The impact of patient participation on adherence and clinical outcome in primary care of depression

Effectiveness of patient decision aid supported shared decision-making intervention in in-person and virtual hybrid pulmonary rehabilitation in older adults with chronic obstructive pulmonary disease: A pilot randomized controlled trial

INTRODUCTION

Tele-pulmonary rehabilitation is increasingly advocated but cannot completely substitute for in-person services for chronic conditions. Adherence to Pulmonary rehabilitation (PR) remains low in chronic obstructive pulmonary disease (COPD) patients. Shared decision-making (SDM) promotes patients' participation in PR decisions and helps patients and healthcare providers to jointly make decisions that patients are informed and aligned with patient preferences and values, which are critical for patient adherence to PR.

OBJECTIVE

This study aimed to develop a hybrid in-person and virtual model of home-based PR services for older COPD patients and study the effectiveness of the patient decision aid (PDA)-supported recurring SDM intervention on patient adherence to PR, rehabilitation outcomes, and decision-related outcomes, as well as to explore the mechanisms of the intervention on PR adherence.

METHODS

A total of 78 older COPD patients were randomly assigned to the PR group (n = 39) or PDA-PR group (n = 39). Both groups were conducted hybrid in-person and virtual PR intervention for 3 months. The primary outcomes were patients' quality of life and PR adherence. The secondary outcomes were dyspnea symptoms, exercise self-efficacy, knowledge, and decision-related outcomes.

RESULTS

A total of 72 participants completed the 3-month PR program. There were statistically significant differences in PR adherence (p = 0.033), COPD assessment test (CAT) scores (p = 0.016), PR knowledge (p < 0.001), decision self-efficacy (p < 0.001), decision conflict (p < 0.001), and decision regret scores (p = 0.027) between the two groups. The modified Medical Research Council Dyspnoea scale (mMRC) score was significantly decreased only in PDA-PR group (p = 0.011). No statistically significant differences were observed in St George's Respiratory Questionnaire (SGRQ) score (p = 0.078), Exercise Self-Regulatory Efficacy Scale (Ex-SRES) score (p = 0.29) and COPD knowledge (p = 0.086) between the two groups. PR value score had a significant effect on adherence to PR (p = 0.007) and CAT score (p = 0.028).

CONCLUSIONS

PDA supported recurring SDM intervention was helpful in maintaining older COPD patients' PR adherence and had advantages in improving quality of life, enhancing PR knowledge, decision self-efficacy, and reducing decision conflict and decision regret, but did not improve SGRQ and Ex-SRES. PR value score influenced patients' rehabilitation adherence and quality of life.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR): ChiCTR1900028563; http://apps.who.int/trialsearch/default.aspx.

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration

OBJECTIVE

To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience.

DATA SOURCES AND STUDY SETTING

From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare.

STUDY DESIGN

Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached.

DATA COLLECTION/EXTRACTION METHODS

For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis.

PRINCIPAL FINDINGS

We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide.

CONCLUSIONS

Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Healthcare and research priorities for women with polycystic ovary syndrome in the UK National Health Service: A modified Delphi method

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a chronic lifelong condition affecting up to 20% of women worldwide. There is limited input from affected women to guide the provision of healthcare services and future research needs. Our objective was to scope the healthcare and research priorities of women with PCOS in the United Kingdom.

DESIGN

A three-staged modified Delphi method, consisting of two questionnaires and a consensus meeting involving lay representatives and healthcare professionals.

PATIENTS AND MEASUREMENTS

Lay patient representatives of women with PCOS. Participants were asked to identify and rank healthcare and research priorities for their importance.

RESULTS

Six hundred and twenty-four lay participants took part in our Delphi method. Over 98% were diagnosed with PCOS (614/624, 98.4%). More than half experienced difficulties to receive a PCOS diagnosis (375/624, 60%), and the majority found it difficult to access specialised PCOS health services in the NHS (594/624, 95%). The top two healthcare priorities included better education for health professionals on the diagnosis and management of PCOS (238/273, 87.1%) and the need to set up specialist PCOS services (234/273, 85.7%). The top two research priorities focused on identifying better treatments for irregular periods (233/273, 85.3%) followed by better tests for early PCOS diagnosis (230/273, 84.2%).

CONCLUSIONS

We identified 13 healthcare and 14 research priorities that reflect the current health needs of women with PCOS in the United Kingdom. Adopting these priorities in future healthcare and research planning will help to optimise the health of women with PCOS and increase patient satisfaction.

Flourishing, Mental Health Professionals and the Role of Normative Dialogue

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers and patients, proposing that 'liberal' approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust.

Patients' experiences of preparing for transfer from the intensive care unit to a hospital ward: A multicentre qualitative study

BACKGROUND

The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer.

AIM

The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward.

STUDY DESIGN

Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist.

RESULTS

The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer.

CONCLUSIONS

ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery.

RELEVANCE TO CLINICAL PRACTICE

The study suggests that current transfer strategies are not optimal, and a more person-centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward.

Protocol for randomized personalized trial for stress management compared to standard of care

Stress is a significant public health burden in the United States, with most Americans reporting unhealthy levels of stress. Stress management techniques include various evidence-based treatments shown to be effective but with heterogeneous treatment responses, indicating a lack of uniform benefits for all individuals. Designed to assess a participant's response to a specific intervention, personalized (N-of-1) trials provide guidance for which treatment (s) work (s) best for the individual. Prior studies examining the effects of mindfulness meditation, yoga, and walking for stress reduction found all three interventions to be associated with significant reductions in self-reported measures of stress. Delivering these treatments using a personalized trial approach has the potential to assist clinicians in identifying the best stress management techniques for individuals with persistently high stress while fostering treatment decisions that consider their personal condition/barriers. This trial will evaluate a personalized approach compared to standard of care for three interventions (guided mindfulness meditation; guided yoga; and guided brisk walking) to manage perceived stress. Participants will respond to daily surveys and wear a Fitbit device for 18 weeks. After a 2-week baseline period, participants in the personalized trial groups will receive 12 weeks of interventions in randomized order, while participants in the standard-of-care group will have access to all interventions for self-directed stress management. After intervention, all participants will undergo 2 weeks of observation, followed by two additional weeks of the stress management intervention of their choosing while continuing outcome measurement. At study completion, all participants will be sent a satisfaction survey. The primary analysis will compare perceived stress levels between the personalized and standard of care arms. The results of this trial will provide further support for the use of personalized designs for managing stress. Clinical Trial Registration: clinicaltrials.gov, NCT05408832. Protocol version: 9/14/2022, 21-0968-MRB.

Why a distinct medical stream is necessary to support patients using cannabis for medical purposes

BACKGROUND

Since 2001, Canadians have been able to obtain cannabis for medical purposes, initially through the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Cannabis Act (Bill C-45) came into force on October 17, 2018, replacing the ACMPR. The Cannabis Act enables Canadians to possess cannabis purchased from a licensed retailer without authorization for either medical or nonmedical purposes. The Cannabis Act is currently the guiding legislation which governs both medical and nonmedical access. The Cannabis Act contains some improvements for patients but is essentially the same as its previous legislation. Beginning in October 2022, the federal government is conducting a review of the Cannabis Act and is questioning whether a distinct medical cannabis stream is still required, given the ease of access to cannabis and cannabis products. Although there is overlap in the reasons for medical and recreational cannabis use, the distinct legislation of medical versus recreational use of cannabis in Canada may be under threat.

MAIN BODY

A large segment of the medical, academic, research, and lay communities agree that there is a need for distinct medical and recreational cannabis streams. Perhaps most importantly, separation of these streams is necessary to ensure that both medical cannabis patients and healthcare providers receive the required support needed to optimize benefits while minimizing risks associated with medical cannabis use. Preservation of distinct medical and recreational streams can help to ensure that needs of different stakeholders are met. For example, patients require guidance in the form of assessing the appropriateness of cannabis use, selection of appropriate products and dosage forms, dosing titration, screening for drug interactions, and safety monitoring. Healthcare providers require access to undergraduate and continuing health education as well as support from their professional organizations to ensure medical cannabis is appropriately prescribed. Although there are challenges in conducing research, as motives for cannabis use frequently straddle boundaries between medical versus recreational cannabis use, maintenance of a distinct medical stream is also necessary to ensure adequate supply of cannabis products appropriate for medical use, to reduce stigma associated with cannabis in both patients and providers, to help enable reimbursement for patients, to facilitate removal of taxation on cannabis used for medical purposes, and to promote research on all aspects of medical cannabis.

CONCLUSION

Cannabis products for medical and recreational purposes have different objectives and needs, requiring different methods of distribution, access, and monitoring. HCPs, patients, and the commercial cannabis industry would serve Canadians well to continue to advocate to policy makers to ensure the continued existence of two distinct streams and must strive to make ongoing improvements to the current programs.

Treatment outcome of an intensive psychiatric home treatment for children and adolescents: a non-randomized controlled pilot evaluation

Home treatment (HT) may offer an effective and cost-efficient alternative to inpatient treatment for children and adolescents with acute mental disorders. This study introduces and evaluates a pilot HT project from Bern, Switzerland, with HT completely replacing an inpatient treatment. A total of n = 133 children and adolescents with acute mental disorders and inpatient treatment needs were treated either in the new HT program (n = 37) or in an active control group with inpatient treatment as usual (I-TAU, n = 96). Psychopathological burden was assessed by the Health of the Nation Outcome Scale for Children and Adolescents clinician-rated (HoNOSCA) and self-rated (HoNOSCA-SR) at the time of admission and at discharge. Treatment effects were assessed and compared using Augmented Inverse Probability Weights to adjust for baseline differences and to control for treatment duration. Participants ranged in age from 6 to 17 years (M = 13.71 years, SD = 2.93), 54% were female. HT resulted in significant improvements in the HoNOSCA (d = 0.79, p < .001) and HoNOSCA-SR (d = 0.63, p = .006). No significant differences on treatment effects were observed between HT and the reference group I-TAU in the HoNOSCA (d = 0.01, p = .96) or the HoNOSCA-SR (d = 0.11, p = .63). Overall, results indicate HT to be an effective alternative for children and adolescents with acute mental health disorders instead of hospitalization. Further evaluation with random group allocation and long-term follow-up should attempt to replicate and extend the current findings.

Linking Nonverbal Rapport to Health Outcome: Testing an Organizational Pathway Model

A growing body of research on medical communication indicates that nonverbal rapport (e.g., smiling, eye contact, closer proximity) is central to productive health care delivery. However, mechanisms integral to the process by which nonverbal rapport influences health improvement remain under-researched. This study breaks new grounds in proposing and testing mediation pathways that take into account organizational factors. We conducted a cross-sectional survey in a private hospital in Singapore among 417 patients to examine their communication with physicians and nurses. Results indicated that nonverbal rapport did not have a significant direct relationship with perceived health outcome in both the patient-physician dyad and the patient-nurse dyad. Instead, communication satisfaction and organizational identity completely mediated this relationship. In addition, respect positively moderated the relationship between nonverbal rapport and communication satisfaction in both dyads, while health literacy was not a significant moderator. The findings suggest that the organizational context should be considered in pathways research.

HIOPP-6 – a pilot study on the evaluation of an electronic tool to assess and reduce the complexity of drug treatment considering patients’ views

Background

A complex drug treatment might pose a barrier to safe and reliable drug administration for patients. Therefore, a novel tool automatically analyzes structured medication data for factors possibly contributing to complexity and subsequently personalizes the results by evaluating the relevance of each identified factor for the patient by means of key questions. Hence, tailor-made optimization measures can be proposed.

Methods

In this controlled, prospective, exploratory trial the tool was evaluated with nine general practitioners (GP) in three study groups: In the two intervention groups the tool was applied in a version with (G_{I_with}) and a version without (G_{I_without}) integrated key questions for the personalization of the analysis, while the control group (G_C) did not use any tools (routine care). Four to eight weeks after application of the tool, the benefits of the optimization measures to reduce or mitigate complexity of drug treatment were evaluated from the patient perspective.

Results

A total of 126 patients regularly using more than five drugs could be included for analysis. GP suggested 117 optimization measures in G_{I_with}, 83 in G_{I_without}, and 2 in G_C. Patients in G_{I_with} were more likely to rate an optimization measure as helpful than patients in G_{I_without} (IRR: 3.5; 95% CI: 1.2—10.3). Thereby, the number of optimization measures recommended by the GP had no significant influence (P = 0.167).

Conclusions

The study suggests that an automated analysis considering patient perspectives results in more helpful optimization measures than an automated analysis alone – a result which should be further assessed in confirmatory studies.

Trial registration

The trial was registered retrospectively at the German Clinical Trials register under DRKS-ID DRKS00025257 (17/05/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01757-0.

Examining the relationship between clinician communication and patient participatory behaviors in cardiology encounters

OBJECTIVES

Examine the association of coder ratings of cardiologist behaviors and global scores of cardiologist communication style with patient participation in clinic encounters.

METHODS

We coded transcripts of clinic encounters for patient participatory behaviors: asking questions, assertive statements, and expressing negative emotions; clinician behavior counts: reflective statements, open-ended questions, empathic statements, and eliciting questions. We used general linear regression models to examine associations of mean number of patient participatory behaviors with clinician behaviors.

RESULTS

Our sample included 161 patients of 40 cardiologists. Patient female gender was associated with on average 2.1 (CI: 0.06, 4.1; p = 0.04) more patient participatory behaviors. In an adjusted model, clinician reflective statements were associated with on average 0.3 (CI: 0.04, 0.4; p = 0.02) more patient participatory behaviors. A clinician making at least one empathic statement was associated with on average 3.7 (CI: 0.2, 7.1; p = 0.04) more patient participatory behaviors.

CONCLUSIONS

These results demonstrate that some individual clinician behaviors are associated with higher patient participation in cardiology encounters.

PRACTICE IMPLICATIONS

Clinician reflective and empathic statements may be important targets in communication training to increase patient participation.

SECTION

Communication Studies.

The Role of Pharmaceutical Compounding in Promoting Medication Adherence

Pharmaceutical compounding is an important component of pharmacy practice despite its low prevalence. Several therapeutic needs can be met by a compounded medicine such as dosing adjusted for pediatric patients, special drug combinations, medicines for patients allergic to a given excipient, and medicines for orphan drugs not provided by the pharmaceutical industry. Examples of such applications are provided in this review. Adherence to medication is a critical public health issue as nonadherence to pharmacotherapy has been associated with adverse outcomes and higher costs of patient care. Adherence to therapy represents a key factor in the reduction in morbidity and mortality and optimization of the use of financial resources. The role of pharmaceutical compounding in promoting medication adherence is underexploited. The customization might represent a positive reinforcement of the initiation of the treatment, while implementation and persistence might also be favored in a pharmacy setting. However, studies addressing the influence of compounding in adherence promotion are lacking in the literature. The results of such studies could support health policies including proper regulatory framework, pharmacist training, and information to health care practitioners.

Managing uncertainty: Physicians’ decision-making for stroke prevention for patients with atrial fibrillation and intracerebral haemorrhage

Background Stroke prevention in patients with atrial fibrillation (AF) post-intracerebral haemorrhage (ICH) is an area of clinical equipoise. Little is known about the tools and processes that physicians use to make decisions regarding anticoagulation in this high-risk patient population. Objective To explore physicians’ decision-making process regarding stroke prevention in patients with AF and a recent history of ICH. Method Qualitative study, utilising semi-structured interviews and analysed using Framework analysis. Results Twenty physicians from five European countries (Austria, France, Germany, Spain, United Kingdom) participated. The over-arching theme ‘Managing uncertainty’, addressed the process of making high-risk clinical decisions in the context of little available robust clinical evidence for best practice. Three sub-themes were identified under the umbrella theme: (1) ‘Computing the Risks’, captured the challenge of balancing the risks of ischaemic stroke with the risk of recurrent ICH in a complex patient population; (2) ‘Patient Factors’ highlighted the influence that patients’ beliefs and previous experience of stroke had on physicians’ decisions; and (3) ‘Making a Decision’ explored the process of reaching a final decision regarding initiation of OAC therapy or not. Conclusion Physicians described the process of deciding on stroke prevention in patients with AF post-ICH as ‘challenging’ due to considerable ‘clinical equipoise’. Key factors that affected decision-making was patient comorbidities, functional status, and patient willingness to engage with oral anticoagulation therapy. Shared decision-making was believed to be beneficial, but physicians believed that the ultimate responsibility to decide on stroke prevention lay with the clinician.

A collaborative strategy with community pharmacists and physicians to improve patient experience and implement quality standards for patients with depression

Background

The experience for patients with mental health disorders may be negatively impacted by the barriers to care, such as low health care provider-to-population ratios, travel time to reach service providers, higher hospital readmission rates, and local demand for services, especially in suburban and rural areas.

Objectives

The project aimed to design a model in which physicians and pharmacists collaborate to provide comprehensive care to patients with depression in two northern communities and improve the patient and provider experience.

Methods

Pharmacists and primary care physicians developed a model in which patients starting on new antidepressant medications received regular follow-up care and education on adjunct therapies from the community pharmacists instead of the physician. The patient and provider experiences were measured through surveys.

Results

Out of the 14 patients who completed the patient survey, 13 reported feeling more supported by receiving follow-up care from pharmacists. Out of the 5 providers who completed the provider survey, 4 reported that the physician-pharmacist collaboration and additional support were helpful to patients.

Conclusion

Overall, the project positively impacted patient experience and providers perceived value in the shared-care model.

Shared decision-making between older people with multimorbidity and GPs: focus group study

Background

Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.

Aim

To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.

Design and setting

Qualitative study. General practices (rural and urban) in Devon, England.

Method

Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.

Results

Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.

Conclusion

Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

National train-the-trainer certificate programme for improving healthcare communication in Austria

OBJECTIVES

In Austria a national train-the-trainer programme (TTT) has been developed, implemented and evaluated with the aim of training and certifying participants for developing, implementing and delivering communication skills training (CST) for health professionals.

METHODS

The programme included 5 in-person courses, application homework with feedback, peer work, and regular trainer network meetings. Global satisfaction with training and changes in self-efficacy among TTT-participants and their learners in the CST delivered as practice projects were evaluated.

RESULTS

18 participants have graduated from the TTT-pilot. 98 people took part in the 9 CST delivered by TTT-participants. Participants' satisfaction has been rated very positively both for TTT and CST. At post-programme/post-training, statistically significant improvement was observed in self-efficacy for the TTT-participants and for the CST-participants. Additionally, valuable suggestions for programme/training improvement were identified.

CONCLUSIONS

This programme is an important step to sustainably improving CST in Austria. To guarantee high quality and consistency, a set of standards for certification have been developed for TTT and CST.

PRACTICE IMPLICATIONS

Implementation of best practices in training trainers and communication skills teaching can be guided by a structured approach. Those wanting to implement similar programmes can benefit from strengths and suggestions for improvement identified in this national project.

Treatment options and shared decision-making in the treatment of opioid use disorder: A scoping review

BACKGROUND

Shared decision-making (SDM) is an approach to clinical decision-making that includes patients' values and preferences during health-related decisions. Previous research suggests that SDM may be beneficial in the treatment of substance use disorders; however, the impact of SDM in the treatment of opioid use disorder (OUD) remains unclear.

OBJECTIVES

To identify relevant peer-reviewed literature related to SDM in the treatment of adults with OUD, and to summarize the main findings according to patient outcomes.

METHODS

The research team conducted a scoping review. The team searched five electronic health databases from database inception until September 2019 using MeSH and keywords related to SDM. The team included only peer-reviewed studies where adults (≥18 years) with OUD were provided a choice and/or allowed input into their treatment plan. Two independent reviewers screened, extracted, and assessed the quality of included studies.

RESULTS

Fourteen studies (n = 1748 participants) met inclusion criteria, including seven randomized controlled trials, three non-randomized controlled trials, two observational studies, and one qualitative study. Treatment options included: patient regulated methadone dosing vs. fixed dosing (n = 4 studies), optional vs. mandatory counseling (n = 4 studies), home vs. office buprenorphine inductions (n = 2 studies), and inpatient vs. outpatient treatment (n = 1 study). None of the studies measured SDM with a validated instrument. Seven of 14 studies reported at least one improved patient outcome.

CONCLUSIONS

The review found few studies that explored whether providing treatment options and/or encouraging participation in decision-making are beneficial for adults with OUD. Preliminary evidence suggests that SDM may be promising for this population. However, the field needs more research on person-centered care and SDM.

Exploring the Role of Social Support in Promoting Patient Participation in Health Care among Women with Breast Cancer

Scholars have adopted Street's (2003) ecological model of communication in medical encounters to investigate the factors promoting patient participation in health care. However, factors demonstrated in the ecological model were bounded in the context of medical care primarily focusing on health care providers and patients. Social factors, such as patients' relationships and supportive communication with others outside the context of health care remain relatively unexplored. To expand the purview of our understanding of factors that influence patient participation, this research integrated social support literature into the research on physician-patient communication and proposed a model which described a process through which social support can enhance patient participation in health care. The data analyzed in this study were a part of two larger clinical trials in which 661 women with breast cancer were recruited from three cancer institutions in the United States. The results from structural equation modeling analysis from cross-sectional and longitudinal data provided strong evidence for the hypotheses predicting that perceived social support was positively associated with health information competence, which in turn fully mediated the association between social support and patient participation in health care. Theoretical and practical implications are discussed.

Investigating patients´ views on screening for depression in cardiac practice: A qualitative interview study

OBJECTIVE

Recommendations on screening for depression in patients with coronary heart disease (CHD) are highly debated. While recent research has prioritized efficacy studies, little is known about what is potentially required for screening to be efficacious. Expanding our knowledge of how patients with CHD view screening is likely to pose a first step towards addressing this gap. We aimed to investigate patients ́ views on routine screening for depression in cardiac practice.

METHODS

This exploratory, qualitative study was conducted among 12 patients with CHD, who completed semi-structured interviews. We used a purposive sampling strategy to include patients within a range of ages, gender and self-reported depression. Thematic analysis was carried out.

RESULTS

We identified four main themes: Acceptance, utility, barriers and expectations. Patients in this sample appeared to be in favor of standardized routine screening for depression in cardiac practice, if the rationale was disclosed. Patients reported that standardized screening addresses holistic care demands, promotes validation of individual symptom burden and legitimizes the display of psychological distress in cardiac practice. Yet, skepticism towards the validity of screening instruments and perceived stigmatization could pose a main barrier to screening efficacy. Patients expected to receive feedback on results and consecutive recommendations.

CONCLUSION

We found that depression screening is endorsed by patients with CHD in this study sample. Standardized routine screening procedures could serve as a useful tool to combat stigmatization, and encourage patients to display symptoms of depression towards cardiologists. The efficacy of depression screening could potentially be enhanced by tailoring the screening process towards patients´ needs.

Effectiveness of guided internet-based interventions in the indicated prevention of depression in green professions (PROD-A): Results of a pragmatic randomized controlled trial

BACKGROUND

Major Depressive Disorder (MDD) has a major impact on public health. Reduction of depression burden in general population is of greatest importance and might be achieved by implementation of depression prevention measures into routine care. We evaluate an online prevention measure as part of a national project aiming to reduce depression in the occupational group of green professions.

METHODS

This two-armed pragmatic RCT (n = 360) evaluates the effectiveness of a tailored internet-based intervention (IMI) program compared to enhanced treatment as usual. The IMI program entailed access to one of six guided IMIs each focusing on different symptom areas (depressive mood with optional comorbid diabetes, perceived stress, insomnia, panic and agoraphobia and harmful alcohol consumption). Eligible were entrepreneurs, spouses, family members and pensioners in green professions with adequate insurance status and at least subthreshold depression (PHQ≥5). Primary outcome was depressive symptom severity (QIDS-SR16) at 9-weeks post-treatment (T1). Various secondary outcomes were assessed at T1.

RESULTS

A small effect of depression reduction (d=-0.28, 95%-CI: -0.50 to -0.07) was found at T1 favouring the IMI program (β=-0.22, 95%-CI: -0.41 to -0.02, p=.033). Categorical analysis indicated a reduced risk of potential MDD with NNTB=28.11. Adherence to the IMI program at T1 was exceptionally low.

LIMITATIONS

Results are limited to green professions and representativeness might be restricted by self-selection of participants.

CONCLUSION

Depression burden in green professions can be reduced by this online prevention measure. Yet, short-term effectiveness is restricted by low adherence rates.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000. Registered: 09 April 2018.

Measuring the Patient Experience of Mental Health Care: A Systematic and Critical Review of Patient-Reported Experience Measures

BACKGROUND

There is growing concern about measuring patient experience with mental health care. There are currently numerous patient-reported experience measures (PREMs) available for mental health care, but there is little guidance for selecting the most suitable instruments. The objective of this systematic review was to provide an overview of the psychometric properties and the content of available PREMs.

METHODS

A comprehensive review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted using the MEDLINE database with no date restrictions. The content of PREMs was analyzed using an inductive qualitative approach, and the methodological quality was assessed according to Pesudovs quality criteria.

RESULTS

A total of 86 articles examining 75 PREMs and totaling 1932 items were included. Only four PREMs used statistical methods from item response theory (IRT). The 1932 items covered seven key mental health care domains: interpersonal relationships (22.6%), followed by respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%), psychological care (6.8%) and care environment (6.1%). Additionally, a few items focused on patient satisfaction (6.7%) rather than patient experience. No instrument covered the latent trait continuum of patient experience, as defined by the inductive qualitative approach, and the psychometric properties of the instruments were heterogeneous.

CONCLUSION

This work is a critical step in the creation of an item library to measure mental health care patient-reported experience that will be used in France to develop, validate, and standardize item banks and computerized adaptive testing (CAT) based on IRT. It will also provide internationally replicable measures that will allow direct comparisons of mental health care systems.

TRIAL REGISTRATION

NCT02491866.

Relationship Between Patient Engagement and Depressive Symptoms Among People Living With HIV in a Mobile Health Intervention: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Associations between higher levels of patient engagement and better health outcomes have been found in face-to-face interventions; studies on such associations with mobile health (mHealth) interventions have been limited and the results are inconclusive.

OBJECTIVE

The objective of this study is to investigate the relationship between patient engagement in an mHealth intervention and depressive symptoms using repeated measures of both patient engagement and patient outcomes at 4 time points.

METHODS

Data were drawn from a randomized controlled trial (RCT) of an mHealth intervention aimed at reducing depressive symptoms among people living with HIV and elevated depressive symptoms. We examined the association between patient engagement and depressive symptoms in the intervention group (n=150) where participants received an adapted cognitive-behavioral stress management (CBSM) course and physical activity promotion on their WeChat social media app. Depressive symptoms were repeatedly measured using the Patient Health Questionnaire (PHQ-9) at baseline and 1 month, 2 months, and 3 months. Patient engagement was correspondingly measured by the completion rate, frequency of items completed, and time spent on the program at 1 month, 2 months, and 3 months. Latent growth curve models (LGCMs) were used to explore the relationship between patient engagement and depressive symptoms at multiple time points in the intervention.

RESULTS

The mean PHQ-9 scores were 10.2 (SD 4.5), 7.7 (SD 4.8), 6.5 (SD 4.7), and 6.7 (SD 4.1) at baseline, 1 month, 2 months, and 3 months, respectively. The mean completion rates were 50.6% (SD 31.8%), 51.5% (SD 32.2%), and 50.8% (SD 33.7%) at 1, 2, and 3 months, respectively; the average frequencies of items completed were 18.0 (SD 14.6), 32.6 (SD 24.8), and 47.5 (SD 37.2) at 1, 2, and 3 months, respectively, and the mean times spent on the program were 32.7 (SD 66.7), 65.4 (SD 120.8), and 96.4 (SD 180.4) minutes at 1, 2, and 3 months, respectively. LGCMs showed good model fit and indicated that a higher completion rate (β at 3 months=-2.184, P=.048) and a greater frequency of items completed (β at 3 months=-0.018, P=.04) were associated with fewer depressive symptoms at 3 months. Although not significant, similar trends were found in the abovementioned relationships at 1 and 2 months. There was no significant relationship between time spent on the program and depressive symptoms.

CONCLUSIONS

This study revealed a positive association between patient engagement and health outcomes at 3 months of an mHealth intervention using LGCMs and repeated measures data. The results underscore the importance of improving patient engagement in mHealth interventions to improve patient-centered health outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://tinyurl.com/yxb64mef.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-018-5693-1.

Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol

BACKGROUND

The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today's older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function.

AIMS

To undertake feasibility testing of an intervention ('VOLITION') aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness.

METHODS

This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days.

DISCUSSION

Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care.

TRIAL REGISTRATION

CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18.

Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged)

OBJECTIVE

To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations.

METHODS

Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate.

RESULTS

8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured.

CONCLUSION

The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare.

PRACTICE IMPLICATIONS

There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

What the doctor doesn't know: Discarded patient knowledge of older adults with multimorbidity

OBJECTIVES

Adherence to treatment has proven to require the involvement of patients in treatment and care planning. This process involves incorporating patient knowledge, or knowledge about the patients' everyday life, into the clinical encounter. This article explores the disclosure practices of such knowledge from older adults with multimorbidity.

METHODS

This was an 18-month qualitative study among 14 older adults with multimorbidity living in Denmark. A thematic analysis was applied, focusing on perceptions of patient knowledge and disclosure practices among the participating patients.

RESULTS

Older adults with multimorbidity have various reasons for not disclosing personal knowledge. The results present three different domains of what we termed discarded patient knowledge: (1) knowledge that had no direct biomedical relevance from participants' perspective; (2) knowledge considered too private; and (3) knowledge assumed to position one as inferior.

DISCUSSION

The participants made judgments on what they believed was welcome in the clinical encounter, framing their knowledge within the purview of biomedicine. Participants' disclosure practices showed that personal knowledge is sometimes not recognized as important for health and care by participants themselves. Knowledge that could have influenced practitioners' understanding of the problem and provided different solutions, is argued to be discarded patient knowledge.

The Communicative Ecology of Chinese Patients' Experiences with Health Care

Patient satisfaction and trust are important intermediate outcomes along pathways linking clinician-patient communication to improve well-being, but they are difficult to achieve in Chinese health care. Problematic physician-patient interactions, questionable health-care organizational practices, and media coverage of medical scandals may have contributed to this problem. Nevertheless, there isscant literature documenting reasons underlying dissatisfaction with Chinese health care. Using Street's ecological model of communication in medical encounters as a conceptual framework, this study explores how media and organizational factors affect Chinese patients' satisfaction and trust both directly and as mediated by the quality of patients' past communication experiences with clinicians. A survey was conducted among 257 Ob-gyn patients in a top-tier hospital in Sichuan, China. The results show that several organizational and media factors, along with patients' experiences with physician communication, predict patient satisfaction and trust. Perceptions of physician communication mediated some of the relationships between organizational and media factors with outcomes. Theoretical and practical implications are discussed, particularly with respect to improving health-care services in China.

Experiences with legally mandated treatment in patients with schizophrenia: A systematic review of qualitative studies

Background:

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Methods:

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

Results:

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Conclusions:

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

Involvement in maternal care by migrants and ethnic minorities: a narrative review

BACKGROUND

Guidelines for improving the quality of maternal health services emphasise women's involvement in care. However, evidence about migrant and ethnic minorities' preferences for participation in maternal care remains unsystematised. Understanding these populations' experiences with and preferred forms of involvement in care provision is crucial for imbuing policies and guidelines with sensitivity to diversity and for implementing people-centred care. This paper presents a narrative synthesis of empirical studies of involvement in maternal health care by migrants and ethnic minorities based on four key dimensions: information, communication, expression of preferences and decision-making.

METHODS

Studies indexed in PubMed and Scopus published until December 2019 were searched. Original quantitative, qualitative and mixed methods studies written in English and reporting on migrant and ethnic minority involvement in maternal care were included. Backward reference tracking was carried out. Three researchers conducted full-text review of selected publications.

RESULTS

In total, 22 studies met the inclusion criteria. The majority of studies were comparative and addressed only one or two dimensions of involvement, with an emphasis on the information and communication dimensions. Compared to natives, migrants and ethnic minorities were more likely to (1) lack access to adequate information as a result of health care staff's limited time, knowledge and misconceptions about women's needs and preferences; (2) report suboptimal communication with care staff caused by language barriers and inadequate interpreting services; (3) be offered fewer opportunities to express preferences and to have preferences be taken less into account; and (4) be less involved in decisions about their care due to difficulties in understanding information, socio-cultural beliefs and previous experiences with care provision less attuned with playing an active role in decision-making and care staff detracting attitudes.

CONCLUSION

Constraints to adequate and inclusive involvement in maternal care can hinder access to quality care and result in severe negative health outcomes for migrant and ethnic minority women. More research is needed into how to tailor the dimensions of involvement to migrant and ethnic minorities' needs and preferences, followed by provision of the resources necessary for effective implementation (e.g. sufficient time for consultations, optimal interpreter systems, health care staff training).

Patients' and clinicians' perspectives on shared decision-making regarding treatment decisions for depression, anxiety disorders, and obsessive-compulsive disorder in specialized psychiatric care

RATIONALE, AIMS, AND OBJECTIVES

People worldwide are affected by psychiatric disorders that lack a "best" treatment option. The role of shared decision-making (SDM) in psychiatric care seems evident, yet remains limited. Research on SDM in specialized mental health is scarce, concentrating on patients with depressive disorder or psychiatric disorders in general and less on patients with anxiety and obsessive-compulsive disorder (OCD). Furthermore, recent research concentrates on the evaluation of interventions to promote and measure SDM rather than on the feasibility of SDM in routine practice. This study investigated patients' and clinicians' perspectives on SDM to treat depression, anxiety disorders, and OCD as to better understand SDM in specialized psychiatric care and its challenges in clinical practice.

METHODS

Transcripts of eight focus groups with 17 outpatients and 33 clinicians were coded, and SDM-related codes were analysed using thematic analyses.

RESULTS

Motivators, responsibilities, and preconditions regarding SDM were defined. Patients thought SDM should be common practice given the autonomy they have over their own bodies and felt responsible for their treatments. Clinicians value SDM for obtaining patients' consent, promoting treatment adherence, and establishing a good patient-clinician relationship. Patients and clinicians thought clinicians assumed the most responsibility regarding the initiation and achievement of SDM in clinical practice. According to clinicians, preconditions were often not met, were influenced by illness severity, and formed important barriers (eg, patient's decision-making capacity, treatment availability, and clinicians' preferences), leading to paternalistic decision-making. Patients recognized these difficulties, but felt none of these preclude the implementation of SDM. Personalized information and more consultation time could facilitate SDM.

CONCLUSIONS

Patients and clinicians in specialized psychiatric care value SDM, but adapting it to daily practice remains challenging. Clinicians are vital to the implementation of SDM and should become versed in how to involve patients in the decision-making process, even when this is difficult.

Patients' experiences of seeking help for emotional concerns in primary care: doctor as drug, detective and collaborator

Background

NICE guidelines for the management of emotional concerns in primary care emphasise the importance of communication and a trusting relationship, which is difficult to operationalise in practice. Current pressures in the NHS mean that it is important to understand care from a patient perspective. This study aimed to explore patients’ experiences of primary care consultations for emotional concerns and what patients valued when seeking care from their GP.

Methods

Eighteen adults with experience of consulting a GP for emotional concerns participated in 4 focus groups. Data were analysed thematically.

Results

(1) Doctor as Drug: Patients’ relationship with their GP was considered therapeutic with continuity particularly valued. (2) Doctor as Detective and Validator: Patients were often puzzled by their symptoms, not recognising their emotional concerns. GPs needed to play the role of detective by exploring not just symptoms, but the person and their life circumstances. GPs were crucial in helping patients understand and validate their emotional concerns. (3) Doctor as Collaborator: Patients prefer a collaborative partnership, but often need to relinquish involvement because they are too unwell, or take a more active role because they feel GPs are ill-equipped or under too much pressure to help. Patients valued: GPs booking their follow up appointments; acknowledgement of stressful life circumstances; not relying solely on medication.

Conclusions

Seeking help for emotional concerns is challenging due to stigma and unfamiliar symptoms. GPs can support disclosure and understanding of emotional concerns by fully exploring and validating patients’ concerns, taking into account patients’ life contexts. This process of exploration and validation forms the foundation of a curative, trusting GP-patient relationship. A trusting relationship, with an emphasis on empathy and understanding, can make patients more able to share involvement in their care with GPs. This process is cyclical, as patients feel that their GP is caring, interested, and treating them as a person, further strengthening their relationship. NICE guidance should acknowledge the importance of empathy and validation when building an effective GP-patient partnership, and the role this has in supporting patients’ involvement in their care.

Integration of mental health care in private not-for-profit health centres in Guinea, West Africa: a systemic entry point towards the delivery of more patient-centred care?

BACKGROUND

Patient-centred care is an essential component of quality of health care. We hypothesize that integration of a mental health care package into versatile first-line health care services can strengthen patient participation, an important dimension of patient-centred care. The objective of this study is to analyse whether consultations conducted by providers in facilities that integrated mental health care score higher in terms of patient participation.

METHODS

This study was conducted in Guinea in 12 not-for-profit health centres, 4 of which had integrated a mental health care package (MH+) and 8 had not (MH-). The study involved 450 general curative consultations (175 in MH+ and 275 in MH- centres), conducted by 18 care providers (7 in MH+ and 11 in MH- centres). Patients were interviewed after the consultation on how they perceived their involvement in the consultation, using the Patient Participation Scale (PPS). The providers completed a self-administered questionnaire on their perception of patient's involvement in the consultation. We compared scores of the PPS between MH+ and MH- facilities and between patients and providers.

RESULTS

The mean PPS score was 24.21 and 22.54 in MH+ and MH- health centres, respectively. Participation scores depended on both care providers and the health centres they work in. The patients consulting an MH+ centre were scoring higher on patient participation score than the ones of an MH- centre (adjusted odds ratio of 4.06 with a 95% CI of 1.17-14.10, p = 0.03). All care providers agreed they understood the patients' concerns, and patients shared this view. All patients agreed they wanted to be involved in the decision-making concerning their treatment; providers, however, were reluctant to do so.

CONCLUSION

Integrating a mental health care package into versatile first-line health services can promote more patient-centred care.

Shared decision-making in mental and behavioural health interventions

Elements of shared decision-making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision-making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision-making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision-making when working with patients.

Ethical challenges of seclusion in psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental health professionals

BACKGROUND

Seclusion is an invasive clinical intervention used in inpatient psychiatric wards as a continuation of milieu therapy with vast behavioural implications that raise many ethical challenges. Seclusion is in Norway defined as an intervention used to contain the patient, accompanied by staff, in a single room, a separate unit, or an area inside the ward. Isolation is defined as the short-term confinement of a patient behind a locked or closed door with no staff present. Few studies examine how staff experiences the ethical challenges they encounter during seclusion. By making these challenges explicit and reflecting upon them, we may be able to provide better care to patients. The aim of this study is to examine how clinical staff in psychiatric inpatient wards describes and assess the ethical challenges of seclusion.

METHODS

This study was based on 149 detailed written descriptions of episodes of seclusion from 57 psychiatric wards. A descriptive and exploratory approach was used. Data were analysed using qualitative content analysis.

RESULTS

The main finding is that the relationship between treatment and control during seclusion presents several ethical challenges. This is reflected in the balance between the staff's sincere desire to provide good treatment and the patients' behaviour that makes control necessary. Particularly, the findings show how taking control of the patient can be ethically challenging and burdensome and that working under such conditions may result in psychosocial strain on the staff. The findings are discussed according to four core ethical principles: autonomy, beneficence, non-maleficence, and justice.

CONCLUSION

Ethical challenges seem to be at the core of the seclusion practice. Systematic ethical reflections are one way to process the ethical challenges that staff encounters. More knowledge is needed concerning the ethical dimensions of seclusion and alternatives to seclusion, including what ethical consequences the psychosocial stress of working with seclusion have for staff.

Shared decision-making in older children and parents considering elective adenotonsillectomy

OBJECTIVES

Shared decision-making describes a collaborative process in which healthcare providers and patients/families make treatment decisions using the best available evidence, while taking into account the patient's values and preferences. The objectives of this study were to assess the level of decisional conflict and shared decision-making experienced by older children and their parents when considering elective adentonsillectomies.

DESIGN

A prospective cohort study.

SETTING

Paediatric otolaryngology clinic in a teaching hospital.

PARTICIPANTS

Participants included 53 children older than 9 years and their parents who underwent consultation for tonsillectomy with or without adenoidectomy.

MAIN OUTCOMES MEASURES

Children and parents completed the Decisional Conflict Scale (DCS) and Shared Decision-Making Questionnaire-Patient Version (SDM-Q-9). Surgeons completed the Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc).

RESULTS

Overall, 10 (19%) parents and 18 (34%) children reported clinically significant decisional conflict. Parents who opted not to proceed with surgery had significantly higher DCS scores than those who decided to proceed with surgery. Both parents and children SDM-Q-9 and total DCS scores were significantly negatively correlated. Physician SDM-Q-Doc and parent total DCS scores were negatively correlated, while parent and physician SDM scores were positively correlated.

CONCLUSIONS

Many older children and parents reported significant decisional conflict when considering elective paediatric otolaryngology surgery. Decisional conflict levels for both children and parents decreased with greater perceived levels of shared decision-making. Older children did not appear to discern the same levels of shared decision-making as parents and surgeons. Future research should assess methods to implement shared decision-making into clinical practice for clinicians, parents and children when appropriate.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations

BACKGROUND

Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options.

OBJECTIVES

To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis.

MAIN RESULTS

We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'.

AUTHORS' CONCLUSIONS

Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Self-Determination and Choice in Mental Health: Qualitative Insights From a Study of Self-Directed Care

SELF-DETERMINATION AND CHOICE IN MENTAL HEALTH.

Shared Decision Making for Psychiatric Rehabilitation Services Before Discharge from Psychiatric Hospitals

Shared decision making (SDM) is an effective health communication model designed to facilitate patient engagement in treatment decision making. In mental health, SDM has been applied and evaluated for medications decision making but less for its contribution to personal recovery and rehabilitation in psychiatric settings. The purpose of this pilot study was to assess the effect of SDM in choosing community psychiatric rehabilitation services before discharge from psychiatric hospitalization. A pre-post non-randomized design with two consecutive inpatient cohorts, SDM intervention (N = 51) and standard care (N = 50), was applied in two psychiatric hospitals in Israel. Participants in the intervention cohort reported greater engagement and knowledge after choosing rehabilitation services and greater services use at 6-to-12-month follow-up than those receiving standard care. No difference was found for rehospitalization rate. Two significant interaction effects indicated greater improvement in personal recovery over time for the SDM cohort. SDM can be applied to psychiatric rehabilitation decision making and can help promote personal recovery as part of the discharge process.

Effect of Patient Participation on Nurse and Patient Outcomes in Inpatient Healthcare

Using service-dominant logic as a theoretical lens, this study investigated the co-production of healthcare service and service value co-creation between nurses and patients. The main objective of this study was to: (1) examine the effect of patient participation on patient satisfaction and nurses' attitudes and behaviors; (2) examine boundary conditions of the effect of patient participation on patients and nurses. We proposed that patient participation positively impacted patient satisfaction and nurse job satisfaction, work engagement, and helping behaviors. We further proposed that first inpatient stay and length of stay moderated the effect of patient participation on patient satisfaction, and nurses' sociodemographic characteristics moderated the effect of patient participation on nurse job satisfaction, work engagement, and helping behaviors. Using survey data from 282 nurses and 522 inpatients from a public hospital in China, we found that the effect of patient participation on patient satisfaction was contingent upon first inpatient stay and length of stay. We also found that patient participation improved nurse job satisfaction, work engagement, and helping behaviors. Furthermore, nurses' sociodemographic characteristics, namely age and organizational tenure, moderated the effect of patient participation on nurse job satisfaction, but not on work engagement and helping behaviors. Theoretical and practical implications of our findings were discussed.

Pathways Linking Patient-Centered Communication to Health Improvement: A Longitudinal Study in China

The Chinese health care system has suffered from severe tension between patients and doctors during the past decade. Patient-centered communication (PCC) may play a significant role in mitigating this problem. With a general basis of the pathway model linking communication to health, this paper illustrates social mechanisms that underlie how PCC improves health outcomes in China. Using three-wave panel data collected in China, the results showed that PCC failed to directly influence health. Instead, PCC at Wave 1 predicted patient satisfaction and patient trust at Wave 2, which in turn enhanced self-reported health outcomes at Wave 3. In addition, bonding social capital positively moderated the effect of PCC on patient trust.

Illness Beliefs, Treatment Beliefs and Information Needs as Starting Points for Patient Information: The Evaluation of an Intervention for Patients with Depression

Patients with depression are often dissatisfied with disease- and therapy-related information. The objective of this study was to evaluate an intervention that applied the Common Sense Model to the provision of information during inpatient rehabilitation for patients with depression. The intervention was evaluated in a sequential control group design. Analyses of covariance were used to assess differences between the control and intervention groups. Changes with respect to illness and treatment beliefs (personal control, treatment control, coherence and concerns about medicines), satisfaction with information about medicines, illness and rehabilitation, and depressive burden were selected as primary outcome measures. We observed significant between-group differences indicating the intervention group's superiority in terms of satisfaction with information regarding medicines. However, the two groups' changes during rehabilitation did not differ in terms of the other outcomes. The intervention resulted in patients judging that their medication information needs had been more thoroughly fulfilled than those patients who received care-as-usual information. However, the intervention did not prove to be effective when the other outcome variables are considered. Taken together and bearing in mind the limitations of our study-particularly the non-randomised design-our results should be replicated in a randomised controlled trial.

Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively

The shared decision-making (SDM) model is one in which providers and consumers of health care come together as collaborators in determining the course of care. The model is especially relevant to youth mental health care, when planning a treatment frequently entails coordinating both youth and parent perspectives, preferences, and goals. The present article first provides the historical context of the SDM model and the rationale for increasing our field's use of SDM when planning psychosocial treatments for youth and families. Having established the potential utility of SDM, the article then discusses how to apply the SDM model to treatment planning for youth psychotherapy, proposing a set of steps consistent with the model and considerations when conducting SDM with youth and families.

The Role of Primary Care Experiences in Obtaining Treatment for Depression

BACKGROUND

Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.

OBJECTIVE

In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.

DESIGN AND PARTICIPANTS

We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients.

MAIN MEASURES

We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.

KEY RESULTS

Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.

CONCLUSIONS

In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation

BACKGROUND

Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.

OBJECTIVE

To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence.

DESIGN

Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.

PARTICIPANTS

Thirty-two physicians and 217 patients.

MAIN MEASURES

Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.

KEY RESULTS

Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures.

CONCLUSIONS

Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.