Charles P Felton National Tuberculosis Center, International Center for AIDS Care and Treatment Programs, Columbia University, New York, New York 10027, USA. pwc2@columbia.edu
An estimated 300?000 individuals are treated for latent tuberculosis infection (LTBI) in the United States and Canada annually. Little is known about the proportion or characteristics of those who decline treatment.
To define the proportion of individuals in various groups who accept LTBI treatment and to identify factors associated with non-acceptance of treatment.
Persons offered LTBI treatment at 30 clinics in 12 Tuberculosis Epidemiologic Studies Consortium sites were prospectively enrolled. Multivariate regression models were constructed based on manual stepwise assessment of potential predictors.
Of 1692 participants enrolled from March 2007 to September 2008, 1515 (89.5%) accepted treatment and 177 (10.5%) declined. Predictors of acceptance included believing one could personally spread TB germs, having greater TB knowledge, finding clinic schedules convenient and having low acculturation. Predictors of non-acceptance included being a health care worker, being previously recommended for treatment and believing that taking medicines would be problematic.
This is the first prospective multisite study to examine predictors of LTBI treatment acceptance in general clinic populations. Greater efforts should be made to increase acceptance among health care workers, those previously recommended for treatment and those who expect problems with LTBI medicines. Ensuring convenient clinic schedules and TB education to increase knowledge could be important for ensuring acceptance.
In the opinion of the public, accessibility is probably one of the most important features of general practice. More than 3,500 patients in North Norway answered a questionnaire asking for their opinions on waiting time for consultation, the time spent in consultation and the possibility of the doctor visiting them at home. 80% thought that a waiting time of more than one week was too long. The actual waiting times differ considerably, but only a few practices serving less than 900 inhabitants per physician managed to satisfy their patients. On the other hand, about 80% found the time allocated for the consultation to be adequate. Almost half the patients who expressed an opinion thought it too difficult to get a doctor to visit them at home. Less than 10% considered a long distance to travel to a doctor to be an obstacle. Not surprisingly, young people were most demanding as regards quick service. Men were somewhat more satisfied than women, as were patients in rural areas compared with patients in the towns. In our opinion, some of the patients' causes of dissatisfaction can be removed by better routines. However, it seems that the resources available within general practice, are inadequate to meet all the patients' wishes, either now or in the future.
To explore access to health care for patients presenting with multiple chronic conditions and to identify barriers and factors conducive to access.
Qualitative study with focus groups.
Family practice unit in Chicoutimi (Saguenay), Que.
Twenty-five male and female adult patients with at least four chronic conditions but no cognitive disorders or decompensating conditions.
For this pilot study, only three focus group discussions were held.
The main barriers to accessing follow-up appointments included long waits on the telephone, automated telephone-answering systems, and needing to attend at specific times to obtain appointments. The main barriers to specialized care were long waiting times and the need to get prescriptions and referrals from family physicians. Factors reported conducive to access included systematic callbacks and the personal involvement of family physicians. Good communication between family physicians and specialists was also perceived to be an important factor in access.
Systematic callbacks, family physicians' personal efforts to obtain follow-up visits, and better physician-specialist communication were all suggested as ways to improve access to care for patients with multiple chronic conditions.
Several methods exist to quantitate small-solute clearance by daily hemodialysis (HD) regimens, but these have not been empirically applied or compared.
In the London Daily/Nocturnal Hemodialysis Study, dosing and adequacy of quotidian HD regimens, both short daily HD (n = 11) and long nocturnal HD (n = 12), were compared with conventional thrice-weekly HD (n = 22) using several models. Urea clearance was computed by percentage of reduction in urea, kinetic modeling (single-pool Kt/V [spKt/V]), Daugirdas rate equation (equilibrated Kt/V [eKt/V]), and Gotch standardized Kt/V (stdKt/V).
Nocturnal HD patients maintained a mean single-session spKt/V of 1.64 throughout the study, similar to that of conventional HD patients (1.73), whereas daily HD patients showed a significant decrease in mean single-session spKt/V (0.93) compared with baseline (t(0)) values. Mean weekly spKt/V values increased from t(0) for both quotidian HD groups (9.08 for nocturnal HD, 5.55 for daily HD) and were higher in both quotidian HD groups compared with conventional HD patients. Weekly eKt/V, stdKt/V, and normalized protein equivalent of nitrogen appearance values showed similar trends. Comparison of the 3 different adequacy models showed an increase in weekly HD doses for both quotidian HD regimens compared with conventional HD; however, percentages of increases from t(0) to follow-up differed according to the model used. The calculated efficiency of dose delivery at the 10-month follow-up comparing daily HD with conventional HD was 257 +/- 26 minutes versus 306 +/- 17 stdKt/V unit delivered, respectively, amounting to almost 1 dialysis-hour saved per stdKt/V unit delivered for daily HD.
These results show that both quotidian HD regimens are more effective than conventional HD in improving weekly urea clearance measured by spKt/V, stdKt/V, and eKt/V.
Department of Pediatrics, Division of Nephrology, Children's Hospital, London Health Science Centre, University of Western Ontario, 800 Commissioners Road East, London, ON, Canada.
Waiting times for specialist consultation have not been adequately studied, especially in the pediatric population. The aim of this study was to determine the extent to which pediatric nephrology subspecialty clinic referral waiting times are adhered to with regard to previously determined access targets. Referrals to the pediatric nephrology clinics at Children's Hospital, London, Ontario, Canada, received between October 2007 and November 2008 were retrospectively analyzed. Appointment schedule was allotted by a nephrologist based on the patient's presenting complaint, reported in the referral, in accordance with the previously determined access targets. Adherence to access targets was assessed by the actual clinic visit. There were a total of 250 referrals during the timeframe studied. The median waiting time was 73 (range 0-193) days. Overall, 64% (159/250) of patients met their access target. The median time that patients waited over their access target was 6 (range 0-78) days. Of the patients who did not meet their access targets, 31% (28/91) exceeded their target by 20% or more. Office handling was a component for patients with access target
