Enhancing parent-provider communication in ambulatory pediatric practice

OBJECTIVE: To address the need for interventions to enhance parent-provider communication, the present study evaluated the effectiveness of a brief intervention to enhance interpersonal communication skills by pediatric and internal medicine/pediatric residents with parents of children seen in ambulatory practice. METHODS: In a within-subjects, repeated measures research design, residents (N=28) participated in a 1-112h intervention designed to increase the use of effective communication skills with their patients' families (N=92). Three pediatric visits (one prior to and two following the intervention) were audio-taped and coded using Roter's Interaction Analysis System. Parents' perceptions of residents' communication skills and satisfaction with care were gathered. RESULTS: Residents used more effective interpersonal communication skills following the intervention (p<.05). Parent satisfaction with care also increased (p<.01) with parents reporting greater satisfaction with distress relief (p=.01) and communication following the intervention (p=.05). However, parents' perceptions of resident communication did not change over time. CONCLUSION: These findings suggest that a relatively brief intervention shows promise in improving the quality of care provided within a pediatric ambulatory care setting. PRACTICE IMPLICATIONS: Training residents to increase their use of praise, empathy, and collaboration with families can be done within a brief intervention and may be associated with increased parental satisfaction with care.     

Costly patients with unexplained medical symptoms: a high-risk population

OBJECTIVES: To identify a group of costly patients with unexplained medical symptoms (UMS), and address their needs. METHODS: Prospective controlled trial; 42 patients with annual costs of care of $6500 or more were randomized into an intervention and a usual care group. A primary care team with expertise in the biopsychosocial (BPS) approach implemented the intervention. RESULTS: In the intervention group, the annual number of visits to consultants declined from 31.8 to 12.6 (p<.0001) and 14.6 (p=.72) after 1 and 2 years, respectively; visits to hospital emergency wards declined from 33.5 to 4.1 (p<.0001) and 3.5 (p=.18); and in-hospital days declined from 112.7 to 19 (p<.0001) and 6.5 (p=.25). Those parameters remained unchanged in the control group. Five years follow-up demonstrated a reduction in mortality rates between the two groups: 6/21 versus 17/21 (p<0.001). CONCLUSIONS: When compared to usual care, a BPS intervention was followed by a decline in patients' visits to medical settings and health-care expenditures, along with significant decline in mortality rate. PRACTICE IMPLICATION: Costly UMS patients should be identified every year and treated using a BPS approach.     

Abstracts 2016

Background

Musculoskeletal pain is associated with comorbidity, extensive use of health services, long-term disability and reduced quality of life. The scientific literature on effects of treatment for musculoskeletal pain is inconclusive.

Purpose

The purpose of this study is to compare a multidisciplinary intervention (MI), including use of the novel Interdisciplinary Structured Interview with a Visual Educational Tool (ISIVET), with a brief intervention (BI), on effects on mental and physical symptoms, functioning ability, use of health services and coping in patients sick-listed due to musculoskeletal pain.

Method

Two hundred eighty-four adults aged 18–60, referred to a specialist clinic in physical rehabilitation, were randomized to MI or BI. Patients received a medical examination at baseline and completed a comprehensive questionnaire at baseline, 3 months and 12 months.

Results

Both groups reported improvements in mental and physical symptoms, including pain, and improved functioning ability at 3 and 12 months, but the MI group improved faster than the BI group except from reports of pain, which had a similar course. Significant interactions between group and time were found on mental symptoms (anxiety (p?<?0.05), depression (p?<?0.01), somatization (p?<?0.01)) and functioning ability (p?<?0.01) due to stronger effects in the MI group at 3 months. At 3 and 12 months, the MI group reported significantly less use of health services (general practitioner (p?<?0.05)). At 12 months, the MI group reported better self-evaluated capability of coping with complaints (p?<?0.001) and they took better care of their own health (p?<?0.001), compared to the BI group.

Conclusion

The results indicate that the MI may represent an important supplement in the treatment of musculoskeletal pain.

     

Provider and patient intervention to improve weight loss: a pilot study in a public hospital clinic

OBJECTIVE: To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy. METHODS: The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy. RESULTS: 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01). CONCLUSIONS: This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital. PRACTICE IMPLICATIONS: Hospital-based weight loss interventions need to target both physicians and patients.     

综合护理干预对促进抑郁症患者康复的临床效果分析

目的 探究综合护理干预对促进抑郁症患者康复的临床效果。方法 选取我院2016年1月～2017年1月收治的80例抑郁症患者进行研究。随机分为观察组和对照组,每组40例,对照组采用常规护理,观察组采用综合护理干预,对两组患者护理进行对比分析。结果 观察组患者的HRSD评分、生活质量评分以及护理满意度优于对照组,两组差异存在统计学意义（P＜0.05）。结论 综合护理干预对促进抑郁症患者康复的临床效果显著,值得在临床推广及应用。     

Modification of physical activity 5 months after myocardial infarction: Relevance of biographic and personality characteristics

The relation between modification of physical activity, a risk factor for coronary heart disease, and personality characteristics was assessed in 166 survivors of a first myocardial infarction (MI). Physical activity was assessed before MI in retrospect and again 5 months after MI. Patients were divided into 3 categories according to their current daily-life physical activities: less active than before MI (n=24), equally active as before MI (n=82), or more active than before MI (n=60). A significant differentiation was found between patients who became less physically active than before MI and the other 2 categories. This less active category was characterized by feelings of disability, a low level of vigor, and feelings of anxiety. In addition, this patient group was on average older and more often female. The results were adjusted for participation in a cardiac rehabilitation program. Finally, the discussion recommends involving psychological intervention in the exercise program for the less active category of patients to diminish feelings of anxiety and disability and to improve vigor.     

Aspiring to physical health: the role of aspirations for physical health in facilitating long-term tobacco abstinence

OBJECTIVE: To assess aspirations for physical health over 18 months. To examine whether maintained importance of aspirations for physical health mediated and/or moderated the effect of an intensive intervention on long-term tobacco abstinence. METHODS: Participants were randomly assigned to an intervention based on self-determination theory or to community care, and provided data at baseline and at 18 and 30 months post-randomization. RESULTS: Aspirations for physical health were better maintained over 18 months among participants in the intervention (mean change=.05), relative to community care (mean change=-.13), t=2.66, p<.01. Maintained importance of aspirations for physical health partially mediated the treatment condition effects on seven-day point prevalence tobacco abstinence (z'=1.68, p<.01) and the longest number of days not smoking (z'=2.16, p<.01), and interacted with treatment condition to facilitate the longest number of days not smoking (beta=.08, p<.05). CONCLUSION: Maintained importance of aspirations for physical health facilitated tobacco abstinence. PRACTICE IMPLICATIONS: Smokers may benefit from discussing aspirations for physical health within autonomy-supportive interventions. Patients may benefit from discussing aspirations during counseling about therapeutic lifestyle change and medication use.     

职业康复对住院精神分裂症患者康复作用

目的:探讨职业康复对社区精神分裂症病人康复的作用。方法:将69名住院精神分裂症患者随机分为干预组和对照组,对干预组患者实施职业康复干预,经过6个月的观察,每3个月用自制一般情况调查表、阳性和阴性症状量表(PANSS)、现有能力及康复效果评估表对两组进行比较。结果:干预6个月后两组间PANSS中的阳性和阴性症状量表有显著性差异(t=-3.593,-2.216;P均0.05);现有能力及康复效果评估表中,第6个月时讲究卫生能力、生活能力、工作情况及总评有显著差异(t=-2.798,-2.178,-2.474,-2.398;P均0.05)。结论:对慢性精神分裂症患者实行职业康复训练,有利于促进患者康复及阴性症状的改善。     

职业康复对住院精神分裂症生存质量的影响

目的:探讨职业康复对住院精神分裂症病人病情及生存质量的影响。方法:将69名住院精神分裂症患者随机分为干预组和对照组,对干预组患者实施职业康复干预,经过6个月的观察,每3个月用自制一般情况调查表、阳性和阴性症状量表(PANSS)、社会功能缺陷筛选量表(SDSS)、世界卫生组织生存质量测定量表简表(WHOQOL-BREF)对两组进行比较。结果:干预6个月后两组间PANSS中的阳性和阴性症状量表有显著性差异(t=-3.593,-2.216;P0.05);SDSS第6个月时两组间差异有统计学意义(t=-2.112,P0.05);生存质量简表中生理领域在第3个月有显著差异(t=2.608,P0.05),第6个月时生理及社会关系领域有显著差异(t=2.563,2.502;P0.05)。结论:对慢性精神分裂症患者实行职业康复训练,有利于促进患者康复及阴性症状的改善,及社会功能的恢复,对生存质量中的生理及社会关系领域有明显作用。     

Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial

OBJECTIVES: This study evaluated the effectiveness of cardiac counseling and rehabilitation programs led by a nurse counselor, compared with normal care on outcomes for myocardial infarction (MI) patients and their partners. METHODS: A randomized controlled trial with follow-up to 1 year was conducted with 100 patients recruited within 72 hours of a first MI and their partners: a Control group received normal care; an Inpatient group received cardiac rehabilitation from a nurse counselor while in hospital; and an Extended group received the same cardiac rehabilitation as the Inpatient group, but with additional sessions continuing up to 6 weeks after discharge from hospital. The scales for main outcome measures were 1) knowledge of heart disease and treatment (correct, misconceptions, and uncertainty); 2) mood (Hospital Anxiety and Depression Scale); 3) satisfaction; 4) disability (Functional Limitations Profile). RESULTS: Inpatient cardiac counseling and rehabilitation resulted in more knowledge, less anxiety, less depression, and greater satisfaction with care in both patients and partners and in less disability in patients, with effects enduring to 1 year. There was some evidence of additional benefit from the Extended program. Both nurse counselors achieved benefits on all outcome variables. CONCLUSIONS: This Inpatient cardiac counseling and rehabilitation program resulted in significant and enduring benefits of clinical value. It is likely that it would be acceptable to most post-MI patients, many of whom are not offered or are unable to accept outpatient cardiac rehabilitation.     

Evaluation of generic patient information: effects on health outcomes, knowledge and satisfaction

OBJECTIVE: To establish whether the provision of commercially produced written information in addition to routine hospital information can improve patients' knowledge and satisfaction and affect their health-related quality of life. METHODS: Elective surgical patients were randomised into an experimental group (N = 54) who received three commercially produced information booklets at pre-assessment, before surgery and at discharge, and a control group (N = 55) who received standard hospital information only. RESULTS: The experimental group were significantly less anxious immediately before their operation, and reported greater perceived control compared to controls post-operatively. Two weeks after discharge, health status for the two groups was similar except the experimental group reported significantly less pain. Overall satisfaction was fairly high and similar in both groups. The experimental group demonstrated greater knowledge at pre-admission, but not at discharge or follow-up. DISCUSSION: Patients increasingly expect written information; however amount, quality and timeliness vary considerably. Combining commercially produced information with standard hospital information may be to the patient's benefit. PRACTICE IMPLICATIONS: Providing patients with commercially produced standardised information in addition to internally produced hospital information could have an additional, though limited, benefit to patients' health outcomes. This could be a way of incorporating the expertise of both providers to the patient's benefit.     

Patients perceptions of information about risks at cardiac surgery

OBJECTIVE: The aim was to describe the patients' own experiences of risk information in connection with cardiac surgery and it's outcome. METHODS: Questionnaires were answered prior to and 8 weeks after cardiac surgery. Data were analysed using qualitative content analysis. Patients in the intervention group (n=55) received standard information and a newly written extended information brochure about risks in connection with cardiac surgery. Patients in the control group (n=44) only received standard information. RESULTS: Three categories emerged: attitude towards information, deficiencies and advantages of the information and concerns related to cardiac surgery. Patients in both groups pointed out the importance of information when they were put on the waiting list. Patients in the control group missed information about complications and some patients thought that their complications were caused by maltreatment. Patients having complications in the intervention group were more understanding about their situation. CONCLUSION: Much can be done for the patients on their path from diagnosis and being accepted for cardiac surgery and throughout the treatment period regarding the provision of information. PRACTICE IMPLICATIONS: If patients become carefully and thoroughly informed by the health care professionals, they are more satisfied and better prepared if complications occur.     

Evaluation of a face-to-face psychosocial screening intervention for cancer patients: acceptance and effects on quality of life

OBJECTIVE: This study evaluated a psychosocial screening intervention that offers cancer patients counselling. The assumption underlying the intervention was that barriers are often present that hamper patients' awareness of and active request for psychosocial care. An active yet unobtrusive approach was hypothesized to improve accessibility to psychosocial services. METHODS: In a sequential cohort design, patients newly admitted to the oncology department of an academic hospital were assigned to a usual care group (n=50) or a screening group (n=79). A retrospective, medical records group (n=89) was also included. At baseline and 4 weeks following discharge, the usual care and screening groups completed mental health and quality of life questionnaires. RESULTS: Half the screening group actually wanted and received counselling. At follow-up, the screening group reported significantly less pain, better mental health and better physical and role functioning than the usual care group. CONCLUSION: The face-to-face screening intervention appears an effective means of identifying patients interested in obtaining formal psychosocial counselling, and may result in improvements in physical and mental health outcomes. PRACTICE IMPLICATIONS: This screening intervention may be particularly useful for hospitals that prefer a personal approach to psychosocial screening, but do not have sufficient resources to interview every new patient.     

早期康复护理干预改善首发脑卒中偏瘫患者肢体功能的效果分析

目的 探讨首发脑卒中偏瘫患者给予早期康复护理干预对其肢体功能的影响。方法 将我院收治的132例首发脑卒中偏瘫患者根据住院单双号分为对照组和干预组,每组66例。对照组采用常规临床护理措施,干预组在对照组基础上开展早期康复护理干预,对比两组患者护理前后上下肢肌力评分、Barthel指数和Fugl-meyer评分。结果 护理干预后,两组患者的肌力水平均较护理前有所改善,但干预组患者改善情况优于对照组,差异有统计学意义（P＜0.05）。两组患者的Fugl-meyer评分和Barthel指数评分均较护理前有所改善,但干预组患者改善情况优于对照组患者,差异有统计学意义（P＜0.05）。结论 首发脑卒中偏瘫患者给予早期康复护理干预,能够促进其肢体功能的恢复,降低患者的致残率,从而有效提高其生活质量。     

综合干预对脑梗死恢复早期抑郁障碍的疗效与神经功能的影响

目的 探讨综合干预对脑梗死恢复早期抑郁障碍的疗效与神经功能的影响.方法 新出院初发脑梗死恢复早期患者进行心理评定有抑郁障碍94例,随机分为治疗组45例,对照组49例,于治疗前、治疗后1月和2个月分别进行汉密尔顿抑郁量表(HAMD)与神经功能缺损量表(CNS)评分.结果 94例全部完成测评,综合干预治疗组HAMD评分明显改善,CNS评分明显优于对照组.结论 综合干预对脑梗死恢复早期抑郁障碍有很好疗效,同时也对患者神经康复有积极作用.     

Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial.

BACKGROUND: Studies have shown that patients prefer to received physiotherapy services in the primary care setting, but none has made direct comparisons between hospital and primary care based physiotherapy. AIM: This pragmatic randomized trial set out to compare general-practice-based physiotherapy education and advice clinics with traditional physiotherapy treatment in an acute hospital setting. METHOD: The study involved 130 patients referred to physiotherapy services by 43 general practitioners over a one-year period. Patients were included in the study if they were at work, independent in all activities of daily living and would have routinely been referred to the hospital physiotherapy department for treatment. Patients were randomly allocated to one of two intervention groups: general practice education/advice, or treatment and education/advice at the local hospital. Patients completed a questionnaire prior to their first physiotherapy appointment and again 6 weeks later. RESULTS: A disappointing number of patients failed to attend either the first or subsequent appointments. The post-intervention scores revealed improvements in patients' problems, with the advice group exhibiting a slightly better outcome than the hospital group, as measured by the Nottingham health profile, the anxiety component of the hospital anxiety and depression rating scale, pain and problem size visual analogue scales, and measures of patient satisfaction. Advice group patients also had less attendances than the hospital treatment group. The general practitioners surveyed commented favourably on the advice clinics. CONCLUSIONS: The findings of this study justify the concept of general-practice-based physiotherapy education and advice clinics.     

Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems

OBJECTIVE: We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support. METHODS: Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (response rate 47%) recruited from four urban US public hospital systems. In multivariate models, we measured the association of race/ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients' interest in three self-management support strategies (telephone support, group medical visits, and Internet-based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance. RESULTS: Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in Internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95% CI 1.97-6.05) and group medical visits (OR 2.45, 95% CI 1.49-4.02), but less interested in Internet self-management support (OR 0.56, 95% CI 0.33-0.93). African-Americans were more interested than Whites in all three self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences. CONCLUSION: Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy. PRACTICE IMPLICATIONS: Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.     

Patients' involvement in decisions about medicines: GPs' perceptions of their preferences.

BACKGROUND: Patients vary in their desire to be involved in decisions about their care. AIM: To assess the accuracy and impact of GPs' perceptions of their patients' desire for involvement. DESIGN OF STUDY: Consultation-based study. SETTING: Five primary care centres in south London. METHOD: Consecutive patients completed decision-making preference questionnaires before and after consultation. Eighteen GPs completed a questionnaire at the beginning of the study and reported their perceptions of patients' preferences after each consultation. Patients' satisfaction was assessed using the Medical Interview Satisfaction Scale. Analyses were conducted in 190 patient-GP pairs that identified the same medicine decision about the same main health problem. RESULTS: A total of 479 patients participated (75.7% of those approached). Thirty-nine per cent of these patients wanted their GPs to share the decision, 45% wanted the GP to be the main (28%) or only (17%) decision maker regarding their care, and 16% wanted to be the main (14%) or only (2%) decision maker themselves. GPs accurately assessed patients' preferences in 32% of the consultations studied, overestimated patients' preferences for involvement in 45%, and underestimated them in 23% of consultations studied. Factors protective against GPs underestimating patients' preferences were: patients preferring the GP to make the decision (odds ratio [OR] 0.2 per point on the five-point scale; 95% confidence interval [CI] = 0.1 to 0.4), and the patient having discussed their main health problem before (OR 0.3; 95% CI = 0.1 to 0.9). Patients' educational attainment was independently associated with GPs underestimation of preferences. CONCLUSION: GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when patients have not consulted about their condition before.     

Changes in cardiovascular function on treatment of inhibitors of apoptotic signal transduction pathways in left ventricular remodeling after myocardial infarction.

INTRODUCTION: It has been suggested that apoptosis in cardiac remodeling after myocardial infarction (MI) occurs in cardiomyocytes and is critically involved in the process of postinfarct cardiac remodeling. We investigated the pathophysiological link between myocardial apoptosis and cardiovascular function by modulating apoptotic signal transduction pathways. METHODS: Either a caspase-3 inhibitor (CasI) or a calpain inhibitor (CalI) was administered immediately after MI in a rat model of MI. Blood pressure (BP), heart rate (HR), and blood flow velocity (BFV) were measured, and pressure-rate product (PRP) was calculated to estimate the changes in cardiovascular function (n=6 for each group). RESULTS: BFV showed no remarkable changes in any of the groups. Both systolic blood pressure (SBP) and HR changed significantly (P<.01) in the MI+CasI and MI+CalI groups at 1 day after MI and returned to control levels thereafter. In contrast, SBP and HR remained significantly (P<.01) altered in the MI group. PRP in the MI groups was significantly decreased (P<.05 in the MI and MI+CasI groups; P<.01 in the MI+CalI group) at 1 day after MI and returned to control levels at 4 days. CONCLUSION: This study suggests that inhibition of apoptosis during left ventricular remodeling ameliorates cardiovascular function in remodeled hearts.     

Motivational interviewing with families in the home environment

ObjectiveThis study explored the feasibility and acceptability of using Motivational Interviewing (MI) in the home setting with families of preschoolers.MethodsUsing mixed-methods pilot data from an MI-based obesity prevention intervention delivered via home visits by health educators (HEs) with 44 families (n = 17 four home visit group; n = 14 two home visit group), we examined: 1) fidelity of MI adherence by HEs; 2) parents’ perceptions of the intervention; and 3) HEs insights pertaining to the intervention’s delivery.ResultsMultiple measures of MI fidelity were deemed to exceed defined proficiency levels. Ninety-three percent of families reported being “satisfied” to “very satisfied” with the intervention. HEs reported building a high level of trust with families and gaining a thorough understanding of familial context. Parents appreciated how HEs’ were knowledgeable and provided personalized attention when discussing health goals. Some parents suggested more directive advice and follow-up visits as ways to improve the intervention.ConclusionHome-based MI was conducted with a high level of fidelity, was well accepted by families and practitioners.Practice implicationsOur findings from parents and MI practitioners provide key learnings that can inform future behavior change interventions that propose to use MI within the home setting.