Rationale and methods for a trial assessing placebo, echinacea, and doctor-patient interaction in the common cold

No open-label placebo effect in insomnia? Lessons learned from an experimental trial

BACKGROUND

Open-label placebo (OLP) treatment seems to be effective in several medical conditions but has not yet been investigated in insomnia. Furthermore, it needs to be evaluated whether providing a plausible treatment rationale is essential to obtain OLP effects.

METHODS

In two consecutive nights, the sleep of patients with primary insomnia (n = 45) was assessed via subjective and objective measures. Before the second night, they received a single OLP pill that was randomly provided either with a treatment rationale (OLP+) or without (OLP-). When (M)ANOVAs did not reveal differential effects between the two OLP groups, the OLP+ group was compared post-hoc to a formerly assessed no pill control sample (NPC; n = 23).

RESULTS

Neither the MANOVAs nor the ANOVAs revealed significant interaction effects of treatment group and assessment night. The OLP+ condition was superior neither to OLP- nor to NPC in improving the patients' sleep.

DISCUSSION

Our findings do neither confirm the general efficacy of OLP in primary insomnia nor differential effects depending on the treatment rationale. Possible explanations lie in the dosing scheme (i.e., single OLP application), the provision of the OLP rationale by video and the experimental instead of therapeutic character of our investigation. Trials with larger samples and longer-term OLP treatment in insomnia are needed. Providing the rationale face-to-face and in a clinical setting might be additionally beneficial.

When Your Doctor "Gets It" and "Gets You": The Critical Role of Competence and Warmth in the Patient-Provider Interaction

Background: Research demonstrates that the placebo effect can influence the effectiveness of medical treatments and accounts for a significant proportion of healing in many conditions. However, providers may differ in the degree to which they consciously or unconsciously leverage the forces that produce placebo effects in clinical practice. Some studies suggest that the manner in which providers interact with patients shapes the magnitude of placebo effects, but this research has yet to distill the specific dimensions of patient-provider interactions that are most likely to influence placebo response and the mechanisms through which aspects of patient-provider interactions impact placebo response. Methods: We offer a simplifying and unifying framework in which interactions that boost placebo response can be dissected into two key dimensions: patients' perceptions of competence, or whether a doctor "gets it" (i.e., displays of efficiency, knowledge, and skill), and patients' perceptions of warmth, or whether a doctor "gets me" (i.e., displays of personal engagement, connection, and care for the patient). Results: First, we discuss how this framework builds on past research in psychology on social perception of competence and warmth and in medical literature on models of effective medical care, patient satisfaction, and patient-provider interactions. Then we consider possible mechanisms through which competence and warmth may affect the placebo response in healthcare. Finally, we share original data from patients and providers highlighting how this framework applies to healthcare. Both patient and provider data illustrate actionable ways providers can demonstrate competence and warmth to patients. Discussion: We conclude with recommendations for how researchers and practitioners alike can more systematically consider the role of provider competence and warmth in patient-provider interactions to deepen our understanding of placebo effects and, ultimately, enable providers to boost placebo effects alongside active medications (i.e., with known medical ingredients) and treatment in clinical care.

Validation of the Nasal Mucus Index, a novel measurement of acute respiratory infection severity

BACKGROUND

To assess the concurrent and predictive validity of the Nasal Mucus Index (NMI), a novel measurement of acute respiratory infection (ARI) severity.

OBJECTIVE

ARI, including the common cold and influenza, imposes a great burden on individuals and society. Previous research has attempted to assess the severity of ARI with self-reported and laboratory-based measurements. Self-reported measurements may introduce bias. Laboratory-based metrics are often expensive. Therefore, there is a need for non-self-reported, affordable, and validated ARI severity tests.

METHODS

Participants (N = 719) with an ARI episode underwent nasal lavage on days 1 and 3. The samples were visually assessed for the amount of mucus present in the sample and were given a subsequent NMI score. Collected samples were further assessed for interleukin (IL) 8 values (in pg/mL) and polymorphonuclear neutrophils (PMN) per high-power field. The participants rated episode severity and nasal symptoms daily by using the validated Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21). A subset of nasal symptoms was used as an additional comparator. NMI scores were compared with same-day IL-8 level, PMN count, and WURSS-21 scores for concurrent validation purposes by using the Spearman ρ as the index of correlation. NMI scores were correlated with overall episode severity measurements to assess predictive validity. Overall episode severity was measured as the WURSS-21 area under the curve, nasal symptoms area under the curve, and episode duration.

RESULTS

The NMI score correlated significantly with the same-day IL-8 level (ρ = 0.443, p < 0.001), PMN count (ρ = 0.498, p < 0.001), WURSS-21 score (ρ = 0.098, p = 0.004), and nasal symptom score (ρ = 0.162, p < 0.001). No significant predictive correlations were found.

CONCLUSION

Associations with inflammatory biomarkers and self-reported severity measurements provided evidence of concurrent validity for the novel NMI score. The NMI can be used in future research as a simple, inexpensive, non-self-reported indicator of ARI severity.

Providing evidence for use of Echinacea supplements in Hajj pilgrims for management of respiratory tract infections

OBJECTIVE

To evaluate potential applicability of Echinacea use for management of respiratory tract infections in Hajj travelers.

METHOD

The PubMed database was explored with Mesh terms "Echinacea" and "Respiratory Tract Infections".

RESULTS

A hundred journal articles were yielded but only 66 most relevant ones used for the review.

CONCLUSION

There is a considerable amount of evidence that shows effectiveness of Echinacea products in prevention and treatment of respiratory tract infections in this setting. Although there are some controversial findings, utilization of standardized products with adequate dose or combinations with other immune-stimulants in controlled and well-designed trials will be highly encouraging.

Context Effects in Western Herbal Medicine: Fundamental to Effectiveness?

Western herbal medicine (WHM) is a complex healthcare system that uses traditional plant-based medicines in patient care. Typical preparations are individualized polyherbal formulae that, unlike herbal pills, retain the odor and taste of whole herbs. Qualitative studies in WHM show patient-practitioner relationships to be collaborative. Health narratives are co-constructed, leading to assessments, and treatments with personal significance for participants. It is hypothesized that the distinct characteristics of traditional herbal preparations and patient-herbalist interactions, in conjunction with the WHM physical healthcare environment, evoke context (placebo) effects that are fundamental to the overall effectiveness of herbal treatment. These context effects may need to be minimized to demonstrate pharmacological efficacy of herbal formulae in randomized, placebo-controlled trials, optimized to demonstrate effectiveness of WHM in pragmatic trials, and consciously harnessed to enhance outcomes in clinical practice.

Association of interleukin-8 and neutrophils with nasal symptom severity during acute respiratory infection

Using a large data set (n = 811), the relationship between acute respiratory infection illness severity and inflammatory biomarkers was investigated to determine whether certain symptoms are correlated more closely than others with the inflammatory biomarkers, interleukin‐8 (IL‐8) and nasal neutrophils. Participants with community acquired acute respiratory infection underwent nasal lavage for IL‐8 and neutrophil testing, in addition to multiplex polymerase chain reaction (PCR) methods for the detection and identification of respiratory viruses. Information about symptoms was obtained throughout the duration of the illness episode using the well‐validated Wisconsin Upper Respiratory Symptom Survey (WURSS‐21). Global symptom severity was calculated by the area under the curve (AUC) plotting duration versus WURSS total. Of the specimens tested, 56% were positively identified for one or more of nine different respiratory viruses. During acute respiratory infection illness, both IL‐8 and neutrophils positively correlate with AUC (r_s = 0.082, P = 0.022; r_s = 0.080, P = 0.030). IL‐8 and neutrophils correlate with nasal symptom severity: runny nose (r = 0.13, P = < 0.00001; r = 0.18, P = < 0.003), plugged nose (r = 0.045, P = 0.003; r = 0.14, P = 0.058), and sneezing (r = −0.02, P = < 0.0001; r = −0.0055, P = 0.31). Neutrophils correlate with some quality of life measures such as sleeping well (r = 0.15, P = 0.026). Thus, the study demonstrates that IL‐8 and neutrophils are correlated with severity of nasal symptoms during acute respiratory infection. Further research is necessary to determine if the concentration of these or other biomarkers can predict the overall duration and severity of acute respiratory infection illness. J. Med. Virol. 87:330–337, 2015. © 2014 Wiley Periodicals, Inc.

Detection of viral and bacterial pathogens in acute respiratory infections

OBJECTIVES

The role of bacteria in acute respiratory illnesses (ARI) of adults and interactions with viral infections is incompletely understood. This study tested the hypothesis that bacterial co-infection during ARI adds to airway inflammation and illness severity.

METHODS

Two groups of 97 specimens each were randomly selected from multiplex-PCR identified virus-positive and virus-negative nasal specimens obtained from adults with new onset ARI, and 40 control specimens were collected from healthy adults. All specimens were analyzed for Haemophilus influenzae(HI), Moraxella catarrhalis(MC) and Streptococcus pneumoniae(SP) by quantitative-PCR. General linear models tested for relationships between respiratory pathogens, biomarkers (nasal wash neutrophils and CXCL8), and ARI-severity.

RESULTS

Nasal specimens from adults with ARIs were more likely to contain bacteria (37% overall; HI = 28%, MC = 14%, SP = 7%) compared to specimens from healthy adults (5% overall; HI = 0%, MC = 2.5%, SP = 2.5%; p < 0.001). Among ARI specimens, bacteria were more likely to be detected among virus-negative specimens compared to virus-positive specimens (46% vs. 27%; p = 0.0046). The presence of bacteria was significantly associated with increased CXCL8 and neutrophils, but not increased symptoms.

CONCLUSION

Pathogenic bacteria were more often detected in virus-negative ARI, and also associated with increased inflammatory biomarkers. These findings suggest the possibility that bacteria may augment virus-induced ARI and contribute to airway inflammation.

Item reduction of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) leads to the WURSS-11

PURPOSE

To develop a shorter version of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21), a self-report questionnaire for evaluating daily symptoms and functional impairments during acute respiratory illness (ARI).

METHODS

WURSS-21 data were retrieved from 4 studies (n = 1167) spanning the years 2002-2010. Similar methodologies were employed among these studies. Degree of missingness, ceiling/floor effects, and exploratory (EFA) and confirmatory (CFA) factor analyses were investigated and used to guide item retention. Stability of the reduced WURSS was evaluated across the first 3 days of ARI.

RESULTS

Degree of missingness was <1 % and appeared to be completely at random. Seven WURSS items with >30 % of ratings of zero (floor effects) were eliminated. Cross-loading items (head congestion, sleep well and breathe easily) were excluded following EFA on subset-1. Subsequent CFA using subset-2 showed satisfactory indices of fit. The reduced WURSS-11 instrument demonstrated 3 dimensions of 3 items each and was stable across 3 days of illness. The indicated dimensions (items) include nasal (runny nose, plugged nose, sneezing), throat (cough, sore throat, scratchy throat), and quality of life (feeling tired, think clearly, accomplish daily activities).

CONCLUSION

The WURSS-11 has similar dimensional structure as the WURSS-21. This shorter version may reduce the time and burden required for completing the survey.

Can patients or clinicians predict the severity or duration of an acute upper respiratory infection?

PURPOSE

Acute upper respiratory infections (URI) are the second most common diagnosis in primary care offices. As treatments have limited effectiveness, patient counseling regarding expectations for the course of the URI is an important aspect of care. It is unknown how accurate patients, clinicians or questionnaires such as the Wisconsin Upper Respiratory Symptom Survey (WURSS) instrument are at predicting URI severity and duration, and whether these predictions should be used to counsel patients.

METHODS

Seven hundred and nineteen individuals with recent onset cold in community clinic settings participated. Participants and clinicians predicted the severity and duration of the URI and participants completed the WURSS instrument at initial visit. Subsequent URI global severity was calculated as area under the curve using an average of twice-daily WURSS-21 self-reports as the y-axis and illness duration as the x-axis. URI duration was determined by self-report of beginning and end of illness. Linear regression analysis was used to correlate baseline predictions with subsequent outcomes. Analyses by gender, age and income were also performed.

RESULTS

There was no significant association between participant and clinician predictions of severity or duration. Initial WURSS values explained 0.119 (95% CI: 0.074-0.163) of the variance in subsequent severity outcomes. There were no significant differences in associations by age, gender or income.

CONCLUSIONS

Clinicians should not use their predictive assessments or their patients' predictions when advising patients on the expected course of a URI. This study also suggests that the WURSS instrument could give some predictive information, but whether this is clinically useful is uncertain.

Perception of empathy in the therapeutic encounter: effects on the common cold

OBJECTIVE

To evaluate the effects of patient-practitioner interaction on the severity and duration of the common cold.

METHODS

We conducted a randomized controlled trial of 719 patients with new cold onset. Participants were randomized to three groups: no patient-practitioner interaction, "standard" interaction or an "enhanced" interaction. Cold severity was assessed twice daily. Patients randomized to practitioner visits used the Consultation and Relational Empathy (CARE) measure to rate clinician empathy. Interleukin-8 (IL-8) and neutrophil counts were obtained from nasal wash at baseline and 48 h later.

RESULTS

Patients' perceptions of the clinical encounter were associated with reduced cold severity and duration. Encounters rated perfect on the CARE score had reduced severity (perfect: 223, sub-perfect: 271, p=0.04) and duration (perfect: 5.89 days, sub-perfect: 7.00 days, p=0.003). CARE scores were also associated with a more significant change in IL-8 (perfect: mean IL-8 change 1586, sub-perfect: 72, p=0.02) and neutrophil count (perfect: 49, sub-perfect: 12, p=0.09).

CONCLUSIONS

When patients perceive clinicians as empathetic, rating them perfect on the CARE tool, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change.

PRACTICE IMPLICATIONS

This study helps us to understand the importance of the perception of empathy in a therapeutic encounter.

Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis

OBJECTIVE

The aim of this study was to examine whether lag sequential analysis could be used to describe eye gaze orientation between clinicians and patients in the medical encounter. This topic is particularly important as new technologies are implemented into multiuser health care settings in which trust is critical and nonverbal cues are integral to achieving trust. This analysis method could lead to design guidelines for technologies and more effective assessments of interventions.

BACKGROUND

Nonverbal communication patterns are important aspects of clinician-patient interactions and may affect patient outcomes.

METHOD

The eye gaze behaviors of clinicians and patients in 110 videotaped medical encounters were analyzed using the lag sequential method to identify significant behavior sequences. Lag sequential analysis included both event-based lag and time-based lag.

RESULTS

Results from event-based lag analysis showed that the patient's gaze followed that of the clinician, whereas the clinician's gaze did not follow the patient's. Time-based sequential analysis showed that responses from the patient usually occurred within 2 s after the initial behavior of the clinician.

CONCLUSION

Our data suggest that the clinician's gaze significantly affects the medical encounter but that the converse is not true.

APPLICATION

Findings from this research have implications for the design of clinical work systems and modeling interactions. Similar research methods could be used to identify different behavior patterns in clinical settings (physical layout, technology, etc.) to facilitate and evaluate clinical work system designs.

Placebo effects and the common cold: a randomized controlled trial

PURPOSE

We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all.

METHODS

We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later.

RESULTS

Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were -0.16 days (95% CI, -0.90 to 0.58 days) for illness duration and -22 severity points (95% CI, -70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, -0.28 to 1.12 days) and 22 severity points (95% CI, -19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea's effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, -4.47 to -0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (-97.0, 95% CI, -249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group.

CONCLUSIONS

Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

Reliability and validity of Wisconsin Upper Respiratory Symptom Survey, Korean version

Background

The Wisconsin Upper Respiratory Symptom Survey (WURSS) is a self-administered questionnaire developed in the United States to evaluate the severity of the common cold and its reliability has been validated. We developed a Korean language version of this questionnaire by using a sequential forward and backward translation approach. The purpose of this study was to validate the Korean version of the Wisconsin Upper Respiratory Symptom Survey (WURSS-K) in Korean patients with common cold.

Methods

This multicenter prospective study enrolled 107 participants who were diagnosed with common cold and consented to participate in the study. The WURSS-K includes 1 global illness severity item, 32 symptom-based items, 10 functional quality-of-life (QOL) items, and 1 item assessing global change. The SF-8 was used as an external comparator.

Results

The participants were 54 women and 53 men aged 18 to 42 years. The WURSS-K showed good reliability in 10 domains, with Cronbach’s alphas ranging from 0.67 to 0.96 (mean: 0.84). Comparison of the reliability coefficients of the WURSS-K and WURSS yielded a Pearson correlation coefficient of 0.71 (P = 0.02). Validity of the WURSS-K was evaluated by comparing it with the SF-8, which yielded a Pearson correlation coefficient of −0.267 (P < 0.001). The Guyatt’s responsiveness index of the WURSS-K ranged from 0.13 to 0.46, and the correlation coefficient with the WURSS was 0.534 (P < 0.001), indicating that there was close correlation between the WURSS-K and WURSS.

Conclusions

The WURSS-K is a reliable, valid, and responsive disease-specific questionnaire for assessing symptoms and QOL in Korean patients with common cold.

Employing immersive virtual environments for innovative experiments in health care communication

OBJECTIVE

This report reviews the literature for studies that employ immersive virtual environment technology methods to conduct experimental studies in health care communication. Advantages and challenges of using these tools for research in this area are also discussed.

METHODS

A literature search was conducted using the Scopus database. Results were hand searched to identify the body of studies, conducted since 1995, that are related to the report objective.

RESULTS

The review identified four relevant studies that stem from two unique projects. One project focused on the impact of a clinician's characteristics and behavior on health care communication, the other focused on the characteristics of the patient. Both projects illustrate key methodological advantages conferred by immersive virtual environments, including, ability to maintain simultaneously high experimental control and realism, ability to manipulate variables in new ways, and unique behavioral measurement opportunities.

CONCLUSION

Though implementation challenges exist for immersive virtual environment-based research methods, given the technology's unique capabilities, benefits can outweigh the costs in many instances.

PRACTICE IMPLICATIONS

Immersive virtual environments may therefore prove an important addition to the array of tools available for advancing our understanding of communication in health care.

Effects of So-cheong-ryong-tang and Yeon-gyo-pae-dok-san on the common cold: randomized, double blind, placebo controlled trial

AIM OF THE STUDY

So-cheong-ryong-tang (SCRT) and Yeon-gyo-pae-dok-san (YPS) extracts are widely used in treatment of the common cold. The purpose of this study is to evaluate the efficacy of SCRT and YPS on the common cold.

METHODS

Four hundred eighty participants with symptoms of the common cold within 48 h were recruited for this randomized, double-blind, placebo-controlled trial. SCRT extract and YPS extract were put in gelatin capsules and orally administered 3 times a day. The pattern of participants was determined according to the Questionnaire for Common Cold Pattern Identification (QCCPI), and the severity of illness was assessed by Wisconsin Upper Respiratory Symptom Survey-21 Korean version (WURSS-21-K) every 7 days.

RESULTS

The test and control groups were not significantly different in gender, age, smoking history, and baseline score of WURSS-21-K at the time of enrollment. SCRT treatment significantly decreased the total WURSS-21-K score on the 6th and 7th day (p<0.05) of the enrollment compared with the placebo group. YPS treatment decreased the total WURSS-21-K score on the 5th and 6th day (p<0.05 vs. the placebo group) of the enrollment. In the patients with Wind-cold pattern cold, SCRT significantly decreased the total WURSS-21-K score from 4th to 8th day (p<0.05), and YPS significantly decreased the total WURSS-21-K score from 4th to 6th day (p<0.05). For the Wind-heat pattern cold, neither SCRT nor YPS group showed significant difference from the placebo group. SCRT and YPS did not significantly decrease the time to complete resolution of the cold symptoms.

CONCLUSIONS

SCRT and YPS have beneficial, albeit limited, effects on common cold patients, especially those with the Wind-cold pattern cold.

Echinacea for treating the common cold: a randomized trial

BACKGROUND

Echinacea is widely used to treat the common cold.

OBJECTIVE

To assess the potential benefits of echinacea as a treatment of common cold.

DESIGN

Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00065715)

SETTING

Dane County, Wisconsin.

PATIENTS

719 patients, aged 12 to 80 years, with new-onset common cold.

INTERVENTION

Patients were assigned to 1 of 4 parallel groups: no pills, placebo pills (blinded), echinacea pills (blinded), or echinacea pills (unblinded, open-label). Echinacea groups received the equivalent of 10.2 g of dried echinacea root during the first 24 hours and 5.1 g during each of the next 4 days. Indistinguishable placebo tablets contained only inert ingredients.

MEASUREMENTS

The primary outcome was the area under the curve for global severity, with severity assessed twice daily by self-report using the Wisconsin Upper Respiratory Symptom Survey, short version. Secondary outcomes included interleukin-8 levels and neutrophil counts from nasal wash, assessed at intake and 2 days later.

RESULTS

Of the 719 patients enrolled, 713 completed the protocol. Mean age was 33.7 years, 64% were female, and 88% were white. Mean global severity was 236 and 258 for the blinded and unblinded echinacea groups, respectively; 264 for the blinded placebo group; and 286 for the no-pill group. A comparison of the 2 blinded groups showed a 28-point trend (95% CI, -69 to 13 points) toward benefit for echinacea (P = 0.089). Mean illness duration in the blinded and unblinded echinacea groups was 6.34 and 6.76 days, respectively, compared with 6.87 days in the blinded placebo group and 7.03 days in the no-pill group. A comparison of the blinded groups showed a nonsignificant 0.53-day (CI, -1.25 to 0.19 days) benefit (P = 0.075). Median change in interleukin-8 levels and neutrophil counts were also not statistically significant (30 ng/L and 1 cell/high-power field [hpf] in the no-pill group, 39 ng/L and 1 cell/hpf in the blinded placebo group, 58 ng/L and 2 cells/hpf in the blinded echinacea group, and 70 ng/L and 1 cell/hpf in the open-label echinacea group).

LIMITATION

Higher-than-expected variability limited power to detect small benefits.

CONCLUSION

Illness duration and severity were not statistically significant with echinacea compared with placebo. These results do not support the ability of this dose of the echinacea formulation to substantively change the course of the common cold.

PRIMARY FUNDING SOURCE

National Center for Complementary and Alternative Medicine, National Institutes of Health.

Can patient-provider interaction increase the effectiveness of medical treatment or even substitute it?--an exploration on why and how to study the specific effect of the provider

OBJECTIVE

Numerous studies demonstrate the impact of high-quality patient-provider interaction (PPI) on health outcomes. However, transformation of these findings into clinical practice is still a crucial problem. One reason might be that health communication research rarely investigated whether PPI can increase the effectiveness of medical treatment and/or even substitute it. Therefore, our objective was to provide empirical and methodological background of why and how to investigate the specific effect of the provider on patients' health outcomes.

METHODS

This is a debate paper based on a narrative (non-systematic) literature review in Medline and PsycINFO without any year limitation.

RESULTS

Neurobiological evidence based on expectation and conditioning theory indicates that PPI is able to increase the effectiveness of medical treatment. Moreover, the use of creative RCT study designs described in this paper enables health communication researchers to investigate whether PPI is able to substitute medical treatment.

CONCLUSION

This paper exemplifies that there exist an evidence-based knowledge from neurobiology as well as creative RCT designs which enable researcher to investigate the specific effects of PPI.

PRACTICE IMPLICATIONS

Research on the specific effects of PPI requires intense reflection on which patient groups or types of illness are reasonable, suitable, and ethically justifiable for interventions.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Validation of a short form Wisconsin Upper Respiratory Symptom Survey (WURSS-21)

BACKGROUND

The Wisconsin Upper Respiratory Symptom Survey (WURSS) is an illness-specific health-related quality-of-life questionnaire outcomes instrument.

OBJECTIVES

Research questions were: 1) How well does the WURSS-21 assess the symptoms and functional impairments associated with common cold? 2) How well can this instrument measure change over time (responsiveness)? 3) What is the minimal important difference (MID) that can be detected by the WURSS-21? 4) What are the descriptive statistics for area under the time severity curve (AUC)? 5) What sample sizes would trials require to detect MID or AUC criteria? 6) What does factor analysis tell us about the underlying dimensional structure of the common cold? 7) How reliable are items, domains, and summary scores represented in WURSS? 8) For each of these considerations, how well does the WURSS-21 compare to the WURSS-44, Jackson, and SF-8?

STUDY DESIGN AND SETTING

People with Jackson-defined colds were recruited from the community in and around Madison, Wisconsin. Participants were enrolled within 48 hours of first cold symptom and monitored for up to 14 days of illness. Half the sample filled out the WURSS-21 in the morning and the WURSS-44 in the evening, with the other half reversing the daily order. External comparators were the SF-8, a 24-hour recall general health measure yielding separate physical and mental health scores, and the eight-item Jackson cold index, which assesses symptoms, but not functional impairment or quality of life.

RESULTS

In all, 230 participants were monitored for 2,457 person-days. Participants were aged 14 to 83 years (mean 34.1, SD 13.6), majority female (66.5%), mostly white (86.0%), and represented substantive education and income diversity. WURSS-21 items demonstrated similar performance when embedded within the WURSS-44 or in the stand-alone WURSS-21. Minimal important difference (MID) and Guyatt's responsiveness index were 10.3, 0.71 for the WURSS-21 and 18.5, 0.75 for the WURSS-44. Factorial analysis suggested an eight dimension structure for the WURSS-44 and a three dimension structure for the WURSS-21, with composite reliability coefficients ranging from 0.87 to 0.97, and Cronbach's alpha ranging from 0.76 to 0.96. Both WURSS versions correlated significantly with the Jackson scale (W-21 R=0.85; W-44 R=0.88), with the SF-8 physical health (W-21 R=-0.79; W-44 R=-0.80) and SF-8 mental health (W-21 R=-0.55; W-44 R=-0.60).

CONCLUSION

The WURSS-44 and WURSS-21 perform well as illness-specific quality-of-life evaluative outcome instruments. Construct validity is supported by the data presented here. While the WURSS-44 covers more symptoms, the WURSS-21 exhibits similar performance in terms of reliability, responsiveness, importance-to-patients, and convergence with other measures.

[Scientific evidence and the cost of innovations in the health-care system]

When depicting the relationship between evidence and the cost of an innovation in the health-care system, the overall risks of assessment, the redistribution of risks in a regulated market, and the ethical consequences must first be taken into account. There are also evidence-based criteria and economic considerations which are relevant when calculating the cost of an innovation. These topics can indicate, but not exhaustively deal with the complicated relationship between scientific evidence and calculating the cost of an innovation in the health-care system. The following three statements summarize the current considerations in the continuing discussion of this topic: *Scientific evidence undoubtedly exists which should be taken into consideration when calculating the cost of an innovation in the health-care system. *The existing scientific evidence is, however, not sufficient to reach such a decision. Additional information about the benefit perceived by the patient is required. *No standardized method exists to measure this additional information. Therefore, a definition problem also exists in the health-care system when setting a price according to scientific evidence.

Qualitative assessment of innovations in healthcare provision

Background

The triad of quality, innovation and economic restraint is as important in health care as it is in the business world. There are many proposals for the assessment of quality and of economic restraints in health care but only a few address assessment of innovations. We propose a strategy and new structures to standardize the description of health care innovations and to quantify them.

Discussion

Strategy and structure are based on the assumption that in the early phase of an innovation only data on the feasibility and possibly on the efficacy or effectiveness of an innovation can be expected. From the patient's perspective, benefit resulting from an innovation can be confirmed only in a later phase of development. Early indicators of patient's benefit will be surrogate parameters which correlate only weakly with the desired endpoints. After the innovation has been in use, there will be more evidence on correlations between surrogate parameters and the desired endpoints to provide evidence of the patient benefit. From an administrative perspective, this evidence can be considered in decisions about public financing. Different criteria are proposed for the assessment of innovations in prevention, diagnosis and therapy. For decisions on public financing a public fund for innovations may be helpful. Depending on the phase of innovation risk sharing models are proposed between manufacturers, private insurers and public funding.

Summary

Potential for patient benefit is always uncertain during early stages of innovations. This uncertainty decreases with increasing information on the effects of the innovation. Information about an innovation can be quantified, categorized and integrated into rational economic decisions.

'They don't ask me so I don't tell them': patient-clinician communication about traditional, complementary, and alternative medicine

PURPOSE

Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans.

METHODS

We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care.

RESULTS

One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients' decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians' comfort with patients' self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients.

CONCLUSIONS

Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.