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BMJ No 7110 Volume 315 Papers - Abstracts Saturday 20 September 1997
Should we pay the patient? Review of financial incentives to
enhance patient compliance
Should we pay the patient? Review of financial incentives to enhance patient complianceAntonio Giuffrida, David J Torgerson AbstractObjective: To determine whether financial incentives increase patients' compliance with healthcare treatments.Data sources: Systematic literature review of computer databases-Medline, Embase, PsychLit, EconLit, and the Cochrane Database of Clinical Trials. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. Study selection: Only randomised trials with quantitative data concerning the effect of financial incentives (cash, vouchers, lottery tickets, or gifts) on compliance with medication, medical advice, or medical appointments were included in the review. Eleven papers were identified as meeting the selection criteria. Data extraction: Data on study populations, interventions, and outcomes were extracted and analysed using odds ratios and the number of patients needed to be treated to improve compliance by one patient. Results: 10 of the 11 studies showed improvements in patient compliance with the use of financial incentives. Conclusions: Financial incentives can improve patient compliance.
National Primary Care Research and
Development Centre,
Correspondence to: Mr Giuffrida Long term results of growth hormone treatment in France in children of short stature: population, register based studyJoel Coste, Muriel Letrait, Jean Claude Carel, Jean Pierre Tresca, Pierre Chatelain, Pierre Rochiccioli, Jean Louis Chaussain, Jean Claude Job See editorial by Brook AbstractObjectives: To describe the growth of children treated with growth hormone and to evaluate the prognostic factors for height at the end of treatment.Design: Register based cohort study. Setting: French national register of all children treated with growth hormone. Subjects: 3,233 short stature children (3,165 of whom were deficient in growth hormone) who were treated with growth hormone (excluding children with Turner's syndrome) and whose treatment started between 1973 and 1989, last data being recorded in December 1993. Main outcome measures: Annual changes in height, and height at the end of treatment. Results: Mean height SD score at the end of treatment, after a mean of 4.3 years, was -2, corresponding to gain in mean height SD score of 1 and to a height SD score of 1.1 below target height. In all, 923 children prematurely stopped taking growth hormone treatment, mainly because of insufficient response (insufficient growth) or tiredness. Variables that predicted height at the end of treatment were age, target height, aetiology of short stature, use of puberty inhibitors, and type of growth hormone. Conclusions: The outcome of children of short stature with growth hormone deficiency who were treated with growth hormone has been less favourable than initially assumed. Growth hormone treatment has not restored normal growth to these children. The highly demanding nature and high costs of this treatment require an optimised prescription, and this remains to be determined Departement de Biostatistique Institut de Recherche Therapeutique, Association France Hypophyse,
Correspondence to: Dr Coste Rising incidence of insulin dependent diabetes in children aged under 5 years in the Oxford region: time trend analysisStephen G Gardner, Polly J Bingley, Pamela A Sawtell, Suzanne Weeks, Edwin A M Gale, the Bart's-Oxford Study Group AbstractObjectives: To monitor incidence of insulin dependent diabetes in children in Oxford health region since 1985, and to look for any evidence of disproportionate increase in children aged under 5.Design: Primary ascertainment of cases of childhood diabetes was by prospective registration of all patients with insulin dependent diabetes diagnosed before age 15 years between 1985 and 1996 and resident in Oxford region at time of diagnosis. This was supplemented by examination of centralised hospital discharge records and death certificates. Secondary case ascertainment was by postal surveys of general practitioners in 1987 and 1996. Setting: Area formerly administered by Oxford Regional Health Authority. Subjects: 1,037 children presenting with insulin dependent diabetes under age of 15 years. Main outcome measures: Incidence of insulin dependent diabetes in children aged 0-4, 5-9, and 10-14 years during 1985-95. Results: Overall incidence of diabetes in children aged 0-15 was 18.6 cases/100,000/year and showed an annual increase of 4% from 1985 to 1996. This was mainly due to a rapid increase in children aged 0-4 years, in whom there was an annual increase of 11% (95% confidence interval 6% to 15%, P<0.0001), while the annual increase in those aged 5-9 was 4% (0 to 7%, P=0.05) and in those aged 10-14 was 1% (-2% to 4%, P=0.55). Conclusions: Incidence of insulin dependent diabetes in children aged under 5 years has risen markedly in the Oxford region over the past decade. The cause of the increase is unknown, but environmental influences encountered before birth or in early postnatal life are likely to be responsible. Diabetes and Metabolism,
Correspondence to: Professor Gale Investigation into the increase in hay fever and eczema at age 16 observed between the 1958 and 1970 British birth cohortsBarbara K Butland, David P Strachan, Sarah Lewis, John Bynner, Neville Butler, John Britton AbstractObjective: To investigate whether changes in certain perinatal and social factors explain the increased prevalence of hay fever and eczema among British adolescents between 1974 and 1986.Design: Two prospective birth cohort studies. Setting: England, Wales, and Scotland. Subjects: 11,195 children born 3-9 March 1958 and 9,387 born 5-11 April 1970. Main outcome measures: Parental reports of eczematous rashes and of hay fever or allergic rhinitis in the previous 12 months at age 16. Results: The prevalence of the conditions over the 12 month period increased between 1974 and 1986 from 3.1% to 6.4% (prevalence ratio 2.04 (95% confidence interval 1.79 to 2.32)) for eczema and from 12.0% to 23.3% (prevalence ratio 1.93 (1.82 to 2.06)) for hay fever. Both conditions were more commonly reported among children of higher birth order and those who were breast fed for longer than 1 month. Eczema was more commonly reported among girls and hay fever among boys. The prevalence of hay fever decreased sharply between social classes I and V, increased with maternal age up to the early 30s, and was lower in children whose mothers smoked during pregnancy. Neither condition varied significantly with birth weight. When adjusted for these factors, the relative odds of hay fever (1986 v 1974) increased from 2.23 (2.05 to 2.43) to 2.40 (2.19 to 2.63). Similarly, the relative odds of eczema rose from 2.02 (1.73 to 2.36) to 2.14 (1.81 to 2.52). Conclusions: Taken together, changes between cohorts in sex, birth weight, birth order, maternal age, breast feeding, maternal smoking during pregnancy, and father's social class at birth did not seem to explain any of the observed rise in the prevalence of hay fever and eczema. However, correlates of these factors which have changed over time may still underlie recent increases in allergic disease. Department of Public Health
Sciences, Division of
Respiratory Medicine, Social Statistics Research Unit, City University, London EC1V OHB
Correspondence to: Ms Butland Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish heart health study: cohort studyHugh Tunstall-Pedoe, Mark Woodward, Roger Tavendale, Richard A' Brook, Mary K McCluskey AbstractObjective: To compare prediction by 27 different factors in men and women of coronary heart disease events, coronary deaths, and deaths from all causes.Design: Cohort study. Setting: Scottish population study. Subjects: In 1984-7 random sampling of residents aged 40-59 produced 11 629 men and women who generated survey clinic questionnaires, examination findings, and blood and urine specimens. Main outcome measures: Subsequent death, coronary artery surgery, and myocardial infarction. Risks were calculated for each category of factor or fifth of continuous variables. 27 factors were ranked by descending age adjusted hazard ratio of the top to bottom class in each factor, by sex and end point. Results: Follow up averaged 7.6 years, during which the 5,754 men had 404 coronary events, 159 coronary deaths, and 383 deaths and the 5875 women 177, 47, and 208 respectively. The rankings for factors for the three end points were mainly similar in men and women, although hazard ratios were often higher in women. Classical risk factors ranked better for predicting coronary risk than newer ones. Yet strong prediction of coronary risk was no guarantee of significant prediction of all cause mortality. Findings included an anomalous coronary protective role for type A behaviour in women; raised plasma fibrinogen as a strong predictor of all end points; and an unexpectedly powerful protective relation of dietary potassium to all cause mortality. Conclusions: These initial unifactorial rankings and comparisons must be interpreted with caution until potential interaction, confounding, and problems of measurement and causation are further explored. Cardiovascular Epidemiology Unit,
Correspondence to:
Professor Tunstall-Pedoe
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