What outcomes matter to patients?

The Needs of Patients With Chronic Disease in Transitional Care From Hospital to Home in Sudan: A Qualitative Study

The growing burden of chronic non-communicable diseases demands improved post-discharge care. The Sudanese healthcare system faces challenges in providing coordinated care for patients with chronic conditions after hospital discharge. This qualitative study explored the experiences of patients with chronic disease in transitional care from hospital to home to identify improvement targets. Purposive sampling was used to interview 17 participants from different hospitals in Khartoum, Sudan. Audio recordings were transcribed and analyzed using principles of content analysis to identify themes and the relationship between them. Thematic analysis revealed 4 main themes describing the perceived needs of the patients. These were (1) feeling well-informed about post-discharge care goals and plans; (2) feeling cared for during hospital admission and follow-up visits; (3) feeling safe during the transitional care process; and (4) having access to follow-up services. This study highlights the importance of improving hospital patient education through effective communication to facilitate care transitions.

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

[Patient-reported outcomes in head and neck cancer treatment: relevance, challenges, and benefit]

Next to overall survival, quality of life is becoming more and more pivotal for cancer patients. The various domains of quality of life are complex and have different value to each patient. However, not only patients but also health care professionals, the pharmaceutical industry, and regulatory bodies ask: How can quality of life be reliably ascertained in clinical trials? For this purpose, carefully developed and validated specific questionnaires are needed: the patient-reported outcome measures (PROMs). A key challenge is to define how results based on PROMs can be used for shared decision-making. Next to clinical factors such as health and nutritional status, quality of life acts as a prognostic factor for overall survival in cancer. Thus, it is crucial to take quality of life into account in daily clinical practice.

From guidelines to decision aids and adherence supports: Insights from the process of evidence translation

OBJECTIVE

To explore the evidence-translator's experience of the expert-recommended process of translating guidelines into tools for decision making, action, and adherence with the goal of improvement.

METHODS

A single reviewer dual reviewed the content, quality, certainty, and applicability of primary atherosclerotic cardiovascular prevention guidelines from the U.S. Preventive Services Task Force at the time of this work and used targeted searches of Medline to define the ideal structure and outcomes of tools; fill in gaps in guidelines; identify end-user needs; and choose and optimize existing tools in preparation for testing.

RESULTS

Guidelines addressed screening, treatments, and/or supports, but never the combination of all three. None provided all of the information needed for evidence translation. Searches in Medline filled in some evidence gaps and provided key insights into end-user needs and effective tools. However, evidence translators are left with complicated decisions about how to use and align evidence.

CONCLUSION

Guidelines provide some, but not all, of the evidence needed for evidence translation, requiring additional intensive work. Evidence gaps result in complicated decisions about how to use and align evidence and balance feasibility and rigor.

PRACTICE IMPLICATIONS

Guidelines, standards groups, and researchers should work to better support the process of evidence translation.

Comorbidity and health-related quality of life in people with a chronic medical condition in randomised clinical trials: An individual participant data meta-analysis

BACKGROUND

Health-related quality of life metrics evaluate treatments in ways that matter to patients, so are often included in randomised clinical trials (hereafter trials). Multimorbidity, where individuals have 2 or more conditions, is negatively associated with quality of life. However, whether multimorbidity predicts change over time or modifies treatment effects for quality of life is unknown. Therefore, clinicians and guideline developers are uncertain about the applicability of trial findings to people with multimorbidity. We examined whether comorbidity count (higher counts indicating greater multimorbidity) (i) is associated with quality of life at baseline; (ii) predicts change in quality of life over time; and/or (iii) modifies treatment effects on quality of life.

METHODS AND FINDINGS

Included trials were registered on the United States trials registry for selected index medical conditions and drug classes, phase 2/3, 3 or 4, had ≥300 participants, a nonrestrictive upper age limit, and were available on 1 of 2 trial repositories on 21 November 2016 and 18 May 2018, respectively. Of 124 meeting these criteria, 56 trials (33,421 participants, 16 index conditions, and 23 drug classes) collected a generic quality of life outcome measure (35 EuroQol-5 dimension (EQ-5D), 31 36-item short form survey (SF-36) with 10 collecting both). Blinding and completeness of follow up were examined for each trial. Using trials where individual participant data (IPD) was available from 2 repositories, a comorbidity count was calculated from medical history and/or prescriptions data. Linear regressions were fitted for the association between comorbidity count and (i) quality of life at baseline; (ii) change in quality of life during trial follow up; and (iii) treatment effects on quality of life. These results were then combined in Bayesian linear models. Posterior samples were summarised via the mean, 2.5th and 97.5th percentiles as credible intervals (95% CI) and via the proportion with values less than 0 as the probability (PBayes) of a negative association. All results are in standardised units (obtained by dividing the EQ-5D/SF-36 estimates by published population standard deviations). Per additional comorbidity, adjusting for age and sex, across all index conditions and treatment comparisons, comorbidity count was associated with lower quality of life at baseline and with a decline in quality of life over time (EQ-5D -0.02 [95% CI -0.03 to -0.01], PBayes > 0.999). Associations were similar, but with wider 95% CIs crossing the null for SF-36-PCS and SF-36-MCS (-0.05 [-0.10 to 0.01], PBayes = 0.956 and -0.05 [-0.10 to 0.01], PBayes = 0.966, respectively). Importantly, there was no evidence of any interaction between comorbidity count and treatment efficacy for either EQ-5D or SF-36 (EQ-5D -0.0035 [95% CI -0.0153 to -0.0065], PBayes = 0.746; SF-36-MCS (-0.0111 [95% CI -0.0647 to 0.0416], PBayes = 0.70 and SF-36-PCS -0.0092 [95% CI -0.0758 to 0.0476], PBayes = 0.631.

CONCLUSIONS

Treatment effects on quality of life did not differ by multimorbidity (measured via a comorbidity count) at baseline-for the medical conditions studied, types and severity of comorbidities and level of quality of life at baseline, suggesting that evidence from clinical trials is likely to be applicable to settings with (at least modestly) higher levels of comorbidity.

TRIAL REGISTRATION

A prespecified protocol was registered on PROSPERO (CRD42018048202).

Health-related quality of life of multidrug-resistant tuberculosis patients: A study of eastern Uttar Pradesh, India

INTRODUCTION

Much attention has been given to the microbiological aspect, drug treatment, and clinical indicators of MDR-TB, but patients' QOL has remained a neglected area. In this study, we aimed to find the quality of MDRTB on various quality of life domains during the initiation of the MDR Treatment regimen.

MATERIALS & METHODS

A cross-sectional study was conducted over a period of 6 months at the Drug-Resistance Tuberculosis Management Centre (DR-TB Centre), of a tertiary care centre in the eastern Uttar pradesh, India. Patients with age >18 years diagnosed with MDR-TB (Multidrug resistance TB) were included in the study. The WHO QOL-BREF scale was used to assess the health-related quality of life of patients. Data were analyzed using SPSS version 21. The institutional ethical review committee approved the study, and consent was taken before the participation of patients.

RESULTS

A total of 157 patients were included in the study & 45.85% were dissatisfied with their condition. Social domain of WHO QOL-BREF is having the lowest mean score (28.51 ± 15.4) while psychological has high mean values (39.92 ± 6.91). There was a significant difference in the physical health domain with respect to age (p-value 0.001). Similar differences have been seen in the psychological domain regarding patient sex (p-value 0.001), smoking and alcohol within the social domain, and loss of income in the environmental domain.

CONCLUSION

The mean value of different domains of WHO QOL-BREF is low in MDR-TB patients, with social relation domain being the most affected.

Patients and neurologists have different perceptions of multiple sclerosis symptoms, care and challenges

BACKGROUND

Basic steps in the management of patients with Multiple Sclerosis (MS), such as good patient understanding of the disease and active participation in its management are extremely important, as they directly influence treatment adherence and success. Therefore, this study aimed to evaluate the perception of MS patients and neurologists pertaining to the most common disease symptoms, disabilities that impact on quality of life, and patient concerns and difficulties during medical visits, as information that can be used to improve the doctor-patient relationship.

METHODS

A cross-sectional study involving two groups: the first composed of neurologists and the second of patients. Participants of the first group were selected by a Steering Committee (15 predetermined neurologists representing each region of Brazil and specialized in MS and neuroimmunological disorders, who also assumed the role of creating the survey and questionnaire). Participants of the second group were selected following dissemination of a questionnaire on the AME's social networks (Amigos Múltiplos pela Esclerose, a non-governmental organization to support patients with MS). Questions about sociodemographic data, disease impact on quality of life, symptoms perception, and concerns and issues regarding disease care were put to both groups.

RESULTS

A total of 317 patients and 182 neurologists answered the questionnaires. Significant divergences were found between the perceptions of patients and neurologists in relation to orientation and information given during medical appointments, and also regarding patient participation in treatment and therapy choice. Considering the topic assessing impact on quality of life, more than 70% of neurologists perceived that autonomy to work and travel, and future planning were aspects that most affected patient lives, however, almost 50% of patients reported that disease monitoring did not affect their life in any way. Analysis of data regarding MS symptoms revealed neurologists to consider physical symptoms, such as ambulation issues, imbalance, falls and urinary incontinence, to be those most interfering with patient quality of life, whereas patients considered non-physical symptoms, such as fatigue, pain, cognitive and memory problems to be more significant. Patients with primary progressive MS complained more about ambulation issues, imbalance and falls (p<0.05), when compared to patients with other disease phenotypes.

CONCLUSION

Significant differences in disease perception were found in this study. While neurologists tended to overestimate the consequences and symptoms of the disease, for most patients, the disease impact on activities did not appear to be as significant, with more complaints regarding non-physical symptoms. Although neurologists described involving patients in treatment decisions and providing them with appropriate orientation during medical appointments, the opposite was reported by patients. These results may help to improve treatment adherence and disease outcomes by redefining the doctor-patient relationship.

Model Theory of Planned Behavior to Improve Adherence to Treatment and the Quality of Life in Tuberculosis Patients

Introduction: Tuberculosis (TB) is a global public health problem and a leading cause of death from infectious diseases. The research objective was to determine the relationship between the theory of planned behavior, adherence and quality of life using the path model.Methods: This study employed a cross-sectional design with 154 tuberculosis patients. The research was conducted in all community health centers in the Buleleng, Bali. Data on subjective norms, attitudes, perceived behavior control, intention, physical and mental HRQoL domains and medical adherence were collected. Data were analyzed using a descriptive and structural equation model feature using structural equation model.Results: Most respondents have attitudes in the positive category and subjective norms in the good category. Perceived behavior is control in the good category, intentions in the good category and physical health in the good category. Almost all respondents have mental health in the good category and are married. All respondents in this study had adherence to treatment. The influence of subjective norms on intentions (p = <0.01), the influence of intentions on adherence (p = <0.01) and the effect of adherence on quality of life (p = <0.01) were found.Conclusion:Subjective norms are the most important part to influence intention. Adequate TB treatment causes HRQoL to improve.

Health-Related Quality of Life (HRQoL) scores vary with treatment and may identify potential defaulters during treatment of tuberculosis

Introduction

Nigeria ranks third among the 22 high-burden TB countries in the world. With the availability of effective treatment strategies, and more patients surviving the disease, assessment of Patient Reported Outcomes (PROs) has become imperative to assist with patient evaluation of measured outcomes and thus improve morbidity. Literature is scarce on assessment and impact of chemotherapy on Health-Related Quality of Life (HRQoL) for patients with tuberculosis.

Aim

This study evaluates the variation in Health-Related Quality of Life (HRQoL) in pulmonary TB patients during the intensive phase of treatment.

Methods

We recruited patients with pulmonary TB (PTB), from 3 different TB clinics across Ife Ijesha Zone, Osun State, Nigeria. Consenting patients were administered Short Form-36 HRQoL questionnaire at recruitment and at the end of intensive phase of treatment. HRQoL scores were compared at these two-time points, the degrees of changes were calculated and relationships with some. Directly Observed Therapy-Short (DOTS) course outcome measures were obtained. Logistic regression was used to identify factors associated with greatest change in HRQoL scores.

Results

Of the 130 recruited patients, we analysed data for 126 patients who met the inclusion criteria. Mean age was 36.7(SD15.5). The overall mean HRQoL score obtained at enrolment was 43.18 (SD 17.2) and 60.22 (SD19.83) at end of 2 months; mean change =17.04 p<0.001). The least change was on the emotional well-being domain (mean change = 4.24, p=0.05). Predictor of significant change in HRQoL scores were previous history of TB, HIV status and TB severity, p<0.05 each. High physical functioning score was a strong predictor of defaulters (OR = 5.3; 95%CI: 2.11–9.05, p = 0.01).

Conclusion

Emotional domain is least affected by PTB while younger patients with no physical impairment are more likely to default treatment. Various aspects of HRQoL can be a useful tool for patient's evaluation and outcome prediction.

Health-related quality of life of patients with multidrug-resistant tuberculosis in Yemen: prospective study

BACKGROUND

Substantial efforts are currently focused on investigating and developing new multidrug-resistant tuberculosis (MDR-TB) drugs and diagnostic methods. In Yemen, however, the evaluation of health-related quality of life (HRQoL) and the effect of current MDR-TB treatment on the QoL are commonly ignored. This study evaluated the HRQoL during and after treatment and identified the risk factors that are predictive of HRQoL score differences.

METHOD

A prospective cohort study was conducted in four of the five main MDR-TB centres in Yemen. The patients confirmed with MDR-TB completed the SF-36 V2 survey at the beginning of treatment, end of treatment (continous phase) and at the 1 year follow-up after completing treatment. A total normal base score (NBS) of < 47 reflects impairment of functions, whereas a mental component summary (MCS) score of < 43 indicates a risk of depression.

RESULT

At the beginning of treatment, the mean scores for all health domains were < 47 NBS points (PF = 40.7, RP = 16.1, BP = 21.6, GH = 28.3, VT = 14.55, SF = 25.9, RE = 13.7, and MH = 14.7). At the completion of treatment, all eight health domains increase compare to beginning of treatment (PF = 59.3, RP = 31.1, BP = 40.9, GH = 48.5, VT = 30.5, SF = 46.6, RE =26.6 & MH = 27.7), but a follow-up duration of 1 year after completing treatment showed decreased NBS points in all domains (PF = 51.5, RP = 30.6, BP = 39.1, GH = 47.8, VT = 30.2, SF = 43.7, RE =26.4 & MH = 27.2). Age, history of streptomycin use, baseline lung cavity, marital status and length of sickness before MDR-TB diagnosis were predictive of in PCS score differences, whereas, age, smoking, baseline lung cavity, stigma, residence, marital status and length of sickness before MDR-TB diagnosis were predictive of MCS scores differences.

CONCLUSION

The length of sickness before DR-TB diagnosis was found to be predictive of the trends in both PCS and MCS scores. Despite the positive outcome of MDR-TB treatment, the low HRQoL scores obtained for all heath domains and especially for mental health reflect a high depression status of patients even after 1 year of completing therapy. Moreover, the poor HRQoL, particularly regarding mental health, of study participants at the end of treatment demands the need for urgent attention from national tuberculosis control programme managers. Therefore, the Yemen Ministry of Health and the National Tuberculosis Control Programme should implement an intervention programme to enhance HRQoL at the end of treatment to avoid any further negative consequences of MDRTB in patients after treatment. Moreover, The HRQoL data of patients with MDR-TB must be collected at the different stages of MDR-TB treatment to provide an additional parameter for assessing the effectiveness of the treatment programme.

TRIAL REGISTRATION

SNOYEM 1452. Registered 01 February 2013.

Dental health state utilities among dental patients

OBJECTIVES

To test the efficacy of a dental health state utility measure among a sample of dental patients using the standard gamble (SG) method and to examine its association with two quality of life constructs, namely the Oral Health Impact Profile-14 questionnaire and the global oral health item.

METHODS

A cross-sectional study was conducted with a sample of 202 adult dental patients. Demographic and clinical data were collected. The 14 item oral health impact profile (OHIP-14) and Locker's global rating scale for oral health were administered and a SG utility valuation was carried out.

RESULTS

The mean age of the patients was 38.6 ± 14.1 years. The mean SG score was 0.2 ± 0.2. Bivariate and negative binomial regression using the SG score as the outcome variable showed significant associations between SG scores and the OHIP-14 summary scores, global oral health rating values, as well as with age, gender, and nature/severity of the oral problem.

CONCLUSION

The SG method was effective in assessing dental health state utilities in the patient population. Determining patients' risk tolerance through the SG method may lead to greater awareness about factors that could influence their choice of treatment and could help in planning treatment regimens.

Health Related Quality of Life among TB Patients: Question Mark on Performance of TB DOTS in Pakistan

Due to long duration of treatment and use of several agents, tuberculosis can lead to poor health related quality of life among patients. Objective. The present study was designed to assess health related quality of life among pulmonary tuberculosis patients in Pakistan. Methodology. A descriptive cross-sectional study design was used. SF-36 was self-administered to a sample of 382 pulmonary tuberculosis patients receiving self-administered or directly observed types of treatment, in baseline, initial, or continuous phase of treatment. After data collection, data was cleaned, coded, and statistically analyzed using SPSS version 21.0. Results. The results of the current study highlighted a significant impact on several domains of HRQoL of pulmonary TB patients. Highest HRQoL scores had been observed for the domain of physical functioning (60.03, ±25.779) whereas lowest HRQoL scores were observed for the domain of general health (34.97, ±14.286) perceptions of TB patients followed by bodily pain (43.40, ±24.594). Conclusion. The results of the present study concluded that TB patients had poor HRQoL in spite of the new therapeutic strategies and free availability of medicines. The disease had a negative impact on HRQoL of TB patients across all domains.

Effects of Multidrug Resistant Tuberculosis Treatment on Patients' Health Related Quality of Life: Results from a Follow Up Study

Background

At present, within the management of multidrug resistant tuberculosis (MDR-TB) much attention is being paid to the traditional microbiological and clinical indicators. Evaluation of the impact of MDR-TB treatment on patients’ Health Related Quality of Life (HRQoL) has remained a neglected area.

Objective

To evaluate the impact of MDR-TB treatment on patients HRQoL, and determine the predictors of variability in HRQoL along the course of treatment

Methods

A prospective follow up study was conducted at the programmatic management unit for drug resistant TB of Lady Reading Hospital Peshawar. Culture confirmed eligible MDR-TB patients were asked to self complete SF-36v2 at the baseline visit, and subsequently after the completion of 12 months of treatment and at the end of treatment. A score of <47 norm-based scoring (NBS) points on component summary measures and health domain scales was considered indicative of function impairment. General linear model repeated measures ANOVA was used examine the change and predictors of change in physical component summary (PCS) and mental component summary (MCS) scores over the time.

Results

A total of 68 out of enrolled 81 eligible MDR-TB patients completed SF-36v2 questionnaire at the three time points. Patients’ mean PCS scores at the three time points were, 38.2±4.7, 38.6±4.4 and 42.2±5.2 respectively, and mean MCS were 33.7±7.0, 35.5±6.9 and 40.0±6.9 respectively. Length of sickness prior to the diagnosis of MDR-TB was predictive of difference in PCS scores (F = 4.988, Df = 1, 66), whereas patients’ gender (F = 5.638, Df = 1, 66) and length of sickness prior to the diagnosis of MDR-TB (F = 4.400, Df = 1, 66) were predictive of difference in MCS scores.

Conclusion

Despite the positive impact of MDR-TB treatment on patients' HRQoL, the scores on component summary measures suggested compromised physical and mental health even at the end of treatment. A large multicenter study is suggested to confirm the present findings.

A Comparison of Narrative and Table Formats for Presenting Hypothetical Health States to Patients with Gastrointestinal or Pulmonary Disease

Traditionally, quality-of-life researchers describe states of health for patients to rate either in narrative form or in table form, but evidence about which format patients prefer is limited. The authors performed 2 randomized studies to test whether patients prefer the table or narrative format and whether the format of presentation influences how patients rate health states. Approximately three-fourths of patients with gastrointestinal disease or chronic airflow limitation preferred the table format. There were no differences in patients’ ratings of 3 described health states or of their own health. Investigators should consider using the table presentation for describing health states to subjects who are not familiar with these states of health.

Personal Functional Goals: A New Approach to Assessing Patient-Centered Outcomes

One dilemma in outcomes research is finding measures that show the impact of an intervention on participants' quality of life, especially in areas most salient to participants. The authors describe the development and testing of a method for eliciting information about personal functional goals from older adults entering an exercise program and assessing progress after completion of the program. The authors' Personal Functional Goals (PFG) Checklist and Interview Protocol is a 45-item checklist of goals for health, daily living, and general well-being. Testing on older adult, community-dwelling participants in controlled exercise intervention studies confirmed the ease of administration and provided preliminary evidence of reliability and validity, including responsiveness to change. Thus, the PFG shows promise for measuring health-related quality of life in terms of individual concerns and is suitable for application in clinical and research settings.

Conceptualization of a New Stroke-Specific Outcome Measure: The Stroke Impact Scale

Current stroke outcome measures are unable to detect some consequences of stroke that affect patients, families, and providers. The objective of this study was to ensure the content validity of a new stroke outcome measure. This was a qualitative study using individual interviews with patients and focus group interviews with patients, caregivers, and health care professionals. Participants included 30 individuals with mild and moderate stroke, 23 caregivers, and 9 stroke experts. Qualitative analysis of the individual and focus group interviews generated a list of potential items. Consensus panels reviewed the potential items, established domains for the measure, developed item scales, and decided on mechanisms for administration and scoring. Although the participants with stroke appeared highly recovered based on scores from conventional stroke assessments (Barthel Index and NIH Stroke Scale), stroke survivors and their caregivers identified numerous persisting impairments, disabilities, and handicaps. In general, stroke survivors described themselves as only about 50% recovered and reported that they had difficulty in activities in which they were not independent. To fully assess the impact of stroke on patients, we used the results of this qualitative study to develop a new stroke-specific outcome, the Stroke Impact Scale.

Perceptions of Health Status in Multiple Sclerosis Patients and Their Doctors

Objective:

To compare neurologist and patient perceptions of multiple sclerosis (MS)-related health status.

Methods:

MS patients (n=99) were recruited from six sites in Canada. Following a consultation with their neurologist, patients estimated their relapse frequency, rated their general health and quality of life (QoL), reviewed descriptions of eight health domains and selected the three most important, and completed a utility assessment using the standard gamble (SG). Concurrently, neurologists independently used the same instruments to rate their patients' health status. Assessments were compared on the basis of paired mean values of both groups and the degree of exact agreement quantified by intraclass coefficient (ICC) and kappa analyses, which yield values of 1.0 with 100% agreement.

Results:

There were significant differences (p<0.001) between patient and neurologist ratings for relapses in the last year (0.86 vs. 0.4, respectively), QoL (61.2 vs. 69.7 (maximum score = 100) and utility (0.864 vs. 0.971); ICC analysis revealed moderate to poor levels of agreement (0.56 for QoL to 0.03 for SG). There was little concordance in identification of important health domain and the only significant associations were in bodily pain and social functioning (kappa statistic = 0.24, p = 0.026 for both). Neurologists identified physical functioning domains as important, while patients placed more emphasis on mental health domains.

Conclusions:

Discrepancies between neurologist and patient perceptions of MS were observed. The study identifies a need to educate neurologists on the recognition of MS health domains that are important in the definition of patient QoL.

Instruments for holistic assessment of Parkinson's disease

Assessment of Parkinson's disease is a complex matter as a consequence of the variety of manifestations and complications that can be present in a patient. Although a really holistic assessment is probably a utopia, a comprehensive evaluation is possible using a combination of measures completed by health professionals, patients and/or caregivers. In PD, main domains requiring assessment include motor impairment, motor complications, non-motor symptoms, disability, and patient-reported outcomes. Such scales like the Movement Disorder Society-Unified Parkinson's Disease Rating Scale and the battery of Scales for Outcomes in Parkinson's disease (SCOPA) provide a wide information on the most relevant aspects of the disease. Hoehn and Yahr staging, global impression, and quality of life measures furnish summarized whole evaluations and comprehensive non-motor symptom assessments help to identify and evaluate this kind of manifestations. This article shows a pragmatic review of common instruments (rating scales and questionnaires) usable for a comprehensive assessment of PD and provides information about sources for guiding the selection of measures and outcome analyses.

A proposal for a comprehensive grading of Parkinson's disease severity combining motor and non-motor assessments: meeting an unmet need

Background

Non-motor symptoms are present in Parkinson's disease (PD) and a key determinant of quality of life. The Non-motor Symptoms Scale (NMSS) is a validated scale that allows quantifying frequency and severity (burden) of NMS. We report a proposal for using NMSS scores to determine levels of NMS burden (NMSB) and to complete PD patient classification.

Methods

This was an observational, cross-sectional international study of 935 consecutive patients. Using a distribution of NMSS scores by quartiles, a classification based on levels from 0 (no NMSB at all) to 4 (very severe NMSB) was obtained and its relation with Hoehn and Yahr (HY) staging, motor and health-related quality of life scales was analyzed. Concordance between NMSB levels and grouping based on clinician's global impression of severity, using categorical regression, was determined. Disability and HRQoL predictors were identified by multiple regression models.

Results

The distribution of motor and QoL scales scores by HY and NMSB levels was significantly discriminative. The difference in the classification of cases for both methods, HY and NMSB, was significant (gamma = 0.45; ASE = 0.032). Concordance between NMSB and global severity-based levels from categorical regression was 91.8%, (kappa_w = 0.97). NMS score was predictor of disability and QoL.

Conclusions

Current clinical practice does not address a need for inclusion of non-motor scores in routine assessment of PD in spite of the overwhelming influence of NMS on disability and quality of life. Our data overcome the problems of “pure motor assessment” and we propose a combined approach with addition of NMSB levels to standard motor assessments.

Association of patient-centered outcomes with patient-reported and ICD-9-based morbidity measures

PURPOSE

Evaluating patient-centered care for complex patients requires morbidity measurement appropriate for use with a variety of clinical outcomes. We compared the contributions of self-reported morbidity and morbidity measured using administrative diagnosis data for both patient-reported outcomes and utilization outcomes.

METHODS

Using a cohort of 961 persons aged 65 years or older with 3 or more medical conditions, we explored 9 health outcomes as a function of 4 independent variables representing different types of morbidity measures: International Classification of Diseases, Ninth Revision (ICD-9), a self-reported weighted count of conditions, and self-reported symptoms of depression and of anxiety. Outcomes varied from self-reported health status to utilization. Depending on the outcome measure, we used multivariate linear, negative binomial, or logistic regression, adjusting for demographic characteristics and length of enrollment to assess associations between dependent and all 4 independent variables.

RESULTS

Higher morbidity measured by ICD-9 diagnoses was independently associated with less favorable levels of 7 of the 9 clinical outcomes. Higher self-reported disease burden was significantly associated with less favorable levels of 8 of the outcomes, controlling for the 3 other morbidity measures. Morbidity measured by diagnosis code was more strongly associated with higher utilization, whereas self-reported disease burden and emotional symptoms were more strongly associated with patient-reported outcomes.

CONCLUSIONS

A comprehensive assessment of morbidity requires both subjective and objective measurement of disease burden as well as an assessment of emotional symptoms. Such multidimensional morbidity measurement is particularly relevant for research or quality assessments involving the delivery of patient-centered care to complex patient populations.

Measuring health-related quality of life in tuberculosis: a systematic review

INTRODUCTION

Tuberculosis remains a major public health problem worldwide. In recent years, increasing efforts have been dedicated to assessing the health-related quality of life experienced by people infected with tuberculosis. The objectives of this study were to better understand the impact of tuberculosis and its treatment on people's quality of life, and to review quality of life instruments used in current tuberculosis research.

METHODS

A systematic literature search from 1981 to 2008 was performed through a number of electronic databases as well as a manual search. Eligible studies assessed multi-dimensional quality of life in people with tuberculosis disease or infection using standardized instruments. Results of the included studies were summarized qualitatively.

RESULTS

Twelve original studies met our criteria for inclusion. A wide range of quality of life instruments were involved, and the Short-Form 36 was most commonly used. A validated tuberculosis-specific quality of life instrument was not located. The findings showed that tuberculosis had a substantial and encompassing impact on patients' quality of life. Overall, the anti-tuberculosis treatment had a positive effect of improving patients' quality of life; their physical health tended to recover more quickly than the mental well-being. However, after the patients successfully completed treatment and were microbiologically 'cured', their quality of life remained significantly worse than the general population.

CONCLUSION

Tuberculosis has substantially adverse impacts on patients' quality of life, which persist after microbiological 'cure'. A variety of instruments were used to assess quality of life in tuberculosis and there has been no well-established tuberculosis-specific instrument, making it difficult to fully understand the impact of the illness.

Psychosocial problems in primary care: patient and provider perceptions

Primary care physicians and clinics have become the frontline of health care for most Americans-they are the first point of contact and the source of both treatment and referrals. Psychosocial problems, such as difficulty with finances, family, housing, and work, are associated with a high demand for medical care in primary care practice, yet little is known about the prevalence of psychosocial problems in primary care settings. The purpose of this study is to assess the type and level of psychosocial problems in primary care patients by examining patient and provider perceptions at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). A purposive sample of 684 veterans and a convenience sample of 59 providers anonymously completed the Social Needs Checklist. Patients reported an average of five psychosocial problems, with finances, personal stress, transportation, employment, and legal issues being the most prevalent. Thirty-two percent of patients indicated a desire to see a social worker. Provider and patient differences were compared. Provider estimates of patients' problems were consistently lower than patient estimates in all psychosocial problem areas except need for nursing home placement and problem drinking or drug use. Implications for social work in primary care are discussed.

Health-related quality of life among adults with serious psychological distress and chronic medical conditions

OBJECTIVE

Determine the prevalence of serious psychological distress (SPD) among adults with and without chronic medical conditions and examine the association between SPD and health-related quality of life (HRQOL).

METHODS

Cross-sectional data from the 2005 Los Angeles County Health Survey were used to estimate prevalence of SPD. The association between SPD and HRQOL was evaluated using logistic regression and analysis of covariance, adjusting for sociodemographic variables and number of chronic conditions.

RESULTS

SPD was significantly associated with younger age, lower income, being unemployed or disabled, being unmarried, fair or poor health, and having one or more chronic conditions. Adults with three or more chronic conditions were six times as likely to have SPD as those with no conditions. Adults with SPD reported significantly more unhealthy days (mental and physical) and activity limitation days than adults without SPD. The adjusted mean number of unhealthy days was highest among adults with SPD (23.3), followed by adults with depression (14.1), and diabetes (10.6).

CONCLUSIONS

SPD is associated with decreased HRQOL and presence of chronic medical conditions. Mental health should be routinely assessed when addressing health needs of individuals and communities. Persons with chronic diseases may benefit from targeted mental health screening and programs that employ treatment approaches that jointly manage physical and mental health and provide improved links and access to services.

Lifestyle physical activity of older rural women

The purpose of this study was to describe and examine the lifestyle physical activity behaviors (household, leisure, occupational) of older rural women. Background characteristics included demographics, environment, social support, and health. Intrapersonal characteristics included motivation and self-efficacy. The majority of the women's energy expenditure was in the household dimension. Social support was positively associated with household activities. A higher level of leisure physical activity was associated with living within the two small cities and reporting lower levels of health and lower motivation. This research highlights the importance of household physical activity and the contribution of social support for household physical activity, both of which may be important in developing interventions to promote physical activity in older rural women.

Modeling the information preferences of parents of children with mental health problems: a discrete choice conjoint experiment

Although materials informing parents about children's mental health (CMH) problems can improve outcomes, we know relatively little about the design factors that might influence their utilization of available resources. We used a discrete choice conjoint experiment to model the information preferences of parents seeking mental health services for 6 to 18 year olds. Parents completed 30 choice tasks presenting experimentally varied combinations of 20 four-level CMH information content, transfer process, and outcome attributes. Latent class analysis revealed three segments with different preferences. Parents in the Action segment (43%) chose materials providing step-by-step solutions to behavioral or emotional problems. They preferred weekly meetings with other parents and coaching calls from a therapist. The Information segment (41%) chose materials helping them understand rather than solve their child's problems. These parents were more sensitive to logistical factors such as receiving information in groups, the location where information was available, the modality in which the information was presented, and the time required to obtain and use the information. The Overwhelmed segment (16%) reported more oppositional and conduct problems, felt their children's difficulties exerted a greater adverse impact on family functioning, and reported higher personal depression scores than those in the Action or Information segments. Nonetheless, they did not choose information about, or solutions to, the problems their children presented. Simulations predicted that maximizing utilization and realizing the potential benefits of CMH information would require knowledge transfer strategies consistent with each segment's preferences.

Baseline characteristics and treatment preferences of oral surgery patients

PURPOSE

Patient preferences for treatment choices may depend on patient characteristics. Using standard gamble (SG) and willingness to pay (WTP), this study compares preferences for treatment of mandibular fracture among patients in a low-income urban area.

PATIENTS AND METHODS

Surveys of African-American and Hispanic adults receiving treatment at King/Drew Medical Center for either mandibular fracture (n = 98) or third molar removal (n = 105) were used to investigate differences in patient characteristics across treatment groups (third molar vs fracture) and treatment preference (wiring vs surgery).

RESULTS

The fracture patients were willing to pay more to restore function without scarring or nerve damage than were the third molar patients. Patients who chose surgery were willing to accept a greater risk of possible nerve damage or scarring than those who chose wiring. Among 15 potential predictors of SG and WTP studied in 4 subgroups defined by actual treatment and treatment preference, significant predictors varied, with associations for education and clinical experience for SG and associations with income and psychosocial predictors for WTP.

CONCLUSIONS

SG and WTP capture different domains of health values in patients. There is considerable heterogeneity in relationships among patient characteristics and patient preferences across subgroups defined by actual treatment and treatment preferences.

Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities

PURPOSE

Persons with multiple chronic diseases must integrate self-management tasks for potentially interacting conditions to attain desired clinical outcomes. Our goal was to identify barriers to self-management that were associated with lower perceived health status and, secondarily, with lower reported physical functioning for a population of seniors with multimorbidities.

METHODS

We conducted a cross-sectional telephone survey of 352 health maintenance organization members aged 65 years or older with, at a minimum, coexisting diagnoses of diabetes, depression, and osteoarthritis. Validated questions were based on previous qualitative interviews that had elicited potential barriers to the self-management process for persons with multimorbidities. We analyzed associations between morbidity burden, potential barriers to self-management, and the 2 outcomes using multivariate linear regression modeling.

RESULTS

Our response rate was 47%. Sixty-six percent of respondents were female; 55% were aged 65 to 74 years, and 45% were aged 75 years or older. Fifty percent reported fair or poor health. On average they had 8.7 chronic diseases. In multivariate analysis, higher level of morbidity, lower level of physical functioning, less knowledge about medical conditions, less social activity, persistent depressive symptoms, greater financial constraints, and male sex were associated with lower perceived health status. Potential barriers to self-management significantly associated with lower levels of physical functioning were higher level of morbidity, greater financial constraints, greater number of compound effects of conditions, persistent depressive symptoms, higher level of patient-clinician communication, and lower income.

CONCLUSIONS

In addition to morbidity burden, specific psychosocial factors are independently associated with lower reported health status and lower reported physical functioning in seniors with multimorbidities. Many factors are amenable to intervention to improve health outcomes.

Effect of medical and surgical interventions on health-related quality of life in Parkinson's disease

Motor-related parameters are the standard outcome parameters for treatment interventions. Nonetheless, subjective appraisals about the consequences of treatment on health-related quality of life (HRQoL) are meanwhile established and may uncover important aspects of interventions. We have reviewed the literature with a defined search strategy and collected 61 clinical trials, which have used HRQoL as a planned outcome parameter. The articles were rated similarly as for the Task Force report of the Movement Disorder Society on interventions for Parkinson's disease (PD), but the relevant outcome parameter was HRQoL. We found that unilateral pallidotomy, deep brain stimulation of the subthalamic nucleus, and rasagiline are efficacious to improve the HRQoL of PD patients. For many other interventions, the efficacy to improve HRQoL in the PD setting cannot be considered to be proven so far. HRQoL should be part of future trial designs and more research is necessary to understand the determinants of QoL in PD.

Factors affecting cardiac catheterization rates in elders with acute coronary syndromes

BACKGROUND

Elder patients with acute coronary syndromes (ACS) are less likely to receive cardiac catheterization. The reasons for this are unclear.

OBJECTIVES

To assess whether elder patients who had a documented history of dementia, lived in extended care facilities, or had do not intubate-do not resuscitate (DNR-DNI) advance directives were less likely to receive cardiac catheterization, despite having ACS with high-risk features.

METHODS

This was a medical record review conducted at an urban teaching hospital. DNR-DNI status before hospitalization, extended care facility (nursing home or assisted living) residence, and a previous diagnosis of dementia were obtained from the medical record. Patients 65 years and older who presented to the emergency department with acute myocardial infarction or with unstable angina with ST segment deviation were included. Univariate and multivariate logistic regression were performed, and odds ratios (ORs) were reported with their 95% confidence intervals (CIs).

RESULTS

Of the 201 eligible patients, 66 (32.8%) patients did not undergo cardiac catheterization. In the univariate analysis, patients who had dementia, resided in extended care facilities, or were DNR-DNI were less likely to receive cardiac catheterization. Only extended care facility residence (OR, 0.18; 95% CI = 0.04 to 0.83) and DNR-DNI status (OR, 0.19; 95% CI = 0.04 to 0.92) remained significantly associated with decreased cardiac catheterization in the multivariate analysis.

CONCLUSIONS

Elder patients with ACS residing in extended care facilities or who are DNR-DNI are less likely to receive cardiac catheterization. Future studies concerning the quality of ACS care for elders should take these variables into account.

Serious psychological distress in U.S. adults with arthritis

BACKGROUND

Arthritis and mental health disorders are leading causes of disability commonly seen by health care providers. Several studies demonstrate a higher prevalence of anxiety and depression in persons with arthritis versus those without arthritis.

OBJECTIVES

Determine the national prevalence of serious psychological distress (SPD) and frequent anxiety or depression (FAD) in adults with arthritis, and in adults with arthritis, identify risk factors associated with SPD.

METHODS

Cross-sectional data from the 2002 National Health Interview Survey, an in-person household interview survey, were used to estimate the prevalence of SPD and FAD in adults with (n=6,829) and without (n=20,676) arthritis. In adults with arthritis, the association between SPD and sociodemographic, clinical, and functional factors was evaluated using multivariable logistic regression.

RESULTS

The prevalence of SPD and FAD in adults with arthritis is significantly higher than in adults without arthritis (5.6% vs 1.8% and 26.2% vs 10.7%, P<.001, respectively). In adults with arthritis, SPD was significantly associated with younger age, lower socioeconomic status, divorce/separation, recurrent pain, physical inactivity, having functional or social limitations, and having comorbid medical conditions. Adults aged 18 to 44 years were 6.5 times more likely to report SPD than those 65 years or older, and adults with recurrent pain were 3 times more likely to report SPD than those without recurrent pain.

CONCLUSIONS

Serious psychological distress and FAD affect persons with arthritis and should be addressed in their treatment. Younger adults with arthritis, and those with recurrent pain or either functional or social limitations, may be at higher risk for SPD.

Changes in the SF-12 among Depressed Elders Six Months after Discharge from an Inpatient Geropsychiatric Unit

Using the SF-12 to measure physical and mental functioning, the authors examine the intra-individual changes in health-related quality of life (HRQOL) 6 months post-discharge for depressed older adults. In addition, they examine three sets of predictors that might influence these changes. The sample of depressed older adults was recruited from an inpatient geropsychiatry unit. Although their physical and mental health scores on the SF-12 were lower than comparable norms, the sample showed an average increase in their mental functioning but a decrease in the physical functioning over the 6 months. Negative life-events were significant predictors of people who reported no change in their mental health functioning and decreases in their physical health functioning. Interestingly, those who experienced positive life events were more likely to report declines and younger participants were more likely to report no change in their physical functioning. The findings indicate that the effects of depression on HRQOL can have enduring effects on a sample of previously hospitalized older adults. The significance of life event changes might signify the importance of taking into account non-traditional areas of medical interventions. Further, the findings indicate the usefulness of the SF-12 quantifying HRQOL outcomes.

Integrating Decision Making and Mental Health Interventions Research: Research Directions

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.

Socioeconomic status, depression disparities, and financial strain: what lies behind the income-depression relationship?

Prior studies have consistently found the incidence and persistence of depression to be higher among persons with low incomes, but causal mechanisms for this relationship are not well understood. This study uses the National Longitudinal Survey of Youth 1979 cohort to test several hypotheses about the robustness of the depression-income relationship among adults. In regressions of depression symptoms on income and sociodemographic variables, income is significantly associated with depression. However, when controls for other economic variables are included, the effect of income is considerably reduced, and generally not significant. Employment status and the ratio of debts-to-assets are both highly significant for men and for women both above and below the median income. Fixed-effects estimates suggest that employment status and financial strain are causally related to depression, but income is not. Instrumental variable estimates suggest that financial strain may not lead to depression.

Perceptions of Medical Errors by Internal Medicine Residents

Efforts to identify the underlying structure of 40 survey items dealing with perceptions of medical errors are reported on the basis of responses from 195 medical residents. Factor analysis revealed that the medical errors perceptions were represented by a 10-factor solution. The external validity of these factors was examined relative to perceptions about the cost of medical errors, the cost of errors to health care, and the need for education and interventions to address errors. Results indicated that 13.9% of the variation in the perceived cost of medical errors and 17.1% of the variation in the perceived need for additional physician education was explained by the factor structure.

Treatment of Depression Improves Physical Functioning in Older Adults

OBJECTIVES

To determine the effect of collaborative care management for depression on physical functioning in older adults.

DESIGN

Multisite randomized clinical trial.

SETTING

Eighteen primary care clinics from eight healthcare organizations.

PARTICIPANTS

One thousand eight hundred one patients aged 60 and older with major depressive disorder.

INTERVENTION

Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician.

MEASUREMENTS

The 12-item short form Physical Component Summary (PCS) score (range 0-100) and instrumental activities of daily living (IADLs) (range 0-7).

RESULTS

The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96-2.46) and IADLs of -0.15 (95% CI=-0.29 to -0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning.

CONCLUSION

The IMPACT collaborative care model for late-life depression improves physical function more than usual care.

Implications of patient and physician decision making: an illustration in treatment options for coronary artery disease

The objective of this study was to explore the extent to which patients and physicians desire patient participation in medical decision making. The cross-sectional pilot study involved 92 patients with coronary artery disease (CAD) and 50 physicians involved in treating patients with CAD. Desire to participate in making the decision between treatment options for CAD and factors that influence the decision were assessed. Physicians prefer to participate in shared decision making more often than do the patients (P = .016). When faced with clinical scenarios requiring a decision to be made between percutaneous transluminal coronary angioplasty and coronary artery bypass graft, patients and physicians tended to defer to one another to make the decision. Multinomial logistic regression models showed that the overriding factor influencing patient decision making was the physician's opinion (P < .0001) and the patient's preference was the overriding factor influencing physician decision making (P < .0001). Because patients tend to defer to physicians when making medical decisions, it is incumbent upon the physician to assure that the physician-patient dialogue reflects important information about the procedures (coronary artery bypass graft and percutaneous transluminal coronary angioplasty) and that preferences are acknowledged. This may impact greatly on achieving satisfactory health outcomes and patient satisfaction.

Quality of life in tuberculosis: patient and provider perspectives

Tuberculosis (TB) is a persistent problem in the United States; however, little is known about its impact on functioning and quality of life (QOL) among people with TB. The purpose of this study is to describe the impact of TB on patients' QOL by using focus groups to assess the domains of QOL that are affected. Participants included patients (n = 10) who received treatment for active TB and physicians (n = 4) and nurses (n = 9) caring for patients with TB at a public health clinic in Baltimore, Maryland. TB affected all predicted domains of QOL, including general health perceptions, somatic sensation, psychological health, spiritual well-being, and physical, social and role functioning. Social stigmatization, isolation, pill burden, long duration of therapy, sexual dysfunction, loss of income, and fear were additional specific problems related to TB. Surprisingly, 11% (33) of the comments described benefits of TB illness, including increased spirituality and improved life perspectives. In addition, four additional QOL domains and three elements of treatment specific to TB which substantially impact QOL were identified. While patients and clinicians both identified issues in many areas of QOL, only patients mentioned the impact on sexual function, spirituality and improved life perspectives. Despite available curative therapy, TB and its treatment still have significant short and long-term consequences on patients' QOL.

Tinker, tailor, soldier, patient: work attributes and depression disparities among young adults

Prior studies have consistently found the occurrence of depression to be higher among persons with lower socio-economic status (SES), but causal mechanisms for this relationship are often not well understood. For example, while depression has been shown to increase during spells of unemployment, little work has been done on job attributes that may be related to depression among employed people early in their careers. This study links the 1992 wave of the National Longitudinal Survey of Youth 1979 cohort-which included Depression symptom scores on the Center for Epidemiologic Studies Depression (CES-D) instrument-to the US Department of Labor's new occupational characteristics O*Net dataset. The resulting dataset includes information regarding depression, SES, and specific attributes of jobs held by the young adult respondents. Job attributes included measures of social status, interpersonal stressors, and physical conditions. Multivariate analysis revealed that for young men, higher job status is associated with lower CES-D scores. Higher scores on the opposition scale, which measures the extent to which employees are obliged to take a position opposed to others, is associated with higher CES-D scores. For young women, physically uncomfortable or dangerous jobs are associated with more depressive symptoms. Results are stratified by race/ethnicity. For Black men, unlike for White men or Latinos, job security is associated with fewer depressive symptoms; and for Latino men, but not for Black or White men, physically uncomfortable or dangerous jobs are associated with more depressive symptoms. For Black women, job status is associated with fewer depressive symptoms. We conclude that part of the SES-depression relationship may arise from the psychosocial aspects of jobs, which we have found to be significantly and meaningfully associated with depressive symptoms among employed young adults.

Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine

Complementary and alternative medicine (CAM) has been defined largely in relation to conventional biomedicine. CAM therapies that are used instead of conventional medicine are termed "alternative." CAM therapies used alongside conventional medicine are said to be "complementary." "Integrative medicine" results from the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and conventional medicines. The evolving process of integration between CAM and conventional medicine evokes new conceptual frameworks, as well as new terminology. Interview-based qualitative research at the University of Wisconsin-Madison seeks to probe and develop this theoretical structure. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). These themes characterize CAM and contrast it with conventional medicine. CAM is said to be more holistic and empowering yet less legitimate than conventional medicine. CAM is more intuitive; conventional is more deductive. While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible, at least for those with conventional health insurance and limited income. Substantive barriers--including economic, organizational and scientific differences, as well as an apparent widespread lack of understanding--continue to thwart attempts at integration. More and better evidence is needed if CAM therapies are to be accepted by mainstream medicine. State-of-the-art research methods developed by conventional science will be needed to test CAM therapies. Conventional medicine, however, has much to learn from CAM. By incorporating a more holistic, empowering and accessible therapeutic approach, conventional medicine could build on its present legitimacy, and thereby enhance its power to "HEAL."

Addressing patients' emotional and spiritual needs

BACKGROUND

A comprehensive, systematic literature review and original research were conducted to ascertain whether patients' emotional and spiritual needs are important, whether hospitals are effective in addressing these needs, and what strategies should guide improvement.

METHODS

The literature review was conducted in August 2002. Patient satisfaction data were derived from the Press Ganey Associates' 2001 National Inpatient Database; survey data were collected from 1,732,562 patients between January 2001 and December 2001.

RESULTS

Data analysis revealed a strong relationship between the "degree to which staff addressed emotional/spiritual needs" and overall patient satisfaction. Three measures most highly correlated with this measure of emotional/spiritual care were (1) staff response to concerns/complaints, (2) staff effort to include patients in decisions about treatment, and (3) staff sensitivity to the inconvenience that health problems and hospitalization can cause.

DISCUSSION

The emotional and spiritual experience of hospitalization remains a prime opportunity for QI. Suggestions for improvement include the immediate availability of resources, appropriate referrals to chaplains or leaders in the religious community, a team dedicated to evaluating and improving the emotional and spiritual care experience, and standardized elicitation and meeting of emotional and spiritual needs. Survey data suggested a focus on response to concerns/complaints, treatment decision making, and staff sensitivity.

Psychosocial Training in a Palliative Care Fellowship

We present a description of a one-year palliative care fellowship training program for physicians at the Massachusetts General Hospital. We provide background information on the Palliative Care Service, and offer an overview of the educational content and methods for fellowship training, focusing especially on psychosocial aspects of care. The medical background and post-training positions of fellows are described. This document is meant to assist other palliative care fellowship programs in developing their curricula and possibly to serve as an initial template for creating educational standards and for identifying outcome measures for educational evaluation of such programs.

Medical practices' sensitivity to patients' needs. Opportunities and practices for improvement

This article presents the results of a national study of medical practices' patient satisfaction using data collected from January to December 2001 with Press Ganey Associates' Medical Practice Survey (n = 503,407). The question, "Our sensitivity to your needs" (r = 0.85), most highly correlated with overall patient satisfaction. Patients' age, sex, or first visit were not predictors of sensitivity to patients' needs. Responses highly correlated with sensitivity to patients' needs: (1) concern for patients' privacy, (2) cheerfulness of practice, (3) care received during visit, and (4) likelihood to recommend practice. Patient perception and satisfaction with medical practices' sensitivity to patient needs and recommended practices for improvement are discussed.

A multivariate model of patients' satisfaction with treatment for posttraumatic stress disorder

Prior studies have concluded that patients' pretreatment characteristics contribute more to their satisfaction with mental health treatment than any other domain. We expand the representation of treatment characteristics in an examination of satisfaction across both inpatient and outpatient settings. Data were drawn from an inpatient (n = 831) and an outpatient (n = 554) study of the treatment of PTSD. We used structural equation modeling to specify and evaluate a model of satisfaction with comparable elements for inpatient and both short and long-term outpatient treatment. Results indicate that the quality and quantity of patients' participation in treatment were more important to the development of their satisfaction with treatment than their pretreatment characteristics. Among treatment characteristics, the social climate of the inpatient milieu and the focus on war traumas in outpatient therapy had major effects on the quality and quantity of patients' participation and their satisfaction.

Can utility-weighted health-related quality-of-life estimates capture health effects of quality improvement for depression?

BACKGROUND

Utility methods that are responsive to changes in desirable outcomes are needed for cost-effectiveness (CE) analyses and to help in decisions about resource allocation.

OBJECTIVES

Evaluated is the responsiveness of different methods that assign utility weights to subsets of SF-36 items to average improvements in health resulting from quality improvement (QI) interventions for depression.

DESIGN

A group level, randomized, control trial in 46 primary care clinics in six managed care organizations. Clinics were randomized to one of two QI interventions or usual care.

SUBJECTS

One thousand one hundred thirty-six patients with current depressive symptoms and either 12-month, lifetime, or no depressive disorder identified through screening 27,332 consecutive patients.

MEASURES

Utility weighted SF-12 or SF-36 measures, probable depression, and physical and mental health-related quality of life scores.

RESULTS

Several utility-weighted measures showed increases in utility values for patients in one of the interventions, relative to usual care, that paralleled the improved health effects for depression and emotional well being. However, QALY gains were small. Directly elicited utility values showed a paradoxical result of lower utility during the first year of the study for intervention patients relative to controls.

CONCLUSIONS

The results raise concerns about the use of direct single-item utility measures or utility measures derived from generic health status measures in effectiveness studies for depression. Choice of measure may lead to different conclusions about the benefit and CE of treatment. Utility measures that capture the mental health and non-health outcomes associated with treatment for depression are needed.

Intention to discontinue care among primary care patients: influence of physician behavior and process of care

BACKGROUND

Specific elements of health care process and physician behavior have been shown to influence disenrollment decisions in HMOs, but not in outpatient settings caring for patients with diverse types of insurance coverage.

OBJECTIVE

To examine whether physician behavior and process of care affect patients' intention to return to their usual health care practice.

DESIGN

Cross-sectional patient survey and medical record review.

SETTING

Eleven academically affiliated primary care medicine practices in the Boston area.

PATIENTS

2,782 patients with at least one visit in the preceding year.

MEASUREMENT

Unwillingness to return to the usual health care practice.

RESULTS

Of the 2,782 patients interviewed, 160 (5.8%) indicated they would not be willing to return. Two variables correlated significantly with unwillingness to return after adjustment for demographics, health status, health care utilization, satisfaction with physician's technical skill, site of care, and clustering of patients by provider: dissatisfaction with visit duration (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4 to 7.4) and patient reports that the physician did not listen to what the patient had to say (OR, 8.8; 95% CI, 2.5 to 30.7). In subgroup analysis, patients who were prescribed medications at their last visit but who did not receive an explanation of the purpose of the medication were more likely to be unwilling to return (OR, 4.9; 95% CI, 1.8 to 13.3).

CONCLUSION

Failure of physicians to acknowledge patient concerns, provide explanations of care, and spend sufficient time with patients may contribute to patients' decisions to discontinue care at their usual site of care.