1
|
Röhricht F, Green C, Filippidou M, Lowe S, Power N, Rassool S, Rothman K, Shah M, Papadopoulos N. Integrated care model for patients with functional somatic symptom disorder - a co-produced stakeholder exploration with recommendations for best practice. BMC Health Serv Res 2024; 24:698. [PMID: 38831287 PMCID: PMC11145802 DOI: 10.1186/s12913-024-11130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Functional somatic symptoms (FFS) and bodily distress disorders are highly prevalent across all medical settings. Services for these patients are dispersed across the health care system with minimal conceptual and operational integration, and patients do not currently access therapeutic offers in significant numbers due to a mismatch between their and professionals' understanding of the nature of the symptoms. New service models are urgently needed to address patients' needs and to align with advances in aetiological evidence and diagnostic classification systems to overcome the body-mind dichotomy. METHOD A panel of clinical experts from different clinical services involved in providing aspects of health care for patients with functional symptoms reviewed the current care provision. This review and the results from a focus group exploration of patients with lived experience of functional symptoms were explored by the multidisciplinary expert group, and the conclusions are summarised as recommendations for best practice. RESULTS The mapping exercise and multidisciplinary expert consultation revealed five themes for service improvement and pathway development: time/access, communication, barrier-free care, choice and governance. Service users identified four meta-themes for best practice recommendations: focus on healthcare professional communication and listening skills as well as professional attributes and knowledge base to help patients being both believed and understood in order to accept their condition; systemic and care pathway issues such as stronger emphasis on primary care as the first point of contact for patients, resources to reduce the length of the patient journey from initial assessment to diagnosis and treatment. CONCLUSION We propose a novel, integrated care pathway for patients with 'functional somatic disorder', which delivers care according to and working with patients' explanatory beliefs. The therapeutic model should operate based upon an understanding of the embodied nature of patient's complaints and provide flexible access points to the care pathway.
Collapse
Affiliation(s)
- Frank Röhricht
- East London NHS Foundation Trust (ELFT), London, United Kingdom.
- Queen Mary University of London, London, United Kingdom.
| | - Carole Green
- Bedfordshire Community Health Services (BCHS), Bedford, United Kingdom
| | - Maria Filippidou
- Bedford Liaison Psychiatry Service, ELFT, Bedford, United Kingdom
| | - Simon Lowe
- Circle Bedfordshire Integrated Care Musculoskeletal Service, Bedford, United Kingdom
| | - Nicki Power
- East London NHS Foundation Trust (ELFT), London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Sara Rassool
- Clinical Health Psychology Services Bedfordshire & Luton, ELFT, Dunstable, United Kingdom
| | - Katherine Rothman
- Bedfordshire & Luton Community Adult Mental Health & Learning Disability Services , ELFT, Clapham, United Kingdom
| | - Meera Shah
- Clinical Health Psychology Service, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | |
Collapse
|
2
|
Terzo M, Rajagopalan D, Nguoe M, Ring D, Ramtin S. Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness. Clin Orthop Relat Res 2024; 482:648-655. [PMID: 37916974 PMCID: PMC10936977 DOI: 10.1097/corr.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment. QUESTIONS/PURPOSES (1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness? METHODS One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% [88 of 103] in this study), mostly academic (83% [85 of 103]), and mostly fracture and upper extremity surgeons (83% [86 of 103]), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation. RESULTS Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median [IQR] 70 [54 to 88]; considered notable because the mean value is above zero [neutral] by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 [-15 to 37]; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20). CONCLUSION Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable. CLINICAL RELEVANCE Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.
Collapse
Affiliation(s)
- Madison Terzo
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Dayal Rajagopalan
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Marielle Nguoe
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| |
Collapse
|
3
|
Nerurkar L, van der Scheer I, Stevenson F. Engagement with emotional concerns in general practice: a thematic analysis of GP consultations. BJGP Open 2024; 8:BJGPO.2023.0202. [PMID: 37940141 PMCID: PMC11169977 DOI: 10.3399/bjgpo.2023.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 10/18/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress. AIM To examine how emotional concerns are engaged with during routine GP consultations. DESIGN & SETTING Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018. METHOD The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes. RESULTS The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised. CONCLUSION Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.
Collapse
Affiliation(s)
- Louis Nerurkar
- University College London, Research Department for Primary Care Research and Population Health, London, UK
| | - Iris van der Scheer
- University College London, Research Department for Primary Care Research and Population Health, London, UK
| | - Fiona Stevenson
- University College London, Research Department for Primary Care Research and Population Health, London, UK
| |
Collapse
|
4
|
Statsenko ME, Turkina SV. [Antiastenic effect of sequential levocarnitine and acetylcarnitine therapy in patients with cardiovascular diseases]. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:95-100. [PMID: 36537638 DOI: 10.17116/jnevro202212212195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Evaluation of the antiasthenic effect of sequential therapy with levocarnitine (LC) and acetylcarnitine (ALC) in patients with arterial hypertension and/or ischemic heart disease (CHD) with asthenic syndrome (AS). MATERIAL AND METHODS An open comparative study included 120 patients aged 54-67 years in patients with arterial hypertension and/or coronary artery disease with AS. Patients of group1 (n=60), in addition to basic therapy for the underlying disease, received LC (Elcar solution for intravenous and intramuscular injection of 100 mg/ml, the company PIQ-PHARMA) intravenously for 10 days at a dose of 1000 mg/day, followed by a transition to oral administration of ALC (Carnicetine, the company PIQ-PHARMA) 500 mg (2 capsules) 2 times a day for 2 months. Group2 patients (n=60) received only basic therapy for major diseases. The duration of observation was 70 days. The severity of AS was assessed using the MFI-20 questionnaire (MultidiMensional Fatigue Inventory) and the visual analog scale VAS-A (Visual Analog Scale Measuring fatigue). RESULTS In patients of group1, a statistically significant decrease in various manifestations of AS was noted. The differences were significant both in comparison with the baseline level and in comparison with the 2nd group. The endothelium-protective effect of LC and ALC has been established. CONCLUSION The results obtained indicate that in such comorbid patients, the use of LC and ALC reduces the severity of AS manifestations, and the established endotheliotropic properties of the drugs allow them to be recommended as part of the complex personalized therapy of patients with cardiovascular diseases.
Collapse
Affiliation(s)
- M E Statsenko
- Volgograd State Medical University, Volgograd, Russia
| | - S V Turkina
- Volgograd State Medical University, Volgograd, Russia
| |
Collapse
|
5
|
Al Salman A, Kim A, Mercado A, Ring D, Doornberg J, Fatehi A, Crijns TJ. Are Patient Linguistic Tones Associated with Mental Health and Perceived Clinician Empathy? J Bone Joint Surg Am 2021; 103:00004623-990000000-00311. [PMID: 34398866 DOI: 10.2106/jbjs.21.00124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Musculoskeletal specialists have the expertise to distinguish between (1) symptoms that correspond well with observed pathophysiology and (2) disproportionate or incongruent symptoms that may suggest mental and social health opportunities. There is evidence that patient verbal and nonverbal communication can help with this discernment. This study carried this line of research one step further by addressing whether patient linguistic tones, as assessed with use of Linguistic Inquiry and Word Count (LIWC), are associated with symptoms of depression and health anxiety. We also sought associations between both patient and clinician linguistic tones and patient-perceived clinician empathy. METHODS A secondary analysis of transcripts of video and audio recordings of 109 adult patients seeking musculoskeletal specialty care was performed. Patients also completed questionnaires quantifying symptoms of depression (PROMIS [Patient-Reported Outcomes Measurement Information System] Depression computerized adaptive test), self-efficacy when in pain (Pain Self-Efficacy Questionnaire, 2-question version), symptoms of health anxiety (5-item Short Health Anxiety Inventory [SHAI-5]), and perceived clinician empathy (Jefferson Scale of Patient Perceptions of Physician Empathy [JSPPPE]). LIWC was used to detect the relative strength of various emotional tones, cognitive processes, and core drives and needs. Bivariate and multivariable regression analyses sought factors associated with symptoms of depression, symptoms of health anxiety, and patient perception of clinician empathy. RESULTS With greater levels of depression, patients express less emotion overall as detected with use of computational linguistic analysis. After accounting for demographic variables, there were no specific linguistic tones associated with health anxiety and symptoms of depression. Stronger negative linguistic tones were associated with lower pain self-efficacy. Greater perceived clinician empathy was associated with more words spoken by the clinician and the patient, greater patient use of adjectives, lower prevalence of patient tones of "analytic," lower clinician tones of "social," and greater tones of "cause." CONCLUSIONS Musculoskeletal specialists cannot depend on people experiencing symptoms of psychological distress to verbally express their feelings. CLINICAL RELEVANCE Specialists may be more likely to identify important symptoms of psychological distress if they anticipate lower emotional expressiveness and are attentive to specific words, concepts, and mannerisms known to be associated with distress.
Collapse
Affiliation(s)
- Aresh Al Salman
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen, Groningen, the Netherlands
| | - Ashley Kim
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Amelia Mercado
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Job Doornberg
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen, Groningen, the Netherlands
| | - Amirreza Fatehi
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Tom J Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| |
Collapse
|
6
|
Exploring syndemic vulnerability across generations: A case study of a former fishing village in the Netherlands. Soc Sci Med 2020; 295:113122. [PMID: 32576403 DOI: 10.1016/j.socscimed.2020.113122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/23/2020] [Accepted: 06/05/2020] [Indexed: 01/09/2023]
Abstract
This qualitative case study uses a life-course approach to explore syndemic vulnerability in a former fishing village in the Netherlands. Building on four years of fieldwork in a low-income neighborhood, we explored salient themes between and across families and generations. Elderly community members (>65 years) were interviewed to map village history and explore how contextual factors have affected family life, health, and wellbeing since the 1940s. We systematically traced and compared processes leading to or from syndemic vulnerability by studying seven families across three generations. Adults with at least one of clustering diseases, their parents (when possible), and their children participated in semi-structured life-course interviews. A complex interaction of endemic social conditions, sociocultural normative processes, learned health behaviors, and disheartening life events shaped families' predispositions for a syndemic of psychological distress, cardiometabolic conditions, and musculoskeletal pain. Educational attainment, continued social support, and aspirational capabilities emerged as themes related to decreasing syndemic vulnerability. This study demonstrates that syndemic vulnerability is potentially intergenerational and reveals the need for culturally sensitive and family-focused syndemic interventions. Future longitudinal research should focus on unravelling the pathogenesis of the clustering of psychological distress, cardiometabolic conditions, and musculoskeletal pain among young people.
Collapse
|
7
|
Ventres W, Crowder J. When I say … anthropological gaze. MEDICAL EDUCATION 2018; 52:590-591. [PMID: 29266396 DOI: 10.1111/medu.13502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/14/2017] [Accepted: 11/03/2017] [Indexed: 06/07/2023]
|
8
|
Shuteeva TV. [The use of neipilept in treatment of asthenic syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:81-84. [PMID: 29560947 DOI: 10.17116/jnevro20181182181-84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the efficacy of neipilept in treatment of asthenic syndrome. MATERIAL AND METHODS Two groups of patients, aged from 30 to 40 years, with functional asthenia were examined. Patients were divided into main (n=40) and control (n=15) groups. In 22% men and 56% women, the disease was precipitated by emotional stress, in 46 and 38% by physical and stressful work conditions. Both groups received standard treatment. Patients of the main group received additionally neipilept in solution (500 mg daily) during 30 days. General physical and neurological examinations and psychometric assessment were performed. RESULTS AND CONCLUSION A significant reduction of asthenic symptoms, an increase in self-rated physical and mental functioning, a decrease in symptoms of cognitive dysfunction, anxiety and depression were observed in the main group compared to the control one. The positive changes in neuropsychological status improved quality of life and psychological adaptation in patients with functional asthenia exposed to chronic stress, physical and psychoemotional overstrain.
Collapse
|
9
|
Thompson DG, O’Brien S, Kennedy A, Rogers A, Whorwell P, Lovell K, Richardson G, Reeves D, Bower P, Chew-Graham C, Harkness E, Beech P. A randomised controlled trial, cost-effectiveness and process evaluation of the implementation of self-management for chronic gastrointestinal disorders in primary care, and linked projects on identification and risk assessment. PROGRAMME GRANTS FOR APPLIED RESEARCH 2018. [DOI: 10.3310/pgfar06010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BackgroundChronic gastrointestinal disorders are major burdens in primary care. Although there is some evidence that enhancing self-management can improve outcomes, it is not known if such models of care can be implemented at scale in routine NHS settings and whether or not it is possible to develop effective risk assessment procedures to identify patients who are likely to become chronically ill.ObjectivesWhat is the clinical effectiveness and cost-effectiveness of an intervention to enhance self-management support for patients with chronic conditions when translated from research settings into routine care? What are the barriers and facilitators that affect the implementation of an intervention to enhance self-management support among patients, clinicians and organisations? Is it possible to develop methods to identify patients at risk of long-term problems with functional gastrointestinal disorders in primary care? Data sources included professional and patient interviews, patient self-report measures and data on service utilisation.DesignA pragmatic, two-arm, practice-level cluster Phase IV randomised controlled trial evaluating outcomes and costs associated with the intervention, with associated process evaluation using interviews and other methods. Four studies around identification and risk assessment: (1) a general practitioner (GP) database study to describe how clinicians in primary care record consultations with patients who experience functional lower gastrointestinal symptoms; (2) a validation of a risk assessment tool; (3) a qualitative study to explore GPs’ views and experiences; and (4) a second GP database study to investigate patient profiles in irritable bowel syndrome, inflammatory bowel disease and abdominal pain.SettingSalford, UK.ParticipantsPeople with long-term conditions and professionals in primary care.InterventionsA practice-level intervention to train practitioners to assess patient self-management capabilities and involve them in a choice of self-management options.Main outcome measuresPatient self-management, care experience and quality of life, health-care utilisation and costs.ResultsNo statistically significant differences were found between patients attending the trained practices and those attending control practices on any of the primary or secondary outcomes. The intervention had little impact on either costs or effects within the time period of the trial. In the practices, self-management tools failed to be normalised in routine care. Full assessment of the predictive tool was not possible because of variable case definitions used in practices. There was a lack of perceived clinical benefit among GPs.LimitationsThe intervention was not implemented fully in practice. Assessment of the risk assessment tool faced barriers in terms of the quality of codting in GP databases and poor recruitment of patients.ConclusionsThe Whole system Informing Self-management Engagement self-management (WISE) model did not add value to existing care for any of the long-term conditions studied.Future workThe active components required for effective self-management support need further study. The results highlight the challenge of delivering improvements to quality of care for long-term conditions. There is a need to develop interventions that are feasible to deliver at scale, yet demonstrably clinically effective and cost-effective. This may have implications for the piloting of interventions and linking implementation more clearly to local commissioning strategies.Trial registrationCurrent Controlled Trial ISRCTN90940049.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David G Thompson
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarah O’Brien
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Anne Kennedy
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Anne Rogers
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Peter Whorwell
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | | | - David Reeves
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| | - Peter Bower
- Centre for Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Elaine Harkness
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Paula Beech
- Stroke Rehabilitation Unit, Salford Royal Foundation Trust, Salford, UK
| |
Collapse
|
10
|
Jauregui ML, Silvestre C, Valdes P, Gaminde I. Qualitative Evaluation of the Implementation of an Integrated Care Delivery Model for Chronic Patients with Multi-Morbidity in the Basque Country. Int J Integr Care 2016; 16:9. [PMID: 28435420 PMCID: PMC5350635 DOI: 10.5334/ijic.1975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 08/01/2016] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The objective of this study was to assess a model for improving healthcare integration for patients with multiple chronic diseases in an integrated healthcare organisation in the Basque Country and to propose areas for improvement. METHODS We organised four nominal groups composed of representatives from different categories of clinicians involved in the development of an integrated healthcare organisation and in the integrated care of patients with multiple diseases, namely, internists, general practitioners, and primary care and hospital nurses. RESULTS The aspect rated most positively was the concept itself of an integrated care model, which is able to improve communication between levels of care, increase the quality of the care provided and enhance patient safety. Additionally, it was agreed that the role of assigned clinicians is a key element. The problems identified mostly concern its implementation in daily practice. CONCLUSIONS The results of this study made it possible to suggest at least 8 areas of improvement to be implemented. These are related to: nurses' roles; care and monitoring of stable patients; team work; communication with patients; coordination with social workers and between internists and family doctors; as well as the development of an office of medical services to lead the integration process.
Collapse
Affiliation(s)
- María Luz Jauregui
- Clinical Management Unit, Tolosaldea Integrated Health Organisation, Basque Health Service (Osakidetza), Spain
| | - Carmen Silvestre
- Quality and Clinical Safety Unit, Servicio Navarro de Salud-Osasunbidea, Spain
| | - Pedro Valdes
- General Practitioner, Deusto Primary Health Centre, Osakidetza, Basque Country, Spain
| | - Idoia Gaminde
- Research, Innovation and Knowledge Management Unit, Department of Health, Government of Navarre, Spain
| |
Collapse
|
11
|
A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 2: How is healthcare perceived? J Adolesc 2015; 45:317-26. [DOI: 10.1016/j.adolescence.2015.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022]
|
12
|
Moulin V, Akre C, Rodondi PY, Ambresin AE, Suris JC. A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 1: Experiences and impact on daily life. J Adolesc 2015; 45:307-16. [PMID: 26530332 DOI: 10.1016/j.adolescence.2015.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 12/18/2022]
Abstract
Medically unexplained symptoms (MUS) are common among adolescents and are frequently encountered in primary care. Our aim was to explore how these adolescents and their parents experience the condition and its impact on their daily lives and to provide recommendations for health professionals. Using a qualitative approach, six focus groups and two individual interviews were conducted. These involved a total of ten adolescents with different types of MUS and sixteen parents. The respondents were recruited in a university hospital in Switzerland. A thematic analysis was conducted according to the Grounded Theory. The analysis of the data highlighted four core themes: disbelief, being different, concealing symptoms, and priority to adolescent's health. Transcending these themes was a core issue regarding the discrepancy between the strategies that adolescents and their parents use to cope with the symptoms. Health professionals should be made aware of the emotional needs of these patients and their families.
Collapse
Affiliation(s)
- Virginie Moulin
- Research Group on Adolescent Health (GRSA), Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, 1010 Lausanne, Switzerland
| | - Christina Akre
- Research Group on Adolescent Health (GRSA), Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, 1010 Lausanne, Switzerland
| | - Pierre-Yves Rodondi
- Research and Teaching Group on Complementary Medicine, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, 1010 Lausanne, Switzerland
| | - Anne-Emmanuelle Ambresin
- Multidisciplinary Adolescent Health Unit (UMSA), Department of Pediatrics (DMCP), Lausanne University Hospital, 1010 Lausanne, Switzerland
| | - Joan-Carles Suris
- Research Group on Adolescent Health (GRSA), Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, 1010 Lausanne, Switzerland.
| |
Collapse
|
13
|
Stern J, Hard E, Rock B. Paradigms, politics and pragmatics: psychotherapy in primary care in City and Hackney – a new model for the NHS. PSYCHOANALYTIC PSYCHOTHERAPY 2015. [DOI: 10.1080/02668734.2015.1033445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
14
|
Harkness EF, Harrington V, Hinder S, O'Brien SJ, Thompson DG, Beech P, Chew-Graham CA. GP perspectives of irritable bowel syndrome--an accepted illness, but management deviates from guidelines: a qualitative study. BMC FAMILY PRACTICE 2013; 14:92. [PMID: 23805998 PMCID: PMC3700862 DOI: 10.1186/1471-2296-14-92] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 06/20/2013] [Indexed: 12/31/2022]
Abstract
Background The estimated prevalence of irritable bowel syndrome (IBS) is 10%. Up to one third of patients develop chronic symptoms, which impact on everyday functioning and psychological wellbeing. Guidelines suggest an increased role for primary care in the management of patients with IBS, and referral for psychological interventions. Literature reports dissatisfaction and frustration experienced by both patients with IBS and healthcare professionals. The aim of this study was to explore the perspectives of general practitioners (GPs) in relation to the diagnosis and management of IBS and their views on the potential use of a risk assessment tool to aid management decisions for patients with IBS in primary care. Methods This was a qualitative study using face-to-face semi-structured interviews with GPs in North West England. Interviews were fully transcribed and data analyzed using constant comparison across interviews. Tensions between GP accounts and the NICE guideline for the management of IBS were highlighted. Results GPs described IBS as a diagnosis of exclusion and the process as tentative and iterative, with delay in adding a Read code to the patient record until they were confident of the diagnosis. Whilst GPs accepted there was a link between IBS and psychological symptoms they suggested that the majority of patients could be managed within primary care without referral for psychological interventions, in conflict with the NICE guideline. They did not feel that a risk assessment tool for patients with IBS would be helpful. Conclusions This study highlights the tensions between evidence recognizing the need to identify patients whose symptoms may become chronic and offer pro-active care, including referral for psychological therapies, and the perspectives of GPs managing patients in every-day clinical practice. The reluctance of GPs to refer patients for evidence-based psychological treatments may have implications for commissioning services and patient care.
Collapse
Affiliation(s)
- Elaine F Harkness
- Institute of Inflammation and Repair, Stopford Building, University of Manchester, Oxford Road, Manchester M13 9PL, England.
| | | | | | | | | | | | | |
Collapse
|
15
|
Ivetić V, Kersnik J, Klemenc-Ketiš Z, Švab I, Kolšek M, Poplas-Susič T. Opinions of Slovenian family physicians on medically unexplained symptoms: A qualitative study. J Int Med Res 2013; 41:705-15. [DOI: 10.1177/0300060513480079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives To determine the views of Slovenian family physicians on medically unexplained symptoms (MUS) and learn more about potential types of treatment for such patients. Methods Five focus groups, comprising 24 family medicine physicians (FMPs) from two Slovenian University centres, were convened. Conversations were led towards the research objectives by professionally trained researchers and followed a preliminarily established protocol. Qualitative content analysis of audio and transcripts of the discussions was performed using ATLAS.ti software to establish categories (‘codes’) relevant to issues regarding MUS. Results Slovenian FMPs emphasized the importance of good communication and trust between physicians and patients with MUS. Systemic barriers to effective management of MUS arising from the Slovenian health system were highlighted. FMPs stressed the need for more education in the recognition and treatment of MUS in primary care. From the discussions, 64 codes comprising broader research fields of MUS were developed, then grouped into a further eight categories: communication; doctor–patient relationship; causes of MUS; patient characteristics; physician characteristics; courses of action so far; positive relationship with patients; proposals for treatment. Conclusions The results are valuable in terms of investigating the treatment of patients with MUS in Slovenia, thereby opening new avenues of research on the subject of MUS.
Collapse
Affiliation(s)
- Vojislav Ivetić
- University of Maribor, Faculty of Medicine, Department of Family Medicine, Maribor, Slovenia
- Family Practice SAVA, Spodnji Duplek, Slovenia
| | - Janko Kersnik
- University of Maribor, Faculty of Medicine, Department of Family Medicine, Maribor, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Ljubljana, Slovenia
| | - Zalika Klemenc-Ketiš
- University of Maribor, Faculty of Medicine, Department of Family Medicine, Maribor, Slovenia
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Ljubljana, Slovenia
| | - Igor Švab
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Ljubljana, Slovenia
| | - Marko Kolšek
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Ljubljana, Slovenia
| | - Tonka Poplas-Susič
- University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Ljubljana, Slovenia
| |
Collapse
|
16
|
Fritzsche K, Anselm K, Fritz M, Wirsching M, Xudong Z, Schaefert R. Illness attribution of patients with medically unexplained physical symptoms in China. Transcult Psychiatry 2013; 50:68-91. [PMID: 23264572 DOI: 10.1177/1363461512470439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The illness behavior of patients with medically unexplained physical symptoms (MUS) depends largely on what the patient believes to be the cause of the symptoms. Little data are available on the illness attributions of patients with MUS in China. This cross-sectional study investigated the illness attributions of 96 patients with MUS in the outpatient departments of Psychosomatic Medicine, biomedicine (Neurology, Gynecology), and Traditional Chinese Medicine in Shanghai. Patients completed the Illness Perception Questionnaire (IPQ) for illness attribution, the Screening Questionnaire for Somatoform Symptoms, the Hospital Anxiety and Depression Scale for emotional distress, and questionnaires on clinical and sociodemographic data. The physicians also filled out a questionnaire regarding the cause of the illness (IPQ). In contrast to previous research, both physicians and patients from all three areas of medicine most frequently reported "psychological attributions." The concordance between the physicians' and the patients' illness attributions was low. Emotional distress was an important predictor of psychological attributions. Further research should include large-scale studies among patients from different regions of China and qualitative studies to deepen our understanding of cultural influences on illness attribution.
Collapse
Affiliation(s)
- Kurt Fritzsche
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg, Germany.
| | | | | | | | | | | |
Collapse
|
17
|
NORDIN STEVEN, PALMQUIST EVA, NORDIN MARIA. Psychometric evaluation and normative data for a Swedish version of the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale. Scand J Psychol 2013; 54:112-7. [DOI: 10.1111/sjop.12029] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
18
|
Greco M. The classification and nomenclature of ‘medically unexplained symptoms’: Conflict, performativity and critique. Soc Sci Med 2012; 75:2362-9. [DOI: 10.1016/j.socscimed.2012.09.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 09/04/2012] [Accepted: 09/08/2012] [Indexed: 01/22/2023]
|
19
|
Schaefert R, Hausteiner-Wiehle C, Häuser W, Ronel J, Herrmann M, Henningsen P. Non-specific, functional, and somatoform bodily complaints. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:803-13. [PMID: 23248710 PMCID: PMC3521192 DOI: 10.3238/arztebl.2012.0803] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 09/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND 4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part. METHODS The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences. RESULTS Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy. CONCLUSION A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.
Collapse
Affiliation(s)
- Rainer Schaefert
- Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Thibautstrasse 2, Heidelberg, Germany.
| | | | | | | | | | | |
Collapse
|
20
|
Weidenhammer W, Hausteiner C, Zilker T, Melchart D, Bornschein S. Does a specific dental amalgam syndrome exist? A comparative study. Acta Odontol Scand 2012; 67:233-9. [PMID: 19391051 DOI: 10.1080/00016350902915348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this article was to investigate whether there is evidence for a specific syndrome of health problems attributed to dental amalgam. MATERIAL AND METHODS A secondary and retrospective analysis of two different databases was performed: (a) 90 patients (47% female, mean (SD) age 34 (6) years) of a clinical trial to remove amalgam fillings who attribute their health complaints to dental amalgam, and (b) 116 patients (62% female, mean (SD) age 37 (8) years) from an outpatient unit for environmental medicine who attribute their symptoms to environmental sources other than amalgam. RESULTS The samples differed in age, sex, and educational level. No statistically significant differences between either of the groups were found in overall psychological distress, intensity of the symptoms, or in numbers of self-reported symptoms in the Symptom Check List after controlling for age, sex, and education (Mean Global Severity Index 0.62 versus 0.63). Patients from the amalgam group showed mean values for private and public self-consciousness similar to the population norm, while patients from the comparison group had statistically significantly decreased mean values. While the amalgam group more frequently reported mental symptoms, patients from the comparison group had a higher prevalence of somatic symptoms. CONCLUSIONS The results showed some differences in symptomatology, while general psychological distress was similar in both groups, indicating no strong evidence for an amalgam-specific syndrome.
Collapse
|
21
|
Diskussion um Konzepte und Diagnostik somatoformer Störungen. DER NERVENARZT 2012; 83:1097-105. [DOI: 10.1007/s00115-011-3443-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Carrington A, Rock B, Stern J. Psychoanalytic thinking in primary care: The Tavistock Psychotherapy Consultation model. PSYCHOANALYTIC PSYCHOTHERAPY 2012. [DOI: 10.1080/02668734.2012.678636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
23
|
|
24
|
Serotonin Transporter Gene Promotor Polymorphism (5-HTTLPR) Associations with Number of Psychotropic Medication Trials in a Tertiary Care Outpatient Psychiatric Consultation Practice. PSYCHOSOMATICS 2011; 52:147-53. [DOI: 10.1016/j.psym.2010.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 05/11/2010] [Accepted: 05/17/2010] [Indexed: 11/22/2022]
|
25
|
Rundell JR, Staab JP, Shinozaki G, Saad-Pendergrass D, Moore K, McAlpine D, Mrazek D. Pharmacogenomic Testing in a Tertiary Care Outpatient Psychosomatic Medicine Practice. PSYCHOSOMATICS 2011; 52:141-6. [DOI: 10.1016/j.psym.2010.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/20/2009] [Accepted: 11/23/2009] [Indexed: 11/29/2022]
|
26
|
Schaefert R, Laux G, Kaufmann C, Schellberg D, Bölter R, Szecsenyi J, Sauer N, Herzog W, Kuehlein T. Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care. J Psychosom Res 2010; 69:267-77. [PMID: 20708449 DOI: 10.1016/j.jpsychores.2010.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE (i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner. METHODS Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient. RESULTS Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented. CONCLUSIONS ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.
Collapse
Affiliation(s)
- Rainer Schaefert
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Thibautstrasse 2, Heidelberg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|