Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care

An Appraisal of the Evidence behind the Use of the CHRODIS Plus Initiative for Chronic Pain: A Scoping Review

Background: Chronic conditions, especially pain conditions, have a very significant impact on quality of life and on workplaces. Workplace interventions for chronic conditions are heterogenous, multidimensional, and sometimes poorly evidenced. The Joint Action for Chronic Disease Plus (CHRODIS Plus), including The CHRODIS Plus Workbox on Employment and Chronic Conditions (CPWEC), aimed to combat this, prevent chronic disease and multimorbidity, and influence policy in Europe. However, the supporting evidence behind CHRODIS Plus has not been formally assessed. Methods: A scoping review was carried out; Embase, MEDLINE, and CINAHL were searched for literature related to CHRODIS Plus and pain. Title and abstract and full-text screening were carried out in duplicate and independently. Additionally, CHRODIS Plus authors were approached for unpublished data. Secondly, the search was broadened to CHRODIS Plus and pain-causing conditions. Grey literature was also searched. Appropriateness appraisal was derived from the Trial Forge Guidance. Systematic reviews, on which CPWEC was based, were appraised using the A Measurement Tool to Assess systematic Reviews (AMSTAR) 2 tool. Results: The initial search yielded two results, of which zero were suitable to be included in the scoping review. The second, broader search revealed 14 results; however, none were deemed suitable for inclusion. AMSTAR 2 scores revealed that the three systematic reviews influencing CPWEC were of varying quality (from critically low to moderate). Conclusions: CPWEC is based on heterogenous reviews of varying quality. However, comparable tools are designed using alternative forms of evidence. Further research evaluating the post-implementation efficacy of the tool is needed.

The Translation and Validation of Patient-Centered Outcomes Questionnaire Into Arabic: A Chronic Periodontitis Patient-Based Study

Background The patient-centered outcomes questionnaire (PCOQ) is a self-report questionnaire that aims to assess four fundamental domains (pain, fatigue, distress, and interference) on an 11-point numerical rating scale from 0 to 10 in chronic diseases. The implementation of this tool will help assess chronic diseases; hence, this study aimed to translate the PCOQ to a sample of periodontitis patients. Methodology This study went through the content validity index. Arabic PCOQ used Cronbach's alpha for reliability with 300 participants. From July to August 2023, patients with periodontitis visiting an outpatient dental center in Riyadh were invited to participate in the study. The language, content, and structure of the questionnaire were appropriate, and with forward and backward translation, external entity translation was implemented. Results Regarding the participants' gender, the number of males was higher at 61%. Regarding age distribution, 50.7% of the participants were between 30 and 50 years old. A clarity score of 95.2% and a representativeness score of 97.3% were reported in the content validity analysis. The Cronbach's alpha of the Arabic PCOQ questionnaire was 0.85, and the subscales ranged between 0.68 and 0.93. Conclusions The translated version of the Arabic PCOQ is a valid tool to be used in Arab countries. Nonetheless, this instrument can provide insights for healthcare professionals, policymakers, and managers to improve patient satisfaction and healthcare system delivery.

Explaining a diagnosis of fibromyalgia in primary care: a scoping review

BACKGROUND

Fibromyalgia is a common cause of chronic pain in the UK, with a huge individual and societal impact. Despite this, it remains difficult to diagnose and treat. The explanation of a fibromyalgia diagnosis can lead to difficult therapeutic relationships, with attitudinal issues and negative profiling of patients. This can lead to frustration, and have a harmful impact on health outcomes.

AIM

To review how an explanation of a fibromyalgia diagnosis is provided in primary care in order to establish a model of best practice when educating patients on their diagnosis.

DESIGN & SETTING

Scoping review of articles written in English.

METHOD

MEDLINE, Embase, Web of Science, and grey literature were searched. Articles were extracted, reviewed, and analysed according to the inclusion criteria.

RESULTS

In total, 29 records met the inclusion criteria. The following six overarching themes were identified: patient education; physician education; importance of the multidisciplinary team; importance of patient-centred care; the value of primary care; and useful resources. The literature illustrated that describing fibromyalgia using analogies to illustrate the pain sensitisation process can help patients understand their diagnosis better. This improves their willingness to accept management plans, particularly engagement with non-pharmacological therapies, which the literature suggested are best delivered within a multidisciplinary team.

CONCLUSION

Key aspects of fibromyalgia should be explained to patients in order for them to gain a better understanding of their diagnosis. A 'one-size-fits-all' model for explaining the fibromyalgia diagnosis to patients is inappropriate because patients' experiences are individualised. Further research is required on whether different explanations impact patient outcomes.

Communication interventions for medically unexplained symptom conditions in general practice: A systematic review and meta-analysis of randomised controlled trials

Background

Medically unexplained symptoms (MUS) account for 3–50% of all General Practitioner (GP) consultations and are difficult to diagnose due to their unknown aetiology, symptom overlap between conditions, and lack of effective treatment options. MUS patients’ and primary care clinicians frequently face challenges during consultations, with GPs reporting difficulty identifying and classifying MUS, whilst patients report stigma and feeling illegitimised by clinicians. Communication interventions have been proposed as a method to facilitate the doctor-patient relationship and aid the management of MUS.

Aim

This systematic review aims to evaluate the effectiveness of primary care based communication interventions at improving MUS patients’ and/or clinician outcomes.

Method

Four electronic databases were searched from inception to November 2021. Two researchers independently undertook screening, data extraction and quality appraisal. Given the heterogeneous nature of the studies identified, narrative syntheses were conducted, along with meta-analyses where possible to pool data.

Results

9 papers from 10 Randomised Controlled Trials were included. The included studies displayed considerable risk of bias and poor reporting. Some limited evidence suggests that communication interventions tailored to MUS and not following a pre-specified model (such as reattribution) could improve pain, mental and physical functioning whilst reattribution training may improve clinician confidence treating MUS. However, methodological limitations mean that these findings should be interpreted with caution.

Conclusion

A range of interventions for improving communication with MUS patients in primary care have been evaluated. However, the heterogeneous nature of existing evidence and poor study quality mean we cannot conclude whether these interventions are effective. Before considering further randomised controlled trials researchers should focus on developing a new or modified communication intervention for MUS patients and their clinicians.

Trail registration

The systematic review was prospectively registered with PROSPERO (registration record CRD42020206437).

Using a discrete choice experiment to develop a decision aid tool to inform the management of persistent pain in pharmacy: a protocol for a randomised feasibility study

INTRODUCTION

In an era of personalised healthcare, it has become increasingly important to elicit individual-level preferences. While discrete choice experiments (DCEs) are widely used to measure patient preferences in the delivery of healthcare, the focus has been sample-level analysis. Using the DCE methodology, this project has designed a digital decision aid tool (DAT) with the potential to estimate individual preferences in real time to inform clinical consultation decisions in persistent pain management.

METHODS

Using a feasibility randomised control trial, this study aims to assess the feasibility of using this Understanding Persistent Pain (UPP) DAT in a pharmacy-based clinical setting and to test processes for a future definite randomised trial. Community and practice-based pharmacists (up to 10) will be recruited in The National Health Service (NHS) Grampian and trained in the use of the digital UPP DAT. Pharmacists will recruit up to 60 patients who are living with persistent pain. Patients will be randomised to one of two groups: using the UPP DAT or usual care. Pharmacists will follow-up patients as needed according to clinical need and following standard practice. DCE response data collected by the UPP DAT will be analysed using the penalised logit model, allowing estimation of individual preferences in real time. We will follow-up pharmacists and patients who use the UPP DAT to gather feedback on their experiences.

ETHICS AND DISSEMINATION

This study received ethical approval from the North of Scotland Research Ethics Committee (21/NS/0059) and received Research & Development Management Permission to proceed from NHS Grampian (2021UA003E). The study has been registered in the ClinicalTrials.gov database. Findings will be disseminated in peer-reviewed publications, presentations and newsletters and made available in the University of Aberdeen and Pharmacy Research UK websites. Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION NUMBER

NCT05102578; clinicaltrials.gov.

Associations between stuttering avoidance and perceived patient-centeredness of health care interactions

PURPOSE

To determine the relationships between (1) stuttering severity and (2) avoidance of speaking on patient centeredness of healthcare system interactions in a sample of persons who stutter.

METHODS

This quantitative study utilized cross-sectional electronic surveys to assess the experiences of one-hundred-twenty-two adults who stutter in the United States with primary care physicians. The surveys evaluated: (1) self-reported stuttering severity and avoidance of speaking; and (2) self-reported patient-centeredness of healthcare interactions. We used multivariate linear regression to model relationships between independent and dependent variables, controlling for age, gender, patient-provider relationship duration, race/ethnicity, the presence of comorbid conditions, and household income.

RESULTS

Patient self-reported avoidance of speaking was significantly negatively associated with self-reported patient-centeredness of healthcare interactions. Patient self-reported stuttering severity was not significantly associated with patient-centeredness.

CONCLUSION

Our findings present evidence that internal non-observable behaviors among persons who stutter, such as avoiding speaking, are associated with negative impact on healthcare interactions. Speech-language pathologists may want to discuss healthcare challenges with their clients and elicit communication barriers to inspire positive interactions within the healthcare system.

A systematic review of impact of person-centred interventions for serious physical illness in terms of outcomes and costs

BACKGROUND

Person-centred care (PCC) is being internationally recognised as a critical attribute of high-quality healthcare. The International Alliance of Patients Organisations defines PCC as care that is focused and organised around people, rather than disease. Focusing on delivery, we aimed to review and evaluate the evidence from interventions that aimed to deliver PCC for people with serious physical illness and identify models of PCC interventions.

METHODS

Systematic review of literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched AMED, CINAHL, Cochrane Library, Embase, Medline, PsycINFO, using the following key concepts: patient/person-centred care, family centred care, family based care, individualised care, holistic care, serious illness, chronic illness, long-term conditions from inception to April 2022. Due to heterogeneity of interventions and populations studied, narrative synthesis was conducted. Study quality was appraised using the Joanna Briggs checklist.

RESULTS

We screened n=6156 papers. Seventy-two papers (reporting n=55 different studies) were retained in the review. Most of these studies (n=47) were randomised controlled trials. Our search yielded two main types of interventions: (1) studies with self-management components and (2) technology-based interventions. We synthesised findings across these two models:Self-management component: the interventions consisted of training of patients and/or caregivers or staff. Some studies reported that interventions had effect in reduction hospital admissions, improving quality of life and reducing costs of care.Technology-based interventions: consisted of mobile phone, mobile app, tablet/computer and video. Although some interventions showed improvements for self-efficacy, hospitalisations and length of stay, quality of life did not improve across most studies.

DISCUSSION

PCC interventions using self-management have some effects in reducing costs of care and improving quality of life. Technology-based interventions improves self-efficacy but has no effect on quality of life. However, very few studies used self-management and technology approaches. Further work is needed to identify how self-management and technology approaches can be used to manage serious illness.

PROSPERO REGISTRATION NUMBER

CRD42018108302.

Defining and implementing patient-centered care: An umbrella review

OBJECTIVES

Patient- or person-centered care (PCC) integrates people's preferences, values, and beliefs into health decision-making. Gaps exist for defining and implementing PCC; therefore, we aimed to identify core elements of PCC and synthesize implementation facilitators and barriers.

METHODS

We conducted an overview of systematic reviews (umbrella review) and included peer-reviewed literature for adults in community/primary care settings. Two reviewers independently screened at Level 1 and 2, extracted data and appraised the quality of reviews. Three reviewers conducted a thematic analysis, and we present a narrative synthesis of findings.

RESULTS

There were 2371 citations screened, and 10 systematic reviews included. We identified 10 PCC definitions with common elements, such as patient empowerment, patient individuality, and a biopsychosocial approach. Implementation factors focused on communication, training healthcare providers, and organizational structure.

CONCLUSIONS

We provide a synthesis of key PCC elements to include in a future definition, and an overview of elements to consider for implementing PCC into practice. We extend existing literature by identifying clinician empowerment and culture change at the systems-level as two future areas to prioritize to enable routine integration of PCC into practice.

PRACTICE IMPLICATIONS

Findings may be useful for researchers and or health providers delivering and evaluating PCC.

A scale for measuring healthcare service quality incorporating patient-centred care and using a psychometric analytics framework

PURPOSE

Recent developments in healthcare contexts increasingly emphasize patient-centred approaches to service quality measures; however, few studies consider this dimension explicitly. The present study develops and psychometrically validates a scale of healthcare service quality explicitly incorporating a patient-centred care dimension from a communicational perspective. The paper also enriches the traditional content of service quality by including equity items and presents the underlying structure of service quality in an emerging country.

DESIGN/METHODOLOGY/APPROACH

The final sample consisted of 869 healthcare users (complete cases in the service quality items derived from 917 surveys received) from Colombia. The authors used a psychometric analytics framework comprising seven processes incorporating exploratory factor analysis, structural equation modelling, and machine learning methods to examine construct plausibility, reliability, construct validity, equity, and criterion/predictive validity (e.g. explaining/predicting subjective well-being and behavioural intentions).

FINDINGS

The final scale consists of 17 items and satisfies all psychometric properties. Its validation allows for the discovery and psychometrical confirmation of two essential dimensions: patient-centred communication (eight items) and process quality (nine items).

PRACTICAL IMPLICATIONS

The authors illustrate three practical uses of the scale: the possibility for diagnoses; hypothesis contrast based on confidence intervals; and estimation of the capacity of the service to satisfy specifications.

ORIGINALITY/VALUE

Both dimensions reveal users' relevant needs and complement previous studies that have focused on process aspects of healthcare service quality.

Recommendations by the Spanish Society of Rheumatology on the management of patients with fibromyalgia. Part II

OBJECTIVE

To prevent the deterioration of patients with fibromyalgia due to potentially avoidable harmful actions in clinical practice.

METHODS

A multidisciplinary panel of experts identified key areas, analysed the scientific evidence and formulated recommendations based on this evidence and qualitative techniques of "formal assessment" or "reasoned judgement".

RESULTS

Thirty-nine recommendations were made on diagnosis, ineffective and unsafe treatments, patient education and practitioner training. This part II shows the 12 recommendations, referring to the latter two areas.

CONCLUSIONS

Good knowledge of fibromyalgia on the part of patients improves their coping and acceptance of the disease and reduces the severity of some clinical manifestations. Healthcare professionals treating patients with fibromyalgia should be well trained in this disease to improve treatment outcomes and patient relationships.

Content and Actionability of Recommendations to Providers After Shadow Coaching

BACKGROUND AND OBJECTIVES

Health care organizations track patient experience data, identify areas of improvement, monitor provider performance, and assist providers in improving their interactions with patients. Some practices use one-on-one provider counseling ("shadow coaching") to identify and modify provider behaviors. A recent evaluation of a large shadow coaching program found statistically significant improvements in coached providers' patient experience scores immediately after being coached. This study aimed to examine the content of the recommendations given to those providers aimed at improving provider-patient interactions, characterize these recommendations, and examine their actionability.

METHODS

Providers at a large, urban federally qualified health center were selected for coaching based on Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) patient experience scores (92 of 320 providers), shadowed by a trained peer coach for a half to full day and received recommendations on how to improve interactions with their patients. We coded 1082 recommendations found in the 92 coaching reports.

RESULTS

Reports contained an average of 12 recommendations. About half encouraged consistency of existing behaviors and half encouraged new behaviors. Most recommendations related to behaviors of the provider rather than support staff and targeted actions within the examination room rather than other spaces (eg, waiting room). The most common recommendations mapped to behavioral aspects of provider communication. Most recommendations targeted verbal rather than nonverbal communication behaviors. Most recommendations were actionable (ie, specific, descriptive), with recommendations that encouraged new behaviors being more actionable than those that encouraged existing actions.

CONCLUSIONS

Patient experience surveys are effective at identifying where improvement is needed but are not always informative enough to instruct providers on how to modify and improve their interactions with patients. Analyzing the feedback given to coached providers as part of an effective shadow-coaching program provides details about implementation on shadow-coaching feedback. Recommendations to providers aimed at improving their interactions with patients need to not only suggest the exact behaviors defined within patient experience survey items but also include recommended behaviors indirectly associated with those measured behaviors. Attention needs to be paid to supplementing patient experience data with explicit, tangible, and descriptive (ie, actionable) recommendations associated with the targeted, measured behaviors. Research is needed to understand how recommendations are put into practice by providers and what motivates and supports them to sustain changed behaviors.

Challenges of Research on Person-Centered Care in General Practice: A Scoping Review

Background: Delivering person-centered care is one of the core values in general practice. Due to the complexity and multifaceted character of person-centered care, the effects of person-centered care cannot be easily underpinned with robust scientific evidence. In this scoping review we provide an overview of research on effects of person-centered care, exploring the concepts and definitions used, the type of interventions studied, the selected outcome measures, and its strengths and limitations.

Methods: Systematic reviews on person-centered care compared to usual care were included from Pubmed, Embase, and PsycINFO. The search was conducted in February 2021. Data selection and charting was done by two reviewers.

Results: The literature search yielded 481 articles. A total of 21 full-text articles were assessed for eligibility for inclusion. Four systematic reviews, published between 2012 and 2018, were finally included in this review. All reviews used different definitions and models and classified the interventions differently. The explicit distinction between interventions for providers and patients was made in two systematic reviews. The classification of outcomes also showed large differences, except patient satisfaction that was shared. All reviews described the results narratively. One review also pooled the results on some outcome measures. Most studies included in the reviews showed positive effects, in particular on process outcomes. Mixed results were found on patient satisfaction and clinical or health outcomes. All review authors acknowledged limitations due to lack of uniform definitions, and heterogeneity of interventions and outcomes measures.

Discussion: Person-centered care is a concept that seems obvious and understandable in real life but is complex to operationalize in research. This scoping review reinforces the need to use mixed qualitative and quantitative methods in general practice research. For spreading and scaling up person-centered care, an implementation or complexity science approach could be used. Research could be personalized by defining therapeutic goals, interventions, and outcome variables based on individual preferences, goals, and values and not only on clinical and biological characteristics. Observational data and patient satisfaction surveys could be used to support quality improvement. Integrating research, education, and practice could strengthen the profession, building on the fundament of shared core values.

Recommendations by the Spanish Society of Rheumatology on the Management of Patients with Fibromyalgia. Part II

OBJECTIVE

To prevent the deterioration of patients with fibromyalgia due to potentially avoidable harmful actions in clinical practice.

METHODS

A multidisciplinary panel of experts identified key areas, analysed the scientific evidence and formulated recommendations based on this evidence and qualitative techniques of «formal assessment» or «reasoned judgement».

RESULTS

Thirty-nine recommendations were made on diagnosis, ineffective and unsafe treatments, patient education and practitioner training. This partII shows the 12 recommendations, referring to the latter two areas.

CONCLUSIONS

Good knowledge of fibromyalgia on the part of patients improves their coping and acceptance of the disease and reduces the severity of some clinical manifestations. Healthcare professionals treating patients with fibromyalgia should be well trained in this disease to improve treatment outcomes and patient relationships.

Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review

BACKGROUND

Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).

METHODS

We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.

RESULTS

Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.

DISCUSSION

Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

The Patient-Centered Approach: A Review of the Literature and Its Application for Acoustic Neuromas

Patient-centered care is defined as "care that is consistent with and respects the values, needs, and wishes of patients" and is best achieved when clinicians involve patients and their support system in health care discussions and decisions. While this approach has been well established and supported in more general medical specialties, such as primary care, that may encompass a more holistic approach, it has rarely been described in surgical disciplines. Acoustic neuromas (ANs) can be unique among other skull base and intracranial pathologies, in that the management of these tumors can vary from patient to patient depending on various factors. Moreover, typical options, including observation, radiation, and surgery, may often have equipoise for some patients and their tumors. Therefore, a patient-centered approach, strongly guided by the expertise of experienced skull base surgeons, may likely be the most appropriate type of care for patients with ANs. Herein, we review the documented use of patient-centered care in other aspects of medicine, propose the benefits of this approach for patients with ANs, and provide ways this can be better implemented in practice.

Effects of (in)validation and plain versus technical language on the experience of experimentally induced pain: A computer controlled simulation paradigm

BACKGROUND AND OBJECTIVES

Amongst social contextual influences on pain, the manner in which pain and painful procedures are communicated to patients is considered an important contributor to the subjective experience of pain. Threatening information, e.g., by the use of technical language, is suggested to increase pain reports. Validation, or communicating understanding towards another person reporting personal experiences, is suggested to reduce pain. The current study examines effects of both information language (technical vs. plain language) and validation (validation vs. invalidation) on the subjective experience of experimentally induced pain.

METHODS

Pain-free participants (N = 132) were randomly assigned to one of four groups as formed by manipulations of validation and information language. After reading a description concerning the upcoming thermal stimulus formulated in technical or plain language, participants engaged in a computer controlled simulation (CCS; based on virtual reality technology). Participants received three thermal stimuli while interacting with an avatar who either validated or invalidated their experience during the CCS. Pain intensity and pain unpleasantness were assessed after each stimulus.

RESULTS

The validation manipulation showed to be effective, but the information language manipulation did not induce differential threat expectancies. Results show no effect of validation or information language on subjective pain reports.

LIMITATIONS

Suboptimality of the information language manipulation and shortcomings of the CCS procedure might account for current findings.

CONCLUSIONS

The study offers an interesting model for the further experimental study of isolated and combined effects of (social) contextual factors on pain. Diverse future research avenues are discussed.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills

BACKGROUND

Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences.

METHODS

The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM.

RESULTS

We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills.

CONCLUSIONS

We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Patients' ideas, concerns, expectations and satisfaction in primary health care - a questionnaire study of patients and health care professionals' perspectives

Objective: Explore the perceptions of patients and health care professionals about patients' ideas, concerns, expectations (ICE), and satisfaction in consultations with general practitioners (GPs), district nurses (DNs) and physiotherapists (PTs).Design: Cross-sectional questionnaire study of participants in planned consultations.Setting: Five primary health care centers and two rehabilitation centers in Stockholm, Sweden.Subjects: Pairs of patients and GPs (n = 156), patients and DNs (n = 73), and patients and PTs (n = 69).Main outcome measures: Multiple-choice questions about patients' ICE and satisfaction.Results: Approximately 75% of patients and GPs reported that patients' thoughts and explanations about their symptoms emerged during the consultation. For patient-DN pairs, the figure was 60%, and for patient-PT pairs, 80%. A majority of patients reported not having concerns and anxiety about the investigation/treatment, whereas health care professionals thought patients were more concerned. One-third of patients consulting GPs and PTs expected to receive a reason/explanation for their symptoms. Figures were lower for the DNs. About 70% of patients were satisfied with the consultation.Conclusions: Most patients expressed their ideas, a minority had concerns, and a minority expected an explanation of their illness. Patients and health care professionals rated patient satisfaction high, but health care professionals tended to believe patients were less satisfied than patients reported they were.Key pointsPatient surveys show that important aspects of patient-centeredness remain weak in Swedish primary health care; for example, shared decision-making.In this study of planned consultations, few patients expected to receive an explanation of their symptoms, but most were satisfied with the consultation.Health care professionals thought patients' experiences were more negative than they were.This discrepancy was observed in responses to questions about patients' concerns, expectations and satisfaction.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study

BACKGROUND

Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD.

OBJECTIVE

To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD.

METHODS

We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied.

RESULTS

Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP.

CONCLUSION

Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Impact of a primary care training program on the prevention and management of unhealthy alcohol use: A quasi-experimental study

OBJECTIVE

To assess the impact of a training program targeted to Primary Care (PC) professionalson the acquisition of communication skills, attitudes, and knowledge about the prevention and management of unhealthy alcohol use.

METHODS

A quasi-experimental, pre- and post-intervention study was performed in PC centers of Cordoba (Spain). Family doctors, residents and nurses participated in the study. The intervention was based on a motivational interviewing training program, which consisted in a workshop on learning skills, attitudes and knowledge about the alcohol management. PC providers were videotaped with a standardized patient in order to check the clinical and communication competencies acquired. A descriptive, bivariate and multivariate analysis was carried out (p < 0.05).

RESULTS

PC providers' communication skills and attitudes showed significant improvements in the variables studied (p < 0.001), as well as in the clinical interview evaluation parameters.

CONCLUSION

The present study reveals the impact of a training program targeted to PC professionals on communication skills, attitudes, and knowledge about the prevention and management of patients with unhealthy alcohol use.

PRACTICE IMPLICATIONS

Training activities targeted to PC providers represent a valuable strategy to improve communication skills, attitudes and knowledge of these professionals in their clinical practice.

Support for teams, technology and patient involvement in decision-making associated with support for patient-centred care

OBJECTIVE

Patient-centred care is recommended to transform healthcare delivery to improve the quality and safety of healthcare. This study aimed to assess the determinants of support for attributes of patient-centred care (PCC) from Canadian public and professionals' perspectives.

DESIGN

A national population-based survey, the Health Care in Canada Survey.

SETTING

Canada.

PARTICIPANTS

One-thousand Canadian adults, 101 doctors, 100 nurses, 100 pharmacists and 104 administrators, randomly selected from online panels based on multiple source recruitment.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Support for PCC, assessed using a summary score across seven items.

RESULTS

Of 1000 Canadian public adults surveyed, 51% were female, 74% were living with another person, and 62% had at least one chronic condition. Only 18% of health professionals were working in teams. Multivariable regression models showed that work in teams (0.24, 95%CI: 0.20, 0.28), use of e-technology (0.29, 95%CI: 0.17, 0.42), and patient older age (0.59, 95%CI: 0.32, 0.86) and involvement in decision-making (0.42, 95%CI: 0.30, 0.55) were significantly associated with higher support for PCC while lower adherence to medications (-0.81, 95%CI: -1.16, -0.47) was associated with a decreased support for attributes of PCC.

CONCLUSIONS

The findings confirmed that perceptions of requiring health professionals to work in teams and the use of technology in healthcare are associated with support for PCC from both the public and health professionals. Programs to accelerate the implementation of healthcare teams supported by information and communication technologies are needed to deliver PCC, particularly for individuals living with chronic conditions.

Sleep disturbance in individuals with physical disabilities and chronic pain: The role of physical, emotional and cognitive factors

BACKGROUND

Sleep problems are common for individuals living with physical disabilities and chronic pain. However, the factors that influence the relationship between pain and sleep problems in these populations remain unknown.

OBJECTIVE

The aim of this study was to increase our understanding of the physical, emotional and cognitive factors associated with sleep disturbance in individuals with chronic health conditions often associated with physical disabilities.

METHODS

Participants were recruited from a database of individuals with a variety of chronic health conditions, including multiple sclerosis, spinal cord injury, back pain, osteoarthritis, and amputations. To participate in the study, they needed to report having a chronic pain problem. Participants completed an online survey using REDCap assessing average pain intensity (Numerical Rating Scale-11), pain extent (number of painful body areas), sleep disturbance (PROMIS Sleep Disturbance), depression (PROMIS Emotional Distress-Depression) and catastrophizing (Coping Strategies Questionnaire). A total of 455 participants (M_age = 58.9; SD = 11.4), of which 292 (64%) were women, provided complete data. We performed a series of four regression analyses.

RESULTS

After controlling for age and sex, the predictors explained an additional 7-16% of the variance in sleep disturbance. The final model with all of the predictors explained 22%.

CONCLUSIONS

Consistent with the study hypothesis, all the variables examined made significant and independent contributions to the variance in sleep disturbance. The findings provide additional evidence that physical, emotional and cognitive factors all play a role in the sleep quality of individuals with chronic health conditions often associated with physical disabilities.

The impact of contract service policy and doctor communication skills on rural patient-doctor trust relationship in the village clinics of three counties

Background

Trust is regarded as the cornerstone of the doctor-patient relationship in the world of medicine; it determines the decisions patients make when choosing doctors and influences patients’ compliance with recommended treatments. In China, patient-doctor trust acts as a thermometer measuring harmony in the doctor-patient relationship. The objective of this study is to explore the relationship between the contract service and patient-doctor trust-building in 25 village clinics of rural China.

Method

The research was carried out in village clinics in rural China. A simple random sampling method was used to choose clinics and subjects. Based on feasibility and financial support, we chose three counties as our study settings: Dafeng District, Jiangsu Province; Yinan County, Shandong Province; and Wufeng Tujia Autonomous County, Hubei Province. Twenty-five village clinics and 574 subjects were selected in the three areas from the contract service and patient list. Descriptive statistics, t-tests, MANOVA, SEM, and multiple regression statistical analysis were employed to analyze the data.

Result

Statistical analysis showed that contract service directly and indirectly influenced patient-doctor trust-building in village clinics. The patient perception of doctor communication skills was a mediator in the relationship between contract service policy and patient-doctor trust-building.

Conclusions

Building patient-doctor trust is important in developing and enhancing rural health. The policy of contract service plays a significant role in building relationships. Well-developed communication skills of doctors contribute to the implementation of the contract service policy and to establishing patient-doctor trust.

Effectiveness of health education in patients with fibromyalgia: a systematic review

INTRODUCTION

Fibromyalgia (FM) is a chronic illness characterized by the presence of generalised musculoskeletal pain among other symptoms, which reduce the quality of life of the patient. Clinical interventions such as patient education on central pain management could lead to promising results. The aim of this study is to evaluate the effectiveness of education techniques on the main symptoms such as pain, quality of life, anxiety, functionality or catastrophization in the treatment of FM.

EVIDENCE ACQUISITION

The bibliographic search was carried out on PubMed, Web of Science, Scopus, CINAHL, EMBASE, Medline, ProQuest, Cochrane Plus and PEDro databases. The quality assessment of the selected studies was carried out by means of the PEDro scale, obtaining external and internal validity scores to evaluate the generalizability and the appropriateness of design, conduction, and reporting.

EVIDENCE SYNTHESIS

The electronic search produced 2,050 articles up to February 2018. After applying the inclusion criteria, 12 articles were identified, without the presence of any RCT of high methodological quality (PEDro≤8; Internal Validity Score [PVI] ≤4). Despite the heterogeneity of the interventions, a significant reduction in the perception of the disease, the catastrophization, pain intensity and anxiety was observed.

CONCLUSIONS

Patient education is considered to be the first step in self-management for a patient with FM, but the scientific evidence that supports the effectiveness of education in the reduction of the main symptoms is limited. Future research designed on more solid and homogeneous interventions is required.

The Impact of Pain Invisibility on Patient-Centered Care and Empathetic Attitude in Chronic Pain Management

Objectives

The use of interdisciplinary patient-centered care (PCC) and empathetic behaviour seems to be a promising avenue to address chronic pain management, but their use in this context seems to be suboptimal. Several patient factors can influence the use of PCC and empathy, but little is known about the impact of pain visibility on these behaviours. The objective of this study was to investigate the influence of visible physical signs on caregiver's patient-centered and empathetic behaviours in chronic pain context.

Methods

A convenience sample of 21 nurses and 21 physicians participated in a descriptive study. PCC and empathy were evaluated from self-assessment and observer's assessment using a video of real patients with chronic pain.

Results

The results show that caregivers have demonstrated an intraindividual variability: PCC and empathetic behaviours of the participants were significantly higher for patients who have visible signs of pain (rheumatoid arthritis and complex regional pain syndrome) than for those who have no visible signs (Ehler–Danlos syndrome and fibromyalgia) (p < 0.001). Participants who show a greater difference in their patient-centered behaviour according to pain visibility have less clinical experience.

Discussion

The pain visibility in chronic pain patients is an important factor contributing to an increased use of PCC and empathy by nurses and physicians, and clinical experience can influence their behaviours. Thus, pain invisibility can be a barrier to quality of care, and these findings reinforce the relevance to educating caregivers to these unconscious biases on their behaviour toward chronic pain patients.

What are the effective elements in patient-centered and multimorbidity care? A scoping review

BACKGROUND

Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients.

METHOD

A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed.

RESULTS

Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases.

CONCLUSION

This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.

Normalizing fibromyalgia as a chronic illness

Fibromyalgia (FM) is a complex chronic disease that affects 3-10% of the general adult population and is principally characterized by widespread pain, and is often associated with disrupted sleep, fatigue, and comorbidities, among other symptoms. There are many gaps in our knowledge of FM, such that, compared with other chronic illnesses including diabetes, rheumatoid arthritis, and asthma, it is far behind in terms of provider understanding and therapeutic approaches. The experience that healthcare professionals (HCPs) historically gained in developing approaches to manage and treat patients with these chronic illnesses may help show how they can address similar problems in patients with FM. In this review, we examine some of the issues around the management and treatment of FM, and discuss how HCPs can implement appropriate strategies for the benefit of patients with FM. These issues include understanding that FM is a legitimate condition, the benefits of prompt diagnosis, use of non-drug and pharmacotherapies, patient and HCP education, watchful waiting, and assessing patients by FM domain so as not to focus exclusively on one symptom to the detriment of others. Developing successful approaches is of particular importance for HCPs in the primary care setting who are in the ideal position to provide long-term care for patients with FM. In this way, FM may be normalized as a chronic illness to the benefit of both patients and HCPs.

Patients with Concomitant Chronic Neck Pain and Myofascial Pain in Masticatory Muscles Have More Widespread Pain and Distal Hyperalgesia than Patients with Only Chronic Neck Pain

Objective

Insufficient evidence exists to compare widespread pain (WP), pain sensibility, and psychological factors that occur in patients presenting with chronic neck pain (CNP) or a combination of temporomandibular disorder (TMD) and other complaints. The present study compared the pain sensibility and psychological factors of subjects with CNP with those with TMD + CNP.

Design

Cross-sectional study.

Setting

Local community.

Subjects

A nonprobabilistic convenience sample of 86 persons with CNP or TMD was recruited into three groups: CNP, TMD with myofascial pain in masticatory muscles with cocomitant CNP (TMD + CNP), and asymptomatic control groups consisted of 27, 29, and 30 participants, respectively.

Methods

Participants underwent a clinical examination to evaluate WP with computerized assessment based on the pain drawing, pressure pain thresholds (PPT), and psychological factors, which were evaluated using the pain catastrophizing scale (PCS) and the state-trait anxiety inventory (STAI).

Results

Statistically significant differences were observed between participants with CNP and TMD + CNP for WP (t = -2.80, P  < 0.01, d = -1.06). Post hoc analyses only revealed significant differences between TMD + CNP participants and asymptomatic controls for PPT at extratrigeminal areas. Pearson correlation analyses showed a moderate positive association between symptomatic groups within the WP and STAI ( P  < 0.05) and a moderate negative association between PCS and PPT ( P  < 0.05) at the right tibialis muscle.

Conclusion

TMD + CNP participants had more areas of pain and also showed widespread pain hyperalgesia. Both groups of participants had psychological factors positively associated with STAI and WP; further, PCS and the PPT at the extratrigeminal region were negatively associated with each other in both groups, except for the left tibialis in the TMD + CNP group.

Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine whether patient- and family-centered care interventions in the ICU improve outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.

STUDY SELECTION

We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.

DATA EXTRACTION

We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.

DATA SYNTHESIS

There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

CONCLUSIONS

Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

It's About Me: Patients' Experiences of Patient Participation in the Web Behavior Change Program for Activity in Combination With Multimodal Pain Rehabilitation

Background

Patients’ participation in their health care is recognized as a key component in high-quality health care. Persons with persistent pain are recommended treatments with a cognitive approach from a biopsychosocial explanation of pain, in which a patient’s active participation in their rehabilitation is in focus. Web-based interventions for pain management have the potential to increase patient participation by enabling persons to play a more active role in rehabilitation. However, little is known about patients’ experiences of patient participation in Web-based interventions in clinical practice.

Objective

The objective of our study was to explore patients’ experiences of patient participation in a Web Behavior Change Program for Activity (Web-BCPA) in combination with multimodal rehabilitation (MMR) among patients with persistent pain in primary health care.

Methods

Qualitative interviews were conducted with 15 women and 4 men, with a mean age of 45 years. Data were analyzed with qualitative content analysis.

Results

One theme, “It’s about me,” and 4 categories, “Take part in a flexible framework of own priority,” “Acquire knowledge and insights,” “Ways toward change,” and “Personal and environmental conditions influencing participation,” were developed. Patient participation was depicted as being confirmed in an individualized and structured rehabilitation framework of one’s own choice. Being confirmed was fundamental to patient participation in the interaction with the Web-BCPA and with the health care professionals in MMR. To acquire knowledge and insights about pain and their life situation, through self-reflection in the solitary work in the Web-BCPA and through feedback from the health care professionals in MMR, was experienced as patient participation by the participants. Patient participation was described as structured ways to reach their goals of behavior change, which included analyzing resources and restrictions, problem solving, and evaluation. The individual’s emotional and cognitive resources and restrictions, as well as health care professionals and significant others’ attitudes and behavior influenced patient participation in the rehabilitation. To some extent there were experiences of restrained patient participation through the great content of the Web-BCPA.

Conclusions

Patient participation was satisfactory in the Web-BCPA in combination with MMR. The combined treatment was experienced to increase patient participation in the rehabilitation. Being confirmed through self-identification and finding the content of the Web-BCPA trustworthy was emphasized. Patient participation was experienced as a learning process leading to new knowledge and insights. Higher user control regarding the timing of the Web-BCPA and therapist guidance of the content may further increase patient participation in the combined treatment.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

Assessing patient-centred care for chronic pain: Validation of a new research paradigm

BACKGROUND

Chronic pain is a complex phenomenon resulting from biological, psychological and social factors, and the use of patient-centred care (PCC) appears to be a promising avenue for its treatment. Various methods have been used for measuring PCC in nurses and physicians (caregivers); however, methodological problems have been raised following the observation of real clinical encounters or standardized patient simulations. The development of new strategies is required.

OBJECTIVE

To develop and validate an observation scale for the assessment of PCC in caregivers, using standardized videos of real patients with chronic pain.

METHODS

An expert panel developed five videos and the Sherbrooke Observation Scale of Patient-Centered Care (SOS-PCC), which were tested in a sample of 21 nurses and 21 physicians working with chronic pain patients. The content validity, internal consistency and inter-rater reliability of the SOS-PCC were assessed.

RESULTS

The expert panel was satisfied with the content validity of the SOS-PCC. Results revealed good internal consistency (Cronbach's alpha = 0.88) and inter-rater reliability (intraclass coefficient = 0.93) for this scale.

CONCLUSIONS

To the authors' knowledge, the SOS-PCC is the first instrument available in French to assess PCC behaviour of caregivers using videos of real patients with chronic pain. The psychometric qualities of these instruments are good. Future studies will need to assess this instrument with other populations of caregivers.

Personalised care planning for adults with chronic or long-term health conditions

BACKGROUND

Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition.

OBJECTIVES

To assess the effects of personalised care planning for adults with long-term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013.

SELECTION CRITERIA

We included randomised controlled trials and cluster-randomised trials involving adults with long-term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both.

DATA COLLECTION AND ANALYSIS

Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health-related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long-term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings.

MAIN RESULTS

We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end-stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face-to-face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods. Physical healthNine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of -0.24% (95% confidence interval (CI) -0.35 to -0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).Six studies measured systolic blood pressure, a combined mean difference of -2.64 mm/Hg (95% CI -4.47 to -0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD -0.71 mm/Hg (95% CI -2.26 to 0.84).We found no evidence of an effect on cholesterol (LDL-C), standardised mean difference (SMD) 0.01 (95% CI -0.09 to 0.11) (five studies) or body mass index, MD -0.11 (95% CI -0.35 to 0.13) (four studies).A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control. Psychological healthSix studies measured depression. We were able to pool results from five of these, giving an SMD of -0.36 (95% CI -0.52 to -0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes. Subjective health statusTen studies used various patient-reported measures of health status (or health-related quality of life), including both generic health status measures and condition-specific ones. We were able to pool data from three studies that used the SF-36 or SF-12, but found no effect on the physical component summary score SMD 0.16 (95% CI -0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI -0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.Four studies measured condition-specific health status. The combined results showed no difference between the intervention and control groups, SMD -0.01 (95% CI -0.11 to 0.10) (moderate quality evidence). Self-management capabilitiesNine studies looked at the effect of personalised care on self-management capabilities using a variety of outcome measures, but they focused primarily on self efficacy. We were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43) (moderate quality evidence).A further five studies measured other attributes that contribute to self-management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support. Other outcomesPooled data from five studies on exercise levels showed no effect due to personalised care planning, but there was a positive effect on people's self-reported ability to carry out self-care activities: SMD 0.35 (95% CI 0.17 to 0.52).We found no evidence of adverse effects due to personalised care planning.The effects of personalised care planning were greater when more stages of the care planning cycle were completed, when contacts between patients and health professionals were more frequent, and when the patient's usual clinician was involved in the process.

AUTHORS' CONCLUSIONS

Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people's capability to self-manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.

Challenges faced in Latin America for the implementation of an ideal health-care model for rheumatoid arthritis patients: are we ready?

Rheumatoid arthritis (RA) is a chronic, inflammatory, progressive disease characterized by inflammation of the synovial tissue. It results in the severe functional deterioration of the joints involved and the incapacity to work. Our main aim is to determine the characteristics of the current health-care models used in treating rheumatoid arthritis patients in Latin America. We want to analyze the details, using them as the foundation to create an ideal health-care model that is focused on the patient. We have revised documents, including guides to clinical practice, monitoring models and health-care models according to the current policies and resources available in various Latin American countries. Based on this information, the qualities and deficiencies of the current models will be analyzed, in order to use this as a basis on which to construct a proposed health-care model that covers the specific needs of rheumatoid arthritis patients, considering the resources of each population. Despite the collapse seen in many health systems throughout history, we can learn from them and should develop a new model starting from the path pursued, capitalizing on our experiences, teachings, and errors committed. However, in most cases, the obstacles to the success of the systems do not lie in the fundamental structure or the "spirit of the legislator" but rather in the day-to-day development within the community and the special interest of each agent in a system.

Medication and the patient-doctor relationship: a qualitative study with patients suffering from fibromyalgia

BACKGROUND

Fibromyalgia is characterized by a diffuse and predominantly axial and chronic pain, for which there is no explicit rationale for treatment options.

OBJECTIVE

This qualitative study aims to understand the medication experience of patients with fibromyalgia and their relationship with the doctors derived from treatment negotiation.

DESIGN

A qualitative approach was used, based on interviews with patients.

SETTING AND PARTICIPANTS

Semi-structured interviews were held in a public hospital, with 35 patients diagnosed with fibromyalgia. Qualitative content analysis was performed.

RESULTS

The first axis is centred on the unsuccessful quest for an effective treatment for pain and the feeling of dismissal of patients, who are in search of validation and recognition. The second part of the accounts explains the medication adjustments and the search for collaboration. Developing a model of partnership with the doctor enables the patients to shape their own illness, through the medication.

DISCUSSION

It is by mediating their relationship with medication that patients gain access to this state of co-expertise and that they put sense into the collaboration they develop with their doctors. Through this collaboration, useful drugs are identified and adjusted to treat the pain.

Enhanced care by generalists for functional somatic symptoms and disorders in primary care

BACKGROUND

Patients with medically unexplained or functional somatic symptoms are common in primary care. Previous reviews have reported benefit from specialised interventions such as cognitive behavioural therapy and consultation letters, but there is a need for treatment models which can be applied within the primary care setting. Primary care studies of enhanced care, which includes techniques of reattribution or cognitive behavioural therapy, or both, have shown changes in healthcare professionals' attitudes and behaviour. However, studies of patient outcome have shown variable results and the value of enhanced care on patient outcome remains unclear.

OBJECTIVES

We aimed to assess the clinical effectiveness of enhanced care interventions for adults with functional somatic symptoms in primary care. The intervention should be delivered by professionals providing first contact care and be compared to treatment as usual. The review focused on patient outcomes only.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR-Studies and CCDANCTR-References) (all years to August 2012), together with Ovid searches (to September 2012) on MEDLINE (1950 - ), EMBASE (1980 - ) and PsycINFO (1806 - ). Earlier searches of the Database of Abstracts of Reviews of Effectiveness (DARE), CINAHL, PSYNDEX, SIGLE, and LILACS were conducted in April 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2009. No language restrictions were applied. Electronic searches were supplemented by handsearches of relevant conference proceedings (2004 to 2012), reference lists (2011) and contact with authors of included studies and experts in the field (2011).

SELECTION CRITERIA

We limited our literature search to randomised controlled trials (RCTs), primary care, and adults with functional somatic symptoms. Subsequently we selected studies including all of the following: 1) a trial arm with treatment as usual; 2) an intervention using a structured treatment model which draws on explanations for symptoms in broad bio-psycho-social terms or encourages patients to develop additional strategies for dealing with their physical symptoms, or both; 3) delivery of the intervention by primary care professionals providing first contact care; and 4) assessment of patient outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently screened identified study abstracts. Disagreements about trial selections were resolved by a third review author. Data from selected publications were independently extracted and risk of bias assessed by two of three authors, avoiding investigators reviewing their own studies. We contacted authors from included studies to obtain missing information. We used continuous outcomes converted to standardised mean differences (SMDs) and based analyses on changes from baseline to follow-up, adjusted for clustering.

MAIN RESULTS

We included seven studies from the literature search, but only six provided sufficient data for analyses. Included studies were European, cluster RCTs with adult participants seeing their usual doctor (in total 233 general practitioners and 1787 participants). Methodological quality was only moderate as studies had no blinding of healthcare professionals and several studies had a risk of recruitment and attrition bias. Studies were heterogeneous with regard to selection of patient populations and intensity of interventions. Outcomes relating to physical or general health (physical symptoms, quality of life) showed substantial heterogeneity between studies (I(2) > 70%) and post hoc analysis suggested that benefit was confined to more intensive interventions; thus we did not calculate a pooled effect. Outcomes relating to mental health showed less heterogeneity and we conducted meta-analyses, which found non-significant overall effect sizes with SMDs for changes at 6 to 24 months follow-up: mental health (3 studies) SMD -0.04 (95% CI -0.18 to 0.10), illness worry (3 studies) SMD 0.09 (95% CI -0.04 to 0.22), depression (4 studies) SMD 0.07 (95% CI -0.05 to 0.20) and anxiety (2 studies) SMD -0.07 (95% CI -0.38 to 0.25). Effects on sick leave could not be estimated. Three studies of patient satisfaction with care all showed positive but non-significant effects, and measures were too heterogeneous to allow meta-analysis. Results on healthcare utilisation were inconclusive. We analysed study discontinuation and found that both short term and long term discontinuation occurred more often in patients allocated to the intervention group, RR of 1.25 (95% CI 1.08 to 1.46) at 12 to 24 months.

AUTHORS' CONCLUSIONS

Current evidence does not answer the question whether enhanced care delivered by front line primary care professionals has an effect or not on the outcome of patients with functional somatic symptoms. Enhanced care may have an effect when delivered per protocol to well-defined groups of patients with functional disorders, but this needs further investigation. Attention should be paid to difficulties including limited consultation time, lack of skills, the need for a degree of diagnostic openness, and patient resistance towards psychosomatic attributions. There is some indication from this and other reviews that more intensive interventions are more successful in changing patient outcomes.

Clinical utility of the Hospital Anxiety and Depression Scale (HADS) for an outpatient fibromyalgia education program

This paper examines the clinical utility of the Hospital Anxiety and Depression Scale (HADS) in the context of evaluating the Fibromyalgia Outpatient Education Program at Southlake Regional Health Centre (Newmarket, Canada). A pre-test/post-test design was implemented for data analysis. A total of 232 patients' data were obtained through retrospective patient chart review. Complete pre-post data were available for 70 patients and qualitative analysis was done for 12 patients. Main outcome measures included HADS and Arthritis Self-Efficacy (ASE) scores. At the end of the education program, subgroups of patients (high attendance, high exercise habit, low medication) experienced significant improvement on HADS-depression and ASE scores. Linear regression analysis found that HADS pre-program scores explain far more variance in HADS post-test scores than ASE pre-program scores explain in ASE post-program scores; more variance in ASE post-program scores was explained by other variables. In contrast to the quantitative analysis of the Anxiety subscale of HADS, patients in the focus group indicated that their anxiety level decreased through attending the education program. These findings suggest that HADS is an appropriate tool for evaluating fibromyalgia and related patient education programs. Moreover, patient education programs have positive effects on enhancing patients' psychological well-being and self-confidence in controlling fibromyalgia-related symptoms.

Patient-centered approaches to health care: a systematic review of randomized controlled trials

There is growing interest in patient-centered care, but there is little guidance about the interventions required for its delivery and whether it leads to better health outcomes. This systematic review evaluates the efficacy of patient-centered care interventions for people with chronic conditions. Thirty randomized controlled trials were identified from health-related databases. The findings indicated that most interventions were based on the notion of empowering care and included attempts to educate consumers or prompt them about how to manage a health consultation. Other common interventions focused on training providers in delivering empowering care. Although it was difficult to draw firm conclusions because of the moderate to high risk of bias of the research designs, this review has shown some promising findings from implementing a patient-centered care approach. There appeared to be benefits associated with this model of care in terms of patient satisfaction and perceived quality of care.

[Fibromyalgia syndrome. General principles and coordination of clinical care and patient education]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

A diagnosis of FMS should be explicitly communicated with the afflicted individual. A step-wise treatment, depending on the severity of FMS and the responses to therapeutic measures, is recommended. Therapy should only be continued if the positive effects outweigh the side effects. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Family physician enabling attitudes: a qualitative study of patient perceptions

Background

Family physicians frequently interact with people affected by chronic diseases, placing them in a privileged position to enable patients to gain control over and improve their health. Soliciting patients’ perceptions about how their family physician can help them in this process is an essential step to promoting enabling attitudes among these health professionals. In this study, we aimed to identify family physician enabling attitudes and behaviours from the perspective of patients with chronic diseases.

Methods

We conducted a descriptive qualitative study with 30 patients, 35 to 75 years of age presenting at least one common chronic disease, recruited in primary care clinics in two regions of Quebec, Canada. Data were collected through in-depth interviews and were analyzed using thematic analysis.

Results

Family physician involvement in a partnership was perceived by participants as the main attribute of enablement. Promoting patient interests in the health care system was also important. Participants considered that having their situation taken into account maximized the impact of their physician’s interventions and allowed the legitimization of their feelings. They found their family physician to be in a good position to acknowledge and promote their expertise, and to help them maintain hope.

Conclusions

From the patient’s perspective, their partnership with their family physician is the most important aspect of enablement.