Predictors and moderators of three online interventions for eating disorder symptoms in a randomized controlled trial

OBJECTIVE

To optimize treatment recommendations for eating disorders, it is important to investigate whether some individuals may benefit more (or less) from certain treatments. The current study explored predictors and moderators of an automated online self-help intervention "Featback" and online support from a recovered expert patient.

METHODS

Data were used from a randomized controlled trial. For a period of 8 weeks, participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, (2) chat or e-mail support from an expert patient, (3) Featback with expert-patient support, and (4) a waitlist. A mixed-effects partitioning method was used to see if age, educational level, BMI, motivation to change, treatment history, duration of eating disorder, number of binge eating episodes in the past month, eating disorder pathology, self-efficacy, anxiety and depression, social support, or self-esteem predicted or moderated intervention outcomes in terms of eating disorder symptoms (primary outcome), and symptoms of anxiety and depression (secondary outcome).

RESULTS

Higher baseline social support predicted less eating disorder symptoms 8 weeks later, regardless of condition. No variables emerged as moderator for eating disorder symptoms. Participants in the three active conditions who had not received previous eating disorder treatment, experienced larger reductions in anxiety and depression symptoms.

DISCUSSION

The investigated online low-threshold interventions were especially beneficial for treatment-naïve individuals, but only in terms of secondary outcomes, making them well-suited for early intervention. The study results also highlight the importance of a supportive environment for individuals with eating disorder symptoms.

PUBLIC SIGNIFICANCE

To optimize treatment recommendations it is important to investigate what works for whom. For an internet-based intervention for eating disorders developed in the Netherlands, individuals who had never received eating disorder treatment seemed to benefit more from the intervention than those who had received eating disorder treatment, because they experienced larger reductions in symptoms of depression and anxiety. Stronger feelings of social support were related to less eating disorder symptoms in the future.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

Effectiveness of an online self-help program, expert-patient support, and their combination for eating disorders: Results from a randomized controlled trial

OBJECTIVE

Many individuals with an eating disorder do not receive appropriate care. Low-threshold interventions could help bridge this treatment gap. The study aim was to evaluate the effectiveness of Featback, a fully automated online self-help intervention, online expert-patient support and their combination.

METHOD

A randomized controlled trial with a 12-month follow-up period was conducted. Participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, a fully automated online self-help intervention, (2) chat or email support from a recovered expert patient, (3) Featback with expert-patient support and (4) a waiting list control condition. The intervention period was 8 weeks and there was a total of six online assessments. The main outcome constituted reduction of eating disorder symptoms over time.

RESULTS

Three hundred fifty five participants, of whom 43% had never received eating disorder treatment, were randomized. The three active interventions were superior to a waitlist in reducing eating disorder symptoms (d = -0.38), with no significant difference in effectiveness between the three interventions. Participants in conditions with expert-patient support were more satisfied with the intervention.

DISCUSSION

Internet-based self-help, expert-patient support and their combination were effective in reducing eating disorder symptoms compared to a waiting list control condition. Guidance improved satisfaction with the internet intervention but not its effectiveness. Low-threshold interventions such as Featback and expert-patient support can reduce eating disorder symptoms and reach the large group of underserved individuals, complementing existing forms of eating disorder treatment.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with eating-related problems who received (1) a fully automated internet-based intervention, (2) chat and e-mail support by a recovered individual or (3) their combination, experienced stronger reductions in eating disorder symptoms than those who received (4) usual care. Such brief and easy-access interventions play an important role in reaching individuals who are currently not reached by other forms of treatment.

Cost-effectiveness of three internet-based interventions for eating disorders: A randomized controlled trial

OBJECTIVE

The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition.

METHOD

An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration.

RESULTS

No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (€16,741) while the highest costs were seen in the care-as-usual condition (€28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values.

DISCUSSION

Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment.

PUBLIC SIGNIFICANCE STATEMENT

Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

Transformative learning experience among nursing students with patients acting as teachers: Mixed methods, non-randomized, single-arm study

AIM

To examine the effects of expert HIV patients acting as teachers to Spanish nursing students both on their HIV-related knowledge, attitudes and practices and on their approach to the care model as well as to explore their learning experience.

DESIGN

Non-randomized, single-arm study with quantitative before and after measurements and qualitative data.

METHODS

The intervention consisted of five 90-min workshops led by two women living with HIV. Thirty-four nursing students participated, and quantitative and qualitative data were gathered from February to June 2018. We used the Patient-Practitioner Orientation Scale (PPOS) and the KAP questionnaire on HIV/AIDS to collect quantitative data.

RESULTS

Statistically significant differences were found in the global score for care orientation and its two dimensions, caring and sharing. About the changes resulting from the workshops, the quantitative results-more patient-centred care perception and better attitudes towards people living with HIV-match the qualitative findings in all the aspects studied, except in sharing.

CONCLUSION

Incorporating expert patients as teachers in the nursing bachelor's degree resulted in more patient-centred care and improved knowledge, attitudes and practices. The workshops conducted by qualified expert patients showed transformative learning power, as the participants improved professional and personal aspects.

Narrative photography with an expert patient as a method to improve empathy: a satisfaction study with health sciences students

OBJECTIVES

To assess health sciences students' satisfaction with narrative photography with an expert patient as an empathy-fostering teaching method.

METHODS

Nineteen students from a public medical sciences university in Barcelona (Spain) voluntarily completed six online training sessions using narrative photography and expert patient. Data were collected using an anonymous online satisfaction questionnaire verified by experts, including 29 quantitative and qualitative questions that were analyzed descriptively.

RESULTS

Eighteen valid questionnaires were obtained (90% response rate). All students evaluated the teaching method as highly satisfactory. The main positive aspects of the teaching method were being able to express one's emotions and reflections. Students felt the activity enhanced their empathy and helped them minimize their prejudices, specifically to patients living with HIV. Students also evaluated the online format as less optimal than if it were delivered in person.

CONCLUSION

The students found the teaching method to have a personal and professional impact, which facilitated the integration of empathy in their daily practice when caring for people living with HIV.

[Patient experience, epistemic authority and health challenges: the example of long COVID]

Since February 2020, hundreds of thousands of patients have been left with persistant symptoms after their infection. Along with their clinicians, these patients are exposed to a high degree of uncertainty and the urgent need to produce conceptual frameworks aimed at recognising, treating and validating their experience as patients suffering from new and protracted symptoms and witnessing debates as to how these symptoms should be qualified. In this respect, long covid illustrates the need to combine the collective experiential knowledge of patients and scientific knowledge for the benefit of the patients, clinicians and research.

[Home dialysis and me]

Mourning the loss of one's former life is the challenge facing the novice patient with renal failure. Discovering the consequences of end-stage renal failure can be devastating if the patient is not well accompanied. Testimony of an expert patient.

[The role of patients in the training systems of nursing training institutes in France]

Launched by the University of Patients-Sorbonne University, a survey explores the number of nursing training institutes that develop patient interventions in their teaching curricula. Presentation of the preliminary results of this study.

[Nursing student, expert patient, knowledge broker]

Therapeutic education plays an important role in nursing education in terms of knowledge and skills. Indeed, the support of the chronic patient represents a new challenge for the caregiver and requires a change in his or her posture. Thus, he may have to collaborate with the expert patient, who is now fully recognised as a care partner. Sharing experience with a student from a Parisian nursing training institute, himself an expert patient.

Patient expertise: Contested territory in the realm of long-term condition care

Objectives

The aim of this study was to describe the experience of people with multiple long-term conditions with particular reference to the notion of the ‘expert patient’ in the context of self-management.

Methods

A multiple case study of 16 people with several long-term conditions, included interviews and contacts over an 18-month period and an interview with their primary care clinicians. Analysis included both case-by-case and some cross-case analysis.

Results

The findings reveal the patient participants had little capacity to exercise the agency necessary be an expert patient as premised. Weariness, shame, expertise, issues of compliance and control and collaboration are contested areas underpinning clinician encounters.

Discussion

Patient expertise is at the heart of self-management approaches but the findings surfaced several inherent contradictions between the idealised expert patient and their position within a health care system that is entrenched in biomedicine.

Conclusion

There is a mismatch between how the self-management approach has been operationalised and what the participants who have multiple LTCs reveal as what they want and need. The research concludes that the self-management approach is inappropriate for people with multiple LTCs and that other ways of offering care should be considered.

Effect of expert-patient teaching on empathy in nursing students: a randomized controlled trial

Background: Empathy is a relevant clinical competence for nursing students. Involvement of expert patients in nursing education could help students develop their innate capacity to empathize.

Objective: To evaluate the effect of expert-patient teaching on empathy development in nursing students.

Methods: This randomized controlled trial was conducted among 144 first-year undergraduate nursing students divided into two equal groups. In the experimental group, the educational intervention consisted of a seminar focused on empathy, followed by a presentation on expert-patient function. Subsequently, each student participated in two interactive meetings with nursing teacher and expert patient. At the end, the nursing teacher encouraged students to reflect on this experience. In the control group, students only attended a similar seminar focused on empathy and afterward participated in two interactive meetings with a nursing teacher to reflect on this topic without expert-patient involvement. Before (T0) and after (T1) the training intervention, the Balanced Emotional Empathy Scale, Jefferson Scale of Empathy — Health Professions Student (JSE-HPS), and a short demographic questionnaire were administered to the two student groups to measure their empathy levels. The study was approved by the Local Ethics Committee of Area Vasta Emilia Nord (protocol 1763, May 11, 2017). Data were statistically analyzed.

Results: We found a statistically significant difference between mean scores at T0 and T1 in both scales in the experimental group. Male students, who presented significantly lower levels of empathy at baseline in comparison with females, showed increased in empathy after training on the the Balanced Emotional Empathy Scale in both the experimental and control groups.

Conclusion: The present study highlights that involvement of expert patients in teaching is effective in improving empathy levels in both male and female nursing students. Expert-patient teaching can be a promising nursing-education modality for developing empathy.

[The future of kidney failure treatments]

The future of nephrology lies in the miniaturisation of renal replacement techniques, the development of the use of stem cells and xenotransplants. Moreover, medicine must be personalised, from screening and throughout the care pathway of the patient with chronic kidney failure. Thereby, the risk of morbidity can be reduced and the quality of life improved, with the help of connected tools. The role of the patients themselves and all healthcare professionals is essential.

The patient with a complex chronic respiratory disease: a specialist of his own life?

INTRODUCTION

The independent and central role of the patient with a complex chronic respiratory disease in targeted, personalized disease management strategies is becoming increasingly important. Patients are the ones living with the disease and are finally responsible for their lives underlining their role as essential members of the interdisciplinary treatment team. Areas covered: The present paper narratively reviews existing research and discusses the special, as well as specialized, role of the patient with a complex chronic respiratory disease in the healthcare system and highlights fundamental elements of the (future) relationship between patient and healthcare professionals. Expert commentary: Since the chronic respiratory disease at hand is part of the patient's entire life, we need holistic, personalized approaches optimizing patients' quality of life by not only treating the disease but considering the patients' whole environment and where healthcare professionals and patients are co-creating value care.

[A personalised support programme for patients with diabetes]

On the initiative of the Fédération française des diabétiques, a personalised support project has been set up for people with diabetes. They are invited to talks and to take part in individual interviews led by specially trained volunteer expert patients. The aim is to give them an opportunity to talk with peers and to learn how to live with the disease.

[Haemophilia: how sentinel patients have developed a warning semiotics]

Haemophilia: how sentinel patients have developed warning semiotics. The experience of the disease may help the patient to develop effective actions to manage every day, if it is accompanied by a personal reflection. Following a process that sometimes can be long, some people with hemophilia, called sentinel patients have developed a personal semiology of early and subclinical signs of hemarthrose, complementary to medical semiology. Learning such an approach can be made possible within therapeutic education workshops co-facilitated by patient/parent and caregiver resources. Facilitated by peer intervention, the expression of singular feelings of early signs, helps patients reflect on strategies adapted to their situation and conducive to faster adequate reaction towards their bleeding episodes, particularly through self-care actions. This collaborative work between patients and caregivers also brings benefits to professionals who, for some, consider differently the care they provide to people they meet in their healthcare activity.

[Expert patient: the story of a social movement]

Expert patient: the story of a social movement. The recognition of patients' expertise appeared in the 80's in the Anglo-Saxon culture. Originally linked to activism, social movements and non-profit organizations of fight against AIDS, this concept has given rise to multiple name variations such as resource-patient, user-peer or mediator-peer, intervening patient. Despite the debates regarding the name of expert-patient, the expertise of patients' experience with chronic illness leads to a recognition and the patient has become a key player in health decision-making bodies, in therapeutic education and in the improvement of healthcare system.

[Patient advisors for victims of traumatic amputation: a critical intervention]

Patient advisors for victims of traumatic amputation: a critical intervention. Since 2014, the Centre of Expertise in Reimplantation and Microsurgical Revascularization at the University of Montreal (CEVARMU) has been recruiting on an ad hoc basis former patients, who have completed the rehabilitation process, to accompany and support new patients at the Centre during their care process. Considered full-fledged partners of the care team, these patient advisors are invited to meet with patients who are hospitalized or in the rehabilitation process to not only share their experience but also ensure that the treatment plans proposed to the patients are well understood and meet their needs. Around forty interventions have been conducted by five patient advisors, helping to strengthen the credibility of professional interventions, break down patients' isolation, and give new meaning to the work of health professionals.

[Expert patients and caregivers, towards relationships of reciprocity]

The increased effectiveness of therapies and the changes to the treatment pathways of chronic patients have given rise to new needs for these patients. They require new types of programmes, including training. They show that these patients can produce knowledge and acquire skills which can be useful for the wider community and can be transferred outside the immediate care environment.

Chronic and integrated care in Catalonia

INTRODUCTION

The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011-2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented.

METHOD

The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals.

RESULTS

It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization.

DISCUSSION

The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.

Achieving patient-centred care: the potential and challenge of the patient-as-professional role

BACKGROUND

The patient-as-professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams.

OBJECTIVE

To investigate (i) patients' and carers' experiences of actively engaging in interprofessional care by enacting the patient-as-professional role and (ii) clinicians' perspectives of this involvement.

DESIGN, SETTING AND PARTICIPANTS

A two-phased qualitative study. In Phase 1, people with chronic disease (n = 50) and their carers (n = 5) participated in interviews and focus groups. Phase 2 involved interviews with clinicians (n = 14). Data were analysed thematically.

FINDINGS

Patients and carers described the characteristics of the role (knowing about the condition, questioning clinicians, coordinating care, using a support network, engaging an advocate and being proactive), as well as factors that influence its performance (the patient-clinician partnership, benefits, barriers and applicability). However, both patients and carers, and clinicians cautioned that not all patients might desire this level of involvement. Clinicians were also concerned that not all patients have the required knowledge for this role, and those who do are time-consuming. When describing the inclusion of the patient-as-professional, clinicians highlighted the patient and clinician's roles, the importance of the clinician-patient relationship and ramifications of the role.

CONCLUSION

Support exists for the patient-as-professional role. The characteristics and influencing factors identified in this study could guide patient engagement with the interprofessional team and support clinicians to provide patient-centred care. Recognition of the role has the potential to improve health-care delivery by promoting patient-centred care.

A feasibility study of expert patient and community mental health team led bipolar psychoeducation groups: implementing an evidence based practice

BACKGROUND

Group psychoeducation is a cost effective intervention which reduces relapse and improves functioning in bipolar disorder but is rarely implemented. The aim of this study was to identify the acceptability and feasibility of a group psychoeducation programme delivered by community mental health teams (CMHTs) and peer specialist (PS) facilitators. Organisational learning was used to identify and address systematically barriers and enablers, at organisational, health professional and patient levels, to its implementation into a routine service.

METHODS

A systematic examination of barriers and enablers to a three day training process informed the delivery of a first treatment group and a similar process informed the delivery of the second treatment group. Triangulation of research methods improved its internal validity: direct observation of training, self-rated surveys of participant experiences, group discussion, and thematically analysed individual participant and facilitator interviews were employed.

RESULTS

Barriers and enablers were identified at organisational, educational, treatment content, facilitator and patient levels. All barriers under the control of the research team were addressed with subsequent improvements in patient knowledge about the condition and about local service. In addition, self-management, agency and altruism were enhanced. Barriers that could not be addressed required senior clinical and education leadership outside the research team's control. PS and professional facilitators were successfully trained and worked together to deliver groups which were generally reported as being beneficial.

CONCLUSION

Psychoeducation groups involving CMHT and PS facilitators is acceptable and feasible but their sustainment requires senior leadership within and outside the organisation that control finance and education services.

Negotiating access to medical treatment and the making of patient citizenship: the case of hepatitis C treatment

Drawing on qualitative interview accounts with people who have injected drugs, we deploy ideas of biological and therapeutic citizenship to explore how the negotiation of access to hepatitis C treatment enacts patient citizenship potential. We find that the patient citizenship made through hepatitis C treatment divides those who are deserving from those who are not, largely in relation to their presentations of self-control, responsibility and recovery regarding drug use. Accessing treatment requires that patients negotiate their entitlement by reflexively producing the patient citizen role expected of them. In this context of rationed treatment expectation, access to treatment is constructed in relation to gratitude rather than entitlement. Rationed treatment expectation also interplays with a utilitarian approach to hepatitis C expertise. Accounts of the bio-effects of hepatitis C and its treatment as uncertain further weaken the potential for shared illness identity and biosocial membership as well as contributing to treatment delay. We conclude that the construction of hepatitis C treatment as a negotiation of 'recovery towards normality' positions people who continue to use or inject drugs as beyond patient citizenship. Our findings underscore the situated limits of therapeutic and biological citizenship, emphasising that these processes are unavoidably forces of governance.

Adult cystic fibrosis patients' experiences of primary care consultations: a qualitative study

BACKGROUND

"Expert patient" programmes have been introduced in the UK as a new approach to chronic disease management for the 21st century. The average survival age of those with cystic fibrosis (CF) has steadily increased such that the majority of those with the condition now live into adulthood. Currently, specialist CF centres deliver the core of medical care, with primary care providing access to prescribed medicines, referral to other services, and care of non-CF needs, however, it is necessary to provide a more comprehensive service for adult CF patients, involving both specialist centres and primary care. To date, little is known about these expert patients' experiences of primary care.

AIM

To investigate how young adults with CF perceive and experience primary healthcare services.

DESIGN OF STUDY

Qualitative study.

SETTING

One specialist CF centre in southeast England.

METHOD

Interview study of 31 patients with CF, aged 18 years or over.

RESULTS

Adults with CF consult in primary care on two distinct levels: as lay and expert patients. When consulting as experts, patients tend to operate as consumers of health care and perceive a satisfactory doctor-patient relationship to be influenced by three factors: GPs' understanding of how people live with CF, GPs' ability to prescribe certain specialist medications, and sensitive management of the cost of health care for adults with CF. A doctor-patient relationship based on trust and understanding is seen as desirable, but requires that these factors are addressed both by the GP and the patient.

CONCLUSION

Expert patient policy has focused on the role of patients with common chronic conditions in secondary and tertiary care, with little consideration of how adults with rare chronic illness and their GPs manage health problems that can be addressed in primary care. Enabling easy access to holistic care, as well as establishing successful trusting relationships with people with long-term rare conditions, is a necessary foundation for expert patients to take an active role in their care.