Individual patient education for low back pain

BACKGROUND

While many different types of patient education are widely used, the effect of individual patient education for low-back pain (LBP) has not yet been systematically reviewed.

OBJECTIVES

To determine whether individual patient education is effective in the treatment of non-specific low-back pain and which type is most effective.

SEARCH STRATEGY

A computerized literature search of MEDLINE (1966 to July 2006), EMBASE (1988 to July 2006), CINAHL (1982 to July 2006), PsycINFO (1984 to July 2006), and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2) was performed. References cited in the identified articles were screened.

SELECTION CRITERIA

Studies were selected if the design was a randomised controlled trial; if patients experienced LBP; if the type of intervention concerned individual patient education, and if the publication was written in English, German, or Dutch.

DATA COLLECTION AND ANALYSIS

The methodological quality was independently assessed by two review authors. Articles that met at least 50% of the quality criteria were considered high quality. Main outcome measures were pain intensity, global measure of improvement, back pain-specific functional status, return-to-work, and generic functional status. Analysis comprised a qualitative analysis. Evidence was classified as strong, moderate, limited, conflicting or no evidence.

MAIN RESULTS

Of the 24 studies included in this review, 14 (58%) were of high quality. Individual patient education was compared with no intervention in 12 studies; with non-educational interventions in 11 studies; and with other individual educational interventions in eight studies. Results showed that for patients with subacute LBP, there is strong evidence that an individual 2.5 hour oral educational session is more effective on short-term and long-term return-to-work than no intervention. Educational interventions that were less intensive were not more effective than no intervention. Furthermore, there is strong evidence that individual education for patients with (sub)acute LBP is as effective as non-educational interventions on long-term pain and global improvement and that for chronic patients, individual education is less effective for back pain-specific function when compared to more intensive interventions. Comparison of different types of individual education did not show significant differences.

AUTHORS' CONCLUSIONS

For patients with acute or subacute LBP, intensive patient education seems to be effective. For patients with chronic LBP, the effectiveness of individual education is still unclear.

WITHDRAWN: Interventions to implement prevention in primary care

BACKGROUND

Primary care physicians hold a strategic position in delivering preventive services. However discrepancies exist between evidence based guidelines and practice.

OBJECTIVES

To assess the effects of interventions to improve the delivery of preventive services in primary care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (November 1995; August 1999), MEDLINE (1980 to 1995) and hand searched relevant journals.

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of interventions to improve preventive services by primary care professionals responsible for patient care.

DATA COLLECTION AND ANALYSIS

Two researchers independently extracted data and assessed study quality.

MAIN RESULTS

Fifty-five studies were included, involving more than 2000 health professionals and 99,000 people, with 83 comparisons between intervention and control groups. Post intervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not in others. Five comparisons of group education versus no intervention showed absolute change of preventive services varying between -4% and +31%. Nine comparisons of physician reminders versus no intervention showed absolute change of preventive services varying between 5% and 24%. Fourteen comparisons of multifaceted interventions versus no intervention showed absolute change of preventive services varying between -3% and +64%. Six comparisons of multifaceted interventions versus group education reported absolute changes varying between -31% and +28%. All these comparisons used randomised groups. Ten comparisons of multifaceted interventions versus no intervention used non-randomised groups and showed absolute change of preventive services varying between -5% and +21%. The remaining planned comparisons within categories of interventions contained less than five comparisons.

AUTHORS' CONCLUSIONS

There is currently no solid basis for assuming that a particular intervention or package of interventions will work. Effective interventions to increase preventive activities in primary care exist, but there is considerable variation in the level of change achieved, with effect sizes usually small or moderate. Tailoring interventions to address specific barriers to change in a particular setting is probably important. Multifaceted interventions may be more effective than single interventions, because more barriers to change can be addressed. Future research should analyse barriers to change and interventions to implement preventive services in more detail, to clarify how interventions relate to specific barriers. Since more complex interventions are likely to be more effective but also more costly, economic evaluations should also be included.

Interventions for improving older patients' involvement in primary care episodes

BACKGROUND

There is a growing expectation among patients that they should be involved in the delivery of medical care. Accumulating evidence from empirical studies shows that patients of average age who are encouraged to participate more actively in treatment decisions have more favourable health outcomes, in terms of both physiological and functional status, than those who do not. Interventions to encourage more active participation may be focused on different stages, including: the use of health care; preparation for contact with a care provider; contact with the care provider; or feedback about care. However, it is unclear whether the benefits of these interventions apply to the elderly as well.

OBJECTIVES

To assess the effects of interventions in primary medical care that improve the involvement of older patients (>=65 years) in their health care.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (May 2003); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 1, 2004; MEDLINE (Ovid) (1966 to June 2004); EMBASE (1988 to June 2004); PsycINFO (1872 to June 2004); DARE, The Cochrane Library issue 1, 2004; ERIC (1966 to June 2004); CINAHL (1982 to June 2004); Sociological Abstracts (1963 to June 2004); Dissertation Abstracts International (1861 to June 2004); and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised trials of interventions to improve the involvement of older patients (>= 65 years) in single consultations or episodes of primary medical care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Results are presented narratively as meta-analysis was not possible.

MAIN RESULTS

We identified three studies involving 433 patients. Overall, the quality of studies was not high, and there was moderate to high risk of bias. Interventions of a pre-visit booklet and a pre-visit session (either combined or pre-visit session alone) led to more questioning behaviour and more self-reported active behaviour in the intervention group (3 studies). One study (booklet and pre-visit session) showed no difference in consultation length and time engaged in talk between the intervention and control groups. The booklet and pre-visit session in one study was associated with more satisfaction with interpersonal aspects of care for the intervention group although no difference in overall satisfaction between intervention and control. There was no long-term follow up to see if effects were sustained. No studies measured outcomes relating to the use of health care, health status and wellbeing, or health behaviour.

AUTHORS' CONCLUSIONS

Overall this review shows some positive effects of specific methods to improve the involvement of older people in primary care episodes. Because the evidence is limited, however, we can not recommend the use of the reviewed interventions in daily practice. There should be a balance between respecting patients' autonomy and stimulating their active participation in health care. Face-to-face coaching sessions, whether or not complemented with written materials, may be the way forward. As this is impractical for the whole population, it could be worthwhile to identify a subgroup of older patients who might benefit the most from enhanced involvement, ie. those who want to be involved, but lack the necessary skills. This group could be coached either individually or, more practically, in group sessions.

A microscale device for measuring emissions from materials for indoor use

Emission test chambers or cells are used to determine organic vapour emissions from construction products under controlled conditions. Polymeric car trim component emissions are typically evaluated using direct thermal desorption/extraction. The Microchamber/Thermal Extractor (mu-CTE, Markes International) was developed to provide both a complementary tool for rapid screening of volatile organic compound (VOC) emissions--suitable for industrial quality control--and a means for thermal extraction of larger, more representative samples of car trim components. To determine the degree of correlation between conventional emission test methods and the microchamber, experiments were carried out under different conditions of temperature, air change rate and sample conditioning time. Good quantitative and qualitative correlation was obtained for measurements at ambient temperature. Moreover, it was shown that ambient-temperature emissions data collected using the mu-CTE as rapidly as possible--i.e. with minimal or no sample conditioning time--nevertheless provided a reliable guide as to how well that material would perform in subsequent 3-day chamber tests of VOC emissions. The parameters found to have the greatest influence on data correlation for experiments carried out at elevated temperatures were the sample mass (for bulk emissions testing) and the conditioning time. The results also showed that, within the constraints of inherent sample homogeneity, the mu-CTE gave reproducible emissions data, despite its small sample size/capacity relative to that of conventional chambers. Preliminary results of modelling the air flow within a microchamber using computational fluid dynamics showed a high degree of turbulent flow and two potential areas of still air which could cause sink effects. However, the experimental data reported here and in previous studies showed enhanced recovery of semivolatile components from the mu-CTE relative to a recovery from a 1 m(3) conventional chamber. This indicates that if these areas of relatively still air are present within the microchamber, they do not appear to be significant in practice.

Evaluation and cultural adaptation of a German version of the AIMS2-SF questionnaire (German AIMS2-SF)

OBJECTIVES

The aim of the study was to examine the validity of a translated and culturally adapted version of the Arthritis Impact Measurement Scales 2, Short Form (AIMS2-SF) in patients suffering from osteoarthritis (OA) in primary care.

METHODS

A structured procedure was used for the translation and cultural adaptation of the AIMS2-SF into German. The questionnaire was administered to 220 primary care patients with OA of the knee or hip. Test-retest reliability was tested in 35 randomly selected patients, who received the questionnaire a second time after 1 week. The physical scale of the original AIMS2-SF was divided into an 'upper body limitations' scale and a 'lower body limitations' scale.

RESULTS

With values ranging from 0.52 to 0.97 for Pearson's r, item-scale correlations were reasonably good. The discriminative power of separate scales was also good, reflected in low values for correlation between different scales, indicating little redundancy. Only two items (13 and 15) referring to the symptom scale showed item-scale correlation of r = 0.72 and r = 0.67, respectively with the lower body limitation scale. The assessment of internal consistency reliability also revealed satisfactory values: Cronbach's alpha was > or =0.83 for all scales, except for the social interaction scale (0.66). The test-retest reliability, estimated as the intraclass correlation coefficient (ICC), exceeded 0.85 except for the affect scale (0.72). Substantial floor effects occurred in the upper limb scale (33.8%). Principal factor analysis confirmed the postulated three-factor structure with physical, physiological and social dimensions, explaining 49.8, 14.1 and 6.4% of the variation, respectively. The assessment of external validity revealed satisfactory correlations with the corresponding WOMAC (Western Ontario and McMaster Universities Arthrosis Index) scales. As expected, correlations with radiological grading were moderate to low. The correlation with the physician's assessment was high in the scales that were dominated by physical factors, but rather low in the areas of health, which were found to be dominated by psychological or social factors.

CONCLUSION

The German AIMS2-SF is a reliable and valid instrument to assess the quality of life in primary care patients suffering from OA. When addressing the different impacts of OA, the physical scale should be divided into an upper body scale and a lower body scale. The floor and ceiling effects revealed are in accordance with the disease characteristics of the study sample and do not limit the significance of the questionnaire.

Plastics additives in the indoor environment--flame retardants and plasticizers

Phthalic acid esters and phosphororganic compounds (POC) are generally known as semivolatile organic compounds (SVOCs) and are frequently utilized as plasticizers and flame retardants in commercial products. In the indoor environment, both compound groups are released from a number of sources under normal living conditions and accumulate in air and dust. Therefore, inhalation of air and ingestion of house dust have to be considered as important pathways for the assessment of exposure in living habitats. Especially in the case of very young children, the oral and dermal uptake from house dust might be of relevance for risk assessment. A critical evaluation of indoor exposure to phthalates and POC requires the determination of the target compounds in indoor air and house dust as well as emission studies. The latter are usually carried out under controlled conditions in emission test chambers or cells. Furthermore, chamber testing enables the determination of condensable compounds by fogging sampling. In the case of automobiles, specific scenarios have been developed to study material emissions on a test stand or to evaluate the exposure of users while the vehicle is driving. In this review, results from several studies are summarized and compared for seven phthalic esters and eight POC. The available data for room air and dust differ widely depending on investigated compound and compartment. Room air studies mostly include only a limited number of measurements, which makes a statistical evaluation difficult. The situation is much better for house dust measurements. However, the composition of house dust is very inhomogeneous and the result is strongly dependent on the particle size distribution used for analysis. Results of emission studies are presented for building products, electronic equipment, and automobiles. Daily rates for inhalation and dust ingestion of phthalic esters and POC were calculated from 95-percentiles or maximum values. A comparison of the data with results from human biomonitoring studies reveals that only a small portion of intake takes place via the air and dust paths.

Achieving involvement: process outcomes from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice

BACKGROUND

A consulting method known as 'shared decision making' (SDM) has been described and operationalized in terms of several 'competences'. One of these competences concerns the discussion of the risks and benefits of treatment or care options-'risk communication'. Few data exist on clinicians' ability to acquire skills and implement the competences of SDM or risk communication in consultations with patients.

OBJECTIVE

The aims of this study were to evaluate the effects of skill development workshops for SDM and the use of risk communication aids on the process of consultations.

METHODS

A cluster randomized trial with crossover was carried out with the participation of 20 recently qualified GPs in urban and rural general practices in Gwent, South Wales. A total of 747 patients with known atrial fibrillation, prostatism, menorrhagia or menopausal symptoms were invited to a consultation to review their condition or treatments. Half the consultations were randomly selected for audio-taping, of which 352 patients attended and were audio-taped successfully. After baseline, participating doctors were randomized to receive training in (i) SDM skills or (ii) the use of simple risk communication aids, using simulated patients. The alternative training was then provided for the final study phase. Patients were allocated randomly to a consultation during baseline or intervention 1 (SDM or risk communication aids) or intervention 2 phases. A randomly selected half of the consultations were audio-taped from each phase. Raters (independent, trained and blinded to study phase) assessed the audio-tapes using a validated scale to assess levels of patient involvement (OPTION: observing patient involvement), and to analyse the nature of risk information discussed. Clinicians completed questionnaires after each consultation, assessing perceived clinician-patient agreement and level of patient involvement in decisions. Multilevel modelling was carried out with the OPTION score as the dependent variable, and rater, consultation and clinician levels of data, standardized by rater within clinician.

RESULTS

Following each of the interventions, the clinicians significantly increased their involvement of patients in decision making (OPTION score increased by 10.6 following risk communication training [95% confidence interval (CI) 7.9 -13.3; P < 0.001] and by 12.9 after SDM skill development (95% CI 10 -15.8, P < 0.001), a moderate effect size. The level of involvement achieved by the risk communication aids was significantly increased by the subsequent introduction of the skill development workshops (7.7 increase in OPTION score, 95% CI 3.4-12; P < 0.001). The alternative sequence (skills followed by risk communication aids) did not achieve this effect. The use of most risk information formats increased after the provision of specific risk communication aids (P < 0.001). Clinicians using the risk communication tools perceived significantly higher patient and clinician agreement on treatment (P < 0.001), patient satisfaction with information (P < 0.01), clinician satisfaction with decision (P < 0.01) and general overall satisfaction with the consultation (P < 0.001) than those who were exposed to SDM skill development workshops.

CONCLUSIONS

These clinicians were able to acquire the skills to implement SDM competences and to use risk communication aids. Each intervention provided independent effects. Further progress towards greater patient involvement in health care decision making is possible, and skill development in this area should be incorporated into postgraduate professional development programmes.

Relevance of Ara h1, Ara h2 and Ara h3 in peanut-allergic patients, as determined by immunoglobulin E Western blotting, basophil-histamine release and intracutaneous testing: Ara h2 is the most important peanut allergen

BACKGROUND

A number of allergenic proteins in peanut has been described and the relative importance of these allergens is yet to be determined.

OBJECTIVES

We have investigated the relevance of previously identified peanut allergens in well-characterized peanut-allergic patients by in vitro, ex vivo and in vivo assays.

METHODS

Thirty-two adult peanut-allergic patients were included based on careful and standardized patient history and the presence of peanut-specific IgE. The diagnosis peanut allergy was confirmed using double-blind placebo-controlled food challenges in 23 patients. Major peanut allergens Ara h1, Ara h2 and Ara h3 were purified from peanuts using ion-exchange chromatography. IgE immunoblotting was performed and IgE-cross-linking capacity was examined by measuring histamine release (HR) after incubating patient basophils as well as passively sensitized basophils with several dilutions of the allergens. Intracutaneous tests (ICTs) using 10-fold dilution steps of the purified allergens and crude peanut extract were performed.

RESULTS

Ara h2 was recognized most frequently (26 out of 32) in all tests and induced both positive skin tests and basophil degranulation at low concentrations, whereas Ara h1 and Ara h3 were recognized less frequently and reacted only at 100-fold higher concentrations as analysed with HR and intracutaneous testing (ICT). Next to the three tested allergens, proteins with molecular weights of somewhat smaller than 15 kDa were identified as a IgE-binding proteins on immunoblot in the majority of the patients (20 out of 32).

CONCLUSION

We conclude that Ara h2 is, for our patient group, the most important peanut allergen, and that previously unidentified peanut proteins with molecular weights of somewhat smaller than 15 kDa may be important allergens as well. ICT in combination with basophil-HR and IgE immunoblotting provides insight in the patient specificity towards the individual peanut allergens.

Patient-directed strategy to reduce prescribing for patients with dyspepsia in general practice: a randomized trial

BACKGROUND

The percentage of patients receiving long-term treatment with acid suppressive drugs, mainly proton pump inhibitors, is higher than the prevalence of diseases that are commonly accepted as the proper indication for long-term proton pump inhibitor use.

AIM

To evaluate whether a patient-directed intervention (direct mail) reduced the prescription of antisecretory medication for dyspepsia in general practice.

METHODS

A cluster-randomized trial was performed. One hundred and thirteen chronic users of proton pump inhibitors were recruited by 20 general practitioners. An unsolicited information leaflet was sent to patients that suggested stopping or reducing the use of proton pump inhibitors. The number of patients who stopped or reduced proton pump inhibitor use was measured at 12 and 20 weeks after the intervention. Secondary outcome measures were dyspepsia symptom severity and perceived quality of life measured at 12 weeks after the intervention.

RESULTS

Fourteen of the 59 (24%) intervention group patients stopped or reduced their use of proton pump inhibitors, compared with three of the 45 (7%) control group patients (relative risk ratio 3.56; CI 95%: 1.088-11.642). Dyspepsia symptom severity and quality of life did not change.

CONCLUSIONS

A simple patient-directed intervention reduced the volume of long-term prescriptions of proton pump inhibitors in patients with dyspepsia.

Sensory testing of recipes masking peanut or hazelnut for double-blind placebo-controlled food challenges

BACKGROUND

In a double-blind placebo-controlled food challenge (DBPCFC), it is necessary that recipes comprising the allergen cannot be distinguished from placebo.

AIMS OF THE STUDY

We investigated whether the method of paired comparisons, a sensory difference test, could be used to test the suitability of recipes for a DBPCFC.

METHODS

We used two recipes, each with three concentrations of peanut or hazelnut flour. The recipe for peanut consisted of mashed potatoes with 2.7, 8.9, or 26.8 mg of peanut flour, and the recipe for hazelnut of oatmeal porridge with 74, 247, or 742 mg of hazelnut flour. Corresponding amounts of protein in the provided 15 g portions of each recipe were 0.7, 2.3, and 6.8 mg for peanut, and 11.6, 39, and 117 mg for hazelnut, respectively. Recipes were offered together with a placebo, and evaluated on sensory features by 81 healthy volunteers.

RESULTS

The sensory test was easy to perform. Volunteers were not able to detect peanut flour in mashed potatoes, but they recognized hazelnut flour in oatmeal porridge on visual features.

CONCLUSIONS

Sensory testing by means of the method of paired comparisons is a useful method to evaluate masking of foods for DBPCFC.

Effectiveness and efficiency of guideline dissemination and implementation strategies

OBJECTIVES

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.

DATA SOURCES

MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.

REVIEW METHODS

Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.

RESULTS

In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.

CONCLUSIONS

There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

Peanut allergen Ara h 3: isolation from peanuts and biochemical characterization

BACKGROUND

Peanut allergen Ara h 3 has been the subject of investigation for the last few years. The reported data strongly depend on recombinant Ara h 3, since a purification protocol for Ara h 3 from peanuts was not available.

METHODS

Peanut allergen Ara h 3 (glycinin), was purified and its posttranslational processing was investigated. Its allergenic properties were determined by studying IgE binding characteristics of the purified protein.

RESULTS

Ara h 3 consists of a series of polypeptides ranging from approximately 14 to 45 kDa that can be classified as acidic and basic subunits, similar to the subunit organization of soy glycinin. N-terminal sequences of the individual polypeptides were determined, and using the cDNA deduced amino-acid sequence, the organization into subunits was explained by revealing posttranslational processing of the different polypeptides. IgE-binding properties of Ara h 3 were investigated using direct elisa and Western blotting with sera from peanut-allergic individuals. The basic subunits, and to a lesser extent the acidic subunits, bind IgE and may act as allergenic peptides.

CONCLUSIONS

We conclude that peanut-derived Ara h 3, in contrast to earlier reported recombinant Ara h 3, resembles, to a large extent, the molecular organization typical for proteins from the glycinin family. Furthermore, posttranslational processing of Ara h 3 affects the IgE-binding properties and is therefore an essential subject of study for research on the allergenicity of Ara h 3.

Methods for evaluation of small scale quality improvement projects

Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small scale quality improvement initiatives at a local level. This type of evaluation is useful for a number of different reasons including monitoring the impact of local projects, identifying and dealing with issues as they arise within a project, comparing local projects to draw lessons, and collecting more detailed information as part of a bigger evaluation project. Focused audits and developmental studies can be used for evaluation within projects, while methods such as multiple case studies and process evaluations can be used to draw generalised lessons from local experiences and to provide examples of successful projects. Evaluations of small scale quality improvement projects help those involved in improvement initiatives to optimise their choice of interventions and use of resources. Important information to add to the knowledge base of quality improvement in health care can be derived by undertaking formal evaluation of local projects, particularly in relation to building theory around the processes of implementation and increasing understanding of the complex change processes involved.

Shared decision making: developing the OPTION scale for measuring patient involvement

BACKGROUND

A systematic review has shown that no measures of the extent to which healthcare professionals involve patients in decisions within clinical consultations exist, despite the increasing interest in the benefits or otherwise of patient participation in these decisions.

AIMS

To describe the development of a new instrument designed to assess the extent to which practitioners involve patients in decision making processes.

DESIGN

The OPTION (observing patient involvement) scale was developed and used by two independent raters to assess primary care consultations in order to evaluate its psychometric qualities, validity, and reliability.

STUDY SAMPLE

186 audiotaped consultations collected from the routine clinics of 21 general practitioners in the UK.

METHOD

Item response rates, Cronbach's alpha, and summed and scaled OPTION scores were calculated. Inter-item and item-total correlations were calculated and inter-rater agreements were calculated using Cohen's kappa. Classical inter-rater intraclass correlation coefficients and generalisability theory statistics were used to calculate inter-rater reliability coefficients. Basing the tool development on literature reviews, qualitative studies and consultations with practitioner and patients ensured content validity. Construct validity hypothesis testing was conducted by assessing score variation with respect to patient age, clinical topic "equipoise", sex of practitioner, and success of practitioners at a professional examination.

RESULTS

The OPTION scale provided reliable scores for detecting differences between groups of consultations in the extent to which patients are involved in decision making processes in consultations. The results justify the use of the scale in further empirical studies. The inter-rater intraclass correlation coefficient (0.62), kappa scores for inter-rater agreement (0.71), and Cronbach's alpha (0.79) were all above acceptable thresholds. Based on a balanced design of five consultations per clinician, the inter-rater reliability generalisability coefficient was 0.68 (two raters) and the intra-rater reliability generalisability coefficient was 0.66. On average, mean practitioner scores were very similar (and low on the overall scale of possible involvement); some practitioner scores had more variation around the mean, indicating that they varied their communication styles to a greater extent than others.

CONCLUSIONS

Involvement in decision making is a key facet of patient participation in health care and the OPTION scale provides a validated outcome measure for future empirical studies.

The range of minimum provoking doses in hazelnut-allergic patients as determined by double-blind, placebo-controlled food challenges

BACKGROUND

The risk for allergic reactions depends on the sensitivity of individuals and the quantities of offending food ingested. The sensitivity varies among allergic individuals, as does the threshold dose of a food allergen capable of inducing an allergic reaction.

OBJECTIVE

This study aimed at determining the distribution of minimum provoking doses of hazelnut in a hazelnut-allergic population.

METHODS

Thirty-one patients with a history of hazelnut-related allergic symptoms, a positive skin prick test to hazelnut and/or an elevated specific IgE level, were included. Double-blind, placebo-controlled food challenges (DBPCFC) were performed with seven increasing doses of dried hazelnut (1 mg to 1 g hazelnut protein) randomly interspersed with seven placebo doses.

RESULTS

Twenty-nine patients had a positive challenge. Itching of the oral cavity and/or lips was the first symptom in all cases. Additional gastrointestinal symptoms were reported in five patients and difficulty in swallowing in one patient. Lip swelling was observed in two patients, followed by generalized urticaria in one of these. Threshold doses for eliciting subjective reactions varied from a dose of 1 mg up to 100 mg hazelnut protein (equivalent to 6.4-640 mg hazelnut meal). Extrapolation of the dose-response curve showed that 50% of our hazelnut-allergic population will suffer from an allergic reaction after ingestion of 6 mg (95% CI, 2-11 mg) of hazelnut protein. Objective symptoms were observed in two patients after 1 and 1,000 mg, respectively.

CONCLUSION

DBPCFCs demonstrated threshold doses in half of the hazelnut-allergic patients similar to doses previously described to be hidden in consumer products. This stresses the need for careful labelling and strategies to prevent and detect contamination of food products with hazelnut residues.

Comparison of patients' and general practitioners' evaluations of general practice care

OBJECTIVES

To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care.

DESIGN

Written surveys among patients and GPs.

SETTING

General practice in the Netherlands.

SUBJECTS

1772 patients (from 45 GPs) and a random sample of 315 GPs.

MAIN OUTCOME MEASURES

Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale.

RESULTS

The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone").

CONCLUSIONS

GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

Lower urinary tract symptoms: social influence is more important than symptoms in seeking medical care

OBJECTIVE

To determine associations among lower urinary tract symptoms (LUTS), symptom severity, subjective beliefs and social influences when seeking primary medical care in men aged > or = 50 years.

SUBJECTS AND METHODS

A population-based survey was conducted among 5052 men aged > or = 50 years, using patient registers of 22 general practitioners (GPs) in the Netherlands from November 1999 to May 2000. The questionnaire contained items concerning age, educational level, International Prostate Symptom Score (IPSS), bothersome score (BS), and questions from the Health Belief Model on attitude and social influences. The study population comprised men with an IPSS openface> 7. The odds ratios (ORs) corrected for the IPSS were calculated.

RESULTS

In all, 3544 questionnaires (70.2%) were returned. Two groups of men with an IPSS openface> 7 were compared: those who consulted their GP in the previous 2 years because of voiding problems (268 cases) and the controls (272) who did not visit a GP for these symptoms. Cases more often thought a physician could improve their condition (OR 2.85), appeared to be more often advised by others to seek medical care (OR 6.36) and thought more often that this advice influenced their decision (OR 13.95). They also had more frequently received information from the media (OR 2.66) which affected their attendance (OR 12.52). In a multiple regression analysis, advice from others or information from the media were stronger predictors of seeking care than the influence of symptoms on daily life, the IPSS or the BS.

CONCLUSION

Social influences, i.e. advice from others or the media, were more important factors in the decision to seek medical care than symptom severity.

Research on patients' views in the evaluation and improvement of quality of care

The identification of methods for assessing the views of patients on health care has only developed over the last decade or so. The use of patients' views to improve healthcare delivery requires valid and reliable measurement methods. Four approaches are recognised: inclusion of patients' views in the information to those seeking health care, identification of patient preferences in episodes of care, patient feedback on delivery of health care, and patients' views in decision making on healthcare systems. Outcome measures for the evaluation of the use of patients' views should reflect the aims in terms of processes or outcomes of care, including possible negative consequences. Rigorous methodologies for the evaluation of methods have yet to be implemented.

Feedback of patients' evaluations of general practice care: a randomised trial

OBJECTIVE

To assess the effects of feedback of patients' evaluations of care to general practitioners.

DESIGN

Randomised trial.

SETTING

General practice in the Netherlands.

SUBJECTS

55 GPs and samples of 3691 and 3595 adult patients before and after the intervention, respectively.

INTERVENTIONS

GPs in the intervention group were given an individualised structured feedback report concerning evaluations of care provided by their own patients. Reference figures referring to other GPs were added as well as suggestions for interpretation of this feedback, an evidence-based overview of factors determining patients' evaluations of care, and methods to discuss and plan improvements.

MAIN OUTCOME MEASURES

Patients' evaluations of nine dimensions of general practice measured with the CEP, a previously validated questionnaire consisting of 64 questions, using a six point answering scale (1= poor, 6 = very good).

RESULTS

Mean scores per CEP dimension varied from 3.88 to 4.77. Multilevel regression analysis showed that, after correction for baseline scores, patients' evaluations of continuity and medical care were less positive after the intervention in the intervention group (4.60 v 4.77, p < 0.05 and 4.68 v 4.71, p < 0.05, respectively). No differences were found in the remaining seven CEP dimensions.

CONCLUSIONS

Providing feedback on patients' evaluations of care to GPs did not result in changes in their evaluation of the care received. This conclusion challenges the relevance of feedback on patients' evaluations of care for quality improvement.

Feedback of patients' evaluations of general practice care: a randomised trial

OBJECTIVE

To assess the effects of feedback of patients' evaluations of care to general practitioners.

DESIGN

Randomised trial.

SETTING

General practice in the Netherlands.

SUBJECTS

55 GPs and samples of 3691 and 3595 adult patients before and after the intervention, respectively.

INTERVENTIONS

GPs in the intervention group were given an individualised structured feedback report concerning evaluations of care provided by their own patients. Reference figures referring to other GPs were added as well as suggestions for interpretation of this feedback, an evidence-based overview of factors determining patients' evaluations of care, and methods to discuss and plan improvements.

MAIN OUTCOME MEASURES

Patients' evaluations of nine dimensions of general practice measured with the CEP, a previously validated questionnaire consisting of 64 questions, using a six point answering scale (1= poor, 6 = very good).

RESULTS

Mean scores per CEP dimension varied from 3.88 to 4.77. Multilevel regression analysis showed that, after correction for baseline scores, patients' evaluations of continuity and medical care were less positive after the intervention in the intervention group (4.60 v 4.77, p < 0.05 and 4.68 v 4.71, p < 0.05, respectively). No differences were found in the remaining seven CEP dimensions.

CONCLUSIONS

Providing feedback on patients' evaluations of care to GPs did not result in changes in their evaluation of the care received. This conclusion challenges the relevance of feedback on patients' evaluations of care for quality improvement.

Functional status, health problems, age and comorbidity in primary care patients

OBJECTIVES

To determine the relationship between functional status and health problems, age and comorbidity in primary care patients.

METHODS

Patients from 60 general practitioners who visited their general practitioner were recruited and asked to complete a written questionnaire, including a list of 25 health problems and the SF-36 to measure functional status. The response rate was 67% (n = 4,112). Differences between subgroups were tested with p < 0.01.

RESULTS

Poorer functional status which was associated with increased age (except for vitality) and increased co-morbidity. Patients with asthma/ bronchitis/COPD, severe heart disease/infarction, chronic backpain, arthrosis of knees, hips or hands, or an 'other disease' had poorer scores on at least five dimensions of functional status. Patients with hypertension, diabetes mellitus or cancer did not differ from patients without these conditions on more than one dimension of functional status. In the multiple regression analysis age, had a negative effect on functional status (standardised beta-coefficients between -0.03 and -0.34) except for vitality. Co-morbidity had a negative effect on physical role constraints (-0.15) and bodily pain (-0.09). All health problems had effects on dimensions of functional status (coefficients between -0.04 and -0.13). General health and physical dimensions of functional status were better predicted by health problems, age and co-morbidity (between 6.4 and 16.5% of variation explained) than mental dimensions of functional status (between 1.1 and 3.2%).

CONCLUSION

Higher age was a predictor of poorer functional status, but there was little evidence for an independent effect of co-morbidity on functional status. Health problems had differential impact on functional status among primary care patients.

Implementation barriers for general practice guidelines on low back pain a qualitative study

STUDY DESIGN

Qualitative study design, using semi-structured interviews.

OBJECTIVE

To explore factors that determine non-adherence to the guidelines for low back pain.

SUMMARY OF BACKGROUND DATA

Guidelines for low back pain have been published in the past decade in various countries. In the Netherlands, general practitioners adhere to them to a fair extent, and it is unclear whether room for improvement remains.

METHODS

Forty semistructured, in-depth interviews were conducted with twenty patients who consulted for low back pain, and with their general practitioners. The interviews were fully transcribed and analyzed qualitatively.

RESULTS

Patients often had limited expectations of the consultation. They wanted to hear a diagnosis or expected to receive simple advice. The general practitioners said they were well informed about the guideline and mostly agreed with its content. Reasons for non-adherence were mainly related to patients' experiences in the past and general practitioners' interpretations of their preferences. General practitioners stated that they were inclined to give in to patients' demands, for example the request for radiographic films or a referral to a physical therapist. In general, patients and their general practitioners were satisfied with the chosen management.

CONCLUSIONS

Improvement of the quality of back pain care may still be possible. Implementation strategies should aim at training physicians in communication skills, especially about subjects for debate, where patients' beliefs and experiences color their expectations.

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns

The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding

METHOD

The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.