Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care
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《英国医生杂志》
1 Primary Medical Care, Community Clinical Sciences Division, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST, 2 Nightingale Surgery, Romsey SO51 7QN, 3 Three Swans Surgery, Salisbury SP1 1DX
Correspondence to: P Little psl3@soton.ac.uk
Abstract
Effective doctor-patient communication probably improves patient satisfaction and health outcomes.1 Modifying doctors' behaviour and empowering patients (patient "activation") are two ways that patients can be encouraged to bring their concerns and agenda to the consultation. In patients with particular chronic diseases this can be by intensive counselling and for most other conditions by leaflets.1 Patient satisfaction and consultation time have generated mixed results when patients have been encouraged to write lists or to use patient activation leaflets before a consultation.2-10 Few of these studies, however, were from typical UK primary care settings, most were small (< 200 patients), some were not randomised, and few reported changes in number of investigations or referrals. Patient activation might help bring difficult issues such as depression to the consultation, where detection rates are low, where training of doctors does not help, and where outcomes vary when doctors are informed about a patient with depression.11-18
General practitioners have concerns about the effects of patient activation on time and patients' introspection and anxiety.1 3 4 7 8 19 Pressures may also be increased on the doctor to prescribe, refer, or investigate. We aimed to assess in the range of patients presenting in primary care whether patient activation leaflets improve patient satisfaction and health outcomes and whether they increase consultation time and the number of prescriptions, referrals, and investigations and help doctors to detect depression.
Methods
We recruited fewer patients from doctors with short (< 9 minutes) consultation times (14 v 30) because we had less time in which to comply with study protocols before the consultation. We obtained information on 45 consecutive patients booked to see doctors with long consultation times (where nearly all eligible patients could be approached): 14 (31%) were excluded (six were receiving treatment for anxiety or depression, four were out of our age range, two were too ill, and two only collected prescriptions). Seventeen of the 31 eligible patients (55%) agreed to participate. They had similar characteristics to those who did not agree to participate. The whole study population was similar to previous national samples for age, and for being male, in paid work, and married (table 1).28
Table 1 Characteristics of groups. Values are numbers (percentages) of patients unless specified otherwise
We received all questionnaires completed before the consultation, 418 (76%) of those completed after the consultation, and 612 (96%) completed by the doctors. Non-responders to the post consultation questionnaire were equally distributed between groups (general leaflet 75/317 (24%), depression leaflet 72/318 (23%)), similar to those who completed the study.
Satisfaction and perceived communication
We found no significant interactions between the two leaflets for any outcome and thus present the main effects (table 2). No significant changes were found in any of the outcomes for either of the leaflets, except for satisfaction: 0.17 represents a 6% (six centile point) increase in satisfaction. Both consultation time and the general leaflet were significantly associated with improved satisfaction, and the leaflet was significantly more effective when consultations were short, even after clustering by doctor was allowed for (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to -0.009). This meant that for consultations lasting five, eight, and 10 minutes, satisfaction increased by 14%, 10%, and 7%, respectively. The effect of the leaflet on subscales for satisfaction was similar when the interaction with time was allowed for: comfort from communication 1.02 (0.36 to 1.68), relief of distress 0.74 (0.0 to 1.49), intention to comply with management decisions 0.65 (0.06 to 1.23), and rapport 0.81 (0.16 to 1.45).
Table 2 Effect of leaflets on outcomes. Values are means (95% confidence intervals) for control arms and mean differences (95% confidence intervals) for intervention arms unless stated otherwise
Effect of leaflet on doctors' behaviour
The general leaflet increased the number of investigations (odds ratio 1.43, 1.00 to 2.05 after control for clustering for doctor). Perceptions of the medical need for investigation and of patients' expectations strongly predicted investigation.29 After controlling for these potential confounders we found that the effect of leaflets on investigations was unlikely to be due to either chance or confounding (odds ratio 1.87, 1.10 to 3.19). Most of the increase in number of investigations (90 v 71—that is, 19 extra) was among patients in whom investigations were thought not to be needed or slightly needed (14 extra: leaflet 41 (46%), no leaflet 27 (38%)). In the study population there were 60 consultations where the doctor thought the pressure from patients was moderate or strong, but of these patients only 20 (33%) actually reported a moderate or strong preference for investigation.
Detection of depression
Overall, 80 patients (16%) had possible major depression (score of 8 on the hospital anxiety and depression scale). Of these patients the doctors judged 45 to be depressed and 35 not depressed. Neither leaflet significantly increased the detection of depression (table 3).
Table 3 Odds of detecting depression according to leaflet type. Values are numbers (percentages) of doctors detecting depression in patients with possible major depression
Discussion
Stewart M. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152: 1423-33.
Thompson S, Nanni C, Schwankovsky L. Patient oriented interventions to improve communication in a medical office visit. Health Psychol 1990;9: 390-404.
Albertson G, Lin C, Schilling L, Cyran S, Anderson S, Anderson R. Impact of a simple intervention to increase primary care provider recognition of patient referral concerns. Am J Managed Care 2002;8: 375-81.
Hornberger J, Thom D, MaCurdy T. Effects of a self-administered previsit questionnaire to enhance awareness of patients' concerns in primary care. J Gen Intern Med 1997;12: 597-606.
Frederikson L, Bull P. Evaluation of a patient education leaflet designed to improve communication in medical consultations. Patient Educ Counsel 1995;25: 51-7.
Tabak E. Encouraging patient question-asking: a clinical trial. Patient Educ Counsel 1998;12: 37-49.
Middleton J. Written lists in the consultation: attitudes of general practitioners to lists and the patients who bring them. Br J Gen Pract 2002;44: 309-10.
McCann S, Weinman J. Empowering the patient in the consultation: a pilot study. Patient Educ Counsel 1996;27: 227-34.
Butow PN, Dunn S, Tattersall M, Jones Q. Patient participation in the cancer consultation: evaluation of a question prompt sheet. Ann Oncol 1994;5: 199-204.
Fleissig A, Glasser B, Lloyd M. Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want? Patient Educ Counsel 1999;38: 69-79.
Pill R, Prior L, Wood F. Lay attitudes to professional consultations for common mental disorder: a sociological perspective. Br Med Bull 2001;57: 207-19.
Moore R. Improving the treatment of depression in primary care: problems and prospects. Br J Gen Pract 1997;47: 587-90.
Carmin C, Klocek J. To screen or not to screen: symptoms identifying primary care medical patients in need of screening for depression. Int J Psychol Med 1998;28: 293-302.
Kendrick T. Why can't GPs follow guidelines on depression? BMJ 2002;320: 200-1.
Thompson C, Kinmonth A, Stevens L, Peveler R, Stevens A. Effects of a clinical practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet 2000;355: 185-91.
Freeling P, Rao B, Paykel E. Unrecognised depression in general practice. BMJ 1985;290: 1880-3.
Simon G, von Korff M. Recognition, management and outcomes of depression in primary care. Arch Fam Med 1995;4: 99-105.
Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995;311: 1274-6.
Coulter A. After Bristol: putting patients at the centre. BMJ 2002;324: 648-51.
Little P, Everitt H, Williamson I, Moore M, Warner G, Gould C, et al. An observational study of patient-centeredness in primary care, and its relationship to outcome. BMJ 2001;323: 908-11.
Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. BMJ 1997;315: 1506-10.
MacFarlane J, Holmes W, MacFarlane R, Britten N. Influence of patients' expectations on antibiotics management of acute lower respiratory illness in general practice: questionnaire study. BMJ 1997;315: 1211-4.
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. BMJ 1997;315: 520-3.
Zigmond A, Snaith R. The hospital anxiety and depression rating scale. Acta Psychiatr Scand 1983;67: 361-70.
Wilkin D, Hallam L, Doggett AM. Measures of need and outcome for primary health care. Oxford: Oxford University Press, 1992.
Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996;312: 1016-20.
Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319: 738-43.
Her Majesty's Stationery Office, Office of Population Censuses and Surveys. Morbidity statistics from general practice: fourth national study 1991. London: HMSO, 1994.
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. The importance of patient pressure and perceived medical need for investigations, referral, and prescribing in primary care: observational nested study. BMJ 2004;328: 444-6.
Kendrick T, Stevens L, Bryant A, Goddard J, Stevens A, Thompson C. Hampshire depression project: changes in the process of care and cost consequences. Br J Gen Pract 2001;51: 911-3.
Ostler K, Thompson C, Kinmonth AL, Peveler R, Stevens L, Stevens A. Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care. Br J Psychol 2001;178: 12-7.
Armitage C, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol 2001;40: 471-99.(Paul Little, professor of)
Correspondence to: P Little psl3@soton.ac.uk
Abstract
Effective doctor-patient communication probably improves patient satisfaction and health outcomes.1 Modifying doctors' behaviour and empowering patients (patient "activation") are two ways that patients can be encouraged to bring their concerns and agenda to the consultation. In patients with particular chronic diseases this can be by intensive counselling and for most other conditions by leaflets.1 Patient satisfaction and consultation time have generated mixed results when patients have been encouraged to write lists or to use patient activation leaflets before a consultation.2-10 Few of these studies, however, were from typical UK primary care settings, most were small (< 200 patients), some were not randomised, and few reported changes in number of investigations or referrals. Patient activation might help bring difficult issues such as depression to the consultation, where detection rates are low, where training of doctors does not help, and where outcomes vary when doctors are informed about a patient with depression.11-18
General practitioners have concerns about the effects of patient activation on time and patients' introspection and anxiety.1 3 4 7 8 19 Pressures may also be increased on the doctor to prescribe, refer, or investigate. We aimed to assess in the range of patients presenting in primary care whether patient activation leaflets improve patient satisfaction and health outcomes and whether they increase consultation time and the number of prescriptions, referrals, and investigations and help doctors to detect depression.
Methods
We recruited fewer patients from doctors with short (< 9 minutes) consultation times (14 v 30) because we had less time in which to comply with study protocols before the consultation. We obtained information on 45 consecutive patients booked to see doctors with long consultation times (where nearly all eligible patients could be approached): 14 (31%) were excluded (six were receiving treatment for anxiety or depression, four were out of our age range, two were too ill, and two only collected prescriptions). Seventeen of the 31 eligible patients (55%) agreed to participate. They had similar characteristics to those who did not agree to participate. The whole study population was similar to previous national samples for age, and for being male, in paid work, and married (table 1).28
Table 1 Characteristics of groups. Values are numbers (percentages) of patients unless specified otherwise
We received all questionnaires completed before the consultation, 418 (76%) of those completed after the consultation, and 612 (96%) completed by the doctors. Non-responders to the post consultation questionnaire were equally distributed between groups (general leaflet 75/317 (24%), depression leaflet 72/318 (23%)), similar to those who completed the study.
Satisfaction and perceived communication
We found no significant interactions between the two leaflets for any outcome and thus present the main effects (table 2). No significant changes were found in any of the outcomes for either of the leaflets, except for satisfaction: 0.17 represents a 6% (six centile point) increase in satisfaction. Both consultation time and the general leaflet were significantly associated with improved satisfaction, and the leaflet was significantly more effective when consultations were short, even after clustering by doctor was allowed for (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both -0.045, -0.08 to -0.009). This meant that for consultations lasting five, eight, and 10 minutes, satisfaction increased by 14%, 10%, and 7%, respectively. The effect of the leaflet on subscales for satisfaction was similar when the interaction with time was allowed for: comfort from communication 1.02 (0.36 to 1.68), relief of distress 0.74 (0.0 to 1.49), intention to comply with management decisions 0.65 (0.06 to 1.23), and rapport 0.81 (0.16 to 1.45).
Table 2 Effect of leaflets on outcomes. Values are means (95% confidence intervals) for control arms and mean differences (95% confidence intervals) for intervention arms unless stated otherwise
Effect of leaflet on doctors' behaviour
The general leaflet increased the number of investigations (odds ratio 1.43, 1.00 to 2.05 after control for clustering for doctor). Perceptions of the medical need for investigation and of patients' expectations strongly predicted investigation.29 After controlling for these potential confounders we found that the effect of leaflets on investigations was unlikely to be due to either chance or confounding (odds ratio 1.87, 1.10 to 3.19). Most of the increase in number of investigations (90 v 71—that is, 19 extra) was among patients in whom investigations were thought not to be needed or slightly needed (14 extra: leaflet 41 (46%), no leaflet 27 (38%)). In the study population there were 60 consultations where the doctor thought the pressure from patients was moderate or strong, but of these patients only 20 (33%) actually reported a moderate or strong preference for investigation.
Detection of depression
Overall, 80 patients (16%) had possible major depression (score of 8 on the hospital anxiety and depression scale). Of these patients the doctors judged 45 to be depressed and 35 not depressed. Neither leaflet significantly increased the detection of depression (table 3).
Table 3 Odds of detecting depression according to leaflet type. Values are numbers (percentages) of doctors detecting depression in patients with possible major depression
Discussion
Stewart M. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152: 1423-33.
Thompson S, Nanni C, Schwankovsky L. Patient oriented interventions to improve communication in a medical office visit. Health Psychol 1990;9: 390-404.
Albertson G, Lin C, Schilling L, Cyran S, Anderson S, Anderson R. Impact of a simple intervention to increase primary care provider recognition of patient referral concerns. Am J Managed Care 2002;8: 375-81.
Hornberger J, Thom D, MaCurdy T. Effects of a self-administered previsit questionnaire to enhance awareness of patients' concerns in primary care. J Gen Intern Med 1997;12: 597-606.
Frederikson L, Bull P. Evaluation of a patient education leaflet designed to improve communication in medical consultations. Patient Educ Counsel 1995;25: 51-7.
Tabak E. Encouraging patient question-asking: a clinical trial. Patient Educ Counsel 1998;12: 37-49.
Middleton J. Written lists in the consultation: attitudes of general practitioners to lists and the patients who bring them. Br J Gen Pract 2002;44: 309-10.
McCann S, Weinman J. Empowering the patient in the consultation: a pilot study. Patient Educ Counsel 1996;27: 227-34.
Butow PN, Dunn S, Tattersall M, Jones Q. Patient participation in the cancer consultation: evaluation of a question prompt sheet. Ann Oncol 1994;5: 199-204.
Fleissig A, Glasser B, Lloyd M. Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want? Patient Educ Counsel 1999;38: 69-79.
Pill R, Prior L, Wood F. Lay attitudes to professional consultations for common mental disorder: a sociological perspective. Br Med Bull 2001;57: 207-19.
Moore R. Improving the treatment of depression in primary care: problems and prospects. Br J Gen Pract 1997;47: 587-90.
Carmin C, Klocek J. To screen or not to screen: symptoms identifying primary care medical patients in need of screening for depression. Int J Psychol Med 1998;28: 293-302.
Kendrick T. Why can't GPs follow guidelines on depression? BMJ 2002;320: 200-1.
Thompson C, Kinmonth A, Stevens L, Peveler R, Stevens A. Effects of a clinical practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire depression project randomised controlled trial. Lancet 2000;355: 185-91.
Freeling P, Rao B, Paykel E. Unrecognised depression in general practice. BMJ 1985;290: 1880-3.
Simon G, von Korff M. Recognition, management and outcomes of depression in primary care. Arch Fam Med 1995;4: 99-105.
Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? BMJ 1995;311: 1274-6.
Coulter A. After Bristol: putting patients at the centre. BMJ 2002;324: 648-51.
Little P, Everitt H, Williamson I, Moore M, Warner G, Gould C, et al. An observational study of patient-centeredness in primary care, and its relationship to outcome. BMJ 2001;323: 908-11.
Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. BMJ 1997;315: 1506-10.
MacFarlane J, Holmes W, MacFarlane R, Britten N. Influence of patients' expectations on antibiotics management of acute lower respiratory illness in general practice: questionnaire study. BMJ 1997;315: 1211-4.
Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations—a questionnaire study. BMJ 1997;315: 520-3.
Zigmond A, Snaith R. The hospital anxiety and depression rating scale. Acta Psychiatr Scand 1983;67: 361-70.
Wilkin D, Hallam L, Doggett AM. Measures of need and outcome for primary health care. Oxford: Oxford University Press, 1992.
Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996;312: 1016-20.
Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319: 738-43.
Her Majesty's Stationery Office, Office of Population Censuses and Surveys. Morbidity statistics from general practice: fourth national study 1991. London: HMSO, 1994.
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. The importance of patient pressure and perceived medical need for investigations, referral, and prescribing in primary care: observational nested study. BMJ 2004;328: 444-6.
Kendrick T, Stevens L, Bryant A, Goddard J, Stevens A, Thompson C. Hampshire depression project: changes in the process of care and cost consequences. Br J Gen Pract 2001;51: 911-3.
Ostler K, Thompson C, Kinmonth AL, Peveler R, Stevens L, Stevens A. Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care. Br J Psychol 2001;178: 12-7.
Armitage C, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Br J Soc Psychol 2001;40: 471-99.(Paul Little, professor of)