Relevant Patient Factors Research Articles

Patient characteristics and variability in adherence and competence in cognitive-behavioral therapy for panic disorder.

Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. (a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.

Closed-loop glucose control: psychological and behavioral considerations.

Since 2000, the diabetes community has witnessed tremendous technological advances that have revolutionized diabetes management. Currently, closed-loop glucose control (CLC) systems, which link continuous subcutaneous insulin infusion and continuous glucose monitoring, are the newest, cutting edge technology aimed at reducing glycemic variability and improving daily management of diabetes. Although advances in knowledge and technology in the treatment of diabetes have improved exponentially, adherence to diabetes regimens remains complex and often difficult to predict. Human factors, such as patient perceptions and behavioral self-regulation, are central to adherence to prescribed regimens, as well as to adoption and utilization of diabetes technology, and they will continue to be crucial as diabetes management evolves. Thus, the aims of this article are three-fold: (1) to review psychological and behavioral factors that have influenced adoption and utilization of past technologies, (2) to examine three theoretical frameworks that may help in conceptualizing relevant patient factors in diabetes management, and (3) to propose patient-selection factors that will likely affect future CLC systems.

Improving outcome for patients with pancreatic cancer through centralization

High-volume institutions are associated with improved clinical outcomes for pancreatic cancer. This study investigated the impact of centralizing pancreatic cancer surgery in the south of the Netherlands. All patients diagnosed in the Eindhoven Cancer Registry area in 1995-2000 (precentralization) and 2005-2008 (implementation of centralization agreements) with primary cancer of the pancreatic head, extrahepatic bile ducts, ampulla of Vater or duodenum were included. Resection rates, in-hospital mortality, 2-year survival and changes in treatment patterns were analysed. Multivariable regression analyses were used to identify independent risk factors for death. Some 2129 patients were identified. Resection rates increased from 19·0 to 30·0 per cent (P < 0·001). The number of hospitals performing resections decreased from eight to three, and the annual number of resections per hospital increased from two to 16. The in-hospital mortality rate dropped from 24·4 to 3·6 per cent (P < 0·001) and was zero in 2008. The 2-year survival rate after surgery increased from 38·1 to 49·4 per cent (P = 0·001), and the rate irrespective of treatment increased from 10·3 to 16·0 per cent (P < 0·001). There was no improvement in 2-year survival in non-operated patients. After adjustment for relevant patient and tumour factors, those undergoing surgery more recently had a lower risk of death (hazard ratio 0·70, 95 per cent confidence interval 0·51 to 0·97). Changes in surgical patterns seemed largely to explain the improvements. High-quality care can be achieved in regional hospitals through collaboration. Centralization should no longer be regarded as a threat by general hospitals but as a chance to improve outcomes in pancreatic cancer.

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics

BackgroundThe aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance.MethodsIn 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed.ResultsThe global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents.ConclusionsIn a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients.Trial registrationsNCT00184119/NCT00184132

Data linkage: a powerful research tool with potential problems.

BackgroundPolicy makers, clinicians and researchers are demonstrating increasing interest in using data linked from multiple sources to support measurement of clinical performance and patient health outcomes. However, the utility of data linkage may be compromised by sub-optimal or incomplete linkage, leading to systematic bias. In this study, we synthesize the evidence identifying participant or population characteristics that can influence the validity and completeness of data linkage and may be associated with systematic bias in reported outcomes.MethodsA narrative review, using structured search methods was undertaken. Key words "data linkage" and Mesh term "medical record linkage" were applied to Medline, EMBASE and CINAHL databases between 1991 and 2007. inclusion criteria were; the article attempted an empirical evaluation of methodological issues relating to data linkage and reported on patient characteristics, the study design included analysis of matched versus unmatched records, and the report was in English. Included articles were grouped thematically according to patient characteristics that were compared between matched and unmatched records.ResultsThe search identified 1810 articles of which 33 (1.8%) met inclusion criteria. There was marked heterogeneity in study methods and factors investigated. Characteristics that were unevenly distributed among matched and unmatched records were; age (72% of studies), sex (50% of studies), race (64% of studies), geographical/hospital site (93% of studies), socio-economic status (82% of studies) and health status (72% of studies).ConclusionA number of relevant patient or population factors may be associated with incomplete data linkage resulting in systematic bias in reported clinical outcomes. Readers should consider these factors in interpreting the reported results of data linkage studies.

Clinician perceptions of care difficulty and quality of life for lung cancer patients: Results from the ECOG SOAPP study (E2Z02).

9102 Background: Emerging evidence suggests that lung cancer patients experience disparities in medical care compared to other cancer patients. This may be due to providers' perceptions that lung cancer patients are more difficult to care for and have a poorer quality of life (QOL). Methods: Participants included clinicians treating breast (n = 1543), colorectal (n = 717), prostate (n = 320), and lung (n = 522) cancer patients enrolled in the Eastern Cooperative Oncology Group (ECOG) study of Symptom Outcomes and Practice Patterns (SOAPP; Protocol E2Z02). Data included clinicians' written responses to questions about patient QOL and difficulty of care. Analyses focused on repeated measures (baseline and 28-35 day follow-up) analysis of covariance (ANCOVA) with planned comparisons for reports of lung cancer v. other cancer (breast, prostate, and colorectal) patients. Results: After controlling for relevant patient factors (sex, race/ethnicity, current status/stage of disease, metastatic sites, performance status, weight loss, current treatment, number of moderate/severe symptoms) and institution type, clinicians reported greater difficulty in care for lung cancer patients compared to other cancer patients (p < .01). After adding patients' baseline reports of QOL as a covariate (in addition to the above factors), clinicians also estimated a lower QOL for lung cancer patients (p < .001). Conclusions: Even after controlling for a number of relevant patient and disease factors, clinicians reported higher difficulty of care and lower QOL for lung cancer patients compared to patients with other common solid tumors. These data generate the hypothesis that providers have more pessimistic attitudes about lung cancer care, which could lead to disparities in treatment. Further research is needed to confirm these findings and explore potential explanations for these clinician perceptions related to lung cancer patients. No significant financial relationships to disclose.

Komplementärmedizin in der Praxis – der diagnostischtherapeutische Prozess aus Sicht von Hausärzten: Eine qualitative Studie

Hintergrund: Komplementärmedizinische Therapieverfahren kommen in der hausärztlichen Versorgung in Deutschland häufig zum Einsatz. Ziel der vorliegenden Untersuchung war es, den diagnostisch-therapeutischen Prozess und wesentliche Wirkfaktoren beim Einsatz von Komplementärmedizin (KM) aus Sicht von Hausärzten zu untersuchen. Methodik: Im Rahmen eines qualitativen Ansatzes wurden drei leitfragengeführte Fokusgruppen mit 17 Hausärzten durchgeführt. Die Gruppendiskussionen wurden inhaltsanalytisch ausgewertet. Ergebnisse: Aus Sicht von Hausärzten ist der diagnostisch-therapeutische Prozess in der KM komplex und weniger von der angewendeten Methode als sehr stark von methodenunabhängigen Faktoren geprägt. Ausgehend vom Textmaterial der Fokusgruppen wurden vier Hauptkategorien identifiziert, die beim hausärztlichen Einsatz von KM eine wesentliche Rolle spielen: patientenseitige Faktoren, arztseitige Faktoren, Beziehungsfaktoren und methodenübergreifende Faktoren. Als relevante persönliche Faktoren des Patienten wurden Konstitution, Erwartungshaltung und Wertvorstellungen genannt. Empathie, Wertschätzung und Authentizität galten als wichtige Faktoren des Arztes. Für die Beziehung spielten nach Meinung der Hausärzte insbesondere Faktoren wie Zeit, Vertrauen, Passung, Machtverhältnisse und gemeinsame Rituale eine wichtige Rolle. Diskussion: Aus Sicht von Hausärzten wird der diagnostisch-therapeutische Prozess als Kreisprozess verstanden, in dem patientenseitige, arztseitige und Beziehungselemente sowie methodenübergreifende Faktoren eng miteinander verflochten sind. Unter dieser Vorstellung wird KM in der hausärztlichen Praxis breit eingesetzt, wobei genügend Zeit mit und für den Patienten und eine vertrauensvolle Arzt-Patient-Beziehung Grundvoraussetzungen sind. Vor dem Hintergrund der zunehmenden Ökonomisierung in der Medizin besteht allerdings die Gefahr, dass KM prozessualisiert wird, d.h. in Einzelteile zerlegt und von der Arzt-Patient-Beziehung abgekoppelt wird, was ihre Wirksamkeit in der alltäglichen Versorgungspraxis gefährdet.

Surgical Approaches to the Oral Cavity Primary and Neck

A variety of surgical approaches used to treat primary oral cavity tumors are described to delineate the technique and rationale behind each treatment choice. Size, location, proximity to bone, lymph node status, histology, and prior treatment considerations are employed to determine the most appropriate surgical approach for primary oral cavity tumors. Oncologic outcomes and physical function show the best results from surgical treatment of many primary oral cavity, but necessitates careful selection of surgical approach. Each surgical approach must be selected based upon relevant tumor, patient and physician factors.

Pain after Percutaneous Radiofrequency Ablation of Renal Tumors

Most patients have minimal pain after percutaneous radiofrequency ablation (RFA) of a renal tumor. However, anecdotally, there is some variation in the amount of patient discomfort. Our goal was to identify relevant patient factors and characteristics of their renal tumors that may influence pain after percutaneous RF ablation. We performed a retrospective chart review of 59 sequential patients who received percutaneous RFA between 2001 and 2005 at a single institution. Data on patient age, sex, body mass index (BMI), and narcotic administration in the periprocedural period were available for 46 patients. Preoperative imaging (CT or MRI) was reviewed to determine tumor size and location, as well as the shortest distance of the mass to the body-wall musculature. The distance from the renal mass to the body-wall musculature was significantly correlated with the total narcotics received in the periprocedural period. This measured distance did not correlate with the patient's BMI. No other relations between patient factors or tumor characteristics and peri-procedural narcotic usage were identified. Patients whose tumors lie close to their body-wall musculature have greater narcotic requirements in the periprocedural period. Knowledge of this correlation should result in better patient counseling and help anticipate periprocedural analgesia requirements.

Population Pharmacokinetic-Pharmacodynamic Model for Neutropenia with Patient Subgroup Identification: Comparison across Anticancer Drugs

Cancer chemotherapy, although based on body surface area, often causes unpredictable myelosuppression, especially severe neutropenia. The aim of this study was to evaluate qualitatively and quantitatively the influence of patient-specific characteristics on the neutrophil concentration-time course, to identify patient subgroups, and to compare covariates on system-related pharmacodynamic variable between drugs. Drug and neutrophil concentration, demographic, and clinical chemistry data of several trials with docetaxel (637 patients), paclitaxel (45 patients), etoposide (71 patients), or topotecan (191 patients) were included in the covariate analysis of a physiology-based pharmacokinetic-pharmacodynamic neutropenia model. Comparisons of covariate relations across drugs were made. A population model incorporating four to five relevant patient factors for each drug to explain variability in the degree and duration of neutropenia has been developed. Sex, previous anticancer therapy, performance status, height, binding partners, or liver enzymes influenced system-related variables and alpha1-acid glycoprotein, albumin, bilirubin, concomitant cytotoxic agents, or administration route changed drug-specific variables. Overall, female and pretreated patients had a lower baseline neutrophil concentration. Across-drug comparison revealed that several covariates (e.g., age) had minor (clinically irrelevant) influences but consistently shifted the pharmacodynamic variable in the same direction. These mechanistic models, including patient characteristics that influence drug-specific parameters, form the rationale basis for more tailored dosing of individual patients or subgroups to minimize the risk of infection and thus might contribute to a more successful therapy. In addition, nonsignificant or clinically irrelevant relations on system-related parameters suggest that these covariates could be negligible in clinical trails and daily use.

The relationship between depressive symptoms and shoulder mobility among older women: assessment at one year after breast cancer diagnosis

Objective: To examine the association between depressive symptoms and shoulder range of motion at one year after breast cancer diagnosis, controlling for patient characteristics, tumour stage and cancer therapy (surgery, axillary node dissection and radiation). Design: Prospective trial of nurse case management involving 187 older women with complete data, age 60 years and older, newly diagnosed with breast cancer, from 1 November, 1993 to 31 October, 1996 in south-eastern Texas. Depressive symptoms, sociodemographic characteristics and breast cancer treatment were measured at two months and shoulder range of motion at 12 months. The relationship among the variables was evaluated with bivariate chi-square statistics and logistic regression analysis. All logistic models also included a variable indicating whether or not the woman received nurse case management, to control for intervention status. Results: Increasing depressive symptoms at baseline were associated with lower arm mobility at 12 months following breast cancer diagnosis. Each unit increase in depressive symptoms at baseline was associated with an 8% decreased odds of having full range of motion of the shoulder (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.87, 0.97), after controlling for relevant patient and treatment factors. Conclusion(s): Older women with depressive symptoms have an elevated risk of not fully recovering shoulder mobility after being treated for breast cancer. Future studies are needed to assess benefits from early intervention with psychological and or physical interventions in the presence of depressive symptoms on shoulder mobility.

Management and outcome of recurrent well-differentiated thyroid carcinoma.

The AMES (age, distant metastasis, tumor extent, and size), AGES (age, tumor size, histologic grade, tumor extent, distant metastasis), and MACIS (distant metastasis, age, completeness of primary tumor resection, local invasion, and tumor size) prognostic systems for well-differentiated thyroid carcinoma (WDTC) are well known. The development of disease recurrence is associated with a poor outcome; however, the prognostic importance of multiple treatment failures has not been clearly reported. To identify patient, tumor, and treatment factors that may be associated with the development of multiple recurrences in WDTC. All patients treated for residual or recurrent WDTC were retrospectively identified from the thyroid cancer database at the Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, Toronto, Ontario (1963-2000). Data on relevant patient, tumor, and treatment factors were collected. Patient, tumor, and treatment factors predicting the development of multiple treatment failures, disease-specific survival, and overall survival. A total of 574 patients (115 male, 459 female; median age, 42 years [range, 9-92 years]) were identified, whose final histopathologic diagnosis was papillary carcinoma in 468, follicular carcinoma in 76, and mixed in 30 cases. TNM staging was as follows: 409 (71%) stage I, 66 (12%) stage II, 68 (12%) stage III, and 31 (5%) stage IV. Initial management included total thyroidectomy for 217 patients (38%), subtotal thyroidectomy for 357 (62%), and adjuvant iodine 131 therapy for 492 (86%). Seventy-three patients (13%) developed recurrent WDTC (21 male, 52 female; median age, 44 years [range, 18-84 years]). Patients were divided into 3 groups: group 1 (no recurrence, n = 501), group 2 (1 recurrence only, n = 42), and group 3 (multiple recurrences, n = 31). Group 2 data were as follows: site of recurrence (locoregional, 25; distant, 7; unspecified, 10) and treatment (surgery, 12; iodine 131, 42) and for group 3: site of first recurrence (locoregional, 16; distant, 11; unspecified, 4) and treatment (surgery, 14, iodine 131, 22; palliation, 1). Actuarial disease-specific survival at 20 years was 100%, 94%, and 60%, respectively, for the 3 groups (median follow-up, 7 years; range, 1-34 years). Male sex, advanced stage, extrathyroidal spread, and primary treatment with total thyroidectomy were predictive factors for multiple recurrences on multivariate regression (all P<.05). Male sex, advanced initial stage, and presence of extrathyroidal spread within the primary tumor are the most significant independent predictors of developing multiple recurrences in patients with WDTC. These patients have a poor prognosis with a significant reduction in tumor-free survival.

Guidelines for reporting morbidity and mortality after cardiac valvular operations

At the request of the Councils of The Society of Thoracic Surgeons (STS) and The American Association for Thoracic Surgery (AATS) the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity revisited the Guidelines published in September 1988 [1-3]. The purpose of the review was to update and clarify definitions within the guidelines and to consider recommendations made by others [4, 5]. The variety of cardiac valvular procedures has expanded since 1988; therefore, in this document the term indicates prosthetic and bioprosthetic heart valves of all types: operated or repaired native valves and allograft and autograft valves. The term includes any cardiac valve altered by a surgeon during an operation. Much morbidity and mortality is a direct consequence of the interaction between the patient and operated valve(s), although patient variables (e.g., age, degree of coronary arterial disease, follow-up care) may be more responsible for outcomes than an operated valve. However, no set of guidelines can identify all possible patient factors that may affect morbidity and mortality. General agreement regarding the following definitions of terms and suggestions for reporting data do not preclude more detailed analyses or constructive recommendations and investigators are encouraged to identify relevant patient factors in addition to factors related to operated valves.

Guidelines for Reporting Morbidity and Mortality after Cardiac Valvular Operations

At the request of the Councils of The Society of Thoracic Surgeons (STS) and The American Association for Thoracic Surgery (AATS) the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity revisited the Guidelines published in September 1988 [1-3]. The purpose of the review was to update and clarify definitions within the guidelines and to consider recommendations made by others [4, 5]. The variety of cardiac valvular procedures has expanded since 1988; therefore, in this document the term indicates prosthetic and bioprosthetic heart valves of all types: operated or repaired native valves and allograft and autograft valves. The term includes any cardiac valve altered by a surgeon during an operation. Much morbidity and mortality is a direct consequence of the interaction between the patient and operated valve(s), although patient variables (e.g., age, degree of coronary arterial disease, follow-up care) may be more responsible for outcomes than an operated valve. However, no set of guidelines can identify all possible patient factors that may affect morbidity and mortality. General agreement regarding the following definitions of terms and suggestions for reporting data do not preclude more detailed analyses or constructive recommendations and investigators are encouraged to identify relevant patient factors in addition to factors related to operated valves.

Guidelines for reporting morbidity and mortality after cardiac valvular operations.

At the request of the Councils of the Society of Thoracic Surgeons (STS) and the American Association of Thoracic Surgery (AATS) the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity reviewed the "Guidelines" published in September 1988 [3, 7, 8]. The purpose of the review was to update and clarify definitions within the guidelines and to consider recommendations made by other [2, 11]. The variety of cardiac valvular procedures has expanded since 1988; therefore, in this document the term "operated valve" indicates prosthetic and bioprosthetic heart valves of all types, operated or repaired native valves and allograft and autograft valves. The term "operated valve" includes any cardiac valve altered by a surgeon during an operation. Much morbidity and mortality is a direct consequence of the interaction between the patient and operated valve(s), although patient variables (e.g., age, degree of coronary arterial disease, follow-up care, etc.) may be more responsible for outcomes than an operated valve. However, no set of guidelines can identify all possible patient factors that may affect morbidity and mortality. General agreement regarding the following definitions of terms and suggestions for reporting data do not preclude more detailed analyses or constructive recommendations and investigators are encouraged to identify relevant patient factors in addition to factors related to operated valves. Purpose The purpose of these guidelines is to facilitate the analysis and reporting of results of operations on diseased cardiac valves. The definitions and recommendations that follow are guidelines, not standards, and are designed to facilitate comparisons between the experiences of different surgeons who treat different cohorts of patients at different times with different techniques and materials.

Prevention of heterotopic ossification (HO) after total hip replacement: randomized high versus low dose radiotherapy

In a prospectively randomized study 60 hips at high risk for heterotopic ossification (HO) received prophylactic radiotherapy (RT). Randomization was performed between a low dose (LD-RT) of 5 × 2 Gy (arm A: 32 patients) and a high dose (HD-RT) of either 10 × 2 Gy (arm B1; 8 patients) or 5 × 3.5 Gy (arm B2; 20 patients). Relevant patient and risk factors were equally distributed in both treatment arms. 4 (7%) patients developed treatment failures. A short delay of RT after postoperative day (POD) 4 was significantly correlated with failure ( p < 0.001). The results suggest no difference in prophylactic efficacy between LD-RT and HD-RT treatment. 2 19 (11 %) patients receiving additional diphosphonates and 2 18 (11 %) on no medication failed RT treatment, but none on indomethacin did so. In conclusion, immediate postoperative RT has been shown to be an effective prophylactic treatment.