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Scott IA, Crock C, Twining M. Too much versus too little: looking for the "sweet spot" in optimal use of diagnostic investigations. Med J Aust 2024; 220:67-70. [PMID: 38146617 DOI: 10.5694/mja2.52193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/23/2023] [Indexed: 12/27/2023]
Affiliation(s)
- Ian A Scott
- Centre for Health Services Research, University of Queensland, Brisbane, QLD
- Princess Alexandra Hospital, Brisbane, QLD
| | - Carmel Crock
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC
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Ansems SM, Ganzevoort IN, van Tol DG, Fokkema T, Olthof M, Berger MY, Holtman GA. Qualitative study evaluating the expectations and experiences of Dutch parents of children with chronic gastrointestinal symptoms visiting their general practitioner. BMJ Open 2023; 13:e069429. [PMID: 37192810 PMCID: PMC10193100 DOI: 10.1136/bmjopen-2022-069429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/03/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES Chronic gastrointestinal symptoms are common among children and affect their daily activities and quality of life. The majority will be diagnosed with a functional gastrointestinal disorder. Effective reassurance and education are, therefore, key components of the physician's management. Qualitative studies have shown how parents and children experience specialist paediatric care, yet less is known about general practitioners (GPs), who manage most cases in the Netherlands and have a more personal and enduring relationship with their patients. Therefore, this study evaluates the expectations and experiences of parents of children visiting a GP for chronic gastrointestinal symptoms. DESIGN We conducted a qualitative interview study. Online interviews were audio and video recorded, transcribed verbatim and independently analysed by the first two authors. Data were collected and analysed concurrently until data saturation was reached. Using thematic analysis, we developed a conceptual framework reflecting respondent expectations and experiences. We performed a member check of the interview synopsis and the conceptual framework. SETTING Dutch primary care. PARTICIPANTS We purposively sampled participants from a randomised controlled trial evaluating the effectiveness of faecal calprotectin testing in children with chronic gastrointestinal complaints in primary care. Thirteen parents and two children participated. RESULTS Three key themes emerged: disease burden, GP-patient relationship and reassurance. Often, the experienced disease burden and the pre-existing GP-patient relationship influenced expectations (eg, for further investigations or a sympathetic ear), and when a GP fulfilled these expectations, a trusting GP-patient relationship ensued that facilitated reassurance. We found that individual needs influenced these themes and their interrelationships. CONCLUSION Insights provided by this framework could help GPs managing children with chronic gastrointestinal symptoms in daily practice and may therewith improve the consultation experience for parents. Further research should evaluate whether this framework also holds true for children. TRIAL REGISTRATION NUMBER NL7690.
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Affiliation(s)
- Sophie M Ansems
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Ilse N Ganzevoort
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Donald G van Tol
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
- Department of Sociology, Faculty of Behavioral and Social Sciences, University Medical Center Groningen, Groningen, The Netherlands
| | - Tryntsje Fokkema
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Marijke Olthof
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Gea A Holtman
- Department of Primary and Long-term Care, University Medical Center Groningen, Groningen, The Netherlands
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Grumbach K, Gagliardi K, Coleman Hernandez S, Intinarelli G. Messaging About COVID-19 Safety Measures Is Counterproductive in Cancer Screening Outreach: Results of a Pragmatic Randomized Trial. Jt Comm J Qual Patient Saf 2023; 49:120-122. [PMID: 36443165 PMCID: PMC9635946 DOI: 10.1016/j.jcjq.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/28/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
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Dahm MR, Cattanach W, Williams M, Basseal JM, Gleason K, Crock C. Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review. J Gen Intern Med 2023; 38:738-754. [PMID: 36127538 PMCID: PMC9971421 DOI: 10.1007/s11606-022-07768-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Diagnostic uncertainty is a pervasive issue in primary care where patients often present with non-specific symptoms early in the disease process. Knowledge about how clinicians communicate diagnostic uncertainty to patients is crucial to prevent associated diagnostic errors. Yet, in-depth research on the interpersonal communication of diagnostic uncertainty has been limited. We conducted an integrative systematic literature review (PROSPERO CRD42020197624, unfunded) to investigate how primary care doctors communicate diagnostic uncertainty in interactions with patients and how patients experience their care in the face of uncertainty. METHODS We searched MEDLINE, PsycINFO, and Linguistics and Language Behaviour Abstracts (LLBA) from inception to December 2021 for MeSH and keywords related to 'communication', 'diagnosis', 'uncertainty' and 'primary care' environments and stakeholders (patients and doctors), and conducted additional handsearching. We included empirical primary care studies published in English on spoken communication of diagnostic uncertainty by doctors to patients. We assessed risk of bias with the QATSDD quality assessment tool and conducted thematic and content analysis to synthesise the results. RESULTS Inclusion criteria were met for 19 out of 1281 studies. Doctors used two main communication strategies to manage diagnostic uncertainty: (1) patient-centred communication strategies (e.g. use of empathy), and (2) diagnostic reasoning strategies (e.g. excluding serious diagnoses). Linguistically, diagnostic uncertainty was either disclosed explicitly or implicitly through diverse lexical and syntactical constructions, or not communicated (omission). Patients' experiences of care in response to the diverse communicative and linguistic strategies were mixed. Patient-centred approaches were generally regarded positively by patients. DISCUSSION Despite a small number of included studies, this is the first review to systematically catalogue the diverse communication and linguistic strategies to express diagnostic uncertainty in primary care. Health professionals should be aware of the diverse strategies used to express diagnostic uncertainty in practice and the value of combining patient-centred approaches with diagnostic reasoning strategies.
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Affiliation(s)
- Maria R Dahm
- Institute for Communication in Health Care (ICH), ANU College of Arts and Social Sciences, The Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Canberra, ACT 2600, Australia.
| | - William Cattanach
- ANU Medical School, ANU College of Health and Medicine, The Australian National University, Canberra, Australia
| | | | - Jocelyne M Basseal
- Discipline of Infectious Diseases & Immunology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kelly Gleason
- Johns Hopkins School of Nursing, Baltimore City, MD, USA
| | - Carmel Crock
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Appavoo S. Imaging, Paternalism and the Worried Patient: Rethinking Our Approach. Can Assoc Radiol J 2021; 73:121-124. [PMID: 34227431 DOI: 10.1177/08465371211021996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Covid pandemic has taught many lessons, including the importance of mental health. The value of the radiologist in holistic patient care may be underestimated and underresearched. Barriers to the acceptance of imaging as an important component in reassurance may be rooted in old ideas minimizing the importance of mental health.
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Affiliation(s)
- Shushiela Appavoo
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
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Nursing Students' Experiences with Computer Simulation-Based Communication Education. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063108. [PMID: 33803034 PMCID: PMC8003003 DOI: 10.3390/ijerph18063108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/20/2022]
Abstract
Simulation-based communication education has improved nursing students’ communication knowledge and skills. However, communication patterns that students commonly exhibit in simulated situations and students’ responses to specific clinical situations have not been systematically examined. The specific aims of the present study were (1) to identify non-therapeutic communication patterns that nursing students exhibit in simulated situations in the computer simulation-based education (ComEd) program, and (2) explore students’ responses to challenging clinical situations. This study used a mixed-method research design and a convenience sampling method to recruit participants. Frequency analysis and a conventional content analysis method were used to analyze answers provided by participants. A total of 66 students from four Korean nursing schools participated in the study. “False reassurance” was found to be the most common non-therapeutic communication pattern used by nursing students. Nursing students had difficulty in clinical situations such as reporting a patient’s condition to a doctor, communicating with a patient and perform basic nursing skills at the same time, and managing conflicts between patients. Technology-based communication simulation programs, which reflect various clinical situations, are considered a new alternative that can supplement the limitations of clinical practicum and improve the quality of nursing education.
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Kube T, Rozenkrantz L, Rief W, Barsky A. Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts. Clin Psychol Rev 2020; 76:101829. [PMID: 32062101 DOI: 10.1016/j.cpr.2020.101829] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 01/11/2023]
Abstract
Persistent physical symptoms (PPS) are distressing, difficult to treat, and pose a major challenge to health care providers and systems. In this article, we review two disparate bodies of literature on PPS to provide a novel integrative model of this elusive condition. First, we draw on the clinical-psychological literature on the role of expectations to suggest that people with PPS develop dysfunctional expectations about health and disease that become increasingly immune to disconfirmatory information (such as medical reassurance) through cognitive reappraisal. Second, we invoke neuroscientific predictive processing accounts and propose that the psychological process of 'cognitive immunization' against disconfirmatory evidence corresponds, at the neurobiological and computational level, to too much confidence (i.e. precision) afforded to prior predictions. This can lead to an attenuation of disconfirming sensory information so that strong priors override benign bodily signals and make people believe that something serious is wrong with the body. Combining these distinct accounts provides a unifying framework for persistent physical symptoms and shifts the focus away from their causes to the sustaining mechanisms that prevent symptoms from subsiding spontaneously. Based on this integrative model, we derive new avenues for future research and discuss implications for treating people with PPS in clinical practice.
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Affiliation(s)
- Tobias Kube
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany; Pain and Psychotherapy Research Lab, University of Koblenz-Landau, Ostbahnstr. 10, 76829 Landau, Germany.
| | - Liron Rozenkrantz
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Gutenbergstr. 18, 35032 Marburg, Germany
| | - Arthur Barsky
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
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McPhillips R, Salmon P, Wells A, Fisher P. Cardiac Rehabilitation Patients' Accounts of Their Emotional Distress and Psychological Needs: A Qualitative Study. J Am Heart Assoc 2019; 8:e011117. [PMID: 31433708 PMCID: PMC6585358 DOI: 10.1161/jaha.118.011117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/21/2019] [Indexed: 12/14/2022]
Abstract
Background Psychological distress is prevalent among patients with cardiovascular disease and is linked to increased risk of future cardiac events. Cardiac rehabilitation (CR) is widely recommended for treating psychological distress but has been of limited benefit. This study aims to understand how distressed cardiac patients describe their emotional needs and the response of CR. Methods and Results A qualitative descriptive study was conducted with 46 patients who screened positively for anxiety and/or depression. Semi-structured interviews were held, and data were analyzed using a constant comparative approach. Patients described low mood and diverse concerns, including threat of another cardiac event, restrictions on their lives, and problems unrelated to their health. Patients described worrying constantly about these concerns, worrying about their worry, and feeling that worry was uncontrollable and harmful. Patients wanted to "get back to normal" but lacked any sense of how to achieve this and were reluctant to discuss their worries with CR staff. They hoped to recover over time, meanwhile seeking reassurance that they were responding "normally." Patients were mostly dismissive of psychological techniques used in CR. Conclusions These findings expose a conundrum. Distressed CR patients have diverse worries but do not generally want to discuss them, so they invest hopes for feeling better in time passing and reassurance. An intervention acceptable to CR patients would allow them to address diverse worries but without having to share the content of worries, would have "face validity," and would address patients' worry about worry. Metacognitive therapy is an intervention that might be suitable. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02420431.
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Affiliation(s)
- Rebecca McPhillips
- School of Psychological SciencesFaculty of Biology, Medicine and HealthManchester Academic Health Science CentreUniversity of ManchesterUnited Kingdom
- Department of Research and InnovationGreater Manchester Mental Health TrustManchester Academic Health Science CentreManchesterUnited Kingdom
| | - Peter Salmon
- Division of Clinical PsychologyPsychological SciencesUniversity of LiverpoolUnited Kingdom
| | - Adrian Wells
- School of Psychological SciencesFaculty of Biology, Medicine and HealthManchester Academic Health Science CentreUniversity of ManchesterUnited Kingdom
- Department of Research and InnovationGreater Manchester Mental Health TrustManchester Academic Health Science CentreManchesterUnited Kingdom
| | - Peter Fisher
- Division of Clinical PsychologyPsychological SciencesUniversity of LiverpoolUnited Kingdom
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Musey PI, Lee JA, Hall CA, Kline JA. Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain. BMC Emerg Med 2018. [PMID: 29540151 PMCID: PMC5853064 DOI: 10.1186/s12873-018-0161-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Approximately 80% of patients presenting to emergency departments (ED) with chest pain do not have any true cardiopulmonary emergency such as acute coronary syndrome (ACS). However, psychological contributors such as anxiety are thought to be present in up to 58%, but often remain undiagnosed leading to chronic chest pain and ED recidivism. Methods To evaluate ED provider beliefs and their usual practices regarding the approach and disposition of patients with low risk chest pain associated with anxiety, we constructed a 22-item survey using a modified Delphi technique. The survey was administered to a convenience sample of ED providers attending the 2016 American College of Emergency Physicians Scientific Assembly in Las Vegas. Results Surveys were completed by 409 emergency medicine providers from 46 states and 7 countries with a wide range of years of experience and primary practice environment (academic versus community centers). Respondents estimated that 30% of patients presenting to the ED with chest pain thought to be low risk for ACS have anxiety or panic as the primary cause but they directly communicate this belief to only 42% of these patients and provide discharge instructions to 48%. Only 39% of respondents reported adequate hospital resources to ensure follow-up. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% vs. 34%; p = 0.015). Most providers (82%) indicated that they wanted to have referral resources available to a specific clinic for further outpatient evaluation. Conclusion Emergency Department providers believe approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. This highlights an opportunity for patient centered communication. Electronic supplementary material The online version of this article (10.1186/s12873-018-0161-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - John A Lee
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,University of Virginia School of Medicine, Charlottesville, Virginia, 22908, USA
| | - Cassandra A Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
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12
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Page LA, Wessely S. Medically Unexplained Symptoms: Exacerbating Factors in the Doctor-Patient Encounter. J R Soc Med 2017; 96:223-7. [PMID: 12724431 PMCID: PMC539474 DOI: 10.1177/014107680309600505] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- L A Page
- Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
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Eftekhari S, Yaraghi N, Singh R, Gopal RD, Ramesh R. Do Health Information Exchanges Deter Repetition of Medical Services? ACM TRANSACTIONS ON MANAGEMENT INFORMATION SYSTEMS 2017. [DOI: 10.1145/3057272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Repetition of medical services by providers is one of the major sources of healthcare costs. The lack of access to previous medical information on a patient at the point of care often leads a physician to perform medical procedures that have already been done. Multiple healthcare initiatives and legislation at both the federal and state levels have mandated Health Information Exchange (HIE) systems to address this problem. This study aims to assess the extent to which HIE could reduce these repetitions, using data from Centers for Medicare 8 Medicaid Services and a regional HIE organization. A 2-Stage Least Square model is developed to predict the impact of HIE on repetitions of two classes of procedures: diagnostic and therapeutic. The first stage is a predictive analytic model that estimates the duration of tenure of each HIE member-practice. Based on these estimates, the second stage predicts the effect of providers’ HIE tenure on their repetition of medical services. The model incorporates moderating effects of a federal quality assurance program and the complexity of medical procedures with a set of control variables. Our analyses show that a practice's tenure with HIE significantly lowers the repetition of therapeutic medical procedures, while diagnostic procedures are not impacted. The medical reasons for the effects observed in each class of procedures are discussed. The results will inform healthcare policymakers and provide insights on the business models of HIE platforms.
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Affiliation(s)
| | | | - Ranjit Singh
- State University of New York at Buffalo, Buffalo, NY
| | | | - R. Ramesh
- State University of New York at Buffalo, Buffalo, NY
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Traeger AC, O'Hagan ET, Cashin A, McAuley JH. Reassurance for patients with non-specific conditions - a user's guide. Braz J Phys Ther 2017; 21:1-6. [PMID: 28442069 PMCID: PMC5537438 DOI: 10.1016/j.bjpt.2016.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 11/23/2016] [Accepted: 11/25/2016] [Indexed: 12/14/2022] Open
Abstract
Reassurance is a frequently utilized yet poorly understood clinical skill. Emotional distress is an important driver of healthcare use. Diagnostic test results are not reassuring. Some attempts at reassurance can increase rather than decrease concern. Patient education is a promising way for clinicians to manage emotional distress.
Introduction Reassurance is the removal of fears and concerns about illness. In practice reassurance for non-specific conditions, where a diagnosis is unclear or unavailable, is difficult and can have unexpected effects. Many clinical guidelines for non-specific conditions such as low back pain recommend reassurance. Until recently, there was little evidence on how to reassure patients effectively. Results High distress causes patients to consult more often for low back pain. To reduce distress, clinicians should provide structured education, which is effective in the short- and long-term. A newly developed online prognostic tool has the potential to improve the quality of reassurance and reduce the number of inappropriate interventions provided for low back pain. Conclusion Targeted reassurance, including enhanced, prognosis-specific education, could optimize reassurance and possibly prevent disabling symptoms.
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Affiliation(s)
- Adrian C Traeger
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
| | - Edel T O'Hagan
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Aidan Cashin
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - James H McAuley
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Mushlin AI, Kern LM, Paris M, Lambert DR, Williams G. The Value of Diagnostic Information to Patients with Chest Pain Suggestive of Coronary Artery Disease. Med Decis Making 2016; 25:149-57. [PMID: 15800299 DOI: 10.1177/0272989x05275157] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The results of diagnostic tests often have a profound impact on the way patients view their health. Decision analyses and clinical guidelines do not routinely consider this, in part because methods are not well developed for measuring the value of testing to patients. Objectives. To measure the value of stress testing to patients with chest pain suggestive of coronary artery disease (CAD) and to improve methods for measuring the value of diagnostic information. Methods. The authors conducted a prospective cohort study of patients with chest pain who were referred from 44 primary care practices for treadmill testing (N = 320). Current health status, perceived life expectancy, anxiety, uncertainty, and preferences for current health states were measured before and 1 week after testing and receipt of the results. Patients also reported the diagnosis given by their physicians after testing. The authors used paired t tests to assess changes before and after testing. Results. Perceived life expectancy lengthened, anxiety decreased, and uncertainty decreased 1 week after exercise testing, compared to before (P < 0.01). For many patients, sytoms were less bothersome after testing than before. There were few changes in perceptions of current health status, as measured by the SF-36. The authors found evidence of reassurance among patients who reported that CAD had been excluded and no evidence of psychological harm among patients who reported a new CAD diagnosis. Conclusions. Patients experienced measurable psychological benefits from noninvasive diagnostic testing for CAD. Similar measurements should be standard components of diagnostic test evaluation.
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Affiliation(s)
- Alvin I Mushlin
- Department of Public Health, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Schulman-Marcus J, Boden WE. A PROMISE Fulfilled That Quality-of-Life Assessments Afford Incremental Value to Coronary Artery Disease Management. Circulation 2016; 133:1989-91. [PMID: 27143677 DOI: 10.1161/circulationaha.116.022732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joshua Schulman-Marcus
- From Weill Cornell Medical College, New York (J.S.-M.); and Albany Stratton VA Medical Center and Albany Medical College, NY (W.E.B.)
| | - William E Boden
- From Weill Cornell Medical College, New York (J.S.-M.); and Albany Stratton VA Medical Center and Albany Medical College, NY (W.E.B.).
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Carone DA. But the Scores Don't Show How I Really Function: A Feedback Method to Reveal Cognitive Distortions Regarding Normal Neuropsychological Test Performance. APPLIED NEUROPSYCHOLOGY-ADULT 2016; 24:160-168. [DOI: 10.1080/23279095.2015.1116074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Dominic A. Carone
- SUNY Upstate Medical University, Physical Medicine and Rehabilitation, Institute for Human Performance, Syracuse, New York, USA
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McMurtry CM, Taddio A, Noel M, Antony MM, Chambers CT, Asmundson GJG, Pillai Riddell R, Shah V, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin S, Bowles S, Halpert C, Ipp M, Rieder MJ, Robson K, Uleryk E, Votta Bleeker E, Dubey V, Hanrahan A, Lockett D, Scott J. Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research. Cogn Behav Ther 2016; 45:217-35. [PMID: 27007463 PMCID: PMC4867871 DOI: 10.1080/16506073.2016.1157204] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/09/2016] [Indexed: 12/20/2022]
Abstract
Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.
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Affiliation(s)
- C. Meghan McMurtry
- Department of Psychology, University of Guelph, Guelph, Canada
- Pediatric Chronic Pain Program, McMaster Children’s Hospital, Hamilton, Canada
- Children’s Health Research Institute, London, Canada
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Anna Taddio
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- The Hospital for Sick Children, Toronto, Canada
| | - Melanie Noel
- Department of Psychology, University of Calgary, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
| | | | - Christine T. Chambers
- Department of Pediatrics, Department of Psychology and Neuroscience, Dalhousie University, Halifax, Canada
- The Centre for Pediatric Pain Research, IWK Health Centre, Halifax, Canada
| | | | - Rebecca Pillai Riddell
- The Hospital for Sick Children, Toronto, Canada
- Department of Psychology, York University, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Vibhuti Shah
- Mount Sinai Hospital, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Noni E. MacDonald
- Department of Pediatrics, Dalhousie University, Halifax, Canada
- IWK Health Centre, Halifax, Canada
- Canadian Center for Vaccinology, Halifax, Canada
| | - Jess Rogers
- Centre for Effective Practice, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Lucie M. Bucci
- Immunize Canada, Ottawa, Canada
- Canadian Public Health Association, Ottawa, Canada
| | | | - Eddy Lang
- Alberta Health Services and the Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Scott Halperin
- Department of Pediatrics, Dalhousie University, Halifax, Canada
- IWK Health Centre, Halifax, Canada
- Canadian Center for Vaccinology, Halifax, Canada
- Department of Microbiology & Immunology, Dalhousie University, Halifax, Canada
| | - Susan Bowles
- College of Pharmacy, Dalhousie University, Halifax, Canada
| | - Christine Halpert
- Immunization Programs and Vaccine Preventable Diseases Service, BC Centre for Disease Control, Vancouver, Canada
| | - Moshe Ipp
- The Hospital for Sick Children, Toronto, Canada
- Faculty of Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Michael J. Rieder
- Departments of Paediatrics, Physiology & Pharmacology and Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Kate Robson
- Canadian Family Advisory Network, Toronto, Canada
| | | | | | | | - Anita Hanrahan
- Communicable Disease Control, Alberta Health Services, Edmonton, Canada
| | - Donna Lockett
- Bodhi Seed Center for Healing and Conscious Living, Milton, Canada
| | - Jeffrey Scott
- Department of Emergency Medicine, IWK Health Centre, Halifax, Canada
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Webster R, Thompson AR, Norman P, Goodacre S. The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain. PSYCHOL HEALTH MED 2016; 22:1-11. [PMID: 26924523 PMCID: PMC5105082 DOI: 10.1080/13548506.2016.1144891] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.
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Affiliation(s)
- Rosie Webster
- a Research Department of Primary Care and Population Health , University College London , Royal Free Campus, Rowland Hill Street, London , NW3 2PF , UK.,b Department of Psychology , University of Sheffield , UK
| | - Andrew Robert Thompson
- c Department of Psychology , University of Sheffield , Western Bank, Sheffield , S10 2TN , UK
| | - Paul Norman
- d Department of Psychology , University of Sheffield , UK
| | - Steve Goodacre
- e School of Health and Related Research , University of Sheffield , UK
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Risk of revisits to the emergency department in admitted versus discharged patients with chest pain but without myocardial infarction in relation to high-sensitivity cardiac troponin T levels. Int J Cardiol 2016; 203:341-6. [DOI: 10.1016/j.ijcard.2015.10.170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 08/26/2015] [Accepted: 10/19/2015] [Indexed: 11/21/2022]
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Karel YHJM, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. Eur J Intern Med 2015; 26:585-95. [PMID: 26186812 DOI: 10.1016/j.ejim.2015.06.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/15/2015] [Accepted: 06/27/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The increasing use of diagnostic imaging has led to high expenditures, unnecessary invasive procedures and/or false-positive diagnoses, without certainty that the patients actually benefit from these imaging procedures. This review explores whether diagnostic imaging leads to better patient-reported outcomes in individuals with musculoskeletal disorders. METHOD Databases were searched from inception to September 2013, together with scrutiny of selected bibliographies. Trials were eligible when: 1) a diagnostic imaging procedure was compared with any control group not getting or not receiving the results of imaging; 2) the population included individuals suffering from musculoskeletal disorders, and 3) if patient-reported outcomes were available. Primary outcome measures were pain and function. Secondary outcome measures were satisfaction and quality of life. Subgroup analysis was done for different musculoskeletal complaints and high technological medical imaging (MRI/CT). RESULTS Eleven trials were eligible. The effects of diagnostic imaging were only evaluated in patients with low back pain (n=7) and knee complaints (n=4). Overall, there was a moderate level of evidence for no benefit of diagnostic imaging on all outcomes compared with controls. A significant but clinically irrelevant effect was found in favor of no (routine) imaging in low back pain patients in terms of pain severity at short [SMD 0.17 (0.04-0.31)] and long-term follow-up [SMD 0.13 (0.02-0.24)], and for overall improvement [RR 1.15 (1.03-1.28)]. Subgroup analysis did not significantly change these results. CONCLUSION These results strengthen the available evidence that routine referral to diagnostic imaging by general practitioners for patients with knee and low back pain yields little to no benefit.
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Affiliation(s)
- Yasmaine H J M Karel
- Research Group Diagnostics, Avans University of Applied Sciences, Breda, The Netherlands; Department of Family Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Karin Verkerk
- Education for Physiotherapy, Rotterdam University of Applied Sciences, The Netherlands
| | - Silvio Endenburg
- Education for Physiotherapy, Rotterdam University of Applied Sciences, The Netherlands
| | - Sven Metselaar
- Education for Physiotherapy, Rotterdam University of Applied Sciences, The Netherlands
| | - Arianne P Verhagen
- Department of Family Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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Kellett J. Whatever happened to the doctor's opinion? Eur J Intern Med 2015; 26:e17. [PMID: 26138784 DOI: 10.1016/j.ejim.2015.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 11/21/2022]
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Bahremand M, Saeidi M, Komasi S. Non-Coronary Patients with Severe Chest Pain Show More Irrational Beliefs Compared to Patients with Mild Pain. Korean J Fam Med 2015. [PMID: 26217482 PMCID: PMC4515511 DOI: 10.4082/kjfm.2015.36.4.180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Despite providing insufficient medical evidence of the existence of a real cardiac condition, patients with non-coronary chest pain still interpret their pain incorrectly. The present study, therefore, sought to compare the irrational beliefs in non-coronary patients with mild chest pain against those with severe chest pain. Methods A cross-sectional design was used. The statistical population comprised non-coronary patients who presented to the Heart Emergency Center of Kermanshah city, Iran. Using a matching method, 96 participants were selected and studied in two groups of 48. The instruments used were the Comorbidity Index, Brief Pain Index, and the Jones Irrational Beliefs Test (short-form). The multivariate analysis of variance, chi-square test, and t-test were used for data analysis. Results Controlling for the effects of age and comorbid conditions, the severity of three types of irrational beliefs, including emotional irresponsibility (P<0.001), hopelessness changes (P<0.001), and problem avoiding (P=0.002) was higher among patients with severe chest pain (according to effect level). However, in terms of demand for approval, no difference was seen between the two groups (P=0.180). Conclusion Non-coronary patients with severe chest pain showed a greater number of irrational beliefs in comparison to patients with mild pain. Irrational beliefs are common mental occurrences in patients with non-coronary chest pain, and they should be attended to by health professionals, especially in severe non-coronary chest pain. Further investigation to determine the association between irrational beliefs and non-coronary chest pain is necessary.
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Affiliation(s)
- Mostafa Bahremand
- Interventional Cardiologist, Assistant Professor of Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mozhgan Saeidi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeid Komasi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Doust J, Trevena L, Bastian H, Burgess J, Edwards AGK. Interventions for improving understanding and minimising the psychological impact of screening. Hippokratia 2015. [DOI: 10.1002/14651858.cd001212.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jenny Doust
- Bond University; Centre for Research in Evidence Based Practice; Gold Coast Queensland Australia 4229
| | - Lyndal Trevena
- The University of Sydney; Room 322 Edward Ford Building (A27) Sydney NSW Australia 2006
| | - Hilda Bastian
- National Library of Medicine, National Institutes of Health; National Center for Biotechnology Information; 8600 Rockville Pike Bethesda Maryland USA 20894
| | - Jacquii Burgess
- Bond University; Faculty of Health Sciences and Medicine; Gold Coast Queensland Australia 4229
| | - Adrian GK Edwards
- Cardiff University; Cochrane Institute of Primary Care and Public Health, School of Medicine; 2nd Floor, Neuadd Meirionnydd Heath Park Cardiff Wales UK CF14 4YS
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26
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Webster R, Thompson AR, Norman P. 'Everything's fine, so why does it happen?' A qualitative investigation of patients' perceptions of noncardiac chest pain. J Clin Nurs 2015; 24:1936-45. [PMID: 25988506 PMCID: PMC4959531 DOI: 10.1111/jocn.12841] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/30/2022]
Abstract
Aims and objectives To examine patients' perceptions and experiences of noncardiac chest pain, within the framework of the common sense model. Background Patients with noncardiac chest pain have good physical prognosis, but frequently suffer prolonged pain and psychological distress. The common sense model may provide a good framework for examining outcomes in patients with noncardiac chest pain. Design Qualitative thematic analysis with semi‐structured interviews. Methods In 2010, participants recruited from an emergency department (N = 7) with persistent noncardiac chest pain and distress were interviewed using a semi‐structured schedule, and data were analysed using thematic analysis. Results Seven themes were identified; six of which mapped onto core dimensions of the common sense model (identity, cause, timeline, consequences, personal control, treatment control). Contrary to previous research on medically unexplained symptoms, most participants perceived psychological factors to play a causal role in their chest pain. Participants' perceptions largely mapped onto the common sense model, although there was a lack of coherence across dimensions, particularly with regard to cause. Conclusion Patients with noncardiac chest pain lack understanding with regard to their condition and may be accepting of psychological causes of their pain. Relevance to clinical practice Brief psychological interventions aimed at improving understanding of the causes of noncardiac chest pain and providing techniques for managing pain and stress may be useful for patients with noncardiac chest pain.
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Affiliation(s)
- Rosie Webster
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Andrew R Thompson
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
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Bahremand M, Moradi G, Saeidi M, Mohammadi S, Komasi S. Reducing Irrational Beliefs and Pain Severity in Patients Suffering from Non-Cardiac Chest Pain (NCCP): A Comparison of Relaxation Training and Metaphor Therapy. Korean J Pain 2015; 28:88-95. [PMID: 25852829 PMCID: PMC4387467 DOI: 10.3344/kjp.2015.28.2.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/13/2015] [Accepted: 02/27/2015] [Indexed: 11/05/2022] Open
Abstract
Background Patients suffering from non-cardiac chest pain (NCCP) can interpret their chest pain wrongly despite having received a correct diagnosis. The objective of this study was to compare the efficacy of the relaxation method with metaphor therapy for reducing irrational beliefs and pain severity in patients with NCCP. Methods Using a randomized controlled trial, 33 participants were randomly divided into a relaxation training group (n= 13), a metaphor therapy group (n = 10), and a control group (n = 10), and were studied for 4 weeks. The two tools used in this research were the Brief Pain Inventory (BPI) index for determining the degree of pain and the short version of the Jones Irrational Belief Test. Metaphor therapy and a relaxation technique based on Öst's treatment were used as the interventions. The collected data were analyzed with a multivariate analysis of covariance (MANCOVA), a Chi-square test, and the Bonferroni procedure of post-hoc analysis. Results The relaxation training method was significantly more effective than both metaphor therapy and the lack of treatment in reducing the patients' beliefs of hopelessness in the face of changes and emotional irresponsibility, as well as the pain severity. Metaphor therapy was not effective on any of these factors. In fact, the results did not support the effectiveness of metaphor therapy. Conclusions Regarding the effectiveness of the relaxation method as compared with metaphor therapy and the lack of treatment in the control group, this study suggests that relaxation should be paid greater attention as a method for improving the status of patients. In addition, more studies are needed to determine the effectiveness of metaphor therapy in this area.
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Affiliation(s)
- Mostafa Bahremand
- Interventional Cardiologist, Assistant Professor at Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Gholamreza Moradi
- Cardiac Anesthesiologist, Assistant Professor at Kermanshah University of Medical Sciences, Imam Ali Hospital, University of Medical Sciences, Kermanshah, Iran
| | - Mozhgan Saeidi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samira Mohammadi
- Pharmacy Student at Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeid Komasi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Baradaran Motie P, Zare-Mirzaie A, Shayanfar N, Kadivar M. Does routine repeat testing of critical laboratory values improve their accuracy? Med J Islam Repub Iran 2015; 29:176. [PMID: 26034729 PMCID: PMC4431443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 08/05/2014] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Routine repeat testing of critical laboratory values is very common these days to increase their accuracy and to avoid reporting false or infeasible results. We figure that repeat testing of critical laboratory values has any benefits or not. METHODS We examined 2233 repeated critical laboratory values in 13 different hematology and chemistry tests including: hemoglobin, white blood cell, platelet, international normalized ratio, partial thromboplastin time, glucose, potassium, sodium, phosphorus, magnesium, calcium, total bilirubin and direct bilirubin. The absolute difference and the percentage of change between the two tests for each critical value were calculated and then compared with the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error. RESULTS Repeat testing yielded results that were within the allowable error on 2213 of 2233 specimens (99.1%). There was only one outlier (0.2%) in the white blood cell test category, 9 (2.9%) in the platelet test category, 5 (4%) in the partial thromboplastin time test category, 5 (4.8%) in the international normalized ratio test category and none in other test categories. CONCLUSION Routine, repeat testing of critical hemoglobin, white blood cell, platelet, international normalized ratio, partial thromboplastin time, glucose, potassium, sodium, phosphorus, magnesium, calcium, total bilirubin and direct bilirubin results does not have any benefits to increase their accuracy.
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Affiliation(s)
- Pooya Baradaran Motie
- 1 General Practitioner, Iran University of Medical Sciences, Rasoul-e-Akram Hospital, Tehran, Iran.
| | - Ali Zare-Mirzaie
- 2 Associate Professor, Iran University of Medical Sciences, Pathology Ward, Rasoul-e-Akram Hospital, Tehran, Iran.
| | - Nasrin Shayanfar
- 3 Associate Professor, Iran University of Medical Sciences, Pathology Ward, Rasoul-e-Akram Hospital, Tehran, Iran.
| | - Maryam Kadivar
- 4 Professor, Iran University of Medical Sciences, Pathology Ward, Rasoul-e-Akram Hospital, Tehran, Iran.
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29
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Hicks K, Cocks K, Corbacho Martin B, Elton P, MacNab A, Colecliffe W, Furze G. An intervention to reassure patients about test results in rapid access chest pain clinic: a pilot randomised controlled trial. BMC Cardiovasc Disord 2014; 14:138. [PMID: 25280578 PMCID: PMC4197216 DOI: 10.1186/1471-2261-14-138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 09/22/2014] [Indexed: 12/03/2022] Open
Abstract
Background Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. Consequently, many patients are not reassured they have the correct diagnosis or treatment. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention. Methods This was a two-arm pilot randomised controlled trial in outpatient rapid access chest pain clinic in 120 people undergoing investigation for new onset, non-urgent chest pain. Eligible participants were randomised to receive either: a discussion about the meaning and implication of test results, delivered by a nurse before tests in clinic, plus a pre-test pamphlet covering the same information (Discussion arm) or the pre-test pamphlet alone (Pamphlet arm). Main outcome measures were recruitment rate and feasibility for a future multi-centre trial, with an estimate of reassurance in the groups at month 1 and 6 using a 5-item patient-reported scale. Results Two hundred and seventy people attended rapid access chest pain clinic during recruitment and 120/270 participants (44%) were randomised, 60 to each arm. There was no evidence of a difference between the Discussion and Pamphlet arms in the mean reassurance score at month 1 (34.2 vs 33.7) or at month 6 (35.3 vs 35.9). Patient-reported chest pain and use of heart medications were also similar between the two arms. Conclusions A larger trial of the discussion intervention in the UK would not be warranted. Patients reported high levels of reassurance which were similar in patients receiving the discussion with a nurse and in those receiving a pamphlet alone. Trial registration Current Controlled Trials ISRCTN60618114 (assigned 27.05.2011). Electronic supplementary material The online version of this article (doi:10.1186/1471-2261-14-138) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathryn Hicks
- Department of Health Sciences, York Trials Unit, University of York, York YO10 5DD, UK.
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Cotton SC, Sharp L, Little J, Gray NM, Walker LG, Whynes DK, Cruickshank ME. A normal colposcopy examination fails to provide psychological reassurance for women who have had low-grade abnormal cervical cytology. Cytopathology 2014; 26:178-87. [DOI: 10.1111/cyt.12173] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2014] [Indexed: 10/24/2022]
Affiliation(s)
- S. C. Cotton
- Obstetrics & Gynaecology; University of Aberdeen; Foresterhill Aberdeen UK
| | - L. Sharp
- National Cancer Registry Ireland; Cork Ireland
| | - J. Little
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - N. M. Gray
- Centre of Academic Primary Care; University of Aberdeen; Foresterhill Aberdeen UK
| | | | - D. K. Whynes
- School of Economics; University of Nottingham; Nottingham UK
| | - M. E. Cruickshank
- Obstetrics & Gynaecology; University of Aberdeen; Foresterhill Aberdeen UK
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Giroldi E, Veldhuijzen W, Leijten C, Welter D, van der Weijden T, Muris J, van der Vleuten C. 'No need to worry': an exploration of general practitioners' reassuring strategies. BMC FAMILY PRACTICE 2014; 15:133. [PMID: 25001991 PMCID: PMC4118274 DOI: 10.1186/1471-2296-15-133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/30/2014] [Indexed: 11/10/2022]
Abstract
Background In view of the paucity of evidence regarding effective ways of reassuring worried patients, this study explored reassuring strategies that are considered useful by general practitioners (GPs). Methods In a study using a qualitative observational design, we re-analysed an existing dataset of fifteen stimulated recall interviews in which GPs elaborated on their communication with patients in two videotaped consultations. Additionally we held stimulated recall interviews with twelve GPs about two consultations selected for a strong focus on reassurance. Results To reassure patients, GPs pursued multiple goals: 1. influencing patients’ emotions by promoting trust, safety and comfort, which is considered to be reassuring in itself and supportive of patients’ acceptance of reassuring information and 2. influencing patients’ cognitions by challenging patients’ belief that their symptoms are indicative of serious disease, often followed by promoting patients’ belief that their symptoms are benign. GPs described several actions to activate mechanisms to achieve these goals. Conclusions GPs described a wealth of reassuring strategies, which make a valuable contribution to the current literature on doctor-patient communication. This detailed description may provide practicing GPs with new tools and can inform future studies exploring the effectiveness of reassurance strategies.
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Affiliation(s)
- Esther Giroldi
- Department of Family Medicine, Maastricht University, School of Public Health and Primary Care (CAPHRI), P,O, Box 616, Maastricht, The Netherlands.
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Webster R, Norman P, Goodacre S, Thompson A, McEachan R. Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department. Psychol Health 2014; 29:1265-82. [PMID: 24831735 PMCID: PMC4192860 DOI: 10.1080/08870446.2014.923885] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 05/07/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED. METHODS ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month. RESULTS Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain. CONCLUSIONS The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain.
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Affiliation(s)
- R. Webster
- Department of Psychology, University of Sheffield, Sheffield, UK
- e-Health Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - P. Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - S. Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - A.R. Thompson
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - R.R.C. McEachan
- Bradford Institute for Health Research, Bradford Teaching Hopsitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK
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Giroldi E, Veldhuijzen W, Mannaerts A, van der Weijden T, Bareman F, van der Vleuten C. "Doctor, please tell me it's nothing serious": an exploration of patients' worrying and reassuring cognitions using stimulated recall interviews. BMC FAMILY PRACTICE 2014; 15:73. [PMID: 24762333 PMCID: PMC4008437 DOI: 10.1186/1471-2296-15-73] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/17/2014] [Indexed: 11/16/2022]
Abstract
Background Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients’ worries, cognitions underlying reassurance and factors supporting patients’ reassuring cognitions. Methods In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries. Results Patients expressed four different core cognitions underlying their concerns: ‘I have a serious illness’, ‘my health problem will have adverse physical effects’, ‘my treatment will have adverse effects’ and ‘my health problem will negatively impact my life’. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: ‘I trust my doctor’s expertise’, ‘I have a trusting and supporting relationship with my doctor’, ‘I do not have a serious disease’, ‘my health problem is harmless’ and ‘my health problem will disappear.’ Factors expressed as reasons for these reassuring cognitions were GPs’ actions during the consultation as well as patients’ pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients’ worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated. Conclusions Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. The identified reassuring cognitions can guide doctors in applying these strategies in their daily practice.
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Affiliation(s)
- Esther Giroldi
- Department of Family Medicine, Maastricht University, School for Public Health and Primary Care (CAPHRI), P,O, Box 616, Maastricht, The Netherlands.
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Tritter JQ, Lutfey K, McKinlay J. What are tests for? The implications of stuttering steps along the US patient pathway. Soc Sci Med 2014; 107:37-43. [PMID: 24602969 DOI: 10.1016/j.socscimed.2014.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 02/02/2014] [Accepted: 02/07/2014] [Indexed: 11/29/2022]
Abstract
This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.
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Affiliation(s)
- Jonathan Q Tritter
- Department of Sociology and Public Policy, Aston University, Birmingham B4 7ET, United Kingdom.
| | - Karen Lutfey
- Department of Health and Behavioral Sciences, University of Colorado, Denver, United States
| | - John McKinlay
- New England Research Institute, Boston, United States
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Chambers J, Kabir S, Cajeat E. Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals. Br J Gen Pract 2014; 64:e105-11. [PMID: 24567615 PMCID: PMC3905412 DOI: 10.3399/bjgp14x677167] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 10/16/2014] [Accepted: 12/02/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Heart disease is difficult to detect clinically and it has been suggested that echocardiography should be available to all patients with possible cardiac symptoms or signs. AIM To analyse the results of 2 years of open access echocardiography for the frequency of structural heart disease according to request. DESIGN AND SETTING Retrospective database analysis in a teaching hospital open access echocardiography service. METHOD Reports of all open access transthoracic echocardiograms between January 2011 and December 2012 were categorised as normal, having minor abnormalities, or significant abnormalities according to the indication. RESULTS There were 2343 open access echocardiograms performed and there were significant abnormalities in 29%, predominantly valve disease (n = 304, 13%), LV systolic dysfunction (n = 179, 8%), aortic dilatation (n = 80, 3%), or pulmonary hypertension (n = 91, 4%). If echocardiography had been targeted at a high-risk group, 267 with valve disease would have been detected (compared to 127 with murmur alone) and 139 with LV systolic dysfunction (compared to 91 with suspected heart failure alone). Most GP practices requested fewer than 10 studies, but 6 practices requested over 70 studies. CONCLUSION Open access echocardiograms are often abnormal but structural disease may not be suspected from the clinical request. Uptake by individual practices is patchy. A targeted expansion of echocardiography in patients with a high likelihood of disease is therefore likely to increase the detection of clinically important pathology.
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Affiliation(s)
- John Chambers
- Adult Echocardiography, Cardiothoracic Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Cathébras P. [Reassurance: an essential but difficult medical task with neglected social and economic outcomes]. Rev Med Interne 2013; 35:285-8. [PMID: 24315472 DOI: 10.1016/j.revmed.2013.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 10/25/2022]
Affiliation(s)
- P Cathébras
- Service de médecine interne, hôpital Nord, 42055 Saint-Étienne cedex 2, France.
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Marouf F, Giallourakis CC, Baer L, Hanau MS, Holbert BC. Case records of the Massachusetts General Hospital. Case 33-2013. A 40-year-old woman with abdominal pain, weight loss, and anxiety about cancer. N Engl J Med 2013; 369:1639-47. [PMID: 24152264 DOI: 10.1056/nejmcpc1215968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Vis JY, van Zwieten MCB, Bossuyt PMM, Moons KGM, Dijkgraaf MGW, McCaffery KJ, Mol BWJ, Opmeer BC. The influence of medical testing on patients' health: an overview from the gynecologists' perspective. BMC Med Inform Decis Mak 2013; 13:117. [PMID: 24106969 PMCID: PMC3842635 DOI: 10.1186/1472-6947-13-117] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 09/12/2013] [Indexed: 11/10/2022] Open
Abstract
Background A medical tests may influence the health of patients by guiding clinical decisions, such as treatment in case of a positive test result. However, a medical test can influence the health of patients through other mechanisms as well, like giving reassurance. To make a clinical recommendation about a medical test, we should be aware of the full range of effects of that test on patients. This requires an understanding of the range of effects that medical testing can have on patients. This study evaluates the mechanisms through which medical testing can influence patients’ health, other than the effect on clinical management, from a gynecologist’s perspective. Methods A qualitative study in which explorative focus groups were conducted with gynecologists, gynecological residents and gynecological M.D. researchers (n = 43). Discussions were transcribed verbatim. Transcriptions were coded inductively and analyzed by three researchers. Results All participants contributed various clinical examples in which medical testing had influenced patients’ health. Clinical examples illustrated that testing, in itself or in interaction with contextual factors, may provoke a wide range of effects on patients. Our data showed that testing can influence the doctor’s perceptions of the patients’ appraisal of their illness, their perceived control, or the doctor-patient relationship. This may lead to changes in psychological, behavioral, and/or medical outcomes, both favorably or unfavorably. The data were used to construct a conceptual framework of effects of medical testing on patients. Conclusions Besides supporting clinical decision making, medical testing may have favorable or unfavorable effects on patients’ health though several mechanisms.
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Affiliation(s)
- Jolande Y Vis
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
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Incremental cost-effectiveness of pharmacotherapy and two brief cognitive-behavioral therapies compared with usual care for panic disorder and noncardiac chest pain. J Nerv Ment Dis 2013; 201:753-9. [PMID: 23995030 DOI: 10.1097/nmd.0b013e3182a2127d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess the incremental cost-effectiveness ratios (ICERs) of two brief cognitive-behavioral therapy (CBT)-based interventions and a pharmacological treatment, compared with usual care, initiated in the emergency department (ED) for individuals with panic disorder (PD) with a chief complaint of noncardiac chest pain. A total of 69 patients were followed up to 6 months. The primary outcome variables were direct and indirect costs of treatment and PD severity. Panic management (PM) had an ICER of $124.05, per the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, severity score change (95% confidence interval [CI], $54.63-$314.57), compared with pharmacotherapy (paroxetine), with an ICER of $213.90 (95% CI, $133.51-$394.94), and brief CBT, with an ICER of $309.31 (95% CI, $151.27-$548.28). The pharmacological and CBT interventions were associated with a greater clinical improvement compared with usual care at posttest. PM presented a superior ICER, suggesting that it may be a promising treatment option to implement in EDs.
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Weiland A, Blankenstein AH, Willems MHA, Van Saase JLCM, Van der Molen HT, Van Dulmen AM, Arends LR. Post-graduate education for medical specialists focused on patients with medically unexplained physical symptoms; development of a communication skills training programme. PATIENT EDUCATION AND COUNSELING 2013; 92:355-360. [PMID: 23906652 DOI: 10.1016/j.pec.2013.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 06/23/2013] [Accepted: 06/30/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Stepwise description of the development of a post-graduate communication skills training programme for medical specialists focused on patients with medically unexplained physical symptoms (MUPS) to improve specialist interaction with MUPS patients. METHODS Using the 'intervention mapping approach' we accomplished a needs assessment (literature study and pilot) to formulate intervention objectives and identify methods and techniques for a MUPS-focused communication skills training programme for medical specialists. RESULTS A 14-h training programme which consists of experiential learning, role-play and feedback. Using skills from Cognitive Behavioural Therapy, medical specialists are stimulated to explore interrelating factors that reinforce symptoms, to reassure patients effectively and to provide plausible and understandable explanations for MUPS. Dealing with complex referrals and informing GPs properly are also practiced. CONCLUSION By applying the 'intervention mapping approach' we were able to create a feasible and promising intervention to improve specialist interaction with MUPS patients. Intervention effects are currently being assessed in a randomized controlled trial. PRACTICE IMPLICATIONS If the RCT demonstrates sufficient effectiveness and efficiency of the MUPS focused communication skills training programme for medical specialists the intervention could be embedded in post-graduate education of medical specialists and residents.
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Affiliation(s)
- Anne Weiland
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Begtrup LM, Engsbro AL, Kjeldsen J, Larsen PV, Schaffalitzky de Muckadell O, Bytzer P, Jarbøl DE. A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome. Clin Gastroenterol Hepatol 2013; 11:956-62.e1. [PMID: 23357491 DOI: 10.1016/j.cgh.2012.12.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/20/2012] [Accepted: 12/21/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend a positive strategy based on symptom criteria to diagnose patients with irritable bowel syndrome (IBS). We conducted a randomized noninferiority trial to determine whether a positive diagnostic strategy is noninferior to a strategy of exclusion, with regard to patients' health-related quality of life (HRQOL). METHODS We studied 302 patients (18-50 years old) from primary care who were suspected of having IBS and referred by general practitioners. Patients who fulfilled the Rome III criteria for IBS with no alarm signals were randomly assigned to groups assessed by a strategy of exclusion (analyses of blood, stool samples for intestinal parasites, and sigmoidoscopies with biopsies) or a positive strategy (analyses of blood cell count and C-reactive protein). Patients were followed for 1 year. The primary end point was difference in change of HRQOL from baseline to 1 year between groups (on the basis of the Short Form 36 health survey, physical component summary, and noninferiority margin of 3 points). Secondary outcomes were change in gastrointestinal symptoms, satisfaction with management, and use of resources. Findings of diagnostic misclassification were registered. RESULTS A positive strategy was noninferior to a strategy of exclusion (difference, 0.64; 95% confidence interval, -2.74 to 1.45). The positive diagnostic strategy had lower direct costs. Each approach had similar effects on symptoms, satisfaction, and subsequent use of health resources. No cases of inflammatory bowel disease, colorectal cancer, or celiac disease were found. CONCLUSIONS In diagnosing IBS in primary care, use of a positive diagnostic strategy is noninferior to using a strategy of exclusion with regard to the patients' HRQOL. Our findings support the current guideline recommendations.
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Affiliation(s)
- Luise M Begtrup
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
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Arden C, Chambers JB, Sandoe J, Ray S, Prendergast B, Taggart D, Westaby S, Grothier L, Wilson J, Campbell B, Gohlke-Bärwolf C, Mestres CA, Rosenhek R, Pibarot P, Otto CM. Can we improve the detection of heart valve disease? Heart 2013; 100:271-3. [DOI: 10.1136/heartjnl-2013-304223] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Weiland A, Van de Kraats RE, Blankenstein AH, Van Saase JLCM, Van der Molen HT, Bramer WM, Van Dulmen AM, Arends LR. Encounters between medical specialists and patients with medically unexplained physical symptoms; influences of communication on patient outcomes and use of health care: a literature overview. PERSPECTIVES ON MEDICAL EDUCATION 2012; 1:192-206. [PMID: 23205344 PMCID: PMC3508274 DOI: 10.1007/s40037-012-0025-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Medically unexplained physical symptoms (MUPS) burden patients and health services due to large quantities of consultations and medical interventions. The aim of this study is to determine which elements of communication in non-psychiatric specialist MUPS care influence health outcomes. Systematic search in PubMed, PsycINFO and Embase. Data extraction comprising study design, patient characteristics, number of patients, communication strategies, outcome measures and results. Elements of doctor-patient communication were framed according to symptoms, health anxiety, satisfaction, daily functioning and use of health care. Eight included studies. Two studies described the effect of communication on patient outcome in physical symptoms, three studies on health anxiety and patient satisfaction and one study on daily functioning. Two studies contained research on use of health care. Qualitative synthesis of findings was conducted. Communication matters in non-psychiatric MUPS specialist care. Perceiving patients' expectations correctly enables specialists to influence patients' cognitions, to reduce patients' anxiety and improve patients' satisfaction. Patients report less symptoms and health anxiety when symptoms are properly explained. Positive interaction and feedback reduces use of health care and improves coping. Development of communication skills focused on MUPS patients should be part of postgraduate education for medical specialists.
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Affiliation(s)
- Anne Weiland
- Department of Internal Medicine, Erasmus MC, University Medical Center, 2040, 3000 CA, Rotterdam, the Netherlands.
- Faculty of Social Sciences, Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| | | | - Annette H Blankenstein
- Department of General Practice & Elderly Care Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Jan L C M Van Saase
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Henk T Van der Molen
- Faculty of Social Sciences, Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Alexandra M Van Dulmen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Department of Health Science, Buskerud University College, Drammen, Norway
| | - Lidia R Arends
- Faculty of Social Sciences, Institute of Psychology and Institute of Pedagogy, Erasmus University, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Jonsbu E, Martinsen EW, Morken G, Moum T, Dammen T. Illness perception among patients with chest pain and palpitations before and after negative cardiac evaluation. Biopsychosoc Med 2012; 6:19. [PMID: 23017128 PMCID: PMC3538579 DOI: 10.1186/1751-0759-6-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND Patients with chest pain or palpitations often have poor outcomes following a negative cardiac evaluation, with symptom persistence, limitations in everyday activities, and reduced health-related quality of life. The aims of this study were to evaluate illness perceptions before and after negative cardiac evaluations and measure the ability of a self-report questionnaire to predict outcomes. METHODS Patients (N = 138) referred for chest pain or palpitations to a cardiac outpatient clinic were assessed before and six months after a negative cardiac evaluation. In addition to Brief Illness Perception Questionnaire (BIPQ), all patients completed the Beck Depression Inventory and SF-36 Health Survey. RESULTS The emotional reactions to and understanding of symptoms had not improved six months after a negative cardiac evaluation. A stronger correlation between illness perceptions and health at follow-up than before the cardiac evaluation might explain the tendency for poor outcomes among these patients. Most of the eight BIPQ item scores before the negative cardiac evaluation were predictive of the outcome six months later. A single question asking about the perceived consequences of the complaints (BIPQ Item 1) rated before the cardiac evaluation was collapsed into a dichotomous variable with a cut-off at ≥4 which yields a sensitivity of 51%, a specificity of 85%, a positive predictive value of 71%, a negative predictive value of 69%, and an odds ratio of 5.7 (r = .38, p < .001) in predicting poor outcomes. CONCLUSIONS Assessing illness perceptions is important in patients with negative cardiac tests for understanding and predicting outcomes.
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Affiliation(s)
- Egil Jonsbu
- Department of Psychiatry, More and Romsdal Hospital Trust, Molde, 6407, Norway
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Egil W Martinsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, 0318, Norway
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, N-0424, Norway
| | - Gunnar Morken
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- Østmarka Department of Psychiatry, St Olavs University Hospital, Trondheim, Norway
| | - Torbjørn Moum
- Institute of Basic Medical Sciences, Department of Behavioural Sciences in Medicine, Faculty of Medicine, University of Oslo, Oslo, 0317, Norway
| | - Toril Dammen
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, N-0424, Norway
- Institute of Basic Medical Sciences, Department of Behavioural Sciences in Medicine, Faculty of Medicine, University of Oslo, Oslo, 0317, Norway
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The effect of imaging on the clinical management of breast pain. J Gen Intern Med 2012; 27:817-24. [PMID: 22331398 PMCID: PMC3378742 DOI: 10.1007/s11606-011-1982-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/02/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described. OBJECTIVE To determine if initial imaging for breast pain reduces subsequent utilization. DESIGN Retrospective cohort study at a hospital-based breast health practice. PATIENTS Women referred for breast pain from 2006-2009. MAIN MEASURES Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit. KEY RESULTS Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification. CONCLUSIONS Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.
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Abstract
OBJECTIVE To assess whether the number of somatic symptoms and health anxiety are independent predictors of future health care use after adjusting for confounders. METHODS In a random sample of the adult UK population, questionnaires assessed the number of somatic symptoms (Somatic Symptom Inventory), health anxiety (Whiteley Index), anxiety/depression (Hospital Anxiety and Depression Scale), the number of physical illnesses and demographic variables. The number of consultations in primary care was obtained from medical records for 1 year before and after questionnaire assessment, and negative binomial regression analyses identified predictors of consultation rate. RESULTS The sample included 961 participants (58.0% response) with complete medical record data for 609 participants. After adjustment for consultation rate in the prior year, the predictors of subsequent consultation rate in primary care were the number of physical illnesses, off work through illness, Whiteley Index (incidence rate ratio [IRR] = 1.22, 95% confidence interval [CI] = 1.09-1.35), and the Whiteley Index-by-Somatic Symptom Inventory interaction term. Reported physical abuse predicted an increased consultation rate in women (IRR = 2.30, 95% CI = 1.08-4.90) but a reduced rate in men (IRR = 0.43, 95% CI = 0.22-0.84), interaction p = 0.003. CONCLUSIONS These data raise the possibility that both increased health anxiety and number of bothersome somatic symptoms predict frequent medical consultations. A more complex model of predicting future health care use is needed than has been studied previously, which is potentially relevant to the current discussions of the proposed DSM-V and International Classification of Diseases, 11th Revision, diagnostic guidelines regarding complex somatic symptom disorders.
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Verghese GR, Friedman KG, Rathod RH, Meiri A, Saleeb SF, Graham DA, Geggel RL, Fulton DR. Resource Utilization Reduction for Evaluation of Chest Pain in Pediatrics Using a Novel Standardized Clinical Assessment and Management Plan (SCAMP). J Am Heart Assoc 2012; 1:jah39. [PMID: 23130120 PMCID: PMC3487367 DOI: 10.1161/jaha.111.000349] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 01/26/2012] [Indexed: 11/16/2022]
Abstract
Background Chest pain is a common reason for referral to pediatric cardiologists. Although pediatric chest pain is rarely attributable to serious cardiac pathology, extensive and costly evaluation is often performed. We have implemented a standardized approach to pediatric chest pain in our pediatric cardiology clinics as part of a broader quality improvement initiative termed Standardized Clinical Assessment and Management Plans (SCAMPs). In this study, we evaluate the impact of a SCAMP for chest pain on practice variation and resource utilization. Methods and Results We compared demographic variables, clinical characteristics, and cardiac testing in a historical cohort (n=406) of patients presenting to our outpatient division for initial evaluation of chest pain in the most recent pre-SCAMP calendar year (2009) to patients enrolled in the chest pain SCAMP (n=364). Demographic variables including age at presentation, sex, and clinical characteristics were similar between groups. Adherence to the SCAMP algorithm for echocardiography was 84%. Practice variation decreased significantly after implementation of the SCAMP (P<0.001). The number of exercise stress tests obtained was significantly lower in the SCAMP-enrolled patients compared with the historic cohort (∼3% of patients versus 29%, respectively; P<0.001). Similarly, there was a 66% decrease in utilization of Holter monitors and 75% decrease in the use of long-term event monitors after implementation of the chest pain SCAMP (P=0.003 and P<0.001, respectively). The number of echocardiograms obtained was similar between groups. Conclusions Implementation of a SCAMP for evaluation of pediatric chest pain has lead to a decrease in practice variation and resource utilization. (J Am Heart Assoc. 2012;1:jah3-e000349 doi: 10.1161/JAHA.111.000349.)
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Affiliation(s)
- George R Verghese
- Department of Cardiology, Children's Hospital Boston and the Department of Pediatrics, Harvard Medical School Boston, MA
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Healthcare costs incurred by patients repeatedly referred to secondary medical care with medically unexplained symptoms: a cost of illness study. J Psychosom Res 2012; 72:242-7. [PMID: 22325706 DOI: 10.1016/j.jpsychores.2011.12.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 12/13/2011] [Accepted: 12/20/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Some patients are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS). We aimed to estimate the healthcare costs incurred by such referrals and to compare them with those incurred by other referred patients from the same defined primary care sample. METHODS Using a referral database and case note review, all adult patients aged less than 65 years, who had been referred to specialist medical services from one of five UK National Health Service primary care practices in a five-year period, were identified. They were placed in one of three groups: (i) repeatedly referred with MUS (N=276); (ii) infrequently referred (IRS, N=221), (iii) repeatedly referred with medically explained symptoms (N=230). Secondary care activities for each group (inpatient days, outpatient appointments, emergency department attendances and investigations) were identified from primary care records. The associated costs were allocated using summary data and the costs for each group compared. RESULTS Patients who had been repeatedly referred with MUS had higher mean inpatient, outpatient and emergency department costs than those infrequently referred (£3,539, 95% CI 1458 to 5621, £778 CI 705 to 852 and £99, CI 74 to 123 respectively. The mean overall costs were similar to those of patients who had been repeatedly referred with medically explained symptoms. CONCLUSIONS The repeated referral of patients with MUS to secondary medical care incurs substantial healthcare costs. An alternative form of management that reduces such referrals offers potential cost savings.
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van Ravesteijn H, van Dijk I, Darmon D, van de Laar F, Lucassen P, Olde Hartman T, van Weel C, Speckens A. The reassuring value of diagnostic tests: a systematic review. PATIENT EDUCATION AND COUNSELING 2012; 86:3-8. [PMID: 21382687 DOI: 10.1016/j.pec.2011.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 02/02/2011] [Accepted: 02/06/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE This review is a narrative synthesis of the RCTs which studied the efficacy of using diagnostic tests to reassure patients. METHODS We searched for RCTs that examined the level of reassurance after diagnostic testing in outpatients. We used PubMed, Psychinfo, Cochrane Central, Ongoing Trials Database and Scopus. RESULTS We found 5 randomized controlled trials that included 1544 patients. The trials used different diagnostic tests (ECG, radiography of lumbar spine, MR brain scan, laboratory tests, MR of lumbar spine) for different complaints (e.g. chest pain, low back pain and headache). Four out of 5 RCTs did not find a significant reassuring value of the diagnostic tests. One study reported a reassuring effect at 3 months which had disappeared after one year. CONCLUSION Despite the sparse and heterogeneous studies, the results point in the direction of diagnostic tests making hardly any contribution to the level of reassurance. We recommend further studies on the use of diagnostic tests and other strategies to reassure the patient. PRACTICE IMPLICATIONS A clear explanation and watchful waiting can make additional diagnostic testing unnecessary. If diagnostic tests are used, it is important to provide adequate pre-test information about normal test results.
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Affiliation(s)
- Hiske van Ravesteijn
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands; Department of Psychiatry, Radboud University Nijmegen Medical Centre, The Netherlands.
| | - Inge van Dijk
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands; Department of Psychiatry, Radboud University Nijmegen Medical Centre, The Netherlands
| | - David Darmon
- Département d'enseignement et de recherche en médecine générale, UFR médecine, Université Nice Sophia Antipolis, France
| | - Floris van de Laar
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands
| | - Tim Olde Hartman
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands
| | - Chris van Weel
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands
| | - Anne Speckens
- Department of Psychiatry, Radboud University Nijmegen Medical Centre, The Netherlands
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Cramer H, Evans M, Featherstone K, Johnson R, Zaman MJS, Timmis AD, Hemingway H, Feder G. Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain. BMJ Open 2012; 2:e000508. [PMID: 22318662 PMCID: PMC3277903 DOI: 10.1136/bmjopen-2011-000508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina. DESIGN Qualitative ethnographic study based on interviews and observations of clinical practice. SETTING 3 rapid access chest pain clinics in England. PARTICIPANTS Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews. MAIN OUTCOME MEASURE Accounts and observations of consultations in chest pain clinics. RESULTS The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician. CONCLUSIONS Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.
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Affiliation(s)
- Helen Cramer
- Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Maggie Evans
- Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Katie Featherstone
- School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK
| | - Rachel Johnson
- Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - M Justin S Zaman
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Adam D Timmis
- Department of Cardiology, Barts and the London NHS Trust, The London Chest Hospital, London, UK
| | - Harry Hemingway
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Gene Feder
- Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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