Torture-survivors' experiences of healthcare services for pain: a qualitative study.

BACKGROUND: Increasing numbers of torture-survivors are presenting to UK healthcare services with persistent pain. However, there is a paucity of evidence surrounding the management of persistent pain among torture-survivors and their experience of healthcare services for pain is currently unknown. This qualitative study explores their experiences of services for managing pain, to inform clinical practice and service provision. METHODS: Thirteen participants were recruited from a specialist pain clinic for torture-survivors in the United Kingdom. Utilising an ethnographic approach, data were collected via clinic appointment observations, interviews and medical records and analysed using inductive thematic analysis. RESULTS: Three themes emerged in relation to torture-survivors' experiences of healthcare services for pain: the patient-clinician relationship; multiplicity of diagnoses and treatments; lack of service integration. Participants described limited engagement in decision-making processes regarding their care. Lack of recognition of torture experience when diagnosing and treating pain, alongside multiple unsuccessful treatments, led to confusion, frustration and hopelessness. These issues were exacerbated by the disconnect between physical and mental health services. CONCLUSION: This study provides new insight into the challenges faced by torture-survivors when accessing healthcare services for pain. Our findings suggest current service provision is not meeting their complex needs. Clinical implications include the need for integrated care systems and better recognition of the influence of torture experience on persistent pain. Strategies to engage and empower torture-survivors in the management of their pain are suggested.

What psychological and physical changes predict patients' attainment of personally meaningful goals six months following a CBT based pain management intervention?

PURPOSE: To examine the influence of demographic measures, and changes in physical ability, pain, self-efficacy and emotional distress on Goal Attainment Scaling (GAS) scores, after a 15-day CBT based pain management programme. METHOD: Chronic pain patients (N = 257) were referred; 225 (88%) completed the programme and were invited for follow up six months later. One hundred and sixty-two (63%), (mean age 47.7, 71% female) completed the reassessment procedures. GAS scores (which were also repeated at the end the programme), an 11-point Pain Numerical Rating Scale, Pain Self-Efficacy Questionnaire, Hospital Anxiety and Depression Scale, distance walked in 5 mins, number of sit/stand repetitions in 1 min and number of stairs climbed in 1 min were measured on the first day and six months following the programme. RESULTS: At six months post discharge, changes in goal attainment, physical measures, pain intensity, depression and self-efficacy were observed. Hierarchical regression showed change in GAS was predicted by improvement in walking tolerance and self-efficacy. CONCLUSIONS: The achievement of personally important goals was most significantly associated with change in walking ability and self-efficacy, while controlling for the influence of change in pain. Implications for Rehabilitation Chronic pain can reduce psychological and physical functioning, leading to a reduction in meaningful activities. Achievement of personally important activities as measured by Goal Attainment Scaling can be a more sensitive measure of programme outcome than that captured by many other standard measures. Self-efficacy is an important predictor of attainment of patient preferred goals following a CBT based pain management programme, and could be emphasized during treatment along with improved walking ability, to enhance patients' goal achievement.

One stop multidisciplinary pain clinic for survivors of torture.

Bianca Kuehler and Susan Childs speak to Jade Parker, Commissioning Editor: Dr Bianca Kuehler initially qualified in Germany as an anesthetist in 1993 and is on the specialist register in the UK. After moving to the UK she obtained a Diploma in Occupational Health to supplement the understanding and implication of chronic pain on the work environment. She is very interested in multidisciplinary approaches in treatment of chronic and acute pain patients and, therefore, working closely with Dr Childs opened a plethora of opportunities to develop new services including a fibromyalgia clinic and a specialist clinic for patients who are survivors of torture. Dr Susan Childs is an experienced clinical psychologist who has worked within health psychology and mental health since 1997. Her particular area of expertise is chronic pain. Alongside this, she has developed expertise in the assessment and treatment of a wide range of psychological issues. She has more recently focused upon co-developing services alongside her medical lead and co-facilitator, Dr Bianca Kuehler, for patients who are survivors of torture. Susan leads therapy services at a major London National Health Service trust in a Consultant capacity and supports a team of physicians, surgeons, pain specialist physicians, physiotherapists and clinical specialist nurses.

Interventions to increase or decrease the length of primary care physicians' consultation.

BACKGROUND: Observational studies have shown differences in process and outcome between the consultations of primary care physicians whose average consultation lengths differ. These differences may be due to self selection. This is the first update of the original review. OBJECTIVES: To assess the effects of interventions to alter the length of primary care physicians' consultations. SEARCH METHODS: We searched the following electronic databases until 4 January 2016: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). SELECTION CRITERIA: Randomised controlled trials and non-randomised controlled trials of interventions to alter the length of primary care physicians' consultations. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias of included studies using agreed criteria and resolved disagreements by discussion. We attempted to contact authors of primary studies with missing data. Given the heterogeneity of studies, we did not conduct a meta-analysis. We assessed the certainty of the evidence for the most important outcomes using the GRADE approach and have presented the results in a narrative summary. MAIN RESULTS: Five studies met the inclusion criteria. All were conducted in the UK, and tested short-term changes in the consultation time allocated to each patient. Overall, our confidence in the results was very low; most studies had a high risk of bias, particularly due to non-random allocation of participants and the absence of data on participants' characteristics and small sample sizes. We are uncertain whether altering appointment length increases primary care consultation length, number of referrals and investigations, prescriptions, or patient satisfaction based on very low-certainty evidence. None of the studies reported on the effects of altering the length of consultation on resources used. AUTHORS' CONCLUSIONS: We did not find sufficient evidence to support or refute a policy of altering the lengths of primary care physicians' consultations. It is possible that these findings may change if high-quality trials are reported in the future. Further trials are needed that focus on health outcomes and cost-effectiveness.

Provider Burnout and Patient Engagement: The Quadruple and Quintuple Aims.

The Triple Aim has become the guiding light and benchmark by which healthcare organizations plan their future efforts. It has been adopted into healthcare policies with little regard for including the skill sets of compassion and emotional intelligence. The multiple increasing demands on providers of healthcare are unsustainable and will cripple the system, resulting in outcomes that are counter to the Triple Aim goals. Patient engagement with shared decision-making should become the primary focus of care delivery. New delivery models and care plans are unaffordable to far too many patients and payers, despite the efforts of futurists who seek to advance quality and lower costs. Clinical care delivery and patient engagement efforts must be drastically redirected to innovative and sustainable value-based delivery models that support the goals of the Triple Aim.

Different measures, different outcomes? Survey into the effectiveness of chronic pain clinics in a London tertiary referral center.

BACKGROUND: Chronic pain clinics aim to improve challenging conditions, and although numerous studies have evaluated specific aspects of therapies and outcomes in this context, data concerning service impact on outcome measures in a general pain population are sparse. In addition, current trends in commissioning increasingly warrant services to provide evidence for their effectiveness. While a plethora of outcome measures, such as pain-intensity or improvement scores, exist for this purpose, it remains surprisingly unclear which one to use. It also remains uncertain what variables predict treatment success. OBJECTIVES: This cross-sectional study was conducted to evaluate clinic performance employing different tools (pain scores, pain categories, responder analysis, subjective improvement, satisfaction), and to determine predictors of outcome measures. PATIENTS AND METHODS: Patients attending scheduled clinic follow-up appointments were approached. They were asked to complete the modified short-form Brief Pain Inventory (BPI-SF) that also included assessments for satisfaction and subjective improvement. Comparisons were made with BPI-SF responses that were completed by each patient on admission. Nonparametric tests were employed to evaluate service impact and to determine predictors for outcome. RESULTS: Data of 118 patients were analyzed. There was considerable variation in impact of pain clinics depending on the outcome measure employed. While median pain scores did not differ between admission and follow-up, scores improved individually in 30% of cases, such that more patients had mild pain on follow-up than on admission (relative risk 2.7). Furthermore, while only 41% reported at least moderate subjective improvement after admission to the service, the majority (83%) were satisfied with the service. Positive treatment responses were predicted by "number of painful regions" and "changes in mood", whereas subjective improvement was predicted by "helpfulness of treatments". CONCLUSION: Depending on the outcome measure employed, pain clinics showed varying degrees of impact on patients' pain experiences. This calls into question the current practice of using nonstandardized outcome reporting for evaluation of service performances.

Direct Pay/Concierge/Blended Care: Where Is The Sweet Spot? Part II--Seen from Your Patients' Perspective.

Physicians are actively considering the direct pay and concierge models as plausible options in providing more patient-oriented care. What are the major considerations and how do we obtain accurate data that may help in sophisticated decision-making? Part I of this article introduced the models, typical patient contract configurations, physician/provider considerations, and commercial payers. In Part II, we discuss the access, cost, and value from a patient's point of view. We also consider patient loyalty and self-care, approaches for introducing and inviting patients, and how to work with other providers and in community relations. Lastly, we share some creative concierge models that are evolving.

Direct Pay/Concierge/Blended Care: Where Is the Sweet Spot? Part I: Practice and Physician Considerations.

Physicians are actively considering the direct pay and concierge models as a plausible option in providing more patient-oriented care. What are the major considerations and how do we attain accurate data that may help in sophisticated decision-making? Part I of this article provides an introduction of the models, typical patient contract configurations, and physician/provider and commercial payer considerations. Part II will discuss the access, cost, and value from a patient's point of view; patient loyalty and self-care; approaches for inviting patients and other providers; and community relations.

The clinical psychologist and the management of inpatient pain: a small case series.

Recent research has confirmed that between 25% and 33% of all hospitalized patients experience unacceptable levels of pain. Studies further indicate that this reduces patient satisfaction levels, lengthens hospital stays, and increases cost. Hospitals are aiming to discharge patients earlier, and this can interfere with adequate pain management. Therefore, the pain service at Chelsea and Westminster Hospital has adapted to this changing model of care. An increasing body of evidence demonstrates that psychological factors are key components of patients' pain experiences in both acute and chronic pain. Therefore, it is reasonable to suggest a clinical psychologist should be involved in inpatient pain management. This small study discusses three cases that highlight how patient care could be improved by including a clinical psychologist as part of the inpatient pain team. Two cases particularly highlight the active role of the psychologist in the diagnosis and management of common conditions such as fear and anxiety, along with other psychiatric comorbidities. The management therefore employed an eclectic approach adapted from chronic pain and comprising of behavioral, cognitive behavioral, and dialectical behavioral therapeutic techniques blended with brief counseling. The third case exemplifies the importance of nurse-patient interactions and the quality of nurse-patient relationships on patient outcomes. Here, the psychologist helped to optimize communication and to resolve a difficult and potentially risk-laden situation. This small case series discusses the benefits derived from the involvement of a clinical psychologist in the management of inpatient pain, and therefore illustrates the need for novel initiatives for inpatient pain services. However, future research is warranted to validate this approach.

Getting ready to get ready for EHRs: measure for success.

What is the easiest and most efficient way to begin readiness for electronic health records (EHRs) that most support your style of care? Just as you scrub a room before re-painting, steps presented in this article can have your entire staff prepared, trained, and ready to move! Topics covered include options that you can begin now that will "jump start" a successful transition to EHRs. This article will suggest current and future actions along the way to achieve a "win-win" situation as you adopt electronic options while maintaining a partnership of care with your patients.

Older persons' experiences of whole systems: the impact of health and social care organizational structures.

AIMS: An in-depth case study of whole systems working. BACKGROUND: This paper reports on the second part of a two-part study exploring whole systems working. Part 1 of the study focused on an in-depth review of the literature pertaining to continuity of care and service integration. The second part, reported here, focused on an in-depth case study of one whole system. Evaluation Informed by the findings of part 1 of the study, data collection methods included in-depth interviews, real-time tracking of 18 older people, focus groups and consensus conferencing. Different data sets were analysed individually and synthesized using matrices derived from the literature review findings. KEY ISSUE: Key themes from data synthesis include: (1) access to the most appropriate services; (2) service fragmentation; (3) continuity of care; and (4) routinized care. CONCLUSIONS: The four themes of the case study reflect the need to address issues of demarcation of professional responsibilities, complicated channels of communication, information flows, assessment and reassessment in whole systems working. IMPLICATIONS FOR NURSING MANAGEMENT: The impact of disempowering relationships on actual continuity of care and perceptions of quality among service users and providers. Lessons need to be learnt from specialist services and applied to service delivery in general.

The effect of interventions to alter the consultation length of family physicians: a systematic review.

BACKGROUND: Observational studies have shown differences in process and outcome between the consultations of primary care physicians whose average length of consultation differs, however, these differences may be due to self selection. AIM: To assess the effectiveness and cost effectiveness of interventions to alter primary care physicians' consultation length. DESIGN OF STUDY: Systematic review with narrative analysis. METHOD: Data sources included Medline, EMBASE, the Cochrane Controlled Trials Register and Effective Practice and Organisation of Care Group specialised register, the NHS National Research Register and author contacts. To be eligible, studies had to be controlled trials. They had to evaluate interventions to alter the consultation length of primary care physicians, and provide objectively measured process or outcome data. Data were extracted independently using agreed criteria and disagreements resolved by discussion. RESULTS: Six articles describing four trials were included. All took place in the UK and tested short term changes in the time allocated to each patient, and all had methodological weaknesses, particularly due to non random allocation of patients. Altering appointment length resulted in modest changes in average consultation length. There were no consistent differences in problem recognition, examination, prescribing, referral or investigation rates. There was some evidence that blood pressure was checked more frequently and smoking discussed more often when more time was available. None of the interventions were associated with differences in patient satisfaction. No trials examined cost effectiveness. CONCLUSIONS: Our findings do not provide sufficient evidence to support or resist a policy of altering consultation lengths of primary care physicians. Further trials are needed, focussing on health outcomes and cost effectiveness.

Using mobile technologies to give health students access to learning resources in the UK community setting.

OBJECTIVES: This article describes a project which explored the potential for mobile technologies to give health students in the community access to learning resources. The purpose included the need to identify possible barriers students could face in using mobile technologies. Another focus was to assess the students perceptions of the importance of being able to access learning resources in the community. METHODS: This 1-year project used two main approaches for data collection. A review of the literature on mobile technologies in the health context was conducted. This was used in a systematic way to identify key issues and trends. The literature review was used to inform the design and production of a questionnaire. This was distributed to and completed by a group of community health students at Northumbria University, UK. The questionnaire was piloted and there was a 100% completion rate with 49 returned forms. RESULTS: The literature review indicated that most mobile technology applications were occurring in the US. At the time of the review the most prevalent mobile technologies were PDAs, laptops, WAP phones and portable radios with use being concentrated around doctors in the acute sector. A range of advantages and disadvantages to the technology were discovered. Mobile technologies were mainly being used for clinical rather than learning applications. The students showed a low level of awareness of the technology but placed great importance to accessing learning resources from the community. CONCLUSIONS: Significant development and changes are taking place in mobile technologies. Since the data collection for this work was completed in 2004 podcasting and videocasting have become significant in mobile learning for health professionals. Librarians will need to address the relevance and implications of m-learning for their practice. Care and consideration needs to be given on the time and resources librarians allocate for the necessary development work around mobile technologies. Collaboration and partnership working will be most effective approach for librarians wishing to integrate their services with m-learning technologies.

Prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease: systematic review.

OBJECTIVES: To ascertain the prevalence of Helicobacter pylori in patients with gastro-oesophageal reflux disease and its association with the disease. DESIGN: Systematic review of studies reporting the prevalence of H pylori in patients with and without gastro-oesophageal reflux disease. DATA SOURCES: Four electronic databases, searched to November 2001, experts, pharmaceutical companies, and journals. MAIN OUTCOME MEASURE: Odds ratio for prevalence of H pylori in patients with gastro-oesophageal reflux disease. RESULTS: 20 studies were included. The pooled estimate of the odds ratio for prevalence of H pylori was 0.60 (95% confidence interval 0.47 to 0.78), indicating a lower prevalence in patients with gastro-oesophageal reflux disease. Substantial heterogeneity was observed between studies. Location seemed to be an important factor, with a much lower prevalence of H pylori in patients with gastro-oesophageal reflux disease in studies from the Far East, despite a higher overall prevalence of infection than western Europe and North America. Year of study was not a source of heterogeneity. CONCLUSION: The prevalence of H pylori infection was significantly lower in patients with than without gastro-oesophageal reflux, with geographical location being a strong contributor to the heterogeneity between studies. Patients from the Far East with reflux disease had a lower prevalence of H pylori infection than patients from western Europe and North America, despite a higher prevalence in the general population.

The relationship between consultation length, process and outcomes in general practice: a systematic review.

The aim of the study was to examine differences in consultation process and health outcomes between primary care physicians who consult at different rates. A systematic review of observational studies was carried out, restricted to English language journal papers reporting original research or systematic reviews. Qualitative analysis with narrative overview of methodology and key results was undertaken, using MEDLINE (1966 to 1999), EMBASE (1981 to 1999), and the NHS National Research Register. Secondary references from this search were also considered for inclusion. Main outcome measures were objectively measured process or healthcare outcomes. Thirteen papers, describing ten studies, were identified. There were consistent differences in several elements of process and outcome between general practitioners (GPs) who consult at different rates. Although average consultation length may be a marker of other doctor attributes, the evidence suggests that patients seeking help from a doctor who spends more time with them are more likely to have a consultation that includes important elements of care.