in Tuzla, Istanbul. From the results, it can be concluded that environmental compliance performance of industry is low. The total of 92 parameters have been questioned. 53 parameters have been found as satisfactory compliance whereas 26 parameters have been classified as partial compliance and 13 as unsatisfactory compliance. The most important reason for inadequate performance is the lack of effective national and local environmental compliance management system. The other leading reasons are found to be low-level environmental consciousness of the people, absence of environmental management system at the sites, inadequacies in environmental subsidies and insufficiencies in public environmental infrastructure. Four recommendations are made to increase the effectiveness of compliance management: establishing an effective environmental compliance management system, accelerating public investment for environmental infrastructure, developing financial subsidies and incentive schemes for environmental investments and encouraging voluntary initiatives.

Serological tests for celiac disease as indicators of long-term compliance with the gluten-free diet

The efficacy of celiac disease (CD)-related antibodies in monitoring clinical outcome of patients remains unclear. Our aims were to determine dynamics of antibodies after diagnosis and to assess their performances in monitoring patients' long-term compliance with the gluten-free diet (GFD). We prospectively estimated the performance of seven celiac disease-related antibody tests at diagnosis and at 1 year and more than 4 years after treatment initiation in 53 adults. The ability of antibodies to identify patients partially compliant to treatment was explored by the receiver operating characteristic curve analysis. The derived cut-off values ('compliance' cutoffs) were compared with cut-off values used for diagnosis ('diagnostic' cutoffs). The degree of compliance with the GFD was assessed using a standardized, multidisciplinary approach. Concentrations of all antibodies decreased significantly at 1 year after diagnosis. The decline continued for more than 4 years in strictly compliant patients (P<0.05-0.001). The gap between 'compliance' and 'diagnostic' cut-offs values was wider at 1 year than at more than 4 years. The predictability of partial compliance determined by the area under receiver operating characteristic curves was relevant for most tests examined at 1 year (areas ranging: 0.64-0.72) and more than 4 years (0.58-0.78). Immunoglobulin A antibodies to deamidated gliadin peptides and tissue transglutaminase had the best performance for monitoring long-term compliance. Decreased concentrations of antibodies were significantly associated with the degree of compliance with the GFD. Immunoglobulin A antibodies to deamidated gliadin peptides and tissue transglutaminase had the best and more consistent performances. The serial measurement of antibody levels seems to be more reliable in monitoring compliance than the positive/negative expression of results.

Effect of nursing intervention on complications and compliance of cancer patients with PICC

Objective To probe into the effect of nursing intervention on complications and compliance of cancer patients with PICC. Methods 86 tumor patients selected from June 2007 to June 2010were randomly divided into the intervention group and the control group with 43 patients in each group. After the two groups of patients were diagnosed they were treated with routine care, the intervention group wasgiven additional comprehensive nursing interventions aiming at PICC complications and compliance. The complications and treatment compliance of the patients were analyzed. Results Compared with the control group, the rate of full compliance significantly improved and the rate of partial compliance significantly decreased in the intervention group. At the same time, compared with the control group, the incidence rate of phlebitis, catheter-related bloodstream infection and catheter blockage and catheter off of the intervention group were significantly lower. Conclusions Nursing intervention for cancer patients with PICC can reduce complications and improve treatment compliance of them and is of great clinical significance. Key words: Nursing intervention; Cancer; Complications; Compliance

A method to optimize evacuation instructions

In this paper, an optimization method is presented for instructions to evacuate by car the population of a region threatened by a hazard. By giving the optimized instructions to the evacuees, traffic conditions and, therefore, the evacuation efficiency are optimized. The instructions, containing a departure time, a safe destination, and a route, are created using an optimization method consisting of two phases: the generation of the search space and the algorithm AES+ evacuation, a version of ant colony optimization. The main contributions of the proposed optimization method are the unique approach to generate the search space in which network degeneration is taken into consideration, the possibility to optimize instructions under the assumption of both full and partial compliance of the evacuees with the instructions, and the flexibility in the sense that the user of the method can define his or her own objective function and choose a suitable traffic simulation model. The paper contains a comprehensive case study. The case study shows that the effectiveness of the optimized instructions is more than doubled when compared with the effectiveness of instructions set up by straightforward rules (like evacuating to the nearest destination using the shortest route). Further, the case study shows that the number of arrivals under optimized, but possibly sub-optimal instructions is equal to at least 90% of the theoretical upper bound on this number of arrivals.

Compliance with physical activity guidelines in rural, black South Africans in the Limpopo Province: an energy expenditure approach

ObjectiveThe authors used an energy expenditure–based approach to determine the non-compliance and compliance with public health physical activity (PA) guidelines in rural, black South Africans.MethodsThe authors analysed 7-day objectively measured...

Study of compliance with a clinical pathway for suspected pulmonary embolism

Clinical pathways to guide the investigation of suspected pulmonary embolism have been increasingly adopted by emergency departments worldwide. This study evaluated the compliance with a clinical pathway that combines risk assessment (Wells score) with d-dimer, ventilation-perfusion scanning or computed tomographic pulmonary angiography (CTPA). The aims of this study were to identify factors that contribute to compliance and to assess patient outcomes and resource utilization. Repeated retrospective chart reviews of 239 patients who underwent investigation for pulmonary embolism through our emergency department extracted patient demographics, pathway parameters and patient outcomes. A phone interview at 3-month follow up was carried out. Incidence of pulmonary embolism was 8.4% (n= 20). Compliance to the clinical pathway occurred in 120 subjects (50.2%). Non-compliance occurred in 71 subjects (29.7%). Forty-eight subjects (20.1%) underwent risk assessments, but subsequent diagnostic tests did not conform to the stated pathway (partial compliance). Compliance was poor in subjects assessed by non-emergency department doctors (χ(2) = 27.95, P≤ 0.001). Compliance occurred less in pregnant subjects (χ(2) = 7.27, P= 0.007) and those with chronic respiratory disease (χ(2) = 5.31, P= 0.021). Subjects in the compliant group were less likely to undergo CTPA (odds ratio 2.07 (1.16-3.70), P= 0.012). Compliance with this clinical pathway allowed emergency department doctors in an Australian university teaching hospital to complete diagnostic testing for suspected pulmonary embolism appropriately unless non-emergency department doctors became involved. Compliance with this pathway altered the distribution of diagnostic tests performed with less reliance on CTPA, but was not associated with better patient outcomes.

Compliance and loss to follow up of HIV negative and positive mothers recruited from a PMTCT programme in Zimbabwe.

To describe the methodological challenges of a nine months follow up study of mothers recruited from a national Prevention of Mother To Child Transmission (PMTCT) programme with regards to defaulters, drop outs and compliance. Nested case control study. Three peri-urban clinics in Zimbabwe namely: Epworth, St Mary's, Seke North. Pregnant women who enrolled at 36 weeks of gestation were recruited for a follow up of mother and child from delivery, six weeks, four and nine months post partum. Follow up trend of these women was compared between the HIV positive and negative mothers with regards to defaulting, drop outs, full and partial compliance. Statistical significance was computed using the Chi-square test. Of the enrolled 1050 pregnant women with a known HIV status (594 HIV negative and 456 HIV positive) 851 (457 HIV negative and 394 HIV positive) showed up at one or more visits scheduled up to nine months. The denominator was dropping at each point and time. The overall dropout rate was 19% without a significant difference between the HIV positive and negative women at delivery. At six weeks the drop out rate was 35 (7.7%) for the HIV positive versus 75 (12.9%) p=0.010 and at four months 12 (2.9%) versus 39 (7.7%) p=0.002 respectively. However, at nine months the drop out rate was not different (p=0.747). The defaulter rate was significantly different at every stage between the HIV positive and negative mothers from delivery to six weeks, becoming even more significant at the four and nine months visit (p=<0.001). The overall full compliance at nine months was 46.1% with a significant difference between the HIV positive (55.6%) versus (37.9%) for the HIV negative (p=<0.001). Drop out is highest among the HIV negative as opposed to the HIV positive with the peak period being at "six weeks". There is high defaulting among the HIV negative compared to the HIV positive with the peak being at "four months". The study has shown that the HIV negative women are more likely to drop out whereas the HIV positive were twice as likely to fully comply. It is surprising that the peak drop out period, "six weeks visit" is a cardinal existing national scheduled visit where both mother and baby undergo a full medical examination with the mother having a pap smear taken.

PDF/A: A Viable Addition to the Preservation Toolkit

PDF/A, the archival version of the PDF file format, is an International Standards Organization (ISO) vetted, open source tool that can be added to the librarian's and archivist's preservation toolkit. This article describes the format itself, the lessons learned as the authors investigated the tools readily available for creating PDF/A files and the design of the pilot to test implementation of the use of the format in The Ohio State University's repository, the Knowledge Bank. Further, we identify issues in conversion of diverse original formats; strategies for time-saving batch conversion; and considerations in deciding whether to attempt full or partial compliance with the standard.

Measurable Outcomes of Quality Improvement Using a Daily Quality Rounds Checklist: One-Year Analysis in a Trauma Intensive Care Unit With Sustained Ventilator-Associated Pneumonia Reduction

We have previously demonstrated that the use of a daily "Quality Rounds Checklist" (QRC) can increase compliance with evidence-based prophylactic measures and decrease complications in a busy trauma intensive care unit (ICU) over a 3-month period. This study was designed to determine the sustainability of QRC use over 1 year and examine the relationship between compliance and outcome improvement. A prospective before-after design was used to examine the effectiveness of the QRC tool in documenting compliance with 16 prophylactic measures for ventilator-associated pneumonia (VAP), deep venous thrombosis, pulmonary embolism, catheter-related bloodstream infection, and other ICU complications. The QRC was implemented on a daily basis for a 1-year period by the ICU fellow on duty. Monthly compliance rates were assessed by a multidisciplinary team for development of strategies for real-time improvement. Compliance and outcomes were captured over 1 year of QRC use. QRC use was associated with a sustained improvement of VAP bundle and other compliance measures over a year of use. After multivariable analysis adjusting for age (> 55), injury mechanism, Glasgow Coma Scale score (≤ 8), and Injury Severity Score (> 20), the rate of VAP was significantly lower after QRC use, with an adjusted mean difference of -6.65 (per 1,000 device days; 95% confidence interval, -9.27 to -4.04; p = 0.008). During the year of QRC use, 3% of patients developed a VAP if all four daily bundle measures were met for the duration of ICU stay versus 14% in those with partial compliance (p = 0.04). The overall VAP rate with full compliance was 5.29 versus 9.23 (per 1,000 device days) with partial compliance. Compared with the previous year, a 24% decrease in the number of pneumonias was recorded for the year of QRC use, representing an estimated cost savings of approximately $400,000. The use of a QRC facilitates sustainable improvement in compliance rates for clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of the QRC, requiring just a few minutes per patient to complete, equates to cost-effective improvement in patient outcomes.

Accountability and solidarity: Will you stand with me?

This study analyses the strategic responses to institutional pressures through organisational discursive practices. This analysis is developed through an interpretive case study of EDP, the largest Portuguese group in the electricity sector. Our empirical material includes CEO communications in the media from 2010 to 2014, and is interpreted through a theoretical framework derived from institutional theory, developed by complementing Oliver (1991) strategic responses to institutional pressures with the verbal accounts as defined by Elsbach (1994). The study highlights the country-level institutional structures, the organisations’ own characteristics and the power of the constituents involved in the process as important predictors of responses in a complex environment. EDP strategically resisted institutional pressures as it negotiated among competing forces of institutional control, delaying partial compliance to coercive pressures and using time as a resource for organisation actions. EDP’s strategies reinforce the argument that organisations may consider unconditional compliance with broader stakeholder interests unacceptable when the profit logic is called into question before the dominance of the neo-liberal capitalist ideology. We have rendered visible the consequences of the project of neoliberalisation and the agenda of state privatisation of the European Union, resulting in a simple redistribution of resources towards shareholders and investors, to the disadvantage of other groups in society.