Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation?

BACKGROUND: The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred medicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts. OBJECTIVE: Our aim was to explore the nature and importance of doctors' knowledge about patients. METHODS: Fifteen GPs audio-recorded 25-30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it. Semi-structured interviews based on a selection of consultations were conducted to draw out the doctor's views on the factors that were important to their satisfaction. The interviews were transcribed verbatim. Qualitative analysis was inductive and iterative. RESULTS: Within doctors' narratives, we found accounts of two ways of 'knowing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the context of the general practice consultation and led to biomedical and biographical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gave the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and different experiences of the consultation. CONCLUSION: 'Knowing the patient' is important to the way GPs attribute meaning to their work. Doctors were more likely to identify as 'known' those patients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.     

Nutritional assessment of anorexia nervosa patients—Analysis of anthropometric and biochemical variables to evaluate patients at risk

The nutritional status of 33 consecutively admitted patients with anorexia nervosa (AN), was evaluated by anthropometric and biochemical methods.Mean weight loss was 30%, i.e., 17 kg body mass. Both mean triceps skin fold (TSF) and arm muscle circumference (AMC) were below the 5th percentile which is an indication of severe malnutrition. Mean creatinine height index (CHI) was 55% of the reference value which is also below the lower limit of the normal range.Serum transferrin was significantly reduced (p<0.01) compared to the control group, while serum albumin and retinol-binding-protein (RBP) were significantly increased (p<0.01) in the AN-group. Serum prealbumin concentration was within the 95% confidence interval of the control group.The levels of serum immunoglobulins IgA and IgM were also well preserved while IgG was significantly decreased (p<0.04). Serum complement C3 component was also significantly reduced (p<0.01), but not the C4 component. Serum zinc and vitamin B₁₂ were found to be within the normal range in most patients, while serum potassium, iron and folic acid were significantly lower (p<0.01) than the control group.There were significant correlations between relative weight loss and both the anthropometric variables TSF (p<0.05) and AMC (p<0.01) on the other hand and the biochemical serum variables: prealbumin (p<0.05), transferrin (p<0.02) and magnesium (p<0.02).The sensitivity and specificity of the best biochemical variable, serum transferrin, was only 87% and 32%. In comparison the sensitivity and specificity of the best anthropometric variable, TSF, to confirm the diagnosis of AN was 100 and 95%, respectively.Extremely low relative weight loss, TSF and AMC values in addition to low serum levels of albumin, zinc and electrolytes were observed in the two patients with fatal outcome who both had bulimic symptoms.In conclusion, a nutritional assessment including both anthropometric and certain biochemical measurements may give valuable information concerning the evaluation of patients at risk.     

Should patients perception of health status be integrated in the prognostic assessment of heart failure patients? A prospective study

Purpose

Health status measures are widely recognized as providing substantial information on heart failure (HF) patients conditions and prognosis, but they are not included in the data routinely collected. The aim of the study was to assess in a prospective cohort of HF patients, the independent prognostic value of health status measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ) on mortality and hospital admissions over a period of 3.3 years.

Methods

Eighty-three Italian cardiology centers included all their patients randomized in the GISSI-HF trial in an observational outcome study where the KCCQ was administered at baseline by nursing personnel. A total of 1,465 outpatients with chronic HF, NYHA classes II–III, with coronary and non-coronary etiology were included and followed up for mortality and admissions.

Results

The effect of baseline perception of health status on mortality and all causes hospitalizations was explored with Cox proportional hazard regression models progressively adjusted for several variables. When stratified according to pre-defined criteria, lower values of KCCQ scores (<25) as compared with best scores (>75) were predictive of mortality (1.85; 95 % CI 1.16–2.95) but not of hospital admissions risk (p for trend significant for mortality with decreasing scores). Lower KCCQ scores discriminated the risk also within the NYHA II and III classes.

Conclusions

KCCQ scores provide a clinically important and statistically robust independent prognostic information on hard outcome endpoints of HF patients on the top of the clinical scores. It is suggested that KCCQ should become a routine component of the patients care and of prognostic profiles.     

The accuracy of general practitioners’ clinical assessment of chest pain patients

Objective: To study general practitioners’ (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients. Methods: All chest pain patients aged 20–79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The “GP action in daily practice” was classed as “active decisions” (investigation or treatment) or “wait and see”. “IHD” or “not IHD” was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy. Results: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was “IHD” in 47%, 9% and 1% respectively. The sensitivity and specificity of the “GP assessment of the probability of IHD” were 72% and 89%. The sensitivity and specificity of the “GP action in daily practice” were 88% and 72%, respectively. The negative predictive value was 98%. Conclusion: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.     

Survival of Huntington’s disease patients in Serbia: longer survival in female patients

The objective of this study was to estimate probability of survival of Huntington’s disease (HD) patients in Serbia as a function of CAG repeat length and selected demographic variables. This follow-up study was carried out at the Institute of Neurology, Clinical Centre of Serbia, Belgrade, 1982–2004. The study group consisted of 112 HD patients. The significant inverse correlation was found between CAG repeat length and age at onset of HD (r = −0.732, P = 0.001) and age at death (r = −0.760, P = 0.001). The cumulative probabilities of survival in a five, ten, fifteen, and twenty-years’ period were 90.9, 63.2, 10.3 and 4.5%, respectively. Higher survival probabilities were registered in female patients, as well as in those with older age at onset and lower number of CAG repeat length (≤46). The Cox regression analysis showed that significantly poorer outcome of HD in our population was related to younger age at onset (HR-hazard ratio = 1.9; P = 0.047), and larger CAG numbers (HR = 2.4; P = 0.071). The female sex was statistically significantly associated with longer survival (HR = 0.4; P = 0.007). These data might be of some importance for further exploration of natural history and prognosis of HD.     

Save or destroy? The importance of medical record for former patients and future patients

In 1995, a new privacy law was introduced in the Netherlands. According to this law, medical records should be saved for 10 years, and then destroyed, unless keeping the records for a longer period follows reasonably from the duties of the treating physician (as is the case, for example, when treating patients with a chronic disease). There are serious concerns with regard to the future availability of medical record data for clinical research and patient care after 2005. Evaluation of the late effects of many medical treatments will no longer be possible in the Netherlands. Patient care, particularly genetic counselling, will be also seriously compromised. As a possible solution the profession might name diagnoses and treatments regarding for which, from the point of view of good care, it is necessary for files to be kept for longer than 10 years. For a uniform nationwide policy it would be better if all files, perhaps after sorting by diagnosis and treatment, should be obligatorily kept for much longer than 10 years, preferably for the duration of the life expectancy.     

Do patients choose physicians of their own race?

This study seeks to determine whether minority Americans tend to see physicians of their own race as a matter of choice or simply because minority physicians are more conveniently located within predominantly minority communities. Using data from the Commonwealth Fund 1994 National Comparative Survey of Minority Health Care, we found that black and Hispanic Americans sought care from physicians of their own race because of personal preference and language, not solely because of geographic accessibility. As minority populations continue to grow, the demand for minority physicians is likely to increase. Keeping up with this demand will require medical school admissions policies and physician workforce planning to include explicit strategies to increase the supply of underrepresented minority physicians.     

Attitudes of low‐income clinic patients toward menopause

The bulk of menopause research has been conducted on samples of middle‐class White women. In this study, attitudes toward menopause in a sample of 66 low‐income women at a women's clinic were studied using Bowles's (1986) Menopause Attitude Scale (MAS) and the attitude segment of Millette's (1981) survey of attitudes and knowledge about menopause. The typical participant was a single, 34‐year‐old Black woman with a yearly income below $10,000. Research questions examined general attitudes toward menopause, and MAS scores of Bowles's middle‐income, White sample were compared with those of the present low‐income, predominantly Black sample. Results indicated a somewhat positive attitude toward menopause in the low‐income sample. Although the trend was toward higher scores in the low‐income group, only the 18‐ to 25‐year‐olds in the low‐income group had significandy higher MAS scores man the corresponding age group in Bowles's sample. Nursing implications pertain to teaching and support group leadership.     

How should patients consult? A study of the differences in viewpoint between doctors and patients

BACKGROUND: Increasing pressure on limited NHS resources has led to the introduction in primary care of a skill mix which seeks to match clinical presentation to an intervention based on skills and training. There has also been increasing emphasis on the use of telephone consultations. However, outcomes on the benefits of these different approaches may be difficult to obtain and process variables such as the views of patients may be important. OBJECTIVE: The objective of the study was to answer the following questions (i) how many existing GP consultations do doctors and patients assess as being suitable for consultation with a specially trained nurse or for telephone advice from a doctor?; (ii) do doctors and patients share similar views on the suitability of individual cases?; and (iii) do these assessments differ between acute, chronic and urgent cases? METHOD: A sample of 750 patients comprising of 150 patients attending for booked consultation with each of five doctors were interviewed prior to the consultation and asked whether they would be happy to see a specially trained practice nurse or if their problem could be dealt with by a doctor on the telephone. For each case the GP gave his response. A similar study was undertaken with 150 'extras' patients who needed to be seen urgently and who could not wait for an appointment the following day. The viewpoint of the GP was compared with that of the patient. RESULTS: GPs felt that 20% of all booked cases could be seen by a nurse compared with the patients' assessment of 29%. These figures were higher for acute booked cases (30 and 34%) and for urgent extras (44 and 58%). There was a poor agreement between the viewpoints of doctor and patient especially for chronic booked cases although this agreement increased with the more acute presentations. The number of cases that could be dealt with on the telephone ranged from 5 to 9% with poor agreement between doctor and patient. CONCLUSION: This study extends the findings of a number of others which indicate that patients can be seen satisfactorily by nurses, and that both doctors and patients see scope for increasing the number of consultations dealt with by nurses. Booked patients with chronic presentations and urgent extras are more likely than their doctors to think that they could be dealt with by the nurse. This may be due to a difference in perspective between doctors and patients about the outcome they hope to achieve in the consultation. Further qualitative work is needed to explore these differences and to clarify the best approach to this expanding area.     

Comparison of HIV-infected patients’ characteristics, healthcare resources use and cost between native and migrant patients

Objectives:  To assess whether patients’ characteristics and healthcare resources consumption and costs were different between native and migrant populations in Switzerland. Methods:  All adult patients followed-up in the Swiss HIV-cohort study in our institution during 2000–2003 were considered. Patients’ characteristics were retrieved from the cohort database. Hospital and outpatient resource use were extracted from individual charts and valued with 2002 tariffs. Results:  The 66 migrants were younger (29 ± 8 years versus 37 ± 11, p < 0.001), less often of male gender (38 % versus 70 %, p < 0.001), predominantly infected via heterosexual contact (87 % versus 52 %, p < 0.01), with lower mean CD4 level at enrolment (326 ± 235 versus 437 ± 305, p = 0.002) than their 200 native counterparts. Migrants had fewer hospitalizations, more frequent outpatient visits, laboratory tests, and lower total cost of care per year of follow-up (€ 2′215  ±  4′206 versus 4′155  ±  12′304, p = 0.037). Resource use and costs were significantly higher in people with < 200 CD4 cell counts in both groups. Conclusions:  Migrant population had more advanced disease, more outpatient visits but less hospitalizations, resulting in lower costs of care when compared with native population. Submitted: 14 May 2007; revised: 14 April 2008, 27 August 2008; accepted: 05 September 2008     

Evaluation of subjective symptoms of Japanese patients with multiple chemical sensitivity using QEESI©

Objectives

The Quick Environment Exposure Sensitivity Inventory (QEESI^©) has been used as a questionnaire to evaluate subjective symptoms of patients with multiple chemical sensitivity (MCS), also known as idiopathic environmental intolerance, in Japan. However, no cutoff value for Japanese subjects has yet been established. We designed this study to establish a cutoff value for Japanese subjects using QEESI^© for screening of MCS patients.

Methods

A questionnaire using the QEESI^© was administered to 103 MCS patients and 309 healthy control subjects matched for age and sex. QEESI^© scores of the two groups were compared using logistic regression analysis, receiver operating characteristic analysis, and the Mann–Whitney test.

Results

Cutoff values for Japanese subjects were determined for the Chemical Intolerance subscale (40), Symptom Severity subscale (20), and Life Impact subscale (10). The subjects whose scores exceeded the cutoff values in any two subscales accounted for 88.4% of the patients but only 14.5% of the controls.

Conclusions

Our results suggest that subjects meeting two out of three subscale criteria can be screened as “patients suffering from a low level of environmental chemicals such as MCS” in Japan.     

Does participation in clinical trials influence the costs of future management of patients?

Background

An earlier study showed that from a societal perspective it was less expensive to encourage patients to self-regulate their medication for GERD (gastro-esophageal reflux disease) by treating patients on-demand.

Objective

The objective was to investigate whether physician involvement in a clinical trial financed by the pharmaceutical industry subsequently results in higher health care costs.

Study design

An open, observational, multicenter study compared direct medical costs and total costs for three groups of patients with different exposure to the clinical trial; (1) Dual exposed, where both the patients and the GP participated in the former clinical trial, (2) GP exposed, where only the GP participated in the former clinical trial and (3) nonexposed, where neither the patients nor the GP participated in the former clinical trial.

Results

We did not find any statistically significant differences in neither direct medical nor total costs. However, we did observe a numerical difference in direct medical costs of 24% higher in the dual exposed group compared to the nonexposed group mainly due to a higher consumption of prescribed medication. The higher direct medical cost in the dual exposed group was however counterbalanced by lower observed direct nonmedical and indirect costs.

Conclusion

Although we did not find any statistical significant differences in health care costs, we did observe a higher consumption of prescribed medication and lower costs of work hours lost if both patient and GPs participated in a former clinical trial. The results may be limited due to a lower number of patients included than expected.     

Unusual form of ileus, except in elderly patients?

Two women aged 88 and 92, recently admitted to hospital, were diagnosed with gallstone ileus. Over a longer period of time they had suffered intermittently from abdominal pain related to a migrating and impacting stone. This disease is mostly diagnosed correctly during exploratory laparotomy for persistent intestinal obstruction. CT scanning, however, is a new and helpful way to early diagnosis. Both women had successful surgery. Gallstone ileus is a disease of the elderly; its early diagnosis is important. CT can be very helpful in this respect.     

Can the socioeconomic level influence the characteristics of a group of hypertensive patients?

A total of 440 hypertensive patients participated in the study (57 years old +/-12, 66% women, 51% white, 57% married, 52% with primary school and 44% with income from 1 to 3 minimum salaries) to characterize biosocial, beliefs, attitudes and knowledge variables, absence to consultation and treatment interruption, and to associate the socioeconomic level to the variables studied. An index of accumulated goods, from the possession of household appliances converted in minimum salaries/mo., was elaborated in order to evaluate the economic status. The hypertensive people who disagreed with "there is nothing you can do to prevent high blood pressure" presented significantly higher levels of accumulated goods; those who affirmed never getting late to their consultations presented lower levels of accumulated goods; in the subjective well-being evaluation, sadness was associated to a lower accumulated goods index (p<0,05). Results showed that low economic status was associated with factors that can influence the attitude and adherence to anti-hypertensive treatment.     

A qualitative study of patients’ perceptions of the utility of patient-reported outcome measures of symptoms in primary care clinics

Purpose

Sleep, pain, anxiety, depression, and low energy/fatigue (SPADE pentad) symptoms are common, but often unrecognized and undertreated in primary care. In an effort to improve symptom outcomes, primary care clinics are integrating patient-reported outcome measures (PROs), such as the Patient-Reported Outcome Measurement Information System (PROMIS), into practice. Whether patients with SPADE symptoms perceive these measures as useful is unknown. The purpose of this qualitative study was to explore patients’ perceptions of the utility of symptom-based PROs in primary care.

Methods

As part of a mixed-methods study, 23 patients (age 24–77 years) with one or more SPADE symptoms participated in one-on-one interviews about the use, implementation and visual display of PROMIS. All interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

Results

Five themes emerged: (1) PROs may foster communication about symptoms; (2) data from PROs may prompt clinical actions; (3) the visual display of symptom scores could be useful for patients and providers, though modifications may enhance interpretation; (4) implementation may vary according to patients’ perception of PRO features (e.g., length); and (5) PROs may be useful, but only to the extent that they are valued, prioritized, and used.

Conclusions

According to patients, the use of PROs to measure symptoms in primary care clinics has the potential to be useful. However, patients are reluctant to complete PROs if they perceive that clinicians do not use the measures to improve care. Barriers to implementation in primary care (e.g., duration of visit) should be addressed to enhance the utility of PROs. Clinical trial registration ClinicalTrials.gov ID: NCT02383862.