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Evaluation of Efficacy in a Liver Pretransplantation Orientation Group
Evaluation of Efficacy in a Liver Pretransplantation Orientation Group M. Simon Guimaro, S. Silva Lacerda, T.D. Bacoccina, C. Hegedus Karam, J. Roberto de Sá, B.H. Ferraz-Neto, and P. Bruno de Araújo Andreoli ABSTRACT Background. The medical context recognizes the efficiency of working with groups of patients. Group interventions can intensify the understanding, ability, and notion of recognizing the patient’s own condition, increasing the responsibility for him- or herself. This survey sought to evaluate the efficacy of an interdisciplinary orientation group for hepatic transplantation preoperatively. Materials and Methods. The opinions of all patients on a waiting list for liver transplantation and their accompanying persons were evaluated from August to December 2005 through a questionnaire with 17 relevant items concerning the transplantation process. The group efficacy was evaluated according to the percentage of correct answers from the subjects before and after attending the group. Results. The results showed a 59% increase in correct answers for the evaluated items after group attendance. The items which showed significant improvement were: what should I do after being called for transplantation; average time of admission to hospital and ICU; use of immunosuppressive drugs; clinical conditions for transplantation; frequency of appointments with the surgeon within the first month; physical activities; diet; blood transfusion; and forgetting medication. A ceiling effect was observed upon reevaluation of the previous conditions for transplantation item. Conclusions. The percentage of health improvement after attending the group demonstrated an impact of the interdisciplinary orientation intervention on the instruction of patients and their accompanying persons, thus representing an important step in their training process.
W
ORKING WITH GROUPS of patients is recognized for its efficiency in the medical context. Group interventions can intensify the understanding, ability, and notion of recognizing the patient’s own condition, thus increasing the responsibility for him- or herself. The purpose of this technique includes: promoting concordance to treatment; increasing the perception of disease; developing the ability to assimilate information; enhancing the adaptor ability; helping interactions with the institution by increasing the notion of rights and duties; and stimulating the perception of liability for the treatment.1 This kind of intervention was proposed during the preparation process of the patients and their relatives for the transplantation procedure. Many hospitals use instruction programs to provide more complete information concerning the presurgical period; transplantation risks and benefits; process of organ allocation; operative proce-
dures; and postoperative questions, as well as the medications most used in the posttransplantation period.2 Despite its importance, there is little literature concerning the effects and efficacy of interdisciplinary orientation groups for liver transplantation. Therefore, the objective of this research was to evaluate the efficacy of a hepatic pretransplantation orientation group to obtain the necessary information to prepare patients and their families for the transplantation process.
From the Psychology Service (M.S.G., S.S.L., C.H.K., P.B.d.A.A.) and Transplantation Unit (M.S.G., T.D.B., J.R.d.S., B.-H.F.-N.), Hospital Israelita Albert Einstein, São Paulo, Brazil. Address reprint requests to Melissa Simon Guimaro, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 3° Andar, Bl. C. São Paulo, Brazil. E-mail: [email protected]
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.07.026
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2522
Transplantation Proceedings, 39, 2522–2524 (2007)
LIVER PRETRANSPLANTATION ORIENTATION GROUP
2523
Table 1. Demographic Data of Participants in the Hepatic Pretransplantation Orientation Group Sex (%)
Formal Education (%)
Marital Status (%)
Proceeding (%)
Professional Activity (%)
N
Age (y), Mean (SD)
Male
Female
⬍8 y
9–11 y
⬎11 y
Single
Married
Divorced
Sao Paulo
Others
Yes
No
113
49 (13)
47
53
33
44
23
14
78
8
58
42
45
55
first and second applications. The results are presented as percentages with comparisons made using the McNemar statistical test.
METHODS Participants The opinions of all patients on a liver transplantation waiting list as well as their accompanying persons were evaluated from August to December 2005, when they were invited to attend the psychoeducational groups. The selection criteria for the group participation were: be a patient/accompanying person, and be registered at the technical file of the São Paulo State Health Department Office, Brazil, known as the “sole waiting list.”
Instruments and Procedure The orientation intervention was held in 1 session with an average time of 2 hours if sought to provide information about the transplantation process by dealing with the following topics: assistance, structure and admission to hospital; functioning of transplant waiting list; pretransplantation care; surgery-related aspects; organ removal and preservation process; estimated time for healing after surgery; possible complications; care; assistance and orientation after transplantation by professionals of psychology, physiotherapy, nutrition, and social assistance, all from the institutional transplantation team. Prior to the beginning of the group, all patients and their relatives were asked to complete a questionnaire (elaborated for this essay), including 17 items that examined knowledge about the transplantation process, and the relevant aspects which would be dealt with in the session. The same questions were reapplied after the conclusion of the group. For the analysis we considered the differences in knowledge evidenced by the subjects between the
RESULTS
Among 113 evaluated subjects of mean age 48.71 years (SD ⫽ 12.57 years) were 53 patients and 60 accompanying persons. Their demographic distribution is shown is Table 1. The results demonstrated an increase in correct answers on almost all items evaluated on the questionnaire. The items which showed significant improvements were: what should I do when I am called for transplantation: average time of admission hospital and ICU: use of immunosuppressive drugs; clinical conditions for transplantation; how often should the patient return for an appointment with surgeon within the first month; physical activities; diet; blood transfusion; and forgetting medication. A ceiling effect was observed upon reevaluation of the previous conditions for transplantation item. There was no significant difference in knowledge among patients versus accompanying persons. The total success indices of valid answers, as well as the formulated questions, are shown in Table 2. DISCUSSION
Group intervention yielded acquisition of information by most patients on the liver transplantation waiting list. This observation has already been noted in other studies concern-
Table 2. Description of the Valid Amount of Right Answers on the Questionnaire to Evaluate the Knowledge of Participants in the Orientation Group for Hepatic Pretransplantation (N ⴝ 113) Question
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
What does transplantation mean to you? Which is the transplantation purpose? What shall I take to the hospital when I am called for transplantation? How long is the average time of hospitalization? What is the average ICU time in days? When is my best moment for transplantation? (clinical conditions for transplantation) After being called for transplantation, what shall I do? Why is it important to come to appointment and collect material for exams after the transplantation? After transplantation, should I make any physical exercise? Will I have a special diet after transplantation? Do I have to receive blood (blood transfusion) during surgery? After the transplantation, will I have to take any medicine? (previous conditions to transplantation) Does the transplantation surgery present any risk? What may happen in case I stop taking immunosuppressive drugs after the transplantation? What must I do if I forget to take the medicine? How often should I return to an appointment with the surgeon during the first month after the transplantation? What does transplantation require?
*P ⬍ .05. † P ⬍ .01. ‡ Regardless of the evident recovery, it was not possible to achieve P values due to the ceiling effect at the posttest.
Before
After
P
71 84 79 45 53 56 54 80 57 40 76 84 84 67 76 41 81
90 98 93 99 95 94 97 98 93 82 101 102 100 99 99 86 96
.227 1.000 .581 .01* .001† .001† .001† 1.000 .008† .001† .012* ‡
.500 .001† .039* .001† .508
2524
ing the needs of patients and their relatives to receive more information in order to help their understanding.2 Therefore, the intervention of an orientation group demonstrated that such a stage was important for the assistance of patients related to hepatic transplantation together with their accompanying persons. It reduced their anxieties through acquiring specific information. As also acknowledged in the literature, our experience showed that the contributions of a multiprofessional team are important in this kind of intervention.2 In addition, the intervention can improve the adherence to medications and minimize the noncompliance from (43% to 19%) after transplantation procedures.3 Another observed advantage is that the psycho-education significantly enhances the life quality of patients with hepatic cirrhosis.4 The percentage of correct answers (59%) subsequent to the group showed that there had been a useful impact of the
SIMON GUIMARO, SILVA LACERDA, BACOCCINA ET AL
interdisciplinary orientation intervention on the instruction of patients and their accompanying persons, thus representing an important step in their training process. REFERENCES 1. Chazan LF: Grupos Homogêneos Interdisciplinares. In Mello Filho J (ed): Grupo e Corpo. Porto Alegre, Brazil: Artmed; 2000, p 163 2. Sharkey C, Gourishankar S: Transplant Friends: an interactive education program for patients awaiting kidney transplantation. Transplant Proc 35:2405, 2003 3. Beck DE, Fennell RS, Yost RL, et al: Evaluation of an educational program in compliance with medication regimens in pediatric patients with renal transplants. J Pediatr 96:1094, 1980 4. Fakhondeh S, Sadrollah M, Hamid-Reza T, et al: Effects of psycho-educational intervention on health-related quality of life (QOL) of patients with chronic liver disease referring to Shiraz University of Medical Sciences. Health Qual Life Outcomes 3:81, 2005
W
ORKING WITH GROUPS of patients is recognized for its efficiency in the medical context. Group interventions can intensify the understanding, ability, and notion of recognizing the patient’s own condition, thus increasing the responsibility for him- or herself. The purpose of this technique includes: promoting concordance to treatment; increasing the perception of disease; developing the ability to assimilate information; enhancing the adaptor ability; helping interactions with the institution by increasing the notion of rights and duties; and stimulating the perception of liability for the treatment.1 This kind of intervention was proposed during the preparation process of the patients and their relatives for the transplantation procedure. Many hospitals use instruction programs to provide more complete information concerning the presurgical period; transplantation risks and benefits; process of organ allocation; operative proce-
dures; and postoperative questions, as well as the medications most used in the posttransplantation period.2 Despite its importance, there is little literature concerning the effects and efficacy of interdisciplinary orientation groups for liver transplantation. Therefore, the objective of this research was to evaluate the efficacy of a hepatic pretransplantation orientation group to obtain the necessary information to prepare patients and their families for the transplantation process.
From the Psychology Service (M.S.G., S.S.L., C.H.K., P.B.d.A.A.) and Transplantation Unit (M.S.G., T.D.B., J.R.d.S., B.-H.F.-N.), Hospital Israelita Albert Einstein, São Paulo, Brazil. Address reprint requests to Melissa Simon Guimaro, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 3° Andar, Bl. C. São Paulo, Brazil. E-mail: [email protected]
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.07.026
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2522
Transplantation Proceedings, 39, 2522–2524 (2007)
LIVER PRETRANSPLANTATION ORIENTATION GROUP
2523
Table 1. Demographic Data of Participants in the Hepatic Pretransplantation Orientation Group Sex (%)
Formal Education (%)
Marital Status (%)
Proceeding (%)
Professional Activity (%)
N
Age (y), Mean (SD)
Male
Female
⬍8 y
9–11 y
⬎11 y
Single
Married
Divorced
Sao Paulo
Others
Yes
No
113
49 (13)
47
53
33
44
23
14
78
8
58
42
45
55
first and second applications. The results are presented as percentages with comparisons made using the McNemar statistical test.
METHODS Participants The opinions of all patients on a liver transplantation waiting list as well as their accompanying persons were evaluated from August to December 2005, when they were invited to attend the psychoeducational groups. The selection criteria for the group participation were: be a patient/accompanying person, and be registered at the technical file of the São Paulo State Health Department Office, Brazil, known as the “sole waiting list.”
Instruments and Procedure The orientation intervention was held in 1 session with an average time of 2 hours if sought to provide information about the transplantation process by dealing with the following topics: assistance, structure and admission to hospital; functioning of transplant waiting list; pretransplantation care; surgery-related aspects; organ removal and preservation process; estimated time for healing after surgery; possible complications; care; assistance and orientation after transplantation by professionals of psychology, physiotherapy, nutrition, and social assistance, all from the institutional transplantation team. Prior to the beginning of the group, all patients and their relatives were asked to complete a questionnaire (elaborated for this essay), including 17 items that examined knowledge about the transplantation process, and the relevant aspects which would be dealt with in the session. The same questions were reapplied after the conclusion of the group. For the analysis we considered the differences in knowledge evidenced by the subjects between the
RESULTS
Among 113 evaluated subjects of mean age 48.71 years (SD ⫽ 12.57 years) were 53 patients and 60 accompanying persons. Their demographic distribution is shown is Table 1. The results demonstrated an increase in correct answers on almost all items evaluated on the questionnaire. The items which showed significant improvements were: what should I do when I am called for transplantation: average time of admission hospital and ICU: use of immunosuppressive drugs; clinical conditions for transplantation; how often should the patient return for an appointment with surgeon within the first month; physical activities; diet; blood transfusion; and forgetting medication. A ceiling effect was observed upon reevaluation of the previous conditions for transplantation item. There was no significant difference in knowledge among patients versus accompanying persons. The total success indices of valid answers, as well as the formulated questions, are shown in Table 2. DISCUSSION
Group intervention yielded acquisition of information by most patients on the liver transplantation waiting list. This observation has already been noted in other studies concern-
Table 2. Description of the Valid Amount of Right Answers on the Questionnaire to Evaluate the Knowledge of Participants in the Orientation Group for Hepatic Pretransplantation (N ⴝ 113) Question
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
What does transplantation mean to you? Which is the transplantation purpose? What shall I take to the hospital when I am called for transplantation? How long is the average time of hospitalization? What is the average ICU time in days? When is my best moment for transplantation? (clinical conditions for transplantation) After being called for transplantation, what shall I do? Why is it important to come to appointment and collect material for exams after the transplantation? After transplantation, should I make any physical exercise? Will I have a special diet after transplantation? Do I have to receive blood (blood transfusion) during surgery? After the transplantation, will I have to take any medicine? (previous conditions to transplantation) Does the transplantation surgery present any risk? What may happen in case I stop taking immunosuppressive drugs after the transplantation? What must I do if I forget to take the medicine? How often should I return to an appointment with the surgeon during the first month after the transplantation? What does transplantation require?
*P ⬍ .05. † P ⬍ .01. ‡ Regardless of the evident recovery, it was not possible to achieve P values due to the ceiling effect at the posttest.
Before
After
P
71 84 79 45 53 56 54 80 57 40 76 84 84 67 76 41 81
90 98 93 99 95 94 97 98 93 82 101 102 100 99 99 86 96
.227 1.000 .581 .01* .001† .001† .001† 1.000 .008† .001† .012* ‡
.500 .001† .039* .001† .508
2524
ing the needs of patients and their relatives to receive more information in order to help their understanding.2 Therefore, the intervention of an orientation group demonstrated that such a stage was important for the assistance of patients related to hepatic transplantation together with their accompanying persons. It reduced their anxieties through acquiring specific information. As also acknowledged in the literature, our experience showed that the contributions of a multiprofessional team are important in this kind of intervention.2 In addition, the intervention can improve the adherence to medications and minimize the noncompliance from (43% to 19%) after transplantation procedures.3 Another observed advantage is that the psycho-education significantly enhances the life quality of patients with hepatic cirrhosis.4 The percentage of correct answers (59%) subsequent to the group showed that there had been a useful impact of the
SIMON GUIMARO, SILVA LACERDA, BACOCCINA ET AL
interdisciplinary orientation intervention on the instruction of patients and their accompanying persons, thus representing an important step in their training process. REFERENCES 1. Chazan LF: Grupos Homogêneos Interdisciplinares. In Mello Filho J (ed): Grupo e Corpo. Porto Alegre, Brazil: Artmed; 2000, p 163 2. Sharkey C, Gourishankar S: Transplant Friends: an interactive education program for patients awaiting kidney transplantation. Transplant Proc 35:2405, 2003 3. Beck DE, Fennell RS, Yost RL, et al: Evaluation of an educational program in compliance with medication regimens in pediatric patients with renal transplants. J Pediatr 96:1094, 1980 4. Fakhondeh S, Sadrollah M, Hamid-Reza T, et al: Effects of psycho-educational intervention on health-related quality of life (QOL) of patients with chronic liver disease referring to Shiraz University of Medical Sciences. Health Qual Life Outcomes 3:81, 2005