A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations

Preferences, predictions and patient enablement: a preliminary study

BACKGROUND

The widely used patient enablement instrument (PEI) is sometimes contrasted against measures of patient satisfaction as being a more objective measure of consultation quality, in that it is less likely to be positively influenced by fulfilling pre-existing expectations for specific consultation outcomes (such as prescriptions or referrals). However the relationship between expectation and enablement is underexplored, as is the relationship between 'expectation' understood as a patient preference for outcome, and patient prediction of outcome. The aims of the study are to 1) assess the feasibility of measuring the relationship between expectation fulfilment and patient enablement, and 2) measure the difference (if any) between expectation understood as preference, and expectation understood as prediction.

METHODS

A questionnaire study was carried out on 67 patients attending three General Practices in the Australian Capital Territory. Patient preferences and predictions for a range of possible outcomes were recorded prior to the consultation. PEI and the actual outcomes of the consultation were recorded at the conclusion of the consultation. Data analysis compared expectation fulfilment as concordance between the preferred, predicted, and actual outcomes, with the PEI as a dependant variable.

RESULTS

No statistically significant relationship was found between either preference-outcome concordance and PEI, or prediction-outcome concordance. Statistically insignificant trends in both cases ran counter to expectations; i.e. with PEI (weakly) positively correlated with greater discordance. The degree of concordance between preferred outcomes and predicted outcomes was less than the concordance between either preferred outcomes and actual outcomes, or predicted outcomes and actual outcomes.

CONCLUSIONS

The relationship between expectation fulfilment and enablement remains uncertain, whether expectation is measured as stated preferences for specific outcomes, or the predictions made regarding receiving such outcomes. However the lack of agreement between these two senses of 'patient expectation' suggests that explicitly demarcating these concepts during study design is strongly advisable.

A pilot randomised controlled trial of a preconsultation web-based intervention to improve the care quality and clinical outcomes of diabetes outpatients (DIAT)

INTRODUCTION

Diabetes is a chronic condition associated with many long-term complications. People with diabetes need to actively manage their condition, which can be complex. In consultations with healthcare professionals, patients receive advice about their diabetes but do not always discuss things which concern them, perhaps because of the perceived limited time or embarrassment. We want to test a 'preconsultation' intervention in which the patient is supported by a healthcare assistant to complete a web-based intervention aimed at producing an agenda to help them identify important areas for discussion in the consultation. Use of this agenda may enable the patient to play a more active role in that consultation and consequently become more confident, and hence more successful, in managing their condition.

METHODS AND ANALYSIS

In this pilot randomised controlled trial, 120 people with diabetes will be randomised with equal allocation to receive the intervention or usual clinical care. The primary outcome is reduction in glycosylated haemoglobin(HbA1c). Secondary outcomes are patient-reported communication, enablement, self-care activity, diabetes-dependent quality of life, empowerment, satisfaction, health-related quality of life and resource use. The aim of the pilot study was to estimate parameters to inform the design of the definitive trial. Follow-up on quantitative outcomes will be at 3 and 6 months. A nested qualitative study will collect data on the patients' experiences of producing an agenda. Resource use data and medication use will also be collected via a review of medical records for a sample of participants.

ETHICS AND DISSEMINATION

Approval was granted by the NHS Research Ethics Committee North West-Preston (13/NW/0123). Dissemination will include publication of quantitative and qualitative findings, and experience of public involvement in peer-reviewed journals. Results will also be disseminated to trial participants via workshops led by lay coapplicants.

TRIAL REGISTRATION

ISRCTN75070242.

Patient empowerment in long-term conditions: development and preliminary testing of a new measure

Background

Patient empowerment is viewed by policy makers and health care practitioners as a mechanism to help patients with long-term conditions better manage their health and achieve better outcomes. However, assessing the role of empowerment is dependent on effective measures of empowerment. Although many measures of empowerment exist, no measure has been developed specifically for patients with long-term conditions in the primary care setting. This study presents preliminary data on the development and validation of such a measure.

Methods

We conducted two empirical studies. Study one was an interview study to understand empowerment from the perspective of patients living with long-term conditions. Qualitative analysis identified dimensions of empowerment, and the qualitative data were used to generate items relating to these dimensions. Study two was a cross-sectional postal study involving patients with different types of long-term conditions recruited from general practices. The survey was conducted to test and validate our new measure of empowerment. Factor analysis and regression were performed to test scale structure, internal consistency and construct validity.

Results

Sixteen predominately elderly patients with different types of long-term conditions described empowerment in terms of 5 dimensions (identity, knowledge and understanding, personal control, personal decision-making, and enabling other patients). One hundred and ninety seven survey responses were received from mainly older white females, with relatively low levels of formal education, with the majority retired from paid work. Almost half of the sample reported cardiovascular, joint or diabetes long-term conditions. Factor analysis identified a three factor solution (positive attitude and sense of control, knowledge and confidence in decision making and enabling others), although the structure lacked clarity. A total empowerment score across all items showed acceptable levels of internal consistency and relationships with other measures were generally supportive of its construct validity.

Conclusion

Initial analyses suggest that the new empowerment measure meets basic psychometric criteria. Reasons concerning the failure to confirm the hypothesized factor structure are discussed alongside further developments of the scale.

A consulta homeopática: examinando seu efeito em pacientes da atenção básica

O artigo analisa resultados de pesquisa que investigou, sob o prisma da integralidade do cuidado, a contribuição da inserção experimental da atenção homeopática em centro de saúde-escola. São examinados os efeitos da consulta homeopática na perspectiva dos usuários, por meio de dados obtidos em grupo de pacientes acompanhados por um período médio de 12 meses. Tomam-se, para análise, as narrativas desses participantes em grupos focais e os resultados obtidos com a aplicação de questionário desenvolvido na Escócia para avaliar o efeito das consultas médicas na atenção primária. Os resultados sugerem que, enquanto tecnologia de cuidado, a abordagem homeopática utilizada neste estudo é favorecedora da integralidade e depositária de qualidades que merecem uma maior atenção e investigação mais ampla para que possa ser avaliada em seus diferentes modelos de inserção na saúde publica.

INvolvement of breast CAncer patients during oncological consultations: a multicentre randomised controlled trial--the INCA study protocol

INTRODUCTION

Studies on patient involvement show that physicians make few attempts to involve their patients who ask few questions if not facilitated. On the other hand, the patients who participate in the decision-making process show greater treatment adherence and have better health outcomes. Different methods to encourage the active participation during oncological consultation have been described; however, similar studies in Italy are lacking. The aims of the present study are to (1) assess the effects of a preconsultation intervention to increase the involvement of breast cancer patients during the consultation, and (2) explore the role of the attending companions in the information exchange during consultation.

METHODS AND ANALYSIS

All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patient's perceived achievement of her information needs; the patient's satisfaction and ability to cope; the quality of the doctor-patient relationship in terms of patient-centeredness; and the number of questions asked by the patient's companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group.

ETHICS AND DISSEMINATION

The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01510964.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Management of irritable bowel syndrome in primary care: the results of an exploratory randomised controlled trial of mebeverine, methylcellulose, placebo and a self-management website

Background

Many patients with IBS suffer on-going symptoms. The evidence base is poor for IBS drugs but they are widely prescribed and advised in Guidelines. Cognitive Behavioural Therapy (CBT) can be helpful, but availability is poor in the NHS. We developed a web-based CBT self-management programme (Regul8) in partnership with patients and trialled it and common IBS medications in an exploratory factorial RCT to test trial procedures and provide information for a larger trial.

Methods

Patients, 16 to 60 years, with IBS symptoms fulfilling Rome III criteria were recruited via GP practices and randomised to over-encapsulated mebeverine, methylcellulose or placebo for 6 weeks and to 1 of 3 website conditions: Regul8 with a nurse telephone session and email support, Regul8 with minimal email support, or no website.

Results

135 patients recruited from 26 GP practices. Mean IBS SSS score 241.9 (sd 87.7), IBS-QOL 64 (sd 20) at baseline. 91% follow-up at 12 weeks. Mean IBS SSS decreased by 35 points from baseline to 12 weeks. There was no significant difference in IBS SSS or IBS-QOL score between medication or website groups at 12 weeks, or in medication groups at 6 weeks, or IBS-QOL in website groups at 6 weeks. However, IBS SSS at 6 weeks was lower in the No website group than the website groups (IBS SSS no website =162.8 (95% CI 137.4-188.3), website 197.0 (172.4 - 221.7), Website + telephone support 208.0 (183.1-233.0) p = 0.037).

Enablement and Subjects Global Assessment of relief (SGA) were significantly improved in the Regul8 groups compared to the non-website group at 12 weeks (Enablement = 0 in 56.8% of No website group, 18.4% website, 10.5% Website + support, p = 0.001) (SGA; 32.4% responders in No website group, 45.7% website group, 63.2% website + support group, p = 0.035).

Conclusions

This exploratory study demonstrates feasibility and high follow-up rates and provides information for a larger trial. Primary outcomes (IBS SS and IBS QOL) did not reach significance at 6 or 12 weeks, apart from IBS SSS being lower in the no-website group at 6 weeks - this disappeared by 12 weeks. Improved Enablement suggests patients with access to the Regul8 website felt better able to cope with their symptoms than the non-website group. Improved SGA score in the Regul8 groups may indicate some overall improvement not captured on other measures.

Trial registration

ClinicalTrials.gov Identifier (NCT number): NCT00934973.

Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial

OBJECTIVES

To evaluate the effect of training primary care health professionals in behaviour change counselling on the proportion of patients self reporting change in four risk behaviours (smoking, alcohol use, exercise, and healthy eating).

DESIGN

Cluster randomised trial with general practices as the unit of randomisation.

SETTING

General practices in Wales.

PARTICIPANTS

53 general practitioners and practice nurses from 27 general practices (one each at all but one practice) recruited 1827 patients who screened positive for at least one risky behaviour.

INTERVENTION

Behaviour change counselling was developed from motivational interviewing to enable clinicians to enhance patients' motivation to change health related behaviour. Clinicians were trained using a blended learning programme called Talking Lifestyles.

MAIN OUTCOME MEASURES

Proportion of patients who reported making beneficial changes in at least one of the four risky behaviours at three months.

RESULTS

1308 patients from 13 intervention and 1496 from 14 control practices were approached: 76% and 72% respectively agreed to participate, with 831 (84%) and 996 (92%) respectively screening eligible for an intervention. There was no effect on the primary outcome (beneficial change in behaviour) at three months (362 (44%) v 404 (41%), odds ratio 1.12 (95% CI 0.90 to 1.39)) or on biochemical or biometric measures at 12 months. More patients who had consulted with trained clinicians recalled consultation discussion about a health behaviour (724/795 (91%) v 531/966 (55%), odds ratio 12.44 (5.85 to 26.46)) and intended to change (599/831 (72%) v 491/996 (49%), odds ratio 2.88 (2.05 to 4.05)). More intervention practice patients reported making an attempt to change (328 (39%) v 317 (32%), odds ratio 1.40 (1.15 to 1.70)), a sustained behaviour change at three months (288 (35%) v 280 (28%), odds ratio 1.36 (1.11 to 1.65)), and reported slightly greater improvements in healthy eating at three and 12 months, plus improved activity at 12 months. Training cost £1597 per practice.

DISCUSSION

Training primary care clinicians in behaviour change counselling using a brief blended learning programme did not increase patients reported beneficial behaviour change at three months or improve biometric and a biochemical measure at 12 months, but it did increase patients' recollection of discussing behaviour change with their clinicians, intentions to change, attempts to change, and perceptions of having made a lasting change at three months. Enduring behaviour change and improvements in biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling without additional intervention.

TRIAL REGISTRATION

ISRCTN 22495456.

Two principal components, coping and independence, comprise patient enablement in Japan: cross sectional study in Tohoku area

The concept of "patient enablement" involves patients' perceptions of ability to understand and cope with illness. Improving enablement is an important goal of medical consultations for patients with chronic illness. To measure "enablement," a post-medical-consultation patient-reported questionnaire was developed and named "Patient Enablement Instrument (PEI)" in the United Kingdom. Unfortunately, there has been no tool to evaluate patient enablement in Japan. Therefore, this study aimed to develop PEI Japanese version, to examine its validity and reliability, and to clarify the constitution of concept about patient enablement among Japanese patients. The translation process included forward translation, expert panel back-translation, following the standard WHO process. Participants were 256 individuals (157 men and 99 women; mean age 62.9 ± 11.8 years) receiving a regular outpatient treatment due to chronic illness at the Department of Cardiology, Respiratory, or Endocrinology and Metabolism in a regional hospital. To assess validity, we compared PEI with Medical Interview Satisfaction Scale (MISS) by correlation coefficient, which was 0.55 (P < 0.01). Furthermore, factor analysis indicated that PEI had two principal factors labeled "coping with illness and health maintenance" and "confidence in oneself and independence". For an evaluation of reliability, internal consistency was calculated (Cronbach's alpha = 0.875). In conclusion, two principal factors comprise patient enablement measured by PEI with satisfactory validity and reliability. PEI Japanese version will be a useful tool to evaluate and improve medical consultations in Japan.

Prospects for rebuilding primary care using the patient-centered medical home

Existing research suggests that models of enhanced primary care lead to health care systems with better performance. What the research does not show is whether such an approach is feasible or likely to be effective within the U.S. health care system. Many commentators have adopted the model of the patient-centered medical home as policy shorthand to address the reinvention of primary care in the United States. We analyze potential barriers to implementing the medical home model for policy makers and practitioners. Among others, these include developing new payment models, as well as the need for up-front funding to assemble the personnel and infrastructure required by an enhanced non-visit-based primary care practice and methods to facilitate transformation of existing practices to functioning medical homes.

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

BACKGROUND

Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported.

AIM

To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation.

DESIGN AND SETTING

Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month.

METHOD

Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy.

RESULTS

PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas.

CONCLUSION

In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.

Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients

BACKGROUND

Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework.

METHOD/DESIGN

For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life, patient enablement, global rating of change in health and private health service utilization at baseline, 6, 12, 36 and 60 months.

DISCUSSION

The quality of care and effectiveness of the RAMP in enhancing the health for patients with type 2 diabetes will be determined. Possible areas for quality enhancement will be identified and standards of good practice can be established. The information will be useful in guiding service planning and policy decision making.

Comparative effectiveness of traditional Chinese medicine and psychosocial care in the treatment of temporomandibular disorders-associated chronic facial pain

This dual-site study sought to identify the appropriate role for traditional Chinese medicine (TCM; acupuncture and herbs) in conjunction with a validated psychosocial self-care (SC) intervention for treating chronic temporomandibular disorders (TMD)-associated pain. Participants with Research Diagnostic Criteria for Temporomandibular Disorders-confirmed TMD (n = 168) entered a stepped-care protocol that began with a basic TMD class. At weeks 2 and 10, patients receiving SC whose worst facial pain was above predetermined levels were reallocated by minimization to SC or TCM with experienced practitioners. Characteristic facial pain (CFP: mean of worst pain, average pain when having pain, and current pain; each visual analog scale [VAS] 0-10) was the primary outcome. Social activity interference (VAS 0-10) was a secondary outcome. Patients were monitored for safety. TCM provided significantly greater short-term (8-week) relief than SC (CFP reduction difference, -.60 [standard deviation of the estimate .26], P = .020) and greater reduction in interference with social activities (-.81 [standard deviation of the estimate .33], P = .016). In 2 of 5 treatment trajectory groups, more than two thirds of participants demonstrated clinically meaningful responses (≥30% improvement) in pain interference over 16 weeks. This study provides evidence that TMD patients referred for TCM in a community-based model will receive safe treatment that is likely to provide some short-term pain relief and improved quality of life. Similar designs may also apply to evaluations of other kinds of chronic pain. (ClinicalTrials.gov number NCT00856167).

PERSPECTIVE

This short-term comparative effectiveness study of chronic facial pain suggests that TCM is safe and frequently efficacious alone or subsequent to standard psychosocial interventions. TCM is widely available throughout North America and may provide clinicians and patients with a reasonable addition or alternative to other forms of therapy.

Patient empowerment: the need to consider it as a measurable patient-reported outcome for chronic conditions

BACKGROUND

Health policy in the UK and elsewhere is prioritising patient empowerment and patient evaluations of healthcare. Patient reported outcome measures now take centre-stage in implementing strategies to increase patient empowerment. This article argues for consideration of patient empowerment itself as a directly measurable patient reported outcome for chronic conditions, highlights some issues in adopting this approach, and outlines a research agenda to enable healthcare evaluation on the basis of patient empowerment.

DISCUSSION

Patient empowerment is not a well-defined construct. A range of condition-specific and generic patient empowerment questionnaires have been developed; each captures a different construct e.g. personal control, self-efficacy/self-mastery, and each is informed by a different implicit or explicit theoretical framework. This makes it currently problematic to conduct comparative evaluations of healthcare services on the basis of patient empowerment. A case study (clinical genetics) is used to (1) illustrate that patient empowerment can be a valued healthcare outcome, even if patients do not obtain health status benefits, (2) provide a rationale for conducting work necessary to tighten up the patient empowerment construct (3) provide an exemplar to inform design of interventions to increase patient empowerment in chronic disease. Such initiatives could be evaluated on the basis of measurable changes in patient empowerment, if the construct were properly operationalised as a patient reported outcome measure. To facilitate this, research is needed to develop an appropriate and widely applicable generic theoretical framework of patient empowerment to inform (re)development of a generic measure. This research should include developing consensus between patients, clinicians and policymakers about the content and boundaries of the construct before operationalisation. This article also considers a number of issues for society and for healthcare providers raised by adopting the patient empowerment paradigm.

SUMMARY

Healthcare policy is driving the need to consider patient empowerment as a measurable patient outcome from healthcare services. Research is needed to (1) tighten up the construct (2) develop consensus about what is important to include (3) (re)develop a generic measure of patient empowerment for use in evaluating healthcare (4) understand if/how people make trade-offs between empowerment and gain in health status.

Patient participation in the discussions of options in Spanish primary care consultations

OBJECTIVES

To determine patients' participation in the discussion of options in primary care consultations. Identify the patients' wish to participate and their perceptions of their participation and explore the potential factors that may influence these.

DESIGN

Cross-sectional study. Setting. Ninety-seven general practices. Participants. six hundred and fifty-eight patients who went to their doctors for unselected reasons. Measurements. All the encounters were videoed, patient participation in decision making (DM) was assessed with two tools. After the consultation, GPs completed a questionnaire about biomedical and relational information. Patients' preferences and perception of participation was explored with different type of questions.

RESULTS

Encounters successfully videoed: 638. Of these, only 90 interviews clearly showed patient participation. In 161 other interviews, patient participation was considered possible. Questionnaires collected: 645. In 60% of the situations (390 encounters), patients wished they could have stated their views about the proposed option(s), but they perceived this did not happen. The degree of participation at the consultation did not relate significantly with the physician's ideas about the type of problem, evolution and treatment. Neither did any of the considered variables influence either the patients' wish to participate in the discussion of the suggested option or their perception of this.

CONCLUSIONS

GPs ask patients for their opinion and promote discussion about the suggested plan in few encounters. Patients perceive this, including many patients that previously had declared not to be interested in being involved in decisions. These results revealed an important mismatch between what patients wish and what they perceive.

The effect of the Talking Diabetes consulting skills intervention on glycaemic control and quality of life in children with type 1 diabetes: cluster randomised controlled trial (DEPICTED study)

OBJECTIVE

To evaluate the effectiveness on glycaemic control of a training programme in consultation skills for paediatric diabetes teams.

DESIGN

Pragmatic cluster randomised controlled trial.

SETTING

26 UK secondary and tertiary care paediatric diabetes services.

PARTICIPANTS

79 healthcare practitioners (13 teams) trained in the intervention (359 young people with type 1 diabetes aged 4-15 years and their main carers) and 13 teams allocated to the control group (334 children and their main carers).

INTERVENTION

Talking Diabetes programme, which promotes shared agenda setting and guiding communication style, through flexible menu of consultation strategies to support patient led behaviour change.

MAIN OUTCOME MEASURES

The primary outcome was glycated haemoglobin (HbA(1c)) level one year after training. Secondary outcomes were clinical measures (hypoglycaemic episodes, body mass index, insulin regimen), general and diabetes specific quality of life, self reported and proxy reported self care and enablement, perceptions of the diabetes team, self reported and carer reported importance of, and confidence in, undertaking diabetes self management measured over one year. Analysis was by intention to treat. An integrated process evaluation included audio recording a sample of 86 routine consultations to assess skills shortly after training (intervention group) and at one year follow-up (intervention and control group). Two key domains of skill assessment were use of the guiding communication style and shared agenda setting.

RESULTS

660/693 patients (95.2%) provided blood samples at follow-up. Training diabetes care teams had no effect on HbA(1c) levels (intervention effect 0.01, 95% confidence interval -0.02 to 0.04, P=0.5), even after adjusting for age and sex of the participants. At follow-up, trained staff (n=29) were more capable than controls (n=29) in guiding (difference in means 1.14, P<0.001) and agenda setting (difference in proportions 0.45, 95% confidence interval 0.22 to 0.62). Although skills waned over time for the trained practitioners, the reduction was not significant for either guiding (difference in means -0.33, P=0.128) or use of agenda setting (difference in proportions -0.20, -0.42 to 0.05). 390 patients (56%) and 441 carers (64%) completed follow-up questionnaires. Some aspects of diabetes specific quality of life improved in controls: reduced problems with treatment barriers (mean difference -4.6, 95% confidence interval -8.5 to -0.6, P=0.03) and with treatment adherence (-3.1, -6.3 to -0.01, P=0.05). Short term ability to cope with diabetes increased in patients in intervention clinics (10.4, 0.5 to 20.4, P=0.04). Carers in the intervention arm reported greater excitement about clinic visits (1.9, 1.05 to 3.43, P=0.03) and improved continuity of care (0.2, 0.1 to 0.3, P=0.01).

CONCLUSIONS

Improving glycaemic control in children attending specialist diabetes clinics may not be possible through brief, team-wide training in consultation skills.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61568050.

Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial

OBJECTIVE

To determine whether mobile phone based monitoring improves asthma control compared with standard paper based monitoring strategies.

DESIGN

Multicentre randomised controlled trial with cost effectiveness analysis.

SETTING

UK primary care.

PARTICIPANTS

288 adolescents and adults with poorly controlled asthma (asthma control questionnaire (ACQ) score ≥ 1.5) from 32 practices.

INTERVENTION

Participants were centrally randomised to twice daily recording and mobile phone based transmission of symptoms, drug use, and peak flow with immediate feedback prompting action according to an agreed plan or paper based monitoring.

MAIN OUTCOME MEASURES

Changes in scores on asthma control questionnaire and self efficacy (knowledge, attitude, and self efficacy asthma questionnaire (KASE-AQ)) at six months after randomisation. Assessment of outcomes was blinded. Analysis was on an intention to treat basis.

RESULTS

There was no significant difference in the change in asthma control or self efficacy between the two groups (ACQ: mean change 0.75 in mobile group v 0.73 in paper group, mean difference in change -0.02 (95% confidence interval -0.23 to 0.19); KASE-AQ score: mean change -4.4 v -2.4, mean difference 2.0 (-0.3 to 4.2)). The numbers of patients who had acute exacerbations, steroid courses, and unscheduled consultations were similar in both groups, with similar healthcare costs. Overall, the mobile phone service was more expensive because of the expenses of telemonitoring.

CONCLUSIONS

Mobile technology does not improve asthma control or increase self efficacy compared with paper based monitoring when both groups received clinical care to guidelines standards. The mobile technology was not cost effective.

TRIAL REGISTRATION

Clinical Trials NCT00512837.

Insights into Women's Experiences of Hospital Stays: Perceived Control, Powerlessness and Satisfaction

Understanding the psychosocial experiences of women as hospital patients is an important step in assessing the relationship to healthy outcomes of patients' perceived experiences of power and control in hospital. Accordingly, the aims of this study of 124 adult women were (a) to document women's psychosocial experiences during a hospital stay, and (b) to develop and psychometrically evaluate a scale to measure perceived control over treatment, management and daily routine during a hospital stay (Perceived Control in Hospital Scale; PCHS). Women who had experienced a hospital stay of at least one night were surveyed. The qualitative section of the study involved thematic analysis of the written or oral comments of 10 women concerning psychosocial aspects of their hospital experience. Results indicated that the PCHS comprised three factors describing patients' perceptions of their hospital stay: Respect/Communication, Lack of Dignity, and Day-to-Day Control. The survey results showed that although the majority of the women were satisfied with the psychosocial aspects of being an in-patient, there was a substantial core of perceived powerlessness. A significant proportion of women indicated that they either felt “not listened to”, experienced loss of dignity, or experienced unnecessary loss of day-to-day control.

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland

Background

Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.

Methods

A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.

Results

Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.

Conclusions

Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings.

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BACKGROUND

Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.

METHODS

The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.

DISCUSSION

If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN90940049.

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

OBJECTIVE

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

METHODS

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

RESULTS

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

CONCLUSION

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

PRACTICE IMPLICATIONS

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

PURPOSE

To evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy.

METHODS

A two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months.

RESULTS

In all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months.

CONCLUSION

Modelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

Acupuncture for 'frequent attenders' with medically unexplained symptoms: a randomised controlled trial (CACTUS study)

BACKGROUND

Medically unexplained physical symptoms (MUPS) are common and difficult to treat.

AIM

To investigate the effectiveness of adding five-element acupuncture to usual care in 'frequent attenders' with MUPS.

DESIGN AND SETTING

Randomised controlled trial in four London general practices.

METHOD

Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes.

RESULTS

Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control -0.6 [95% CI = -1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = -0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to -0.4 (95% CI = -0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.

CONCLUSION

The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.

Women with breast cancers' preferences for surveillance follow-up

BOCKGROUND: On completion of treatment people with breast cancer are offered surveillance at a hospital clinic and/or in primary care. It is unclear whom patients prefer to consult about their problems following cancer treatment.

METHOD

Patients being followed up by a hospital nurse were surveyed at their follow-up appointment and three months later. The survey included demographic information, symptom profile, and the Patient Enablement Index (PEI). A subsequent survey of the patients' general practitioners (GPs)s confirmed which patients had consulted their GP prior to the nurse appointment. Three months after their appointment patients completed the PEI and were surveyed about their preference of practitioner for problems following treatment.

RESULTS

101 patients responded to the first survey and 60 patients to the follow-up survey. In 68% of cases women reported that they did not consult their GP about breast cancer related symptoms prior to their appointment at the clinic, choosing instead to present to a Breast Care Nurse (BCN). In the survey patients preferred their GP if they needed a physical examination (p = 0.007) or referral to a specialist (p <0.001). Older patients were more likely to choose a BCN if they wanted a mammogram and a GP if they wanted a physical exam or emotional support. The PEI scores after follow-up with the BCNs were equivalent to those reported following GP consultations.

CONCLUSION

Patients prefer their GP overall, but we observed that the majority of women did not consult their GP when they had scheduled appointments with a BCN at a hospital clinic.

The Patient Enablement Instrument-French version in a family practice setting: a reliability study

Background

Patient enablement can be defined as the extent to which a patient is capable of understanding and coping with his or her health issues. This concept is linked to a number of health outcomes such as self-management of chronic diseases and quality of life. The Patient Enablement Instrument (PEI) was designed to measure this concept after a medical consultation. The instrument, in its original form and its translations into several languages, has proven to be reliable and valid. The purpose of this study was to evaluate the reliability of the French version of the PEI (PEI-Fv) in a family practice setting.

Methods

One hundred and ten participants were recruited in a family medicine clinic in the Saguenay region of Quebec (Canada). The PEI-Fv was completed twice, immediately after consultation with a physician (T1) and 2 weeks after the consultation (T2). The internal consistency of the tool was assessed with Cronbach's α and test-retest reliability by intraclass correlation coefficient.

Results

The mean score for the PEI-Fv was 5.06 ± 3.97 (95% confidence interval [CI]: 4.30-5.81) at T1 and 4.63 ± 3.90 (95% CI: 3.82-5.44) at T2. Cronbach's α was high at T1 (α₁ = 0.93; 95% CI: 0.91-0.95) and T2 (α₂ = 0.93; 95% CI: 0.91-0.95). The intraclass correlation coefficient was 0.62 (95% CI: 0.48-0.74), indicating a moderate test-retest reliability.

Conclusions

The internal consistency of the PEI-Fv is excellent. Test-retest reliability was moderate to good. Test-retest reliability should be examined in further studies at a less than 2-week interval to reduce maturation bias. This instrument can be used to measure enablement after consultation in a French-speaking family practice setting.

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

The effect of psychological interventions in inflammatory bowel diseases (IBD) is controversial.

OBJECTIVES

To assess the effects of psychological interventions (psychotherapy, patient education, relaxation techniques) on health related quality of life, coping, emotional state and disease activity in IBD.

SEARCH STRATEGY

We searched the specialized register of the IBD/FBD Group, CENTRAL (Issue 5, 2010) and from inception to April 2010: Medline, Embase, LILACS, Psyndex, CINAHL, PsyInfo, CCMed, SOMED and Social SciSearch. Conference abstracts and reference lists were also checked.

SELECTION CRITERIA

Randomized, quasi-randomized and non randomized controlled trials of psychological interventions in children or adults with IBD with a minimum follow up time of 2 months.

DATA COLLECTION AND ANALYSIS

Data were extracted and study quality was independently assessed by two raters. Pooled standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

MAIN RESULTS

Twenty-one studies were eligible for inclusion (1745 participants, 8 RCT, 4 QRCT, 8 NRCT; 19 in adults, 2 in adolescents). Most studies used multimodular approaches. The risk of bias was high for all studies.In adults, psychotherapy had no effect on quality of life at around 12 months (3 studies, 235 patients, SMD -0.07; 95% CI -0.33 to 0.19), emotional status (depression, 4 studies, 266 patients, SMD 0.03; 95% CI -0.22 to 0.27) or proportion of patients not in remission (5 studies, 287 patients, OR 0.85; 95% CI 0.48 to 1.48). Results were similar at 3 to 8 months. There was no evidence for statistical heterogeneity or subgroup effects based on type of disease or intensity of the therapy. In adolescents, there were positive short term effects of psychotherapy on most outcomes assessed including quality of life (2 studies, 71 patients, SMD 0.70; 95% CI 0.21 to 1.18) and depression (1 study, 41 patients, SMD -0.62; 95% CI -1.25 to 0.01).Educational interventions were ineffective with respect to quality of life at 12 months (5 studies, 947 patients, SMD 0.11; 95% CI -0.02 to 0.24), depression (3 studies, 378 patients, SMD -0.08; 95% CI -0.29 to 0.12) and proportion of patients not in remission (3 studies, 434 patients, OR 1.00; 95% CI 0.65 to 1.53).

AUTHORS' CONCLUSIONS

There is no evidence for efficacy of psychological therapy in adult patients with IBD in general. In adolescents, psychological interventions may be beneficial, but the evidence is limited. Further evidence is needed to assess the efficacy of these therapies in subgroups identified as being in need of psychological interventions, and to identify what type of therapy maybe most useful.

Evaluation of patient centered medical home practice transformation initiatives

BACKGROUND

The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices.

METHODS

Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign.

RESULTS

A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations.

CONCLUSIONS

Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Evaluation of a Web-based intervention providing tailored advice for self-management of minor respiratory symptoms: exploratory randomized controlled trial

Background

There has been relatively little research on the role of web-based support for self-care in the management of minor, acute symptoms, in contrast to the wealth of recent research into Internet interventions to support self-management of long-term conditions.

Objective

This study was designed as an evaluation of the usage and effects of the “Internet Doctor” website providing tailored advice on self-management of minor respiratory symptoms (eg, cough, sore throat, fever, runny nose), in preparation for a definitive trial of clinical effectiveness. The first aim was to evaluate the effects of using the Internet Doctor webpages on patient enablement and use of health services, to test whether the tailored, theory-based advice provided by the Internet Doctor was superior to providing a static webpage providing the best existing patient information (the control condition). The second aim was to gain an understanding of the processes that might mediate any change in intentions to consult the doctor, by comparing changes in relevant beliefs and illness perceptions in the intervention and control groups, and by analyzing usage of the Internet Doctor webpages and predictors of intention change.

Methods

Participants (N = 714) completed baseline measures of beliefs about their symptoms and self-care online, and were then automatically randomized to the Internet Doctor or control group. These measures were completed again by 332 participants after 48 hours. Four weeks later, 214 participants completed measures of enablement and health service use.

Results

The Internet Doctor resulted in higher levels of satisfaction than the control information (mean 6.58 and 5.86, respectively; P = .002) and resulted in higher levels of enablement a month later (median 3 and 2, respectively; P = .03). Understanding of illness improved in the 48 hours following use of the Internet Doctor webpages, whereas it did not improve in the control group (mean change from baseline 0.21 and -0.06, respectively, P = .05). Decline in intentions to consult the doctor between baseline and follow-up was predicted by age (beta = .10, P= .003), believing before accessing the website that consultation was necessary for recovery (beta = .19, P < .001), poor understanding of illness (beta = .11, P = .004), emotional reactions to illness (beta = .15, P <.001), and use of the Diagnostic section of the Internet Doctor website (beta = .09, P = .007).

Conclusions

Our findings provide initial evidence that tailored web-based advice could help patients self-manage minor symptoms to a greater extent. These findings constitute a sound foundation and rationale for future research. In particular, our study provides the evidence required to justify carrying out much larger trials in representative population samples comparing tailored web-based advice with routine care, to obtain a definitive evaluation of the impact on self-management and health service use.

Assessing enablement in clinical practice: a systematic review of available instruments

RATIONALE, AIMS AND OBJECTIVES

Enablement is an intervention by which the health care provider recognizes, promotes and enhances patients' ability to control their health and life. An abundant health literature suggests that enablement is associated with good outcomes. In this review, we aimed at identifying and comparing instruments that assess enablement in the health care context.

METHOD

We conducted a systematic literature review using Medline, Embase, Cochrane, Cinahl and PsycINFO databases, 1980 through March 2009, with specific search strategy for each database. Citations were included if they reported: (1) development and/or validation of an instrument; (2) evaluation of enablement in a health care context; and (3) quantitative results following administration of the instrument. The quality of each main retained citation was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy.

RESULTS

Of 3135 citations identified, 53 were retrieved for detailed evaluation. Four articles were included. Two instruments were found: the Patient Empowerment Scale (PES) and the Empowering Speech Practices Scale (ESPS). Both instruments assessed enablement in hospital setting, one from the inpatient's perspective (PES) and the other from both perspectives (ESPS).

CONCLUSION

Two instruments assess enablement in hospital setting. No instrument is currently available to assess enablement in an ambulatory care context.

Delays in response and triage times reduce patient satisfaction and enablement after using out-of-hours services

BACKGROUND

several different models of out-of-hours primary care now exist in the UK. Important outcomes of care include users' satisfaction and enablement to manage their illness or condition, but the determinants of these outcomes in the unscheduled care domain are poorly understood. Aim. To identify predictors of user satisfaction and enablement across unscheduled care or GP out-of-hours service providers in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP out-of-hours services, three Accident and Emergency units and an all Wales telephone advice service in Wales.

METHODS

postal survey using the Out-of-hours Patient Questionnaire. Logistic regression was used to fit both satisfaction and enablement models, based on demographic variables, service provider and treatment received and perceptions or ratings of the care process.

RESULTS

eight hundred and fifty-five of 3250 users responded (26% response rate, range across providers 14-41%, no evidence of non-response bias for age or gender). Treatment centre consultations were significantly associated with decreased patient satisfaction and decreased enablement compared with telephone advice. Delays in call answering or callback for triage and shorter consultations were significantly associated with lower satisfaction. Waiting more than a minute for initial call answering was associated with lower enablement.

CONCLUSIONS

giving users more time to discuss their illness in consultations may enhance satisfaction and enablement but this may be resource intensive. More simple interventions to improve access by quicker response and triage, and keeping users informed of waiting times, could also serve to increase satisfaction and ultimately impact on their enablement.

The need to improve the interface between in-hours and out-of-hours GP care, and between out-of-hours care and self-care

BACKGROUND

considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement.

AIM

to identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales.

METHOD

survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users' experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups.

RESULTS

eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the 'manner of treatment by call operator' and the 'explanation of the next step by call operator'. Consistent weaknesses were the 'speed of call back by the clinician', the 'information provided by the GP', 'getting medication after the consultation' and 'when to contact the (in-hours) GP'.

CONCLUSIONS

users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

Management of irritable bowel syndrome in primary care: feasibility randomised controlled trial of mebeverine, methylcellulose, placebo and a patient self-management cognitive behavioural therapy website. (MIBS trial)

BACKGROUND

IBS affects 10-22% of the UK population. Abdominal pain, bloating and altered bowel habit affect quality of life, social functioning and time off work. Current GP treatment relies on a positive diagnosis, reassurance, lifestyle advice and drug therapies, but many suffer ongoing symptoms.A recent Cochrane review highlighted the lack of research evidence for IBS drugs. Neither GPs, nor patients have good evidence to inform prescribing decisions. However, IBS drugs are widely used: In 2005 the NHS costs were nearly £10 million for mebeverine and over £8 million for fibre-based bulking agents. CBT and self-management can be helpful, but poor availability in the NHS restricts their use. We have developed a web-based CBT self-management programme, Regul8, based on an existing evidence based self-management manual and in partnership with patients. This could increase access with minimal increased costs.

METHODS/DESIGN

The aim is to undertake a feasibility factorial RCT to assess the effectiveness of the commonly prescribed medications in UK general practice for IBS: mebeverine (anti-spasmodic) and methylcellulose (bulking-agent) and Regul8, the CBT based self-management website.135 patients aged 16 to 60 years with IBS symptoms fulfilling Rome III criteria, recruited via GP practices, will be randomised to 1 of 3 levels of the drug condition: mebeverine, methylcellulose or placebo for 6 weeks and to 1 of 3 levels of the website condition, Regul8 with a nurse telephone session and email support, Regul8 with minimal email support, or no website, thus creating 9 groups.

OUTCOMES

Irritable bowel symptom severity scale and IBS-QOL will be measured at baseline, 6 and 12 weeks as the primary outcomes. An intention to treat analysis will be undertaken by ANCOVA for a factorial trial.

DISCUSSION

This pilot will provide valuable information for a larger trial. Determining the effectiveness of commonly used drug treatments will help patients and doctors make informed treatment decisions regarding drug management of IBS symptoms, enabling better targeting of treatment. A web-based self-management CBT programme for IBS developed in partnership with patients has the potential to benefit large numbers of patients with low cost to the NHS. Assessment of the amount of email or therapist support required for the website will enable economic analysis to be undertaken.

The RISAP-study: a complex intervention in risk communication and shared decision-making in general practice

Background

General practitioners (GPs) and patients find it difficult to talk about risk of future disease, especially when patients have asymptomatic conditions, and treatment options are unlikely to cause immediate perceptible improvements in well-being. Further studies in risk communication training are needed. Aim:1) to systematically develop, describe and evaluate a complex intervention comprising a training programme for GPs in risk communication and shared decision-making, 2) to evaluate the effect of the training programme on real-life consultations between GPs and patients with high cholesterol levels, and 3) to evaluate patients' reactions during and after the consultations.

Methods/Design

The effect of the complex intervention, based around a training programme, will be evaluated in a cluster-randomised controlled trial with an intervention group and an active control group with 40 GPs and 280 patients in each group.

The GPs will receive a questionnaire at baseline and after 6 months about attitudes towards risk communication and cholesterol-reducing medication. After each consultation with a participating high cholesterol-patient, the GPs will complete a questionnaire about decision satisfaction (Provider Decision Process Assessment Instrument). The patients will receive a questionnaire at baseline and after 3 and 6 months. It includes questions about adherence to chosen treatment (Morisky Compliance Scale), self-rated health (SF-12), enablement (Patient Enablement Instrument), and risk communication and decision-making effectiveness (COMRADE Scale). Prescriptions, contacts to the health services, and cholesterol level will be drawn from the registers.

In each group, 12 consultations will be observed and tape-recorded. The patients from these 24 consultations will be interviewed immediately after the consultation and re-interviewed after 6 months.

Eight purposefully selected GPs from the intervention group will be interviewed in a focus group 6 months after participation in the training programme.

The process and context of the RISAP-study will be investigated in detail using an action research approach, in order to analyse adaptation of the intervention model to the specific context.

Discussion

This study aims at providing GPs and patients with a firm basis for active deliberation about preventive treatment options, with a view to optimising adherence to chosen treatment.

Trial registration

ClinicalTrials.gov Protocol Registration System NCT01187056

What happened? GPs' perceptions of consultation outcomes and a comparison with the experiences of their patients

OBJECTIVE

To investigate GPs' perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients.

DESIGN

25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared.

SETTING

GPs and patients from 16 group practices in Norrbotten, Sweden.

RESULTS

The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.

CONCLUSION

The GPs' were lacking in their ability to assess the patients' increased understanding and the concordance between their own and the patients' expectation of cure/symptom relief was low.

New models of self-management education for minority ethnic groups: pilot randomized trial of a story-sharing intervention

OBJECTIVE

no model of self-management education or peer support has yet achieved widespread reach and acceptability with minority ethnic groups. We sought to refine and test a new complex intervention in diabetes education: informal story-sharing groups facilitated by bilingual health advocates.

METHODS

pilot randomized trial with in-depth process evaluation in a socioeconomically deprived area. 157 people referred for diabetes education were randomized by concealed allocation to an intervention (story-sharing group in their own language) or control ('usual care' self-management education, through an interpreter if necessary) arm. Story-sharing groups were held in five ethnic languages and English (for African Caribbeans), and ran fortnightly for six months. Primary outcome was UKPDS (UK Prospective Diabetes Study) risk score. Secondary outcomes included attendance, HbA1c, well-being and enablement. Process measures included ethnographic observation, and qualitative interviews with staff and patients.

RESULTS

some follow-up data were obtained on 87% of participants. There was no significant difference between intervention and control arms in biomedical outcomes. Attendance was 79% in the story-sharing arm and 35% in the control arm (p < 0.0001), and patient enablement scores were significantly higher (8.3 compared to 5.9, p < 0.005). The model was very popular with clinicians, managers and patients, which helped overcome numerous challenges to its successful embedding in a busy public sector diabetes service.

CONCLUSION

people from minority ethnic groups in a socioeconomically deprived area were keen to attend informal story-sharing groups and felt empowered by them, but clinical outcomes were no better than with conventional education. Further research is needed to maximize the potential and evaluate the place of this appealing service model before it is introduced as a part of mainstream diabetes services.

A pilot study on the validity and reliability of the Patient Enablement Instrument (PEI) in a Chinese population

BACKGROUND

The Patient Enablement Instrument (PEI) was developed to measure patients' enablement, which is an indicator of the effectiveness of a primary care consultation; however, to date, the PEI has not been tested in Asian populations.

OBJECTIVES

The purpose of this study is to test the acceptability, validity, reliability and other psychometric properties of a Chinese [Hong Kong (HK)] translation of the PEI in Chinese patients in Hong Kong and whether these properties would be affected by different timing of administration.

METHODS

A Chinese (HK) translation of the PEI was developed by iterative forward-backward translations and the content validity was assessed by a cognitive debriefing interview with 10 Chinese patients. It was then administered to 152 adult patients attending a government-funded primary care clinic in Hong Kong both immediately after the consultation and 2-3 weeks later by telephone. Internal construct validity was assessed by item-scale correlations and factor analysis, test-retest reliability was assessed by intraclass correlation (ICC) and sensitivity was assessed by known group comparison.

RESULTS

The Chinese (HK) PEI was semantically equivalent to the original PEI for all items. Acceptability of the PEI was high with 83.1% response and 100% completion rates. Statistical analyses showed no difference between test and retest means as well as good reproducibility (ICC 0.75). Internal reliability determined by Cronbach's alpha was >0.8 irrespective of timing of administration. Scale construct validity was confirmed by strong (r>0.4) item-scale correlations and resumed to a one-factor hypothesized structure. PEI scores were significantly higher in younger patients supporting sensitivity. There was no significant difference in the psychometric properties or scores between the assessment results from immediately after and 2-weeks post-consultation.

CONCLUSIONS

A Chinese (HK) translation of the PEI equivalent to the original is now available for application to Chinese populations. Pilot testing supported its acceptability, validity, reliability and sensitivity. Further studies to confirm its construct validity and responsiveness will help to establish the Chinese (HK) PEI as an outcome measure of the effectiveness of primary care consultations in Chinese patients.

Streamline triage and manage user expectations: lessons from a qualitative study of GP out-of-hours services

BACKGROUND

Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users' needs and expectations.

AIM

To explore users' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign.

SETTING

Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales.

PARTICIPANTS

Sixty recent service users or carers (20 in each location).

METHOD

Semi-structured telephone interviews; thematic analysis.

RESULTS

Users' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision.

CONCLUSION

Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Point-of-care C-reactive protein testing and antibiotic prescribing for respiratory tract infections: a randomized controlled trial

PURPOSE

Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) point-of-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis.

METHODS

We conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery.

RESULTS

Patients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confidence interval [CI], 0.56-0.98). This difference remained significant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were filled only in a minority of cases (23% vs 72% in control group, P < .001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03).

CONCLUSIONS

CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery.

An evaluation of the impact of a large group psycho-education programme (Stress Control) on patient outcome: does empathy make a difference?

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t= 9.18, d.f. = 55,p= <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.

Development and Evaluation of a Psychosocial Intervention for Children and Teenagers Experiencing Diabetes (DEPICTED): a protocol for a cluster randomised controlled trial of the effectiveness of a communication skills training programme for healthcare professionals working with young people with type 1 diabetes

Background

Diabetes is the third most common chronic condition in childhood and poor glycaemic control leads to serious short-term and life-limiting long-term complications. In addition to optimal medical management, it is widely recognised that psychosocial and educational factors play a key role in improving outcomes for young people with diabetes. Recent systematic reviews of psycho-educational interventions recognise the need for new methods to be developed in consultation with key stakeholders including patients, their families and the multidisciplinary diabetes healthcare team.

Methods/design

Following a development phase involving key stakeholders, a psychosocial intervention for use by paediatric diabetes staff and not requiring input from trained psychologists has been developed, incorporating a communication skills training programme for health professionals and a shared agenda-setting tool. The effectiveness of the intervention will be evaluated in a cluster-randomised controlled trial (RCT). The primary outcome, to be measured in children aged 4-15 years diagnosed with type 1 diabetes for at least one year, is the effect on glycaemic control (HbA1c) during the year after training of the healthcare team is completed. Secondary outcomes include quality of life for patients and carers and cost-effectiveness. Patient and carer preferences for service delivery will also be assessed. Twenty-six paediatric diabetes teams are participating in the trial, recruiting a total of 700 patients for evaluation of outcome measures. Half the participating teams will be randomised to receive the intervention at the beginning of the trial and remaining centres offered the training package at the end of the one year trial period.

Discussion

The primary aim of the trial is to determine whether a communication skills training intervention for specialist paediatric diabetes teams will improve clinical and psychological outcomes for young people with type 1 diabetes. Previous research indicates the effectiveness of specialist psychological interventions in achieving sustained improvements in glycaemic control. This trial will evaluate an intervention which does not require the involvement of trained psychologists, maximising the potential feasibility of delivery in a wider NHS context.

Trial registration

Current Controlled Trials ISRCTN61568050.

Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project

PURPOSE

The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices' transition to patient-centered medical homes (PCMHs).

METHODS

In 2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted. We evaluated 2 types of patient outcomes with repeated cross-sectional surveys and medical record audits at baseline, 9 months, and 26 months: patient-rated outcomes and condition-specific quality of care outcomes. Patient-rated outcomes included core primary care attributes, patient empowerment, general health status, and satisfaction with the service relationship. Condition-specific outcomes were measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set and measures of delivery of clinical preventive services and chronic disease care.

RESULTS

Practices adopted substantial numbers of NDP components over 26 months. Facilitated practices adopted more new components on average than self-directed practices (10.7 components vs 7.7 components, P=.005). ACQA scores improved over time in both groups (by 8.3% in the facilitated group and by 9.1% in the self-directed group, P <.0001) as did chronic care scores (by 5.2% in the facilitated group and by 5.0% in the self-directed group, P=.002), with no significant differences between groups. There were no improvements in patient-rated outcomes. Adoption of PCMH components was associated with improved access (standardized beta [Sbeta]=0.32, P = .04) and better prevention scores (Sbeta=0.42, P=.001), ACQA scores (Sbeta=0.45, P = .007), and chronic care scores (Sbeta=0.25, P =.08).

CONCLUSIONS

After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.

Methods for evaluating practice change toward a patient-centered medical home

PURPOSE

Understanding the transformation of primary care practices to patient-centered medical homes (PCMHs) requires making sense of the change process, multilevel outcomes, and context. We describe the methods used to evaluate the country's first national demonstration project of the PCMH concept, with an emphasis on the quantitative measures and lessons for multimethod evaluation approaches.

METHODS

The National Demonstration Project (NDP) was a group-randomized clinical trial of facilitated and self-directed implementation strategies for the PCMH. An independent evaluation team developed an integrated package of quantitative and qualitative methods to evaluate the process and outcomes of the NDP for practices and patients. Data were collected by an ethnographic analyst and a research nurse who visited each practice, and from multiple data sources including a medical record audit, patient and staff surveys, direct observation, interviews, and text review. Analyses aimed to provide real-time feedback to the NDP implementation team and lessons that would be transferable to the larger practice, policy, education, and research communities.

RESULTS

Real-time analyses and feedback appeared to be helpful to the facilitators. Medical record audits provided data on process-of-care outcomes. Patient surveys contributed important information about patient-rated primary care attributes and patient-centered outcomes. Clinician and staff surveys provided important practice experience and organizational data. Ethnographic observations supplied insights about the process of practice development. Most practices were not able to provide detailed financial information.

CONCLUSIONS

A multimethod approach is challenging, but feasible and vital to understanding the process and outcome of a practice development process. Additional longitudinal follow-up of NDP practices and their patients is needed.

Patient involvement in assessing consultation quality: a quantitative study of the Patient Enablement Instrument in Poland

BACKGROUND

Promoting a more patient-responsive service has been the focus of policy initiatives in newer EU states. One measure of success should be the patient's assessment of their consultation with their doctor.

OBJECTIVES

To measure consultation quality in Polish primary care using patient enablement (a patient-driven instrument developed in the UK) and to test its theoretical framework. To compare the patient enablement outcome of different types of doctor delivering primary care in Poland following reform.

DESIGN

Cross-sectional quantitative questionnaire survey.

SETTING

Random sample of primary care doctors practising within a 60-km radius of Gdansk, Poland.

SUBJECTS AND OUTCOME MEASURES

Patient Enablement Instrument and correlates were measured in 7924 consecutive adult consultations of 48 doctors, stratified according to training: family medicine specialists (diploma holders), non-diplomates and general medicine doctors (polyclinic internists).

RESULTS

Completion was high (78%). The mean patient enablement score in Poland was 4.0 (SD 3.3) and mean consultation length was 10.3 min (SD 5.4 min). Consultation length and knowing the doctor are independently related to patient enablement in the Polish context. Variation between doctors is significant, but earlier differences in enablement between alternative providers have largely been ameliorated in practice.

CONCLUSION

It is feasible to use patient enablement on a large scale at routine consultation in primary care in Poland: acceptability was good in diverse environments. The internal consistency of enablement and its relationships broadly mirror those found in the UK. The effect of patient expectations shaped by social and cultural issues influencing enablement outcome requires further investigation.

The GP Patient Survey for use in primary care in the National Health Service in the UK--development and psychometric characteristics

Background

The UK National GP Patient Survey is one of the largest ever survey programmes of patients registered to receive primary health care, inviting five million respondents to report their experience of NHS primary healthcare. The third such annual survey (2008/9) involved the development of a new survey instrument. We describe the process of that development, and the findings of an extensive pilot survey in UK primary healthcare.

Methods

The survey was developed following recognised guidelines and involved expert and stakeholder advice, cognitive testing of early versions of the survey instrument, and piloting of the questionnaire in a cross sectional pilot survey of 1,500 randomly selected individuals from the UK electoral register with two reminders to non-respondents.

Results

The questionnaire comprises 66 items addressing a range of aspects of UK primary healthcare. A response rate of 590/1500 (39.3%) was obtained. Non response to individual items ranged from 0.8% to 15.3% (median 5.2%). Participants did not always follow internal branching instructions in the questionnaire although electronic controls allow for correction of this problem in analysis. There was marked skew in the distribution of responses to a number of items indicating an overall favourable impression of care. Principal components analysis of 23 items offering evaluation of various aspects of primary care identified three components (relating to doctor or nurse care, or addressing access to care) accounting for 68.3% of the variance in the sample.

Conclusion

The GP Patient Survey has been carefully developed and pilot-tested. Survey findings, aggregated at practice level, will be used to inform the distribution of £65 million ($107 million) of UK NHS resource in 2008/9 and this offers the opportunity for NHS service planners and providers to take account of users' experiences of health care in planning and delivering primary healthcare in the UK.