Determination of risks of lower adherence to CPAP treatment before their first use by patients

A better understanding of Continuous Positive Airway Pressure (CPAP) adherence is a priority in improving patient care. To Identify adherence typology with a longitudinal approach, and explore the early determinants of lower adherence to CPAP. Obstructive sleep apnea patients (N = 204). Prospective and longitudinal study.A classification into four profiles was observed: "Regular Adherents," "Non-Regular Adherents," "Persistent Non-Adherents," and "Non-Persistent Non-Adherents." Specific biopsychosocial factors make it possible to evaluate the risk of belonging to a lower adherence profile. We propose a novel approach of CPAP treatment adherence. Several pre-determinants have been identified.

[Importance of the emotional dimension when providing information to patients with obstructive sleep apnea syndrome]

INTRODUCTION

To promote adaptation to treatment with continuous positive airway pressure, an information document was developed for people starting their treatment with continuous positive airway pressure.

METHODS

Seven patients with obstructive sleep apnea took part in a focus group. This allowed the identification both of useful information and the best way that this information could be presented.

RESULTS

The key specific information objectives and the best emotional register to use were as follows: (1) develop awareness about the physiological mechanisms and consequences that can occur from obstructive sleep apnea syndrome, using formulations arousing fear, (2) enable the recognition of the symptoms, risk factors and chronicity of this syndrome, (3) reassure and motivate the patient about treatment with continuous positive airway pressure.

CONCLUSIONS

To promote adaptation to positive airway pressure in early care, combining different emotional tones is preferable, mixing both fear and reassurance.

[Puncture of the radial vein: a forgotten complication]

The superficial radial vein at the lateral edge of the inferior third of the forearm and of the wrist has strong anatomical relationship with the sensory superficial branch of the radial nerve. At this level, any venous puncture may be responsible for a lesion of this superficial part of the radial nerve. We report two cases of dysesthesia in the radial territory after this kind of puncture. This risk should not be neglected and venous puncture should be avoided in this area.

[Clinical effects of new technologies in medical imagery: the example of breast screening]

In the frame of cancer screening, we present a new psychological concept elaborated from our clinical practice of women affected by a breast cancer. The experience of these women is different depending on whether the cancer is discovered in an asymptomatic context or not. We introduce the concept of "anticipatrice medicine" in order to define the implication of diagnosis precocity on the therapeutic strategy, because of a modification of some main parameters which make up the ordinary personal concept. These parameters are : the time in which disease anticipates the symptom and the space where the treatment anticipates the disease. We discuss the paradoxical experience of screening which imposes a medical intervention before any symptom that is for the patient to be treated before any feeling of the disease, and to experience the disease through the experience of a treatment. The different elements of this paradoxical experience are successively identified and analysed. Finally we propose four directions of research in the field of interaction between human and medical technologies.

Focus group approach for developing written patient information in oncogenetics

We report our experience in developing written patient information in the field of genetic oncology using a focus group approach. A scientific document addressing the issue about the finding of negative (i.e., inconclusive) results in BRCA1/2 diagnostic genetic testing was elaborated in three stages. The initial version written by a scientific committee was discussed in two focus group sessions, and then rewritten to incorporate the comments and suggestions collected. The discussions during focus group meetings were analyzed using a specific analysis grid exploring five dimensions. The input provided from the focus group greatly improved the initial version, leading to the production of a document containing appropriate scientific information that was accessible to patients. Focus groups are useful tools for developing good-quality documents in the complex setting of genetic oncology.

A qualitative approach to the use of economic data in the selection of medicines for hospital formularies: a French survey

OBJECTIVE

Qualitative interviews were conducted with pharmacists in hospitals and clinics in the Rhône-Alpes region of France to determine the role of economic data when selecting medicines for formularies, to identify barriers to the use of this information and to study to what degree a healthcare establishment's financing system influences the use of this data.

METHOD

A stratified sample of healthcare establishments with over 100 short-stay beds were included: (1) thirteen public and semi-private hospitals financed through annual global budgets and (2) six private clinics financed on a fee-for-service basis. Interviews were carried out between October 1999 and January 2000, and coded independently by two researchers.

MAIN OUTCOME MEASURE

A multiple correspondence analysis was performed to compare the two groups of healthcare establishments.

RESULTS

The influence of economic data in the decision-making process is limited, for other factors appear to have greater weight: (1) efficacy and safety of medicines (2) relations between decision-makers and the pharmaceutical industry and (3) patient quality of life. Economic data used was mainly related to medication prices and quantities consumed. This data was used in a large number of decisions and seemed to have more importance in hospitals than in clinics. Information related to resources that could be saved by the inclusion of a new medicine on formularies was seldom used and apparently considered less important in hospitals than in clinics. Pharmacoeconomic evaluations were very rarely used. Six barriers to the use of economic data were raised by the pharmacists, including: lack of time, which limits the collection and analysis of such information; insufficient health economics training, an obstacle to decision-makers' analytical capacity; and closed budgets within hospitals.

CONCLUSION

Economic data concerning 'medication budgets' appears to have a greater impact in public and semi-private hospitals than in private clinics. Obstacles linked to the decision-making context itself were particularly highlighted, and it can be concluded that in order to increase the use of economic data, it is first necessary to create an environment that is more favourable to its application.

Clinical issues in shared decision-making applied to breast cancer

OBJECTIVES

To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision-making in clinical practice and (3) patients' desires concerning the question of 'who should take the decision in breast cancer treatments?'

DESIGN

Qualitative pilot study based on clinical encounters using decision boards and information booklets.

SETTING

Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France.

PARTICIPANTS

One breast cancer surgeon and 22 breast cancer patients.

MAIN OUTCOME MEASURES

Analysis of patients' reactions to a shared decision-making process concerning surgery and chemotherapy, and analysis of its practical feasibility (i.e. duration of the consultations).

RESULTS

(1) Twenty-one patients participated in the decision regarding surgery; all chose conservative treatment; 15 patients had their own say about chemotherapy (nine chose no chemotherapy, six chose chemotherapy). (2) Participating in treatment choice generated anxiety for a majority of patients. Some were dissatisfied because they had to make a choice and consequently to give up the other option. Finally, some were uncertain about making the right choice. Nevertheless, most were satisfied with the information given and the possibility of participating to the treatment decision-making process. (3) The total duration of the entire process of shared decision-making is consistent with the time spent with patients with such a severe disease.

DISCUSSION/CONCLUSION

Most of the patients expressed their satisfaction regarding the possibility to participate in treatment decision-making, knowing that offering treatment choice is very unusual in France. From this pilot study it appears that shared decision-making is feasible in clinical practice. Nevertheless, a quantitative study based on a large sample of patients is necessary to: (1) confirm this hypothesis, (2) ensure that patients are willing to participate in their treatment decision-making, and (3) measure the potential benefits related to this participation.

[How to evaluate the quality of information transfer from physician to patient? Choice of psychometric tests for a decision tree in a Regional Cancer Centre]

BACKGROUND

Decision boards are used to transfer information from physicians to patients to help them participate in the clinical decision-making process. We present the tests and results of the psychometric properties of a decision board in a sample of healthy volunteers.

METHODS

In the Regional Cancer Centre located in Lyon, we developed a decision board for post-menopausal women with breast cancer after lumpectomy without any poor prognostic factors. Two treatment options were proposed, one involving chemotherapy and the other not. We tested for the following psychometric properties: comprehension, construct validity and reliability. Comprehension was evaluated using a questionnaire, in order to test whether the rates of correct answers were due to chance alone. The construct validity was assessed by changing the information provided (relapse and survival rates, characteristics of chemotherapy) and testing whether the proportion of healthy volunteers choosing an option changed in a predictable and significant way. The reliability was evaluated using the test-retest method. Two reliability statistics were computed: the Pearson correlation and the Intraclass Correlation Coefficient.

RESULTS

In the sample of 40 healthy volunteers, 23 chose the option with chemotherapy and 17 the option without chemotherapy. Results show that the decision board was comprehensive, valid (the women changed their choices in a predictable way) and reliable (Pearson correlation and Intraclass Correlation Coefficient close to 1).

CONCLUSION

The choice of the psychometrics properties tested and the statistical tests used are discussed. The psychometric properties of our tool are found to be satisfactory.

Shared decision-making in question

Over recent years, communication within the physician-patient relationship has been profoundly changing. New modes of conveying diagnostic and therapeutic information influence the way in which decisions regarding treatment are made. We propose a critical review of the various theoretical models as presented in the literature, from the paternalistic to the shared decision model, in order to reveal conceptual ambiguities and their related methodological problems. This analysis leads to a project for clarifying these problems through a research protocol based on shared decision-making.

Eliciting patients' preferences for adjuvant chemotherapy in breast cancer: development and validation of a bedside decision-making instrument in a French Regional Cancer Centre

In developed countries, the physician-patient relationship is moving from a paternalistic model to new decision-making models that take patient preferences into account. OBJECTIVES: Our aim was to develop a Decision Board (DB) and to test its acceptability in a French Regional Cancer Centre regarding the decision on whether or not to use chemotherapy after surgery in postmenopausal women with breast cancer. This paper presents the development process for this instrument and reports the pretesting phase, as well as the corresponding results. METHODS: A working group was created with oncologists, psychologists and economists. Following the first phase, i.e. the development process, a first version of the instrument was presented to health professionals. Their feedback led to important modifications of the instrument. The DB was then presented to experienced patients, which resulted in slight changes. The second phase consisted of pretesting the comprehension, internal and across-time consistency of the DB on healthy volunteers. RESULTS: The DB was pretested in a group of 40 healthy volunteers. Eighteen respondents chose chemotherapy and 22 chose not to have chemotherapy. Comprehension rates were very high (>/=87.5%). Internal consistency was assessed considering option attitudes based on outcomes and option attitudes based on process. Women shifted their choices in a predictable way. Across-time consistency was appraised using the test-retest method with Visual Analog Scales. The Intraclass Correlation Coefficient was 0.97. DISCUSSION-CONCLUSION: Due to cultural differences, the DB developed in our French Cancer Centre is quite different from the DBs previously developed elsewhere. Our instrument showed good comprehension and consistency properties, which are corroborated by the DB literature. Whether our DB is acceptable for patients with breast cancer must still be tested. Patients' reactions will tell us which type of decision-making model is at work. Further research is needed in order to explore the shared decision-making process and clarify the concept.

Psychosocial profile of women seeking breast reconstruction

As opposed to studies focused on the role of reconstruction in the rehabilitation of cancer patients, the aim of this study is to define what kind of women undergo post-mastectomy reconstruction. The social, cultural and psychological variables influencing women in this choice were assessed using a questionnaire administered to 45 women who had breast reconstruction and 51 who did not. An univariate analysis shows significant differences between the two groups regarding age, education, socioeconomic status, leisure activities, sexual intercourse, information about breast reconstruction and fear of recurrence. These results show that social status is a deciding factor in a woman's access to information about reconstruction. If every women undergoing mastectomy is to be given the opportunity of plastic surgery, we think that information must be adapted to psychosocial profile.

[Motivations for breast reconstruction after mastectomy. A comparative study]

The aim of this study is to define the psychosocial profile and the motivations of women who seek post-mastectomy reconstruction. A questionnaire was administered to 45 women who had breast reconstruction several months after mastectomy and 51 who did not. Statistical analysis of data shows significant differences between the two groups regarding age, education, leisure activities, sexual intercourse and fear of recurrence. A qualitative analysis shows how women feel about reconstruction. The results suggest that information concerning reconstruction must be adapted to the psychosocial profile of women. Moreover, reconstruction must be considered by the surgeon as an essential stage of breast cancer treatment. In order to help women in their choice, they must give them appropriate information on the technique of breast reconstruction, on the risk of relapse and on the possibility of reimbursement of medical expenses.

[Problem of perception and denial of illness in women who had breast cancer]

It has been noted that some patients demonstrate denial when they have a severe illness such as cancer. We observed this type of denial with respect to perception of illness by patients. We interviewed twenty women who had been treated for breast cancer for more than one year. During these interviews, every patient narrated the story of her illness as she remembered it. One year or more after treatment, four women denied the diagnostic which was given to them when the treatments started. These four women were the only ones who never perceived the first signs of the illness. They never saw or felt any change around their breasts, and they are among the five women for whom breast cancer was detected from a systematic mammography. In contrast the other women, who did not manifest such denial, detected themselves an anomaly or were alerted by their physician. Based upon these observations, we discuss the notion of denial when patients have no perception of the illness or its first signs of onset. We pose a question concerning the interest and usefulness of such research concerning the representational process of illness by patients.