Adherence to antiparkinsonian medication: An in-depth qualitative study

Background: Adherence to prescribed medication is low. It is a major problem as following practitioners’ recommendations is strongly associated with good patient outcomes. Little research has been undertaken with people in the early stages of Parkinson's disease although achieving symptom control depends on regularly timing doses. Research questions: How do people with Parkinson's disease adhere to prescribed medication, and what are the antecedents of non-adherence to antiparkinsonian medication? Design: Exploratory qualitative study using semi-structured interviews. Setting: Specialist Parkinson's disease clinic in one National Health Service hospital in England. Participants: Fifteen consecutive patients not yet in the advanced stages of Parkinson's disease living at home and responsible for managing their own medication or managing medication with the help of their carer. Methods: Semi-structured interviews with open questions. Findings: Each respondent demonstrated at least one type and in most cases several different types of non-adherent behaviour. Inadvertent minor non-adherence occurred because patients forgot to take tablets or muddled doses. Minor deliberate deviations occurred when patients took occasional extra tablets or brought forward doses to achieve better symptom control, often to cater for situations that were anticipated as especially demanding. Deliberate major non-adherence was very common and always related to over-use of medication. The experiences of parkinsonism were particular to the individual. The specific circumstances that prompted an episode of non-adherence varied between patients. Nevertheless there was evidence of negotiation between respondents and the Parkinson's disease nurse specialist; medication regimes were altered in conjunction with the patient during formal consultations and by telephone. Conclusion: Non-adherence to prescribed medication for people with chronic conditions is complex and for people with Parkinson's disease it was possible to identify different types of non-adherence. The possible existence of a typology of non-adherence for people with other chronic conditions merits investigation. Further research is needed to establish whether the findings of this small scale qualitative study can be replicated with a larger, more representative sample and establish how people with Parkinson's disease might be encouraged to adhere to medication regimes to improve symptom control

What are scoping studies? A review of the nursing literature

Scoping studies are increasingly undertaken as distinct activities. The interpretation, methodology and expectations of scoping are highly variable. This suggests that conceptually, scoping is a poorly defined ambiguous term. The distinction between scoping as an integral preliminary process in the development of a research proposal or a formative, methodologically rigorous activity in its own right has not been extensively examined

Developing a model to assess optimum infection control workforce in acute care settings

Background: Little research has been completed to assess the numbers of infection prevention and control personnel employed or optimal size and composition of infection control teams. Methods: Acute national health hospital organizations in England were requested to provide information about the numbers of infection prevention and control personnel employed and weekly hours contributed by each occupational group under the United Kingdom’s Freedom of Information legislation. The relationship between capacity of the infection prevention and control workforce, size of the inpatient population, and routinely collected surveillance data for health care–associated infection were explored. Results: There were 137 (85%) National Health Service (NHS) hospital organizations that responded. The number of infection prevention and control nurses ranged from 1-16 per organization. A total of 46 (33.6%) reported that they received no clinical microbiology sessions, and for 11 (8%) input was inadequate. An antibiotic pharmacist was reported to be employed in 107 (78.1%) organizations. Few infection prevention and control teams reported receiving the following: 1. managerial support, 2. being represented on committees where decisions about resource allocation were made, or 3. assistance with administration. Conclusion: Despite the priority that infection prevention and control have received in the United Kingdom over the last 10 years, many infection prevention and control teams appear underresourced

Late referral for end-stage renal disease: a region-wide survey in the south west of England

Background: The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT.Methods: Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as ‘late’ if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT.Results: One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups.Conclusion: Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1–4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF

A clinical and cost evaluation of hemodialysis in renal satellite units in England and Wales

Background: the prevalence rate of renal replacement therapy in the United Kingdom has increased significantly, particularly by long-term hemodialysis (HD) therapy in renal satellite units (RSUs). These are largely nurse-run units linked to main renal units (MRUs). We compared outcomes, processes of care, and costs in RSUs with those in MRUs. Methods: a cross-sectional comparison was performed of HD patients from a representative sample of 12 RSUs in England and Wales and HD patients in the linked MRUs deemed suitable by the senior nurse for RSU care. Data for patient characteristics, clinical process and outcome measures, health-related quality of life (HRQoL), and patient satisfaction were collected. A partial analysis of National Health Service and social care costs was undertaken. Geographic access was assessed by road time and distance traveled to dialysis sessions. Results: seven hundred thirty-six of 895 eligible patients (82%) participated. RSU patients were older (mean age, 63 versus 57 years), but had comorbidity similar to that of MRU patients. There were no significant differences in most processes of care or clinical outcomes; achievement of standards for adequacy of dialysis (urea reduction ratio) was significantly greater in RSU patients and hospitalization in the last year was less frequent. Patient HRQoL was similar, but patient satisfaction was greater in RSU patients. RSU patients potentially saved 19 minutes traveling for each dialysis session. Costs for routine dialysis and health/social care were similar. Conclusion: RSUs appear to be as effective as main HD units for a wide spectrum of patients, improve geographic access, and are more acceptable to patients. There is evidence that they are as cost-effective as main units