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Meng R, Jiang C, Dzierzewski JM, Zhu Y, Wang M, Yang N, Liu X, Guo L, Ping Y, Zhou C, Xu J, Zou W, Wang X, Lu L, Ma H, Luo Y, Spruyt K. Longitudinal measurement invariance and psychometric properties of the Patient Health Questionnaire-Four in China. BMC Psychiatry 2024; 24:517. [PMID: 39039478 PMCID: PMC11265176 DOI: 10.1186/s12888-024-05873-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/28/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Depression and anxiety symptoms among medical students are often a concern. The Patient Health Questionnaire-Four (PHQ-4), an important tool for depression and anxiety screening, is commonly used and easy to administer. This study aimed to assess and update the longitudinal measurement invariance and psychometric properties of the simplified Chinese version. METHODS A three-wave longitudinal survey was conducted among healthcare students using the PHQ-4. Structural validity was based on one-factor, two-factor, and second-order factor models, construct validity was based on the Self-Rated Health Questionnaire (SRHQ), Sleep Quality Questionnaire (SQQ), and Rosenberg Self-Esteem Scale (RSES), and longitudinal measurement invariance (LMI), internal consistency, and test-retest reliability were based on structural consistency across three time points. RESULTS The results of the confirmatory factor analysis indicated that two-factor model was the best fit, and LMI was supported at three time points. Inter-factor, factor-total, and construct validity correlations of the PHQ-4 were acceptable. Additionally, Cronbach's alpha, McDonald's omega, and the intraclass correlation coefficient demonstrated acceptable/moderate to excellent reliability of the PHQ-4. CONCLUSIONS This study adds new longitudinal evidence that the Chinese version of the PHQ-4 has promising LMI and psychometric properties. Such data lends confidence to the routine and the expanded use of the PHQ-4 for routine screening of depression and anxiety in Chinese healthcare students.
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Affiliation(s)
- Runtang Meng
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China.
- Engineering Research Center of Mobile Health Management System, Ministry of Education, Hangzhou, Zhejiang, China.
| | - Chen Jiang
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | | | - Yihong Zhu
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Meng Wang
- Ophthalmology Center, Ningbo Yinzhou No.2 Hospital, Ningbo, Zhejiang, China
| | - Nongnong Yang
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Xiaoxue Liu
- Global Health Research Division, Public Health Research Center and Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
| | - Lina Guo
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yufan Ping
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Caojie Zhou
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Jiale Xu
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Wenjing Zou
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Xiaowen Wang
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Liping Lu
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
| | - Haiyan Ma
- School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China
- Engineering Research Center of Mobile Health Management System, Ministry of Education, Hangzhou, Zhejiang, China
| | - Yi Luo
- School of Nursing, Ningbo College of Health Sciences, Ningbo, Zhejiang, China
| | - Karen Spruyt
- Université Paris Cité, NeuroDiderot, INSERM, Paris, France
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Putowski Z, Rachfalska N, Majewska K, Megger K, Krzych Ł. Identification of risk factors for post-intensive care syndrome in family members (PICS-F) among adult patients: a systematic review. Anaesthesiol Intensive Ther 2023; 55:168-178. [PMID: 37728444 PMCID: PMC10496103 DOI: 10.5114/ait.2023.130831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/25/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION Relatives of critically ill patients who either die or survive the intensive care unit (ICU) may develop substantial mental health problems that are collectively defined as post-intensive care syndrome in family (PICS-F). MATERIAL AND METHODS By using a systematised search strategy we included studies that focused on PICS-F in relatives of adult ICU patients and reported the risk factors associated with its development. The search was conducted within PubMed, Embase, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 23 August 2022. PRISMA 2020 guidelines were implemented for appropriate reporting. The objective was to document all possible risk factors associated with the development of PICS-F. RESULTS We included 51 papers covering 9302 relatives. The frequency of PICS-F varied between 2.5 and 69%. We identified 51 different risk factors of PICS-F, among which we distinguished patient-related ( n = 16), relative-related ( n = 27), and medical staff-related ( n = 8) risk factors. Among 21 studies of the highest quality, we identified the 33 variables associated with the development of PICS-F, of which younger age of a patient, death of a patient, depression in relatives during the ICU stay, history of mental disorders in relatives, being a female relative, being a spouse, and having low satisfaction with communication and care in the ICU were the most commonly reported risk factors. CONCLUSIONS PICS-F is a highly frequent phenomenon that can be exacerbated by several risk factors. Special attention should be paid to relatives of younger patients with worse prognosis and with the following relative-related risk factors: female sex, being a spouse, and history of mental health disorders. Finally, the medical staff play a role in preventing the PICS-F development, not only by maintenance of proper communication, but also by early identification of relatives prone to PICS-F.
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Affiliation(s)
- Zbigniew Putowski
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University, Kraków, Poland
| | - Natalia Rachfalska
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Karolina Majewska
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
| | | | - Łukasz Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
- Department of Cardiac Anaesthesia and Intensive Therapy, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
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Jennerich AL, Downey L, Engelberg RA, Curtis JR. Heterogeneity of Treatment Effect in a Randomized Trial of a Communication Intervention. J Pain Symptom Manage 2022; 64:298-303. [PMID: 35618247 PMCID: PMC9378632 DOI: 10.1016/j.jpainsymman.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Interventions to promote serious illness conversations have shown promise in promoting high-quality care. However, in randomized trials, some participants may benefit more from the intervention than others. OBJECTIVES To examine heterogeneity of treatment effect and identify subgroups of patients with serious illness who might benefit most from interventions to enhance communication about goals of care. METHODS We used data from a multi-center cluster-randomized trial evaluating a communication intervention to increase goals-of-care discussions in the outpatient setting. Patients (n = 249 intervention, n = 288 usual care) had serious illness with an expected median survival of two years. Using model-based recursive partitioning, we tested heterogeneity of the intervention's effect on the occurrence of patient-reported goals-of-care discussions, electronic health record documentation of goals-of-care discussions, patients' ratings of quality of communication, and patients' symptoms of psychological distress at three and six months. RESULTS We found two significant interactions. For patients' overall rating of clinician communication (n = 251), the intervention effect was positive for patients with higher household income, but not those with lower income (P < 0.001). For patients' symptoms of depression at six months (n = 288), the intervention was associated with fewer symptoms of depression among those whose self-assessed health was poor, but not among those with fair to excellent health (P < 0.001). CONCLUSIONS Identifying heterogeneity of treatment effect can be a valuable exercise following completion of a randomized trial. Interactions between the intervention and patient income and self-assessed health suggest these factors could be used to design more effective interventions to enhance communication about goals of care.
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Affiliation(s)
- Ann L Jennerich
- Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA.
| | - Lois Downey
- Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Department of Medicine (A.L.J., L.D., R.A.E., J.R.C.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (A.L.J., L.D., R.A.E., J.R.C.), University of Washington, Seattle, Washington, USA
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Moehring A, Guertler D, Krause K, Bischof G, Rumpf HJ, Batra A, Wurm S, John U, Meyer C. Longitudinal measurement invariance of the patient health questionnaire in a German sample. BMC Psychiatry 2021; 21:386. [PMID: 34348669 PMCID: PMC8335884 DOI: 10.1186/s12888-021-03390-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Patient Health Questionnaire-8 (PHQ-8) is a screening questionnaire of depressive symptoms. However, it is unknown whether it is equivalent across time and between groups of individuals. The aim of our paper was to test whether the PHQ-8 has the same meaning in two groups of individuals over time. METHODS Primary care patients were proactively recruited from three German cities. PHQ-8 data from a baseline assessment (n = 588), two assessments during the intervention (n = 246/225), and a six (n = 437) and 12 months (n = 447) follow-up assessment were first used to examine the factor structure of the PHQ-8 by confirmatory factor analysis (CFA). The best fitting factor solution was then used to test longitudinal invariance across time and between intervention and control group by Multiple Group CFA. RESULTS A two-factor structure consistently showed the best model fit. Only configural longitudinal invariance was evidenced when the baseline assessment was included in the analysis. Without the baseline assessment, strict longitudinal invariance was shown across the intervention and the follow-up assessments. Scalar invariance was established between the intervention and control group for the baseline assessment and strict invariance between groups and across the 6- and 12-month follow-up assessments. CONCLUSIONS The lack of longitudinal invariance might be attributed to various differences between the baseline assessments and all following assessments, e.g., assessment mode (iPad vs telephone), potential changes in symptom perception, and setting. TRIAL REGISTRATION DRKS0001163 5, date of trial registration: 20.01.2017; DRKS00011637 , date of trial registration: 25.01.2017.
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Affiliation(s)
- Anne Moehring
- Department of Social Medicine and Prevention, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475, Greifswald, Germany. .,DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany.
| | - Diana Guertler
- grid.5603.0Department of Social Medicine and Prevention, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475 Greifswald, Germany ,grid.452396.f0000 0004 5937 5237DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Kristian Krause
- grid.5603.0Institute for Medical Psychology, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475 Greifswald, Germany
| | - Gallus Bischof
- grid.4562.50000 0001 0057 2672Department of Psychiatry and Psychotherapy, Research Group S:TEP, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Hans-Juergen Rumpf
- grid.4562.50000 0001 0057 2672Department of Psychiatry and Psychotherapy, Research Group S:TEP, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Anil Batra
- grid.411544.10000 0001 0196 8249Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Calwer Str. 14, 72076 Tuebingen, Germany
| | - Susanne Wurm
- grid.5603.0Department of Social Medicine and Prevention, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475 Greifswald, Germany
| | - Ulrich John
- grid.5603.0Department of Social Medicine and Prevention, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475 Greifswald, Germany ,grid.452396.f0000 0004 5937 5237DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Christian Meyer
- grid.5603.0Department of Social Medicine and Prevention, Institute of Community Medicine, University Medicine Greifswald, Walther-Rathenau-Str. 48, 17475 Greifswald, Germany ,grid.452396.f0000 0004 5937 5237DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
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5
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Stochl J, Fried EI, Fritz J, Croudace TJ, Russo DA, Knight C, Jones PB, Perez J. On Dimensionality, Measurement Invariance, and Suitability of Sum Scores for the PHQ-9 and the GAD-7. Assessment 2020; 29:355-366. [PMID: 33269612 DOI: 10.1177/1073191120976863] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In psychiatry, severity of mental health conditions and their change over time are usually measured via sum scores of items on psychometric scales. However, inferences from such scores can be biased if psychometric properties such as unidimensionality and temporal measurement invariance for instruments are not met. Here, we aimed to evaluate these properties for common measures of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder Assessment-7) in a large clinical sample (N = 22,362) undergoing psychotherapy. In addition, we tested consistency in dimensionality results across different methods (parallel analysis, factor analysis, explained common variance, the partial credit model, and the Mokken model). Results showed that while both Patient Health Questionnaire-9 and Generalized Anxiety Disorder Assessment-7 are multidimensional instruments with highly correlated factors, there is justification for sum scores as measures of severity. Temporal measurement invariance across 10 therapy sessions was evaluated. Strict temporal measurement invariance was established in both scales, allowing researchers to compare sum scores as severity measures across time.
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Affiliation(s)
- Jan Stochl
- University of Cambridge, Cambridge, UK.,National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England, Cambridge, UK.,Charles University, Prague, Czech Republic
| | - Eiko I Fried
- Leiden University, Leiden, Zuid-Holland, Netherlands
| | | | | | | | | | - Peter B Jones
- University of Cambridge, Cambridge, UK.,National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England, Cambridge, UK
| | - Jesus Perez
- University of Cambridge, Cambridge, UK.,National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England, Cambridge, UK
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6
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Hayduk LA, Estabrooks CA, Hoben M. Fusion Validity: Theory-Based Scale Assessment via Causal Structural Equation Modeling. Front Psychol 2019; 10:1139. [PMID: 31231267 PMCID: PMC6559122 DOI: 10.3389/fpsyg.2019.01139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/30/2019] [Indexed: 11/13/2022] Open
Abstract
Fusion validity assessments employ structural equation models to investigate whether an existing scale functions in accordance with theory. Fusion validity parallels criterion validity by depending on correlations with non-scale variables but differs from criterion validity because it requires at least one theorized effect of the scale, and because both the scale and scaled-items are included in the model. Fusion validity, like construct validity, will be most informative if the scale is embedded in as full a substantive context as theory permits. Appropriate scale functioning in a comprehensive theoretical context greatly enhances a scale's validity. Inappropriate scale functioning questions the scale but the scale's theoretical embedding encourages detailed diagnostic investigations potentially challenging specific items, the procedure used to calculate scale values, or aspects of the theory, but also possibly recommends incorporating additional items into the scale. The scaled items should have survived prior content and methodological assessments but the items may or may not reflect a common factor because items having diverse causal backgrounds can sometimes fuse to form a unidimensional entity. Though items reflecting a common cause can be assessed for fusion validity, we illustrate fusion validity in the more challenging context of a scale comprised of diverse items and embedded in a complicated theory. Specifically we consider the Leadership scale from the Alberta Context Tool with care aides working in Canadian long-term care homes.
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Affiliation(s)
- Leslie A Hayduk
- Department of Sociology, University of Alberta, Edmonton, AB, Canada
| | | | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Mordeno IG, Carpio JGE, Mendoza NB, Hall BJ. The latent structure of major depressive symptoms and its relationship with somatic disorder symptoms among Filipino female domestic workers in China. Psychiatry Res 2018; 270:587-594. [PMID: 30368165 DOI: 10.1016/j.psychres.2018.10.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 07/04/2018] [Accepted: 10/09/2018] [Indexed: 12/24/2022]
Abstract
Emerging research have investigated the factor structure of major depressive disorder (MDD) symptoms based on DSM-5 nomenclature. However, to date, results have been inconsistent on what symptom-structure best represent MDD. This study examines the best fitting MDD among four competing models in a sample of overseas Filipino domestic helpers (N = 232). The results show that a two-factor model (Model 2b; Krause et al., 2010) provided the best fit. The model consist of two factors: somatic and non-somatic/affective symptoms. Somatic component includes sleep difficulties, fatigue, appetite changes, concentration difficulties, and psychomotor agitation/retardation while non-somatic/affective component covers anhedonia, depressed mood, feelings of worthlessness, and thoughts of death. Further, the results reveal a pattern where PHQ-15 somatic symptom-items have a higher significant relationship with MDD's somatic symptoms than with the MDD's non-somatic/affective symptoms. These findings suggest that the items of model 2b are appropriately embedded in their respective factors. Differentiating MDD factors have important clinical implications, particularly in the diagnosis and treatment of depression among overseas Filipino domestic helpers.
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Affiliation(s)
- Imelu G Mordeno
- Department of Professional Education, Mindanao State University-Iligan Institute of Technology, Philippines.
| | - Jennifer Gay E Carpio
- Department of Psychology, Mindanao State University-Iligan Institute of Technology, Philippines
| | - Norman B Mendoza
- Department of Psychology, Holy Angel University, Angeles City, Philippines
| | - Brian J Hall
- Global and Community Mental Health Research Group, Department of Psychology, Faculty of Social Sciences, The University of Macau, Avenida da Universidade, Taipa, Macau (SAR), People's Republic of China; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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8
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Zimmerman M, Morgan TA, Stanton K. The severity of psychiatric disorders. World Psychiatry 2018; 17:258-275. [PMID: 30192110 PMCID: PMC6127765 DOI: 10.1002/wps.20569] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/19/2022] Open
Abstract
The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
| | - Theresa A. Morgan
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
| | - Kasey Stanton
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
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9
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Curtis JR, Downey L, Back AL, Nielsen EL, Paul S, Lahdya AZ, Treece PD, Armstrong P, Peck R, Engelberg RA. Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:930-940. [PMID: 29802770 PMCID: PMC6145723 DOI: 10.1001/jamainternmed.2018.2317] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/07/2018] [Indexed: 12/20/2022]
Abstract
Importance Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication. Objective To evaluate the efficacy of a patient-specific preconversation communication-priming intervention (Jumpstart-Tips) targeting both patients and clinicians and designed to increase goals-of-care conversations compared with usual care. Design, Setting, and Participants Multicenter cluster-randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016. Interventions Clinicians were randomized to the bilateral, preconversation, communication-priming intervention (n = 65) or usual care (n = 67), with 249 patients assigned to the intervention and 288 to usual care. Main Outcomes and Measures The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (Quality of Communication questionnaire [QOC]; 4-indicator latent construct) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (8-item Patient Health Questionnaire; PHQ-8) and anxiety (7-item Generalized Anxiety Disorder survey; GAD-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders. Results We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8%]; mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7%]; mean [SD] age, 73.4 [12.7] years). The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; P < .001) and increased medical record documentation (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .01). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = .03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months. Conclusions and Relevance This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient visits and increased goal-concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study. Trial Registration ClinicalTrials.gov identifier: NCT01933789.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Anthony L. Back
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Sudiptho Paul
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Alexandria Z. Lahdya
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Patsy D. Treece
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Priscilla Armstrong
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ronald Peck
- Community Advisory Board, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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10
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Long AC, Kross EK, Curtis JR. Family-centered outcomes during and after critical illness: current outcomes and opportunities for future investigation. Curr Opin Crit Care 2018; 22:613-620. [PMID: 27685849 DOI: 10.1097/mcc.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Family-centered outcomes during and after critical illness assess issues that are most important to family members. An understanding of family-centered outcomes is necessary to support the provision of family-centered care and to foster development of interventions to improve care and communication in the ICU. RECENT FINDINGS Current family-centered outcomes in critical care include satisfaction with care, including end-of-life care, symptoms of psychological distress, and health-related quality of life. Novel measures include assessments of decisional conflict, decision regret, therapeutic alliance, and caregiver burden, as well as positive adaptations and resilience. SUMMARY Critical illness places a significant burden on family members. A wide variety of family-centered outcomes are available to guide improvements in care and communication. Future research should focus on developing sensitive and responsive measures that capture key elements of the family member experience during and after critical illness.
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Affiliation(s)
- Ann C Long
- aDivision of Pulmonary and Critical Care Medicine, Harborview Medical Center bCambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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