Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Method: Twenty-two participants including 16 rehabilitation clinicians and 6 persons living with a disability participated in four nominal group sessions. Participants were questioned on current or potential rehabilitation strategies carried out to enhance participation in shopping malls for persons living with a disability. Discussions were audio-recorded and qualitative content analysis was conducted.
Results: Participants mentioned strategies that were either carried out by the clinician, or in collaboration with other parties. The latter type of strategies was either carried out with the collaboration of the client, the interdisciplinary team, the relatives, or community organizations.
Conclusions: Rehabilitation clinicians have a role to play in preparing persons living with a disability to resume activities in a shopping mall. Additionally, therapeutic interventions in community settings may enhance the participation of rehabilitation clients in their everyday activities.
- Implications for rehabilitation
Many strategies are currently used in rehabilitation to prepare persons living with a disability to resume shopping activities.
Clinicians could implement shopping-oriented rehabilitation strategies with the client and/or with other rehabilitation partners.
Involving clients in activities related to shopping might enhance their participation in shopping malls after rehabilitation.
Rehabilitation clinicians can be facilitators for people living with a disability to reach optimal participation.
Materials and methods: The literature was searched systematically, including MEDLINE database, EMBASE and PsychINFO, combining variations of the terms stroke, rehabilitation and comorbidities. Results were limited to English language publications. Included studies had a functional outcome.
Results: Twenty relevant articles were identified. Fifteen small prospective or large retrospective studies using global comorbidity scales produced conflicting relationships between comorbidities and rehabilitation outcomes. Five publications addressed specific comorbidities, with three studies finding negative correlation between diabetes and rehabilitation outcomes, although effects diminished with age. In general, there were discrepancies in how comorbidities were identified. Few studies specifically focused on comorbidities and/or rehabilitation outcomes.
Conclusions: There is conflicting evidence regarding the impact of comorbidities on stroke rehabilitation outcomes. However, the presence of more severe diabetes may be associated with worse outcomes. The role of comorbidities in stroke rehabilitation would be best clarified with a large cohort study, with precise comorbidity identification measured against rehabilitation specific outcomes.
- Implications for rehabilitation
Benefit of rehabilitation after stroke in improving functional outcome is well-established.
Many stroke patients have comorbid conditions which can impact rehabilitation participation, leading to less benefit obtained from rehabilitation.
The burden of comorbid conditions may slow rehabilitation progress, which may warrant a longer duration of rehabilitation to obtain required functional gain to be discharged into the community.
Design: A retrospective interrupted times series study.
Setting: Two multidisciplinary general practitioner (GP) practices.
Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.
Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.
Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.
Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.
Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.
- Key Points
An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting.
The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
Methods: A probit analysis was employed to determine which disabilities were associated with admission into an institution (i.e. long-term care). Since this framework imposes strong distributional assumptions, misspecification leads to inconsistent estimators. To overcome such a short-coming, this analysis extended the probit framework by employing an advanced semi-nonparamertic maximum likelihood estimation utilizing Hermite polynomial expansions.
Results: Specification tests show semi-nonparametric estimation is preferred over probit. In terms of the estimates, semi-nonparametric ratios equal 42 for cognitive difficulty, 64 for independent living, and 111 for self-care disability while probit yields much smaller estimates of 19, 30, and 44, respectively.
Conclusions: Public health professionals can use these results to better understand why certain interventions have not shown promise. Equally important, healthcare workers can use this research to evaluate which type of treatment plans may delay institutionalization and improve the quality of life for older adults.
- Implications for rehabilitation
With on-going global aging, understanding the association between disability and institutional entry is important in devising successful rehabilitation interventions.
Semi-nonparametric is preferred to probit and shows ambulatory and cognitive impairments present high risk for institutional entry (long-term care).
Informal caregiving and home-based care require further examination as forms of rehabilitation/therapy for certain types of disabilities.
Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their work with MMR in primary care. Interviews covered experiences of assessing patients and work with patients in the programme. Transcribed interviews were analysed by qualitative content analysis.
Results: The analysis resulted in four categories: select patients for success; a multilevel challenge; ethical dilemmas and considering what is a good result. MMR work was experienced as useful and efficient, but also challenging because of patient complexity. Preconceptions about who is a suitable patient for MMR influenced the selection of patients (e.g. gender, different culture). Interviewees were conflicted about not to being able to offer MMR to patients who were not going to return to work. They thought that there were more factors to evaluate MMR than by the proportion that return to work.
Conclusions: Healthcare professionals perceive MMR as a helpful method for treating chronic pain patients. At the same time, they thought that only including patients who would return to work conflicted with their ethical views on equal healthcare for all patients. Preconceptions can influence selection for, and work with, MMR.
- Implications for rehabilitation
Multimodal pain rehabilitation in primary healthcare is challenging because of the complexity of the patients.
Healthcare professionals must deal with conflicting emotions in regard to different commitments from healthcare legislation and the goals of multimodal rehabilitation.
Healthcare professionals should be aware that stereotypes regarding gender and immigrants can lead to bias when selecting patients for multimodal rehabilitation.
Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their experiences of starting and working with multimodal pain. Interviews were transcribed and analyzed by qualitative content analysis. This study was part of a larger project, which aimed at evaluating multimodal pain rehabilitation in primary care.
Results: The analysis resulted in six categories. Two categories were about management engagement: putting the focus on rehabilitation and creating appropriate conditions. Three were about professional engagement: importance of driving spirits, creating a program – a process, and good teamwork – not a coincidence. The last category was about professional gain from multimodal rehabilitation (MMR): team work is enriching.
Conclusions: To enable implementation of MMR in primary care, managers on all organizational levels must take responsibility for allowing rehabilitation to be a priority. A driving spirit among the professionals facilitates the start, but the entire team is important when processing a program. Creating good teamwork requires hard work, e.g., negotiations for consensus about rehabilitation, and assumption of responsibility by each team member. Collaboration between professionals was perceived to strengthen and enhance knowledge about the patients.
- Implications for rehabilitation
Much can be gained from conducting multimodal pain rehabilitation in primary care.
Front line managers and those at other organizational levels must prioritize and create appropriate conditions to facilitate multimodal pain rehabilitation in primary care.
Creation of an effective multimodal rehabilitation team requires that each team member takes responsibility, drops the focus on individual rehabilitation, seek member consensus about the content of the rehabilitation, and confer equal worth to each team member.
The process of creating a program can be facilitated, especially at the beginning, if the team is supported by speciality pain clinics or more experienced teams.
Method: Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients.
Results: The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0–12 and 2–22 suggesting strong non-linear interaction of the RCS-E items.
Conclusions: We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation.
- Implications for Rehabilitation
Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs.
Validated tools for referral decision support make the process more transparent.
Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test.
RCS-E is an excellent tool for referral decision support.
Materials and methods: A qualitative study using semi-structured interviews with 10 specialist physiotherapists in vestibular rehabilitation in three university teaching hospitals in England. Data were analyzed using thematic analysis.
Results: Four themes were identified: (i) The therapeutic relationship, (ii) Adapting assessment and treatment, (iii) Psychological intervention and support, and (iv) Physiotherapists’ education and training. Physiotherapists reported using a range of behavioral and cognitive techniques and adapting their therapeutic approach by placing greater emphasis on education, building trust and pacing treatment. Physiotherapists highlighted the need for more specialist psychological support for patients during vestibular rehabilitation and tailored training and guidance on addressing anxiety within vestibular rehabilitation.
Conclusions: Physiotherapists working in vestibular rehabilitation consider managing aspects of anxiety within their scope of practice and describe taking a psychosocial therapeutic approach. There is limited access to expert psychological support for patients with anxiety within vestibular rehabilitation.
- Implications for rehabilitation
Anxiety is strongly associated with vestibular disorders and it is common for these patients to be managed by physiotherapists in vestibular rehabilitation.
Vestibular rehabilitation services could improve access to psychological expertise through dedicated psychological input, more effective signposting and referral pathways, and better access to inter-professional support from psychologists and/or CBT practitioners in managing more complex patients.
Physiotherapists requested tailored training and guidance to enhance their ability to manage patients with anxiety more effectively in vestibular rehabilitation.
Method: The medical history of two HIV-positive patients with PML was reviewed; information on their neurological impairments, rehabilitation treatment and outcome was gathered.
Results: The patients, a 47-year-old married man and a 34-year-old single man, both suffered from dense right hemiplegia and motor aphasia. Their rehabilitation course was delayed and prolonged: they were suitable for intensive multidisciplinary rehabilitation only 8 months or more after the initial presentation. Their treatment in outpatient rehabilitation daycare three times a week, that lasted 7 months on average, resulted in slow and steady functional improvement. At the end of the rehabilitation treatment, both patients were living at home, able to express themselves, and able to walk independently with an assistive device. They remained with moderate disability (modified Rankin scale of 3).
Conclusion: PML patients require prolonged multidisciplinary rehabilitation treatment; however, considerable progress can be achieved.
- Implications for Rehabilitation
Progressive multifocal leukoencephalopathy (PML) is a disabling disease occurring in particular in the context of Human Immunodeficiency Virus (HIV).
Presently a growing number of HIV-positive PML patients eventually survive the disease and remain with severe neurological impairments.
PML patients require prolonged multidisciplinary rehabilitation treatment, and considerable progress can be achieved.
Method: Four databases were systematically searched up to March 2017: Medline, CINAHL, PsycINFO and The Cochrane Library.
Results: Forty-five studies met inclusion and exclusion criteria. Level of evidence, methodological quality and results were assessed. People with aphasia with mild depression may benefit from psychosocial-type treatments (based on 3 level ii studies with small to medium effect sizes). For those without depression, mood may be enhanced through participation in a range of interventions (based on 4 level ii studies; 1 level iii-3 study and 6 level iv studies). It is not clear which interventions may prevent depression in post-stroke aphasia. No evidence was found for the treatment of moderate to severe depression in post-stroke aphasia.
Conclusions: This study found some interventions that may improve depression outcomes for those with mild depression or without depression in post-stroke aphasia. Future research is needed to address methodological limitations and evaluate and support the translation of stepped psychological care across the continuum.
- Implications for Rehabilitation
Stepped psychological care after stroke is a framework with levels 1 to 4 which can be used to prevent and treat depression for people with aphasia.
A range of rehabilitation interventions may be beneficial to mood at level 1 for people without clinically significant depression (e.g., goal setting and achievement, psychosocial support, communication partner training and narrative therapy).
People with mild symptoms of depression may benefit from interventions at level 2 (e.g., behavioral therapy, psychosocial support and problem solving).
People with moderate to severe symptoms of depression require specialist mental health/behavioral services in collaboration with stroke care at levels 3 and 4 of stepped psychological care.
Methods: Seven families of children diagnosed with OI type 1 for longer than four years participated. An in-depth semistructured interview with open-ended questions was used to separately collect each participant’s (mother, father, patient and sibling) subjective report of their experience. Interviews were audiotaped and a qualitative discourse analysis was performed.
Results: Pain and fractures, hospitalization, home recovery, back to school and time of diagnosis emerged as the most challenging situations. Time of diagnosis was only mentioned by parents. Some commonalities but also relevant differences in the subjective experience of the same situations, depending on the family role, were found.
Conclusions: Our results reinforce the assumption that OI is a family matter and point to the importance of providing comprehensive and family-centered health and educational services tailored to each family member and to the different situations faced by these families.
- Implications for rehabilitation
Osteogenesis imperfecta is a chronic rare disease that impacts severely the patient’s life and the life of all family members.
The most distressing situations are related to fractures and pain, hospitalization, recovery from fractures while being at home and preparing for school reentry.
All family members participate in the rehabilitation process, each one accomplishing different tasks.
Rehabilitation should include educational and psychological intervention to enhance family strengths and support all family members.
Tailored and effective communication from health providers may play a critical role in the rehabilitation process.
Methods: Interviews were conducted with 15 practitioners working with rehabilitation of persons with chronic pain at an anthroposophic hospital in Sweden. The interviews were analyzed using a phenomenological hermeneutical method.
Findings: When practitioners discussed patient care, they used a shared language with particular concepts. Concepts, such as “trauma,” “self,” and “life intention,” were interpreted as a means of understanding persons with pain and their current life situation. The meaning of the concepts also had explicit or implicit implications for the caring process, e.g., the concept “caring shelter” referred to an inherent and continuous part of the caring culture enabling patients’ own exploration of their life and suffering and the meaning of their pain in the context of their lives.
Conclusions: The practitioners’ use of a conceptual language is here interpreted as a sign of a shared “caring culture” that enabled them to understand patients and their suffering from an existential perspective. A reciprocal understanding within a caring culture may extend the abilities of practitioners to engage in a dialog with patients about life and health as intertwined with the phenomenon of pain.
- Implications for rehabilitation
In the rehabilitation process, health practitioners’ language may contribute to shaping a caring culture that emphasis an understanding of patients’ needs of health.
Shared concepts in rehabilitation might increase health practitioners’ possibilities to support patients from broader and more personalized perspectives, involving not only biopsychosocial aspects but also existential dimensions.
The shared conceptual understanding of anthroposophic practitioners in this study may serve as an example to practitioners in other pain rehabilitation settings, developing a contextual understanding of their central concepts, and caring values.
Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Methods: It was performed with an extensive literature review, mainly clinical practice guidelines, randomized controlled trials, reviews, focusing on the rehabilitation management.
Results: There are few clinical practice guidelines that address GHOA as a pathology with unique characteristics. Evidence based treatment recommendations are mostly supported by low-quality evidence and experts’ opinions, with few high levels of evidence studies guiding treatment decisions.
Conclusions: Despite the lack of good quality evidence, rehabilitation programs have proven to be efficient and reliable, and this revision provides information and recommendations in this field.
- Implication of Rehabilitation
Glenohumeral osteoarthritis is a common cause of pain and functional disability of the shoulder
There are few clinical practice guidelines that address Glenohumeral Osteoarthritis as a pathology with unique characteristics, and recommendations for rehabilitation and therapeutic exercise are poor
The paper provides current information on the characteristics of the disease, its rehabilitation process, and could be of interest for rehabilitation professionals to direct their practices in this field
Method: Using a qualitative approach underpinned by critical realism, we explored the narratives of 10 patients and nine carers using semi-structured interviews approximately one month post-discharge. Thematic analysis was carried out independently by two researchers.
Results: Firstly, perceptions of support were mixed but many patients and carers felt unsupported in the inpatient phase, during transitions between units and when preparing for discharge. Secondly, they struggled to accept a new reality of changed abilities, loss of roles and loss of autonomy. Thirdly, early experiences post-discharge exacerbated fears for the future.
Conclusions: Most patients and carers struggled to identify a cohesive plan that supported their transition to living in the community. Access to services required much persistence on the part of carers and tended to be short-term, and therefore did not meet their long-term needs. We propose the need for a case manager to be involved at an early stage of their rehabilitation and act as a key point for information and access to on-going rehabilitation and other support services.
- Implications for Rehabilitation
Traumatic Brain Injury (TBI) is a major cause of long-term disability. It can affect all areas of daily life and significantly reduce quality of life for both patient and carer.
Professionals appear to underestimate the change in abilities and impact on daily life once patients return home. Community services maintain a short-term focus, whereas patients and carers want to look further ahead – this dissonance adds to anxiety.
The study’s findings on service fragmentation indicate an urgent need for better integration within health services and across health, social care and voluntary sectors.
A link person/case manager who oversees the patient journey from admission onwards would help improve integrated care and ensure the patient, and carer, are at the center of service provision.
Method: An uncontrolled pre- and post-assessment design was employed to study the use of unmodified, low-cost, off-the-shelf smartphones combined with Internet-calendars as a compensatory memory strategy in community-dwelling patients with traumatic brain injury. Thirteen participants received a 6-week group-based intervention with pre-, post- and 2-month follow-up-assessments by questionnaires and by daily assessment of target behaviors for 2-week periods.
Results: Participants reported significantly fewer retro- and prospective memory problems on questionnaires after the intervention and at follow-up with large effect sizes. The performance of target behaviors, however, improved insignificantly with moderate effect sizes. There were no changes in quality of life or symptoms of emotional distress.
Conclusions: This study adds to a growing body of evidence that smartphones are a useful compensatory aid in rehabilitation of prospective memory that should routinely be considered in rehabilitation of traumatic brain injury patients.
- Implication for rehabilitation
Smartphones are easy-to-use and accessible assistive technology for compensatory memory rehabilitation to most traumatic brain injury patients.
By using low-cost, off-the-shelf devices, the technology becomes available to a broader range of patients.
By combining smartphones with Internet-based and cross-platform services (e.g., calendars, contacts) the participants are less device-dependent and less vulnerable to data loss.
Smartphones should routinely be considered as compensatory aid in rehabilitation of prospective memory of traumatic brain injured patients.