Covert dose reduction is a distinct type of medication non-adherence observed across all care settings in inflammatory bowel disease.

BACKGROUND: Non-adherence by dose omission is common and deleterious to outcomes in Inflammatory Bowel Disease (IBD), but covert dose reduction (CDR) remains unexplored. AIMS: To determine frequency and attitudinal predictors of overall medication non-adherence and of covert dose reduction as separate entities. METHODS: A cross sectional questionnaire was undertaken involving IBD patients in three different geographical regions and care settings. Demographics, medication adherence by dose omission, and rate of patient initiated dose reduction of conventional meds without practitioner knowledge (CDR) were assessed, along with attitudes toward IBD medication. RESULTS: Of 473 respondents (mean age 50.3 years, 60.2% female) frequency of non-adherence was 21.9%, and CDR 26.9% (p<0.001). By logistic regression, significant independent predictors of non-adherence were dissatisfaction with the patient-doctor relationship (p<0.001), depression (p=0.001), anxiety (p=0.047), and negative views regarding medication efficacy (p<0.001) or safety (p=0.017). Independent predictors of covert dose reduction included regular complementary medicine (CAM) use (p<0.001), experiencing more informative (p<0.001) and comfortable (p=0.006) consultations with alternative practitioners, disbelieving doctor delivered information (p=0.021) and safety concerns regarding conventional medication (p<0.001). Neither the frequency of non-adherence (p=0.569) nor CDR (p=0.914) differed between cohorts by different treatment settings. CONCLUSIONS: Covert dose reduction of IBD medication is more common than omission of medication doses, predicted by different factors to usual non-adherence, and has not been previously reported in IBD. The strongest predictor of CDR is regular CAM use.

Cancer patient preferences for communication of prognosis in the metastatic setting

PURPOSE: To identify preferences for and predictors of prognostic information among patients with incurable metastatic cancer. PATIENTS AND METHODS: One hundred twenty-six metastatic cancer patients seeing 30 oncologists at 12 outpatient clinics in New South Wales, Australia, participated in the study. Patients were diagnosed with incurable metastatic disease within 6 weeks to 6 months of recruitment. Patients completed a survey eliciting their preferences for prognostic information, including type, quantity, mode, and timing of presentation; anxiety and depression levels; and information and involvement preferences. RESULTS: More than 95% of patients wanted information about side effects, symptoms, and treatment options. The majority wanted to know longest survival time with treatment (85%), 5-year survival rates (80%), and average survival (81%). Words and numbers were preferred over pie charts or graphs. Fifty-nine percent (59%) wanted to discuss expected survival when first diagnosed with metastatic disease. Thirty-eight percent and 44% wanted to negotiate when expected survival and dying, respectively, were discussed. Patients with higher depression scores were more likely to want to know shortest time to live without treatment (P = .047) and average survival (P = .049). Lower depression levels were significantly associated with never wanting to discuss expected survival (P = .03). Patients with an expected survival of years were more likely to want to discuss life expectancy when first diagnosed with metastases (P = .02). CONCLUSION: Most metastatic cancer patients want detailed prognostic information but prefer to negotiate the extent, format, and timing of the information they receive from their oncologists.

Using supervised and unsupervised techniques to determine groups of patients with different doctor-patient stability

Decision trees and self organising feature maps (SOFM) are frequently used to identify groups. This research aims to compare the similarities between any groupings found between supervised (Classification and Regression Trees - CART) and unsupervised classification (SOFM), and to identify insights into factors associated with doctor-patient stability. Although CART and SOFM uses different learning paradigms to produce groupings, both methods came up with many similar groupings. Both techniques showed that self perceived health and age are important indicators of stability. In addition, this study has indicated profiles of patients that are at risk which might be interesting to general practitioners.

Using information and communication technologies to consult with patients in Victorian primary care : the views of general practitioners

Information and communication technologies such as email, text messaging and video messaging are commonly used by the general population. However, international research has shown that they are not used routinely by GPs to communicate or consult with patients. Investigating Victorian GPs’ perceptions of doing so is timely given Australia’s new National Broadband Network, which may facilitate web-based modes of doctor-patient interaction. This study therefore aimed to explore Victorian GPs’ experiences of, and attitudes toward, using information and communication technologies to consult with patients. Qualitative telephone interviews were carried out with a maximum variation sample of 36 GPs from across Victoria. GPs reported a range of perspectives on using new consultation technologies within their practice. Common concerns included medico-legal and remuneration issues and perceived patient information technology literacy. Policy makers should incorporate GPs’ perspectives into primary care service delivery planning to promote the effective use of information and communication technologies in improving accessibility and quality of general practice care.

Nursing the patient with severe communication impairment

Background. Effective communication with patients is critical to effective nursing practice. Surprisingly, there is little information on nurses' experiences in caring for patients who are unable to speak. Purpose and method. This study provides descriptive information from interviews with 20 nurses who cared for patients with severe communication impairment. The interview protocol explored positive and negative experiences of nursing patients with severe communication impairment. Frequency counts and descriptive analyses were conducted to identify the major themes emerging from the interviews. Results. The results suggest that nurse-patient communication is difficult when the patient has severe communication impairment, although some nurses discovered effective strategies to facilitate communication with such patients. Many of the difficulties could be viewed as a breakdown in understanding arising from the lack of a readily interpretable communication system that could be used by nurse and patient. Conclusions. The results suggest a need for training nurses in the use of alternative modes of communication. Nurses also need access to a variety of simple augmentative communication devices for use with patients who are unable to speak. Finally, nurses should collaborate with speech pathologists on the development of preadmission information and bedside training for people who are admitted to hospital with severe communication impairment.

The effects of physical environments in medical wards on medication communication processes affecting patient safety

Physical environments of clinical settings play an important role in health communication processes. Effective medication management requires seamless communication among health professionals of different disciplines. This paper explores how physical environments affect communication processes for managing medications and patient safety in acute care hospital settings. Findings highlighted the impact of environmental interruptions on communication processes about medications. In response to frequent interruptions and limited space within working environments, nurses, doctors and pharmacists developed adaptive practices in the local clinical context. Communication difficulties were associated with the ward physical layout, the controlled drug key and the medication retrieving device. Health professionals should be provided with opportunities to discuss the effects of ward environments on medication communication processes and how this impacts medication safety. Hospital administrators and architects need to consider health professionals' views and experiences when designing hospital spaces.

Patient engagement in clinical communication: an exploratory study

AIM: Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions.

METHOD: An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken.

RESULTS: Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed.

CONCLUSION: Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

Comparison of patient-reported need of psycho-oncologic support and the doctor's perspective: how do they relate to disease severity in melanoma patients?

Objective: Psycho-neuro-immune research suggests an association between cancer outcomes and psychosocial distress. Objective criteria to determine patients’ levels of distress are important to establish potential links to disease outcomes. Methods: We compared three patient-reported with one doctor-reported measures of psychooncologic distress frequently used in routine cancer care and investigated associations with standard disease severity parameters in melanoma patients. We enrolled n = 361 patients, successively seen at two outpatient university clinics in Germany. In the naturalistic study, n = 222 patients had been diagnosed <180 days and were seen for the first time (Group I); n = 139 had been diagnosed >180 days and were in after-care (Group II). Results: Across groups, only moderate associations were seen between patient- reported and doctorreported measures. Regarding clinical variables, disease severity and perceived need of psychooncologic support reported by patients or doctors showed hardly any association. After subgroup stratification, in patients of Group II, patient-reported and doctor-reported instruments showed some small associations with disease parameters commonly linked to more rapid cancer progression in patients who are in cancer after-care. Conclusions: Overall, the few and low associations suggest that need of psycho-oncologic support and clinical variables were largely independent of each other and doctors’ perception may not reflect the patient’s view. Therefore, the assessment of the patient perspective is indispensable to ensure that melanoma patients receive appropriate support, as such need cannot be derived from other disease parameters or proxy report. More research is needed applying psychometrically robust instruments that are ideally combined with sensitive biomarkers to disentangle psycho-neuro-immune implications in melanoma patients.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

AIMS AND OBJECTIVES: This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. BACKGROUND: Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. DESIGN: A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. METHODS: A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. FINDINGS: Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. CONCLUSIONS: The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. RELEVANCE TO CLINICAL PRACTICE: Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.

Euthanasia: why it doesn`t matter (much) what the doctor thinks and why there is no suggestion that doctors should have a duty to kill

A major reason that The Netherlands has taken a different approach to the rest of the world on such a fundamental moral issue is that the courts and legislature in that country have accorded the interests of doctors a cardinal role in the euthanasia debate. This article argues that the interests of doctors are of only incidental and peripheral relevance in relation to the moral status of euthanasia. The moral status of euthanasia has little to do with the
preparedness ofdoctors to administer the lethal injection or their general attitude towards the practice. Euthanasia is principally about the interests of the patient and the impact that the practice may have on the community in general, not preserving the conscience or improving the working life ofdoctors.

Assessing patient satisfaction with day surgery at a metropolitan public hospital

With the advances in health care technology, many surgical procedures are performed as day surgery cases. The provision of day surgery is considered to be a cost effective method of utilising resources, but it does challenge nurses to provide optimal patient care during the patient's short stay in hospital. Patient satisfaction is considered to be an important indicator of quality nursing care. This paper reports on an investigation aimed at assessing patient satisfaction with day surgery in an Australian metropolitan public hospital. One hundred and seven patients completed a recently developed survey assessing patient satisfaction with day surgery. The response rate was 41%. Waiting times, communication, pain management and discharge planning were major areas of patient dissatisfaction. Directions for improvement in day surgery services are discussed.

Pharmaceutical ecomonics and politics vs. patient safety : Lumiracoxib in Australia

Lumiracoxib (Prexige©) 200 mg was listed in Australia’s Pharmaceutical Benefits Scheme (PBS) schedules on 01 August 2006. The listing was intended as a cost-minimisation strategy, as lumiracoxib 200 mg was deemed equivalent in therapeutic effect to celecoxib (Celebrex©) 200 mg, and was available at a lower cost. By the time of listing on the PBS, a safety re-evaluation of the recommended daily dose of lumiracoxib was being considered in other national regulatory jurisdictions. Within 3 months of listing, the manufacturer revised the recommended dosage to half that of the PBS-listed dosage. However, the PBS listing was neither revoked nor modified. At the time of listing on the PBS, lumiracoxib was known to be 17 times as biochemically selective in inhibiting the COX-2 isoform as celecoxib, and twice as selective as rofecoxib, already withdrawn for safety reasons. Safety concerns had already been raised about adverse hepatic outcomes on daily doses of lumiracoxib 200 mg. Communication of information about the risk potential of lumiracoxib was inadequate. Economic and political considerations were prioritised over patient safety, and lumiracoxib 200 mg remained available via the PBS until 10 August 2007, when it was withdrawn for safety reasons following cases of hepatic morbidity and mortality.

Examining communication and team performance during clinical handover in a complex environment : the private sector post-anaesthetic care unit

* Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery.

* In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication.

* We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover.

* The framework can be used to develop viable solutions to the problems of clinical handover.

* The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units.

* The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability.

* We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.