An Integrated Process and Outcome Evaluation of a Web-Based Communication Tool for Patients With Malignant Lymphoma: Randomized Controlled Trial.

BACKGROUND: The complex nature of the medical dialogue and the often emotional context in cancer care present challenges to health care professionals (HCPs) and patients. Patients are increasingly expected to be informed participants and to be able to make conscious decisions, which they often find very difficult. In an attempt to support patients with malignant lymphoma in clinical communication, we developed a stand-alone, Web-based intervention called "PatientTIME." The development of PatientTIME was based on a participatory intervention mapping framework. Its primary aim is to boost patients' self-efficacy in patient-professional communication (ie, their confidence when interacting with their HCP). Patients can use this intervention before their hospital visit to prepare for their clinical consultation. PatientTIME is fully automated and use is patient-initiated. OBJECTIVE: The aim of this study was to evaluate if and in what way patients benefit from PatientTIME and if it enhances their confidence in clinical communication. METHODS: The intervention was evaluated in a closed randomized controlled trial with continuous recruitment (using online and offline methods to reach potential participants) and data collection. In accordance with the Medical Research Council guidance, we started with a process evaluation. Subsequently, an outcome evaluation was performed focusing on the patients' perceived confidence in communication with their HCP, measured with the validated PEPPI questionnaire at baseline and at 3 months after participation. Process and outcome data were obtained through Web-based questionnaires, log files (automatically generated files mapping the interactions between program and users), and a logbook (comprising a record of actions and interactions kept by the researchers). Participants were not blinded. A total of 146 patients registered online, of whom 97 gave their informed consent and were assigned at random to the control group (N=34) or 1 of the 2 intervention groups (N=63). Ultimately 87/97 (90%) of these patients actually participated in the study, producing 87 datasets for analysis. RESULTS: More than half of the intervention group patients reported that the intervention helped them prepare for a clinical consultation; it created awareness about the importance of communication and reinforced their existing communication skills. In the postvisit test, the control group showed a small, nonsignificant improvement in perceived communication efficacy. The intervention group showed a significant improvement in perceived efficacy. However, the interaction effect was not significant, indicating that the improvement solely as a result of the intervention may not be significant. CONCLUSIONS: A considerable number of patients reported that PatientTIME did provide support. We found a trend indicating that in the long run, patients with access to PatientTIME scored better on the perceived efficacy scale than patients without access. However, at this stage we cannot conclude that PatientTIME improves patients' confidence when interacting with HCPs. CLINICALTRIAL: Netherlands National Trial Register (NTR): 3779; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3779 (archived by WebCite at http://www.webcitation.org/6iztxJ5Nt).

Communication during haematological consultations; patients' preferences and professionals' performances.

Many patients with haematological malignancies experience barriers in clinical communication. Reaching effective communication is of great importance as it has been linked to a range of improved patient outcomes such as satisfaction, compliance to treatment, perceived quality of life and physical and mental health. To get a better understanding how communication in haematological consultations can be improved, the current study focussed on patients' preferences and perceived performances regarding the communicative behaviour of their health care professional. Secondly, the mediation of an online communication tool for patients was analysed. Within a controlled pre- post-test design, 78 datasets of clinical consultations could be analysed. Patients considered both affective and instrumental communication aspects important. The affective communication behaviour of the health care professional met the patients' pre-visit preferences well. In the information exchange, more variability and discrepancies were found. Overall, the online intervention did not seem to influence the patients' perceived communication performance of their health care professional much. To further improve the communication during clinical consultations, health care professionals should inquire about patients' expectations, especially during the exchange of information and advices. At the same time, patients should be supported to express their preferences at the start of the consultation. The study was registered in the Netherlands Trial Register, number 3779.

Active patient participation in the development of an online intervention.

BACKGROUND: An important and challenging part of living with cancer relates to the repeated visits to the hospital. Since how patients cope between these post-diagnostic visits depends partly on the information and support received from their physician during the visits, it is important to make the most of them. Recent findings reinforce the importance of training not only the health care professionals in communication skills, but providing patients with support in communication as well. Delivering such supportive interventions online can have potential benefits in terms of accessibility, cost-effectiveness, and ability to tailor information to personal needs. However, problems with attrition (dropout, non-usage) during the test phase and poor uptake after implementation are frequently reported. The marginal level of engagement of the patient as end user seems to play a role in this. Therefore, recent research suggests integrating theory-based development methods with methods that promote involvement of the patient at an early stage. This paper describes a participatory protocol, used to let patients guide a theory-informed development process. OBJECTIVE: The objective of this project was to apply a bottom-up inspired procedure to develop a patient-centered intervention with corresponding evaluation and implementation plan. METHODS: The applied development protocol was based on the intervention mapping framework, combined with patient participatory methods that were inspired by the participation ladder and user-centred design methods. RESULTS: The applied protocol led to a self-directed online communication intervention aimed at helping patients gain control during their communications with health care professionals. It also led to an evaluation plan and an implementation plan. The protocol enabled the continuous involvement of patient research partners and the partial involvement of patient service users, which led to valuable insights and improvements. CONCLUSIONS: The applied protocol realized patient participation on different levels throughout the entire project. Early involvement, involvement on different levels, and flexibility in terms of planning and setup seem to be preconditions to creating a bottom-up inspired development procedure with (seriously ill) patients. Further research is necessary to find out if a more patient-centered approach improves the implementation and uptake of eHealth interventions. TRIAL REGISTRATION: Netherlands National Trial Register ID number: NTR3779; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3779 (Archived by WebCite at http://www.webcitation.org/6TdfALKxV).

Barriers and facilitators to effective communication experienced by patients with malignant lymphoma at all stages after diagnosis.

OBJECTIVE: This study aims to gain insight into patient-perceived communication barriers and facilitators at different stages after the diagnosis of malignant lymphoma. We have detected patterns to explain when these factors influence communication predominantly. METHOD: A qualitative approach was applied, derived from the context mapping framework. A total of 28 patients completed a set of assignments about their experiences with provider-patient communication during medical consultations. Subsequently, these patients and nine companions shared their experiences during a semistructured (group) interview, which was recorded on audiotape. The audiotapes and assignments were analysed with MAXQDA software. RESULTS: From the patients' viewpoint, communicating effectively appears to depend on their own attributes (e.g. emotions), the health care professionals' attributes (e.g. attitude) and external factors (e.g. time pressure). Three patient communication states were identified: (i) overwhelmed, passive; (ii) pro-active, self-motivated; and (iii) proficient, empowered. Patients seem to behave differently in the three communication states. CONCLUSIONS: This study lists patient-perceived communication barriers and facilitators and identifies three different communication states, which indicate when certain barriers and facilitators are encountered. PRACTICAL IMPLICATIONS: These findings may support health care professionals to tailor the provision of support and information and remove communication barriers accordingly. Additionally, they provide input for interventions to support patients in effective communication.

[Summary of the Dutch College of General Practitioners' practice guideline 'Depression']. / Samenvatting van de NHG-Standaard 'Depressie'.

This guideline gives recommendations for the management of depression and depressive symptoms. The diagnosis of suspected depression requires a broad exploration of symptoms, sometimes over several visits. The guideline promotes self-management and patient empowerment during the healing process. The initial step in the treatment of depressive symptoms is patient education; patients with depression are supported with activity scheduling and are offered a short course of psychological treatment. If the initial treatment in patients with depression is not effective or if the depression is associated with severe suffering, severe social dysfunctioning or severe psychiatric comorbidity, psychotherapy or an antidepressant is recommended.

Six formats in simulated and standardized patients use, based on experiences of 13 undergraduate medical curricula in Belgium and the Netherlands.

BACKGROUND: In Belgium and the Netherlands, 13 medical schools collaborate with regard to the use of simulated patients (SPs) and standardized patients in their undergraduate curricula. All schools use SPs in their curriculum but schools differ in (a) the timing or placement of the SPs and (b) the way they are used. AIM: To give an overview of the formats used most in undergraduate medical education with SPs, including a description of the impact of these formats on the different aspects of SPs. METHODS: Representatives of all medical schools in Belgium and The Netherlands all provided a structured overview of their use of SPs. We then collectively made a description of the main working formats. For each format we identified salient consequences on the SP level, including whether the format requires simulated or standardized patients or patient-actors, what is the impact of a format on the selection of SPs, content and duration of SP training, whether or not to use checklists in role training, feedback training or not, debriefing of training, impact on the case (role) description (e.g. free or structured), the number of SPs needed, and the selection criteria for SPs. CONCLUSION: The working format with SPs more or less determines the whole process of selection, training, performance, and logistics of SPs.

Effectiveness of problem-solving treatment by general practice registrars for patients with emotional symptoms.

INTRODUCTION: In general practice many patients present with emotional symptoms. Both patients and physicians desire effective non-pharmacological treatments. AIM: To study the effectiveness of problem-solving treatment (PST) delivered by trained general practice registrars (GP registrars) for patients with emotional symptoms. METHODS: In a controlled clinical trial we compared the effectiveness of PST versus usual care for patients with emotional symptoms. Dutch GP registrars provided either PST or usual care, according to their own preference. Patients were included if they (a) had presented for three or more consultations with emotional symptoms in the past six months; and (b) scored four or more on the 12-item General Health Questionnaire. Outcomes at three- and nine-month follow-up were standard measures of depression, anxiety and quality of life. RESULTS: Thirty-eight GP registrars provided PST and included 98 patients; 43 provided usual care and included 104 patients. PST patients improved significantly more than usual care patients: at nine-month follow-up, recovery rates for somatoform disorder and anxiety were higher in the PST group (OR 6.50, p=0.01 respectively OR 11.25, p=0.03). PST patients had improved significantly more on the domains social functioning, role limitation due to emotional problems and general health perception. DISCUSSION: Patients with emotional symptoms improved significantly more after PST delivered by motivated GP registrars than after usual care by GP registrars. Further research, with randomisation of interested registrars or interested GPs, is needed.

Problem-solving treatment in general practice residency: a focus group study of registrars' views.

OBJECTIVE: General practitioner (GP) registrars often express the need for more expertise of non-pharmacological treatments for patients with mental health problems. Problem-solving treatment (PST) could be an attractive option. We aimed to explore GP registrars' views on PST-training during residency and on the actual use of PST in general practice. METHODS: We performed a qualitative study with four focus groups, interviewing 18 Dutch registrars who had been trained in PST during residency. Data were analysed according to the principles of constant comparative analysis. RESULTS: Registrars thought that PST-training during residency was feasible, interesting and helpful, but found that it took too much time in everyday practice and was not a GP's task. All registrars, however, said they would use specific elements in a variety of consultations, for instance concretising problems, brainstorming about practical solutions, and activating patients. CONCLUSION: Registrars regarded PST-training during residency feasible and helpful. In daily practice they would apply specific elements of the treatment. PRACTICE IMPLICATIONS: We recommend residency programmes to offer training in PST or another psychological treatment with comparable elements. Training should fit in with the registrars' needs and level of training and experience.

Work-related health complaints in surgical residents and the influence of social support and job-related autonomy.

OBJECTIVES: The aim of this cross-sectional study was to investigate the influence of job-related autonomy and social support provided by consultants and colleagues on the stress-related health complaints of surgical residents in the Netherlands. METHODS: All (n = 400) Dutch residents in training in general surgery were sent validated self-report questionnaires. Odds ratios were calculated predicting health and exposure to long-term stress for gender, number of working hours, type of hospital, level of social support, job-related autonomy and training phase. The interactions between job-related autonomy and level of social support provided by consultants and colleagues, and all variables, were analysed. RESULTS: A total of 254 of 400 (64%) residents returned questionnaires that were eligible for analysis. Residents experienced more health complaints than the average member of the Dutch working population (4.0 versus 2.5; p = 0.000). Male and senior residents were significantly 'healthier' than female and junior residents, respectively. Social support by consultants was a strong predictor of health and social support by colleagues showed a significant interaction with gender. Women and residents in university hospitals experienced less social support by consultants than men and residents in general teaching hospitals. Residents working in university hospitals experienced lower levels of job-related autonomy and less support from colleagues in comparison with those working in general teaching hospitals. A working week of > 60 hours adversely affected health and job-related autonomy. CONCLUSIONS: Social support provided by consultants and colleagues, and job control, are important factors that interact with the work-associated, stress-related health of residents in training in general surgery. Residents report a greater number of health complaints than the average member of the working population, especially female and junior residents. General teaching hospitals seem to provide better support at work than university hospitals.