The effect of conflicting medication information and physician support on medication adherence for chronically ill patients

Objective

This article explores the effect of conflicting information, defined as contradictory information about medication topics from different sources, on medication adherence in a sample of chronically ill patients. We specifically investigate whether conflicting information and physician support directly affect medication adherence or whether the effect is mediated by adherence self-efficacy and outcome expectations for medications.

Methods

Vasculitis patients (n = 228) completed two on-line questionnaires which contained measures of conflicting information, adherence self-efficacy, outcome expectations, physician support, and medication adherence. We conducted a mediation analysis using a bootstrapping approach to generate point estimates and 95% confidence intervals to test the significance of each mediated effect.

Results

A majority of patients (51.3%) received conflicting medication information. Conflicting information had a direct negative effect on medication adherence, which was not mediated by self-efficacy or outcome expectations. Alternatively, self-efficacy mediated the positive effect of physician support on medication adherence.

Conclusion

Patients who encounter conflicting medication information are less adherent to their medications. The presence of a supportive physician may counteract the negative effect of conflicting medication information.

Practice implications

Physicians should initiate conversations about conflicting medication information with their patients. Consensus-based guidelines that address medication discrepancies may also reduce the availability of conflicting information.     

Organizational factors affecting successful adoption of innovative eHealth services: a case study employing the FITT framework

Objective

The paper presents an application of the “Fit between Individuals, Task and Technology” (FITT) framework to analyze the socio-organizational-technical factors that influence IT adoption in the healthcare domain.

Method

The FITT framework was employed as the theoretical instrument for a retrospective analysis of a 15-year effort in implementing IT systems and eHealth services in the context of a Regional Health Information Network in Crete. Quantitative and qualitative research methods, interviews and participant observations were employed to gather data from a case study that involved the entire region of Crete.

Results

The detailed analysis of the case study based on the FITT framework, showed common features, but also differences of IT adoption within the various health organizations. The emerging picture is a complex nexus of factors contributing to IT adoption, and multi-level interventional strategies to promote IT use.

Conclusion

The work presented in this paper shows the applicability of the FITT framework in explaining the complexity of aspects observed in the implementation of healthcare information systems. The reported experiences reveal that fit management can be viewed as a system with a feedback loop that is never really stable, but ever changing based on external factors or deliberate interventions. Management of fit, therefore, becomes a constant and complex task for the whole life cycle of IT systems.     

“Michael's Game,” a card game for the treatment of psychotic symptoms

Objective

“Michael's Game” is a card game which aims at familiarizing healthcare professionals and patients with cognitive therapy of psychotic symptoms. The present study tests the feasibility and the impact of the intervention in naturalistic settings.

Methods

135 patients were recruited in 11 centres. They were assessed pre- and post-tests with the Beck Cognitive Insight Scale (BCIS) and the Peters Delusion Inventory-21 items (PDI-21).

Results

Data about 107 patients were included in the entire analyses. Significant improvements were observed on BCIS subscales as well as a reduction of severity of conviction and preoccupation scores on the PDI-21. The intervention has a moderate effect on the PDI-21 preoccupation and conviction as well as the BCIS subscales. Patients who benefit the most from the program are patients who have a low degree of self-reflectiveness and patients who are concomitantly preoccupied by their symptoms.

Conclusion

The present study supports the feasibility and effectiveness of “Michael's Game” in naturalistic settings.

Practical implications

The game seems to be a useful tool for patients with psychotic disorders.     

Counselling in infertility: individual, couple and group interventions

Objective

Infertility is considered a biopsychosocial crisis and infertility counselling is recommended as an integral part of a multidisciplinary approach. This article will outline the theoretical background and describe common interventions used in infertility counselling for individuals, couples and in a group setting.

Methods

This article summarizes the proceedings of the first campus workshop of the Special interest group of Psychology and Counselling of the European Society for Human Reproduction and Embryology (ESHRE).

Results

Infertility counselling offers the opportunity to explore, discover and clarify ways of living more satisfyingly and resourcefully when fertility impairments have been diagnosed. The Heidelberg Fertility Consultation Service is presented as a framework for individual and couples counselling and highlights important issues in counselling patients. For group work a number of steps to set up a group within an infertility framework are discussed.

Conclusion

In recent years, infertility counselling has become a specialist form of counselling requiring professional expertise and qualification. Key issues and common interventions are presented to raise awareness for the specific counselling needs of individuals and couples experiencing infertility and undergoing medical treatment.

Practice implications

Mental health professionals new to the field of reproductive technologies as well as those in other areas of mental health counselling clients with fertility disorders can benefit from the topics addressed.     

A new computer-based counselling system for the promotion of physical activity in patients with chronic diseases—Results from a pilot study

Objective

To develop a computer-based counselling system (CBCS) for the improvement of attitudes towards physical activity in chronically ill patients and to pilot its efficacy and acceptance in primary care.

Methods

The system is tailored to patients’ disease and motivational stage. During a pilot study in five German general practices, patients answered questions before, directly and 6 weeks after using the CBCS. Outcome criteria were attitudes and self-efficacy. Qualitative interviews were performed to identify acceptance indicators.

Results

Seventy-nine patients participated (mean age: 64.5 years, 53% males; 38% without previous computer experience). Patients’ affective and cognitive attitudes changed significantly, self-efficacy showed only minor changes. Patients mentioned no difficulties in interacting with the CBCS. However, perception of the system's usefulness was inconsistent.

Conclusion

Computer-based counselling for physical activity related attitudes in patients with chronic diseases is feasible, but the circumstances of use with respect to the target group and its integration into the management process have to be clarified in future studies.

Practice implication

This study adds to the understanding of computer-based counselling in primary health care. Acceptance indicators identified in this study will be validated as part of a questionnaire on technology acceptability in a subsequent study.     

Static and dynamic pressure prediction for prosthetic socket fitting assessment utilising an inverse problem approach

Objective

It has been recognised in a review of the developments of lower-limb prosthetic socket fitting processes that the future demands new tools to aid in socket fitting. This paper presents the results of research to design and clinically test an artificial intelligence approach, specifically inverse problem analysis, for the determination of the pressures at the limb/prosthetic socket interface during stance and ambulation.

Methods

Inverse problem analysis is based on accurately calculating the external loads or boundary conditions that can generate a known amount of strain, stresses or displacements at pre-determined locations on a structure. In this study a backpropagation artificial neural network (ANN) is designed and validated to predict the interfacial pressures at the residual limb/socket interface from strain data collected from the socket surface. The subject of this investigation was a 45-year-old male unilateral trans-tibial (below-knee) traumatic amputee who had been using a prosthesis for 22 years.

Results

When comparing the ANN predicted interfacial pressure on 16 patches within the socket with actual pressures applied to the socket there is shown to be 8.7% difference, validating the methodology. Investigation of varying axial load through the subject's prosthesis, alignment of the subject's prosthesis, and pressure at the limb/socket interface during walking demonstrates that the validated ANN is able to give an accurate full-field study of the static and dynamic interfacial pressure distribution.

Conclusions

To conclude, a methodology has been developed that enables a prosthetist to quantitatively analyse the distribution of pressures within the prosthetic socket in a clinical environment. This will aid in facilitating the “right first time” approach to socket fitting which will benefit both the patient in terms of comfort and the prosthetist, by reducing the time and associated costs of providing a high level of socket fit.     

Moving beyond the language barrier: The communication strategies used by international medical graduates in intercultural medical encounters

Objective

To understand the communication strategies international medical graduates use in medical interactions to overcome language and cultural barriers.

Methods

In-depth interviews were conducted with 12 international physicians completing their residency training in internal medicine in a large hospital in Midwestern Ohio. The interview explored (a) barriers participants encountered while communicating with their patients regarding language, affect, and culture, and (b) communication convergence strategies used to make the interaction meaningful.

Results

International physicians use multiple convergence strategies when interacting with their patients to account for the intercultural and intergroup differences, including repeating information, changing speaking styles, and using non-verbal communication.

Practice implications

Understanding barriers to communication faced by international physicians and recognizing accommodation strategies they employ in the interaction could help in training of future international doctors who come to the U.S. to practice medicine. Early intervention could reduce the time international physicians spend navigating through the system and trying to learn by experimenting with different strategies which will allow these physicians to devote more time to patient care. We recommend developing a training manual that is instructive of the socio-cultural practices of the region where international physician will start practicing medicine.     

Cortical reorganization and phantom phenomena in congenital and traumatic upper-extremity amputees

The relationship between phantom limb phenomena and cortical reorganization was examined in five subjects with congenital absence of an upper limb and nine traumatic amputees. Neuromagnetic source imaging revealed minimal reorganization of primary somatosensory cortex in the congenital amputees (M=0.69 cm, SD 0.24) and the traumatic amputees without phantom limb pain (M=0.27 cm, SD 0.25); the amputees with phantom limb pain showed massive cortical reorganization (M=2.22 cm, SD 0.78). Phantom limb pain and nonpainful phantom limb phenomena were absent in the congenital amputees. Whereas phantom limb pain was positively related to cortical reorganization (r=0.87), nonpainful phantom phenomena were not significantly correlated with cortical reorganization (r=0.34). Sensory discrimination was normal and mislocalization (referral of stimulation-induced sensation to a phantom limb) was absent in the congenital amputees. The role of peripheral and central factors in the understanding of phantom limb pain and phantom limb phenomena is discussed in view of these findings. Received: 4 June 1997 / Accepted: 13 September 1997     

Averting adverse events in communication skills training: A case series

Objective

To document cases of adverse or near adverse events in communication skills training (CST) and to identify risk factors and strategies to reduce the likelihood of their occurrence.

Methods

Six physician CST cases meeting criteria for an adverse or near adverse collected from experienced facilitators are analyzed and discussed.

Results

Three types of adverse CST events are described: traumatic personal experiences or losses evoked by training; perception that feedback is not empathic; and where trainees are referred for remedial CST as a risk management strategy.

Conclusion

Early identification of risk factors and emotional cues of trainees is a key first step that facilitates implementation of remedial strategies to avert potential adverse events. Consideration of ways that physicians’ personal experiences impact communication and good feedback techniques are vital. The implications of physicians sent to CST for risk management purposes is a new scenario that deserves special consideration.

Practice implications

To make CST safer and to optimize learning, early recognition of potential adverse events is essential. Specific feedback techniques should be mastered by all CST facilitators.     

Impact of a brief intervention on patient communication and barriers to pain management: Results from a randomized controlled trial

Objective

This study examined the impact of a brief pain communication/education intervention on patient outcomes in breast cancer. We hypothesized that our intervention would improve patient communication and reduce misconceptions (“Barriers”) concerning pain management, and that patients with lower Barriers, or who perceived their physician as being more facilitative and receptive, would report better outcomes.

Methods

Female breast cancer patients with persistent pain (n = 89) were randomly assigned to either a 30-min in-person pain education/communication intervention or control condition and followed for 12 weeks.

Results

Intervention group patients reported a significant decrease in pain Barriers but not in other outcomes. Overall, patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication (e.g., asking questions, giving information) reported fewer Barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care.

Conclusion

A brief education/communication intervention reduced patients’ Barriers to pain management but did not impact other patient outcomes.

Practical Implications

Pain outcomes may be improved by addressing patients’ pain misconceptions and emphasizing a receptive and responsive communication style.     

Motor control over the phantom limb in above-elbow amputees and its relationship with phantom limb pain

Recent evidence shows that the primary motor cortex continues to send motor commands when amputees execute phantom movements. These commands are retargeted toward the remaining stump muscles as a result of motor system reorganization. As amputation-induced reorganization in the primary motor cortex has been associated with phantom limb pain we hypothesized that the motor control of the phantom limb would differ between amputees with and without phantom limb pain. Eight above-elbow amputees with or without pain were included in the study. They were asked to produce cyclic movements with their phantom limb (hand, wrist, and elbow movements) while simultaneously reproducing the same movement with the intact limb. The time needed to complete a movement cycle and its amplitude were derived from the kinematics of the intact limb. Electromyographic (EMG) activity from different stump muscles and from the homologous muscles on the intact side was recorded. Different EMG patterns were recorded in the stump muscles depending on the movement produced, showing that different phantom movements are associated with distinct motor commands. Phantom limb pain was associated with some aspects of phantom limb motor control. The time needed to complete a full cycle of a phantom movement was systematically shorter in subjects without phantom limb pain. Also, the amount of EMG modulation recorded in a stump muscle during a phantom hand movement was positively correlated with the intensity of phantom limb pain. Since phantom hand movement–related EMG patterns in above-elbow stump muscles can be considered as a marker of motor system reorganization, this result indirectly supports the hypothesis that amputation-induced plasticity is associated with phantom limb pain severity. The discordance between the (amputated) hand motor command and the feedback from above-elbow muscles might partially explain why subjects exhibiting large EMG modulation during phantom hand movement have more phantom limb pain.     

Factor structure and dimensionality of the two depression scales in STAR*D using level 1 datasets

Background

The factor structure and dimensionality of the HAM-D₁₇ and the IDS-C₃₀ are as yet uncertain, because psychometric analyses of these scales have been performed without a clear separation between factor structure profile and dimensionality (total scores being a sufficient statistic).

Methods

The first treatment step (Level 1) in the STAR*D study provided a dataset of 4041 outpatients with DSM-IV nonpsychotic major depression. The HAM-D₁₇ and IDS-C₃₀ were evaluated by principal component analysis (PCA) without rotation. Mokken analysis tested the unidimensionality of the IDS-C₆, which corresponds to the unidimensional HAM-D_6.

Results

For both the HAM-D₁₇ and IDS-C₃₀, PCA identified a bi-directional factor contrasting the depressive symptoms versus the neurovegetative symptoms. The HAM-D₆ and the corresponding IDS-C₆ symptoms all emerged in the depression factor. Both the HAM-D₆ and IDS-C₆ were found to be unidimensional scales, i.e., their total scores are each a sufficient statistic for the measurement of depressive states.

Limitations

STAR*D used only one medication in Level 1.

Conclusions

The unidimensional HAM-D₆ and IDS-C₆ should be used when evaluating the pure clinical effect of antidepressive treatment, whereas the multidimensional HAM-D₁₇ and IDS-C₃₀ should be considered when selecting antidepressant treatment.     

Coping with infertility online: An examination of self-help mechanisms in an online infertility support group

Objective

To examine communication within an online infertility support group.

Methods

A content analysis of 3500 messages posted to infertility bulletin boards.

Results

The most frequently used self-help mechanisms were support or empathy (45.5%) and sharing personal experiences (45.4%), followed by the provision of information and advice (15.9%), gratitude (12.5%), friendship (9.9%), chit-chat (9.4%), requests for information or advice (6.8%) and universality (4.8%), with negative statements (0.3%) and creative expressions (0.2%) being the least frequent categories.

Conclusion

These findings suggest that online support groups can provide a viable alternative source of support for couples dealing with infertility.

Practice implications

Health care professionals interested in developing online support interventions should look to tailor support resources to the specific needs of patients at different stages of the infertility journey.     

Web-enabled video-feedback: a method to reflect on the communication skills of experienced physicians

Objective

To describe our web-enabled video-feedback method designed to reflect on the communication skills of experienced physicians.

Methods

Participating physicians (n = 28) received a ‘personal web link’ to two of their video-recorded consultations. After watching the consultations physicians received feedback by telephone or in a face-to-face meeting, structured around an individualized feedback report. This report contained scores on the communication behavior of the physician in comparison with colleagues and their own communication behavior observed in a previous study, as well as patients’ opinions about their physician's communication behavior. The physicians were asked to reflect on their communication skills and to comment on the usefulness and efficiency of the feedback method.

Results

Almost all physicians were satisfied with the feedback method and in particular valued the web-enabled link to the video-recorded consultations and the structured written report. Feedback by telephone or face-to-face feedback was considered equally appropriate.

Conclusion

This web-enabled video-feedback method is a useful and structured design to reflect on the communication skills of physicians.

Practice implications

As part of continuing medical education, feedback on communication skills should become a recurrent activity for experienced physicians. This method can also be used to reflect on the communication skills of medical students.     

Does questionnaire-based patient feedback reflect the important qualities of clinical consultations? Context, benefits and risks

Objective

To explore perceptions of clinical consultations and how they relate to questionnaire-based patient feedback.

Methods

Telephone interviews with 35 junior doctors and 40 general practice patients who had used the Doctors’ Interpersonal Skills Questionnaire (DISQ).

Results

Doctors and patients had similar views of ‘good consultations’ as relying on doctors’ listening and explaining skills. Preferences for a consultation style focused on an outcome or on the doctor-patient relationship may be independent of informational and/or affective consultation content. Respondents felt the important consultation elements were similar in different contexts, and so DISQ feedback would be useful in different settings. Benefits of feedback were identified in the form of patient empowerment and doctors’ learning. Risks were identified in the inappropriate use of feedback, both inadvertent and deliberate.

Conclusion

The style and content of consultations may be considered as separate dimensions, an approach that may help doctors adapt their communication appropriately to different consultations. Patient feedback focused on communication skills is appropriate, but there are potential risks.

Practice implications

Doctors should consider the transactional or relational preference of a patient in approaching a consultation. Patient feedback can deliver benefits to doctors and patients, but risks must be acknowledged and mitigated against.     

Electrodermal activity in response to empathic statements in clinical interviews with fibromyalgia patients

Objective

To study patients’ electrodermal response (1) to an interviewer's empathic statements vs. inattention to emotional concerns and (2) to the emotional content in clinical interviews.

Methods

Patients with fibromyalgia (n = 48) were given a clinical interview in a randomized 2 × 2 design, in which interviewer empathic or inattentive behavior (scenario A) and the emotional or neutral content of the interview (scenario B) were manipulated.Electrodermal activity (EDA) was measured during the interview. The patients’ affective state (PANAS) and patient satisfaction were also assessed.

Results

In scenario A a significant main effect of empathy was found, indicating an increased tonic EDA (skin conduction level, SCL) during the empathy condition (p < .05). In scenario B there was a main effect of empathy (p < .01) and a significant empathy × content interaction effect (p < .01). There was a strong positive association between empathy and patient satisfaction (p < .0001).

Conclusions

Empathic statements by the interviewer were associated with increased SCL in patients, most so in interviews with emotional content.

Practice implications

Psychophysiological variables such as EDA may be applied in clinical communication research on emotional communication, but the limitations of such measures should also be recognized.