Adherence to secondary prophylaxis and disease recurrence in 536 Brazi

Adherence to secondary prophylaxis and disease recurrence in 536 Brazilian children with rheumatic fever :

Adherence to secondary prophylaxis and disease recurrence in 536 Brazilian children with rheumatic fever Dr.Nadeem-Ur-Rasool DCH Trainee

CONDUCTED BY:

CONDUCTED BY Christina F Pelajo Jorge M Lopez-Benitez Juliana M Torres Sheila KF de Oliveira

CONDUCTED AT:

CONDUCTED AT the Pediatric Rheumatology outpatient clinic at a tertiary care hospital ( Instituto de Puericultura e Pediatria Martagão Gesteira ) in Rio de Janeiro, Brazil

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DURATION 1985 to 2005 PUBLISHED IN Pediatric Rheumatology 2010, 8:22 STUDY DESIGN Cohort retrospective study

objectives:

objectives to describe the rates of recurrent episodes of RF to quantify adherence to secondary prophylaxis to examine the effects of medication adherence to the rates of RF in children and adolescents with RF.

INCLUSION CRITERIA:

INCLUSION CRITERIA Children aged to 13 (± 3.9) years & from both sexes . All patients who fulfilled jones criteria.

Exclusion Criteria:

Exclusion Criteria They who did not return to the clinic after their first appointment.

METHODS:

METHODS Information was retrieved from patients’ medical records, using a struc­tured data collection sheet. 548 cases of children and adolescents with a diagnosis of RF identified who fulfilled Jones criteria. 12 patients were excluded from the present analysis because they did not return to the clinic after their first appointment. Patients were classified as “ adherent ” to therapy when they did not skip or delay more than one dose of benzathine penicillin G during a 6-month period (interval between appointments)

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If more than one dose of benzathine penicillin G was delayed or missed during this period, patients were classified as “non-adherent”. Administered doses of benzathine penicillin G were recorded on a card given to all patients with RF. Appointment frequency was considered adequate if the interval between visits was less than 9 months otherwise considered inadequate. patients who did not return for an appointment for more than 18 months, were considered lost to follow-up.

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The rates of recurrence, non-adherence to secondary prophylaxis, and inadequate frequency to appointments were calculated. Differences in the characteristics of patients who did and did not have a recurrent episode of RF were examined with regards to age, sex, adherence to prophylaxis, frequency of follow-up appointments and follow-up status.

RESULTS:

RESULTS A total of 536 patients with RF comprised the study sample. The average age of the study sample was 13 (± 3.9) years 53% were girls. Recurrent episodes of RF occurred in 88 of 536 patients (16.5%). Patients with a recurrent episode of RF were younger, more frequently males, and less adherent to secondary prophylaxis than patients without RF recurrence. Higher rate of adequate frequency to appointments in the group of patients that did not have a recurrence . No significant difference between patients who did or did not have a recurrence in relation to loss of follow-up. Within patients who had a recurrence * 54.5% were non-adherent to secondary prophylaxis. * 31% had a recurrence because prophylaxis was not prescribed. * 14.5% of the patients who had recurrences reported adherence to prophylaxis.

Table 1 Characteristics of patients with and without recurrent episodes of RF :

Table 1 Characteristics of patients with and without recurrent episodes of RF Patients with recurrent episodes of RF (n=88) Patients without recurrent episodes of RF (n=448) P value Age (median, years) 9 14 <0.0001 Sex (female) 38% 56% 0.003 Non-adherence 54.5% 20% <0.0001 Adequate frequency to appointments 79% 90% 0.07 Lost to follow-up 37.5% 29% 0.14

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35% (188 out of 536) of patients were non-adherent to medication at some time. Rates of non-adherence were higher in the group of patients that were lost to follow-up (42%) than in the group of patients still in follow-up (32%). The mean age of non-adherent patients was 14.5 years. Appointment frequency was inadequate in 10% of patients. Higher rates of inadequate appointment frequency were observed among patients who were eventually lost to follow-up (14.5%). One hundred eighty patients (33.5%) were lost to follow ­up at some point in time.

Table 2 Recurrence, non-adherence, and inadequate frequency to appointments in the total sample and subgroups:

Table 2 Recurrence, non-adherence, and inadequate frequency to appointments in the total sample and subgroups Patients successfully followed-up (n = 356) N (%) Patients lost to follow-up (n = 180) N (%) p-value Total (% in the total group) Recurrences 55 (15%) 33 ( 18%) ( 0.14 88 (16.5%) Non-adherence 113 (32%) 75 (42%) 0.027 188 (35%) Inadequate frequency to appointments 28 (8%) 26 (14.5%) 0.022 54 (10%)

DISCUSSION:

DISCUSSION Recurrences of RF are directly related to morbidity, mortality and disease progression . 16.5% of patients in our study had a recurrent episode of RF. however recurrence was found * in 0.9% of patients in a study in India * in 0.4% in a study involving 16 developing countries * in Chile (17%) * In Alexandria (Egypt) 37.3%

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In our population, * recurrences associated to non-adherence seen in 54.5% of cases. * in 31% secondary prophylaxis was not prescribed. ( These patients had a previous suspicious episode that did not fulfill Jones criteria, and then presented with a recurrence that made the diagnosis possible, according to the mentioned criteria. After the diagnosis was definitely established, secondary prophylaxis was prescribed.) Precocious use of non-ster­oidal anti-inflammatory (NSAID) drugs was detected. In New Zealand guidelines 2006 for RF,aseptic monoarthritis is considered as a major criterion when prior H/O NSAID use is present.

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Jones criteria should be a guide to help physicians but should not be strictly applied and substitute clinical judgment, as it could result in under-diagnosis of RF . Non-adherence to secondary prophylaxis was 35% in the total sample of patients (536). Among patients lost to follow-up, 42% were non-adherent, compared to 32% in the group successfully followed-up . non-adherence to secondary prophylaxis might be used as a precocious sign of the possibility of loss of follow-up.

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causes of lack of adherence were not analysed as study was retrospective. association to enhancement in adherence to long course treatments in 50%; and among those, 44.5% had improvement of prognosis. Irregularity in appointments indicates an early sign of the possibility of loss of follow-up. Inadequate frequency to appointments correlates to lower indices of adherence to treatment prescribed which is first sign of possible discontinuation of treatment. Patients lost to follow-up were not tracked because of the lack of a recall system.

Limitations of Study:

Limitations of Study the impossibility to establish the causes of non-adherence the lack of further follow-up in one third of the patients.

Strength Of Study:

Strength Of Study One of the biggest cohorts published in RF. the determination of adherence rates to RF secondary prophylaxis and the evidence supporting the necessity of a revision of Jones criteria for areas with high incidences of RF.

CONCLUSION:

CONCLUSION Non-adherence to appointments and secondary prophylaxis leads to recurrent episodes of RF. implementation of a registry and a system of active search of missing patients in every service responsible for the follow-up of RF patients is recommend. Measures to increase adherence to secondary prophylaxis involving patients and families need to be implemented. Detection of irregularity in secondary prophylaxis or in appointments should be an alert about the possibility of loss of follow-up and closer observation should be instituted. Caution in strictly following Jones criteria to diagnose RF in countries with high incidence of the disease, is recommended.

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