Three strategies when physicians provide complex information in interactions with patients: How to recognize and measure them.

OBJECTIVE: To define and operationalize three taught strategies for providing information in interactions with patients using videos collected in a randomized controlled trial (RCT). METHODS: This was a qualitative exploratory study embedded in a randomized controlled design, using microanalysis of face-to-face dialogue as an inductive video analysis method to operationalize physicians' use of three information-provision strategies. Data were 34 video-recorded simulated (but unscripted) interactions between 17 physicians and 34 multiple sclerosis patients collected before and after a brief course on information provision. We operationalized (1) mapping the patient's preferences and (2) checking the patient's understanding, and pauses indicative of (3) portioning information. RESULTS: Results are detailed analytical definitions, criteria, and assessable, quantifiable outcomes for each of the three strategies. Patients responded to portioning pauses as expected: whereas 91% of these pauses elicited an immediate patient response, only 23% of non-portioning pauses did so. CONCLUSION: Our methods revealed how to define and evaluate information sharing strategies physicians used within the contingencies of clinical interaction. PRACTICE IMPLICATIONS: Findings provide applicable methods to teach, analyze, and evaluate information sharing strategies and indications for further training.

Development of a measurement system for complex oral information transfer in medical consultations.

BACKGROUND: Information exchange between physician and patient is crucial to achieve patient involvement, shared decision making and treatment adherence. No reliable method exists for measuring how much information physicians provide in a complex, unscripted medical conversation, nor how much of this information patients recall. This study aims to fill this gap by developing a measurement system designed to compare complex orally provided information to patient recall. METHODS: The development of the complex information transfer measurement system required nine methodological steps. Core activities were data collection, definition of information units and the first draft of a codebook, refinement through independent coding and consensus, and reliability testing. Videotapes of physician-patient consultations based on a standardized scenario and post-consultation interviews with patients constituted the data. The codebook was developed from verbatim transcriptions of the videotapes. Inter-rater reliability was calculated using a random selection of 10% of the statements in the transcriptions. RESULTS: Thirtyfour transcriptions of visits and interviews were collected. We developed a set of rules for defining a single unit of information, defined detailed criteria for exclusion and inclusion of relevant units of information, and outlined systematic counting procedures. In the refinement phase, we established a system for comparing the information provided by the physician with what the patient recalled. While linguistic and conceptual issues arose during the process, coders still achieved good inter-rater reliability, with intra-class correlation for patient recall: 0.723, and for doctors: 0.761. A full codebook is available as an appendix. CONCLUSIONS: A measurement system specifically aimed at quantifying complex unscripted information exchange may be a useful addition to the tools for evaluating the results of health communication training and randomized controlled trials.

Exploring physicians' verbal and nonverbal responses to cues/concerns: Learning from incongruent communication.

OBJECTIVES: Explore physicians' verbal and nonverbal responses to cues/concerns in consultations with older-patients. METHODS: Two teams independently coded a sample of Norwegian consultations (n=24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients' verbal emotional expressions were labeled 'Acknowledging of patients' emotional expressions', and 'Distancing from patients' emotional expressions.' Based on type and extent of nonverbal expressiveness, consultations were labeled 'Affective' and 'Prescriptive.' Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed. RESULTS: Types 1 and 2 consultations were described as 'Congruent,' i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered 'Incongruent,' i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients' needs. CONCLUSIONS: Frequently physicians' display incongruent behavior in challenging situations. Older patients' may perceive this as either alleviating or increasing distress, depending on their needs. PRACTICE IMPLICATIONS: Type 3 consultations may shed light on reasons for physicians' incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients' perceptions of incongruent communication should be further explored.

Cerebrospinal fluid opening pressure measurements in acute headache patients and in patients with either chronic or no pain.

OBJECTIVE: To observe cerebrospinal fluid opening pressure (CSFOP) in different clinical settings and in patients with acute, chronic and no pain and to observe possible differences because of age and sex. METHOD: In this prospective study, CSFOP was measured in lumbar puncture in three different settings of clinical investigations; patients with acute headache investigated for subarachnoidal haemorrhage (n = 222), patients with sciatica undergoing myelography (n = 61), and patients in an outpatient neurological clinic (n = 65). RESULTS: The mean CSFOP in cm H(2)O was 17.3 for the myelography patients, 19.1 for the outpatients, 19.3 for the primary headache patients and 22.4 for the patients with secondary headache. Large proportions of patients in all groups had CSFOP above 20 cm H(2)O. The female patients in all groups had lower mean CSFOP than the male patients. CONCLUSION: The CSFOP levels found in clinical practice among patients without intracranial lesions or infectious conditions were broader than expected. Measurement of CSFOP is of limited value as diagnostic procedure if not closely linked to clinical symptoms and finds.

The Severity of Dependence Scale detects people with medication overuse: the Akershus study of chronic headache.

OBJECTIVE: To evaluate the Severity of Dependence Scale (SDS) in people with primary chronic headache and analyse the pattern of medication overuse. DESIGN: Cross sectional epidemiological survey. A posted questionnaire screened for chronic headache. Neurological residents interviewed those with self-reported chronic headache. The International Classification of Headache Disorders was used. Split file methodology was employed for data analysis. SETTING: Akershus University Hospital, Oslo, Norway. PARTICIPANTS: A random sample of 30,000 people, aged 30-44 years, from the general population of Akershus County, Norway. 405 people had primary chronic headache. MAIN OUTCOME MEASURE: SDS score in those with and without medication overuse. RESULTS: The screening questionnaire response rate was 71% and the participation rate of the interview 74%. Among 405 people with primary chronic headache, 95% had chronic tension-type headache, 4% had chronic migraine and <1% had other primary chronic headaches. Of 386 persons with chronic tension-type headache, 44% had medication overuse and 47% had co-occurrence of migraine. Simple analgesics, combination analgesics, triptans, ergotamine, opioids and a combination of acute medications were overused by 65%, 27%, 4%, <1%, 1% and 2% of people, respectively. The mean SDS score was significantly higher in those with than in those without medication overuse (5.6 vs 2.7; p<0.001). CONCLUSION: The SDS questionnaire detects medication overuse and dependency-like behaviour in persons with primary chronic headache.

Cerebrospinal fluid cytokine levels in migraine, tension-type headache and cervicogenic headache.

Cytokines have been measured in cerebrospinal fluid (CSF) from headache patients [infrequent episodic tension-type headache (TTH) and migraine with or without aura, all during attack, and cervicogenic headache] and compared with levels in pain-free individuals. Both proinflammatory [interleukin (IL)-1beta, tumour necrosis factor-alpha and monocyte chemoattractant protein-1 (MCP-1)] and anti-inflammatory cytokines [IL-1 receptor antagonist (IL-1ra), IL-4, IL-10 and transforming growth factor-beta1 (TGF-beta1)] were included. There were significant group differences in IL-1ra, TGF-beta1 and MCP-1 in episodic TTH and migraine compared with controls, and a significant difference in MCP-1 between cervicogenic headache and migraine with aura. Intrathecal MCP-1 correlated with IL-1ra, IL-10 and TGF-beta1 in episodic TTH, and MCP-1 with IL-10 in migraine with aura. Cytokine increases were modest compared with those often accompanying serious neurological conditions, and may represent a mild response to pain. We believe this to be the first comparative study of CSF cytokine levels in connection with headache.

Acute headache: a prospective diagnostic work-up of patients admitted to a general hospital.

BACKGROUND AND PURPOSE: To find a specified diagnosis for every patient investigated in the hospital emergency room for acute headache suspicious of subarachnoid haemorrhage (SAH), and to describe similarities and differences between the diagnostic groups. METHODS: We used a standardized set of questionnaires and supplementary tests, including cerebral computed tomography (CT) and if needed lumbar puncture, in the investigation of the patients. Two neurologists diagnosed the same cases independently. RESULTS: We found 30 different diagnoses as the cause of acute headache. Sixteen per cent had a SAH, and 57% had a primary headache. Patient characteristics, conditions at headache onset and accompanying symptoms were surprisingly similar in the diagnostic groups. For three SAH patients, it took 30 min to reach maximum pain intensity. In all diagnostic groups, a large proportion of the patients reached maximum pain within 60 s. CONCLUSIONS: To distinguish between benign and malignant causes of acute headache is difficult based on clinical features. The consistent use of CT and lumbar puncture is valuable when investigating sudden onset 'first or worst headache ever'. This can reduce the risk of missing a SAH diagnosis, and make it possible to give more exact diagnoses to patients suffering from both primary and secondary headaches.

Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons. The Akershus study of chronic headache.

We studied secondary chronic headaches (> or = 15 days/month for at least 3 months) in a random sample of 30 000 persons aged 30-44 years. They received a mailed questionnaire. Those with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. The criteria of the International Classification of Headache Disorders (ICHD-II) were applied. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Of the 633 participants, 298 had a secondary chronic headache. The 1-year prevalence of secondary chronic headache was 2.14%, i.e. chronic posttraumatic headache 0.21%, chronic headache attributed to whiplash injury 0.17%, post-craniotomy headache 0.02%, medication-overuse headache (MOH) 1.72%, cervicogenic headache 0.17%, headache attributed to chronic rhinosinusitis 0.33% and miscellaneous headaches 0.04%. The majority of those with ICHD-II-defined secondary chronic headache had MOH, while about one-third had other secondary headaches often in combination with MOH.

Changes in autonomic cardiac control in patients with epilepsy after discontinuation of antiepileptic drugs: a randomized controlled withdrawal study.

The aim of this study was to assess cardiac autonomic control in patients with epilepsy before and after withdrawal of antiepileptic drugs (AEDs). The study was prospective, randomized and double blinded. Spectral analysis of heart rate variability (HRV) in 24 h ECG-registration before and after withdrawal of AEDs was used to assess autonomic cardiac control. The assessment of HRV with spectral analysis was based on sinus rhythm and normal heart beats [normal to normal beat (NN)]. Thirty-nine patients had 24 h rhythms free from any ectopic beats both before and after intervention, and were included in the analysis. Significant differences were found in the withdrawal group: filtered RR intervals for all 5 min segments of the analysis; percentage of differences between adjacent filtered RR intervals that are greater than 50 ms for the whole analysis; very low frequency power; low frequency power and high frequency power. The results demonstrate that slow withdrawal of AEDs in seizure-free patients with epilepsy on drug mono-therapy resulted in an increase in both parasympathetic and sympathetic functions, indicative of increased power amongst patients following cessation of AED treatment. As low HRV has been associated with increased mortality in patients with other diseases, this increased HRV may be beneficial.

Which strategy should be applied? Design of a Norwegian epidemiological survey on chronic headache.

BACKGROUND: Large-scale population-based epidemiological surveys on chronic headache based on clinical interview by a physician are lacking. AIMS OF THE STUDY: To describe a method that aims to provide valid information on chronic headache. METHOD: A self-administered questionnaire including two questions about headache frequency within the last month and within the last year was used to screen for possible chronic headache. Respondents with self-reported headache more than half of the days were interviewed by neurological residents with experience in headache diagnostics. DISCUSSION: Previous studies have shown that a single question from a self-administered questionnaire can be used to screen for chronic headache. However, a precise headache diagnosis requires an interview by a physician experienced in headache diagnostics, as diagnoses extracted from questionnaires or provided by lay interviewers are not sufficiently precise. CONCLUSIONS: A combination of a screening questionnaire and a clinical interview by a physician is likely to be a cost-effective method to conduct an epidemiological survey on chronic headache.

Associations between white matter lesions, cerebrovascular risk factors, and low CSF Abeta42.

OBJECTIVE: To analyze a putative relationship between white matter lesions (WMLs), risk factors for WMLs, and Alzheimer disease (AD) as measured with the surrogate marker CSF Abeta42. METHODS: The authors analyzed effects of acquired risk factors for cerebrovascular disease and WMLs on AD as measured with an intermediate marker, CSF Abeta42. A total of 127 consecutive patients with subjective memory impairment (mean age 66 years; 57 women) investigated at a university-based memory clinic had brain MRI scans. WMLs were rated on a 12-point scale with a semiquantitative procedure. They used path analysis with established and possible risk factors for WMLs and for reduced CSF Abeta42 (age, hypertension, hyperhomocysteinemia, hypercholesterolemia, APOE-epsilon4) as variables. RESULTS: The WML score was 1.5 points higher (p < 0.05) in hypertensive than in nonhypertensive patients and 1.9 points higher (p < 0.05) in patients with hyperhomocysteinemia than in those with normal homocysteine levels. Hypercholesterolemia increased the probability of low CSF Abeta42 levels by 0.2 (p < 0.05). For each point increase in WML score, the probability of low CSF Abeta42 levels increased by 0.03 (p < 0.05). APOE-epsilon4 was associated with reduced CSF Abeta42 (p < 0.01). CONCLUSION: Both hypercholesterolemia and white matter lesions may contribute to low CSF Abeta42 by independent mechanisms.

The OutPatient Experiences Questionnaire (OPEQ): data quality, reliability, and validity in patients attending 52 Norwegian hospitals.

OBJECTIVE: To describe the development and evaluation of the OutPatient Experiences Questionnaire (OPEQ) for somatic outpatients. DESIGN: Literature review, patient interviews, pretesting of questionnaire items, and a cross sectional survey. SETTING: Postal survey of adult outpatient clinics at 52 hospitals in all five regions of Norway during 2003 and 2004. SUBJECTS: 35,719 patients who had attended an outpatient clinic within the previous 3 weeks. RESULTS: 19,266 patients (53.9%) responded to the questionnaire. Low levels of missing data suggest that the questionnaire is acceptable to patients. Factor analysis of items applicable to all patients produced three factors: clinic access (two items), communication (six items), and organisation (four items). The remaining items contributed to the hypothesised scales of hospital standards (three items), information (six items), and pre-visit communication (three items). With the exception of the pre-visit communication scale, the levels of Cronbach's alpha were >0.7. With the exception of the hospital standards scale, all produced test-retest correlations that exceeded 0.7. Most of the results of validity testing were as hypothesised. Correlations between the OPEQ scores ranged from 0.30 (clinic access and hospital standards) to 0.73 (communication and information). As hypothesised, scores were significantly related to patient responses to questions about overall satisfaction, general health and age. CONCLUSIONS: The OPEQ is a self-administered questionnaire that includes the most important aspects of patient experience from an outpatient perspective. It has good evidence for internal consistency, test-retest reliability, and validity.

Hospital quality improvement in context: a multilevel analysis of staff job evaluations.

OBJECTIVE: To investigate how much of the variance in data on nurse evaluation of different aspects of hospital work can be attributed to individual, ward, department and hospital levels, and to discuss the implication of the findings on quality improvement strategies. DESIGN AND METHOD: National survey data of work experiences were collected from hospital nurses working at 124 hospital wards in 36 departments in 15 hospitals across Norway during the autumn of 1998. The multilevel structure of the variation of nine indices of job satisfaction was explored by fitting four-level random intercept models (nurse, ward, department and hospital). RESULTS: A total of 2606 nurses (66%) responded. The indices showed varying clustering to organizational units. Intraclass correlations (ICCs) varied from 0.05 to 0.38, representing considerable higher level variation. The ward level was the dominating level for the clustering of nurses' job aspect evaluations. CONCLUSION: Multilevel modelling of staff work experiences may identify which improvement goals can be addressed at which organizational level. Improvement efforts should be directed specifically towards each aspect of work and at its most relevant organizational level. Strategies aimed at the micro-organizational level (ward management) rather than the individual level or the macro level (hospital top management) might prove worthwhile.

Use of rifampicin and ciprofloxacin combination therapy after surgical debridement in the treatment of early manifestation prosthetic joint infections.

Prosthetic joint infections are difficult to eradicate, and antibiotic and surgical treatment strategies lack standardisation. The present study followed 29 patients (median age 72 years, median American Society of Anesthesia score of two) with early prosthetic joint infections. Treatment consisted of device retention, surgical debridement and therapy with rifampicin and ciprofloxacin for 3 months. This treatment regimen failed in five patients during the study, with a median observation period of 674 days. The results of this study confirm the findings of the only previous study on device retention with antibiotic treatment.

Work ability and duration of certified sickness absence.

AIMS: The aim of this study was to examine the association between assessed work ability and the duration of certified sickness absence. METHODS: A total of 549 patients and 52 doctors provided questionnaire data about 549 episodes of absence. The episodes were classified as new, one month, or three months according to their duration at the time of questionnaire completion. Their duration after that was used as outcome. Uni-and multivariate Cox regression analyses were performed. RESULTS: In the multivariate analyses, a "very much reduced" work ability assessed by patients was associated with a longer duration than a "moderately reduced" work ability, in both one- and three-month episodes. Musculoskeletal and psychological disorders were associated with a longer duration, and respiratory disorders with a shorter duration than other disorders in new episodes. Patient age above 50 years was associated with a longer duration than lower age in new and three-month episodes. The doctors' use of referral and tests in the consultations, and the presence of non-medical factors as judged by the patients, were associated with a longer duration than the absence of those factors in new episodes. The patients' degree of job satisfaction, and non-medical factors as judged by doctors. were significantly associated with duration only in univariate Cox regression analyses in new episodes. Work demands were not significantly associated with duration in any of the analyses. CONCLUSIONS: Work ability assessed by patients may be a useful prognostic indicator of duration in prolonged episodes of certified sickness absence. Further studies using other outcomes, such as disability pensioning, would be of interest to enlighten the concepts of work ability.